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"It's very difficult to know what he had in his head," V茅zina testified at the inquiry, which is investigating the three deaths and the police killing of Shaikh.

"We know that he clearly had anti-social personality disorder traits; did he have a pleasure in causing harm (at the time)? Did he distinguish between right and wrong? Was the illness present?"

"I saw someone who was not psychotic and if he was psychotic, he hid it very, very, well," the doctor testified.

V茅zina's last meeting with Shaikh took place about two weeks before his patient was assessed by Quebec's mental health review board, which concurred with V茅zina's recommendation: Shaikh could remain in the community despite posing a significant risk to public safety.

The board agreed with the doctor that the patient denied and trivialized his behavioural disorder, but had shown improvement over the previous six months.

Shaikh, 26, had been diagnosed with schizophrenia and had been hospitalized in Laval, Montreal's northern suburb, three times between 2018 and 2021.

The inquest has heard that in Montreal on Aug. 2, 2022, Shaikh shot and killed Lemieux and Belhaj within a one-hour period. Then, the 26-year-old travelled to Toronto to visit the city's zoo and Canada's Wonderland before returning to Montreal and shooting dead Levis-Crevier, as the 22-year-old was skateboarding on a Laval street. On Aug. 4, Montreal police tracked Shaikh down to a motel, where he allegedly shot at officers. He died in an exchange of gunfire.

Earlier Thursday, psychiatrist Dr. Simon Roussel presented findings from 2015 indicating that Quebec's mental health board follows patients for less time than do the boards of Ontario and British Columbia. As well, Quebec's board uses less coercive means in its decisions, compared to the two other provinces. Meanwhile, recidivism rates for mental health patients in Quebec were two times higher than they were in Ontario and British Columbia.

Roussel said the 2015 study indicated that in Quebec only 19 per cent of patients were followed by a mental health review board for more than five years, compared to 31 per cent in British Columbia and 58 per cent in Ontario. Psychiatric patients under the surveillance of a mental health board were detained in those two provinces for longer than they were in Quebec: 1.5 times longer in B.C. and four times longer in Ontario.

Earlier in the day, Roussel said he sent a letter on Aug. 4, 2022, to regional health officials about the deaths of Lemieux, Belhaj and Levis-Crevier, denouncing the severe lack of psychiatrists in Laval. He said patients in the Montreal suburb couldn't be properly monitored because of a psychiatrist shortage.

Roussel says he never received a reply to his letter, other than an indirect comment that he had bypassed the hierarchy by writing to health authorities.

This report by 好色tvwas first published Oct. 5, 2023.