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On March 27, 2023, Brouillard Lessard fatally stabbed Breau with a kitchen knife and seriously injured another officer before being shot dead by police in his apartment building in Louiseville, Que., about 100 kilometres northeast of Montreal. Brouillard Lessard, 35, suffered from schizoaffective disorder and was killed while police were attempting to arrest him for uttering threats to a family member and breaking probation.

The coroner's inquest heard of numerous failings in the assessment and supervision of Brouillard Lessard, who had been found not criminally responsible because of mental illness five times for offences in 2014 and 2018, and had been followed by the province's mental health board. Witnesses testified that Brouillard Lessard was resistant to treatment and wasn't following court orders regarding his medication.

The lack of communication between mental health officials and police contributed to Brouillard Lessard's death and that of Breau, a 42-year-old mother of two with more than two decades of policing experience, the coroner said.

"All of the facts heard in the hearings lead me to conclude that it is entirely likely that the deaths of Sgt. Maureen Breau and Mr. Isaac Brouillard Lessard could have been avoided," Kamel wrote. "In retrospect, it is distressing to see so many resources focused on the same individual (Brouillard Lessard) and so little concerted communication between the various stakeholders over the years."

The deaths led to the provincial government tabling a law in May that includes a budget of $11.3 million over five years for a team of "liaison officers" mandated to monitor people who commit crimes but who are judged to be not criminally responsible because of mental health disorders, and to assess the risk they pose.

Breau was just a handful of shifts away from beginning a new job as an investigator before she was murdered.

On March 24, 2023, three days before Brouillard Lessard killed Breau, his parents had called police because he had inundated his mother with hundreds of text messages and phone calls, some menacing. Officers went to see Brouillard Lessard that day but determined they didn鈥檛 have reason to detain him.

Then, on March 27, Brouillard Lessard's uncle filed a police complaint over the alleged threats, resulting in the officers' visit to the apartment building.

In her report, Kamel highlighted several red flags concerning Brouillard Lessard that predated Breau's death, notably that he had moved several times over the years and that the health care network, including the mental health board, was unable to properly keep tabs on him.

In the last year of his life, monitoring by a community mental health team was limited to text messages, and his last psychiatric appointment had been five months before he attacked the sergeant. Kamel said the mental health team and other health workers had the means to assess him for the risk he posed to others, but they never did.

"Monitoring by a case manager would have been more than useful to avoid communication failures between institutions 鈥� and even within the same institution," Kamel wrote.

The coroner said the deaths of Breau and Brouillard Lessard highlight the need for the province's mental health board to revise its approach to surveilling people who are resistant to treatment.

"All the actors in our society will have to think about their approaches to mental health," Kamel said. "The lack of resources is a real problem, but the followup structures for people who are resistant are even more so."

Kamel will address a news conference on Tuesday in Montreal, following which the Quebec provincial police will comment on the report.

"Our duty to remember must be accompanied by societal reflection," she wrote. "Two people lost their lives and each, in their own way, leaves an unfinished story for their loved ones."

This report by 好色tvwas first published Sept. 9, 2024.