Â鶹´«Ã½Ó³»­

MONTREAL — A Quebec coroner has concluded the 2018 death of a teenager shot by provincial police could have been avoided if health-care workers had communicated better and followed up with the teen regarding his mental health issues.

Coroner Géhane Kamel writes in her report released Wednesday that police were justified in shooting Riley Fairholm, 17, because they thought their lives were in danger. But she documents how Fairholm had fallen through the cracks in the years leading up to his death. 

"Although police were justified in using lethal force because of the perceived threat, I stick to the idea that if there had been better communication before the 911 call, if health and school professionals had established connections and dialogue, perhaps Riley's life would not have been cut short," Kamel wrote.

Police shot Fairholm in the head on July 25, 2018, after they were called to the parking lot of an abandoned restaurant in Lac-Brome, Que., and found the teenager yelling and waving what turned out to be an air pistol.

Officers did not know it at the time, but an investigation later discovered it was Fairholm who had called 911 on himself, reporting that a white male dressed in black was carrying a gun and screaming.

"Riley was in crisis. That fact is undeniable," the coroner wrote. "The pain of living was more than he could handle and unfortunately caused immeasurable damage."

The report stated that in 2015, the teen started showing symptoms of depression. His family doctor then requested that he consult mental health professionals. 

A psychological evaluation was done between 2015 and 2016. The psychologist also requested an assessment by the school for attention deficit hyperactivity disorder, but that was never completed, according to the report.

The psychologist submitted the teen's neuropsychological assessment report to the family doctor and had three more consultations with Fairholm before he stopped attending his appointments in January 2016. 

The family doctor was unaware that Fairholm had stopped going to therapy because there was no communication between the physician and the psychologist.

The report also stated that in early 2018, Fairholm was evaluated by a neuropsychologist who recommended a treatment plan in his report, later sent to the family doctor. However, no followup was done to check his medication intake, nor was he ever evaluated for suicide risk. 

Moreover, the coroner said that before the shooting, the teen's parents had been left on their own without the assistance of doctors or their son's school.

Tracy Wing, Fairholm's mother, told the inquest in June that on the night he was killed, she rushed around the house searching for her son and found a handwritten letter from him saying goodbye. In a panic, Wing drove into town and saw police lights flashing and a body on the ground.

"The death of a child is an unbearable ordeal for parents," Kamel wrote. "It is deplorable that these parents had to wait four years before obtaining answers about the death of their son. Transparency and support remain the best remedies to put a balm to such great mourning."

She rejected the label of "suicide by cop" that had been attached to the death by some witnesses at the inquest. She cited expert testimony that people in distress are uncertain whether they want to die. "This situation reminds us unfortunately that the window of opportunity to open a discussion is narrow," she wrote.

Kamel recommends that the provincial Public Security Department promptly put in place annual training to instruct officers across the province on intervening with people in crisis.

"Riley needed help, and his legacy should remind us of the need to advocate for dialogue when possible," wrote Kamel.

This report by The Canadian Press was first published Nov. 9, 2022.

---

This story was produced with the financial assistance of the Meta and Canadian Press News Fellowship.

Marisela Amador, The Canadian Press