Teen's cries for help were mishandled prior to fatal police shooting, Quebec coroner says

Warning: This story contains discussion ofsuicide.

The 911 call from a 17-year-old that led to his fatal shooting by Quebec provincial police was the last in a long list of cries for help that weren't handled properly and ultimately contributed to his death, according to a coroner's report.

Riley Fairholm, from Lac-Brome, Que.,located in the Eastern Townships, was shot and killed during a police interventionin the parking lot of an abandoned restaurant on July 25, 2018.

He was holdingan air gun at the time.The police intervention is said to have lasted just over a minute.

His death triggered an investigation by the Bureau des enqutes indpendantes (BEI) the province's police watchdog as well asa coroner's public inquiry,presided over by Ghane Kamel earlier this year.

Several people testified during the inquiry, including the victim's mother, healthprofessionals and police officers who responded to the call.

Kamel's report, which was made public on Wednesday,highlightsthe 17-year-old's struggles with mental health, how theyaffected his behaviour in school and the treatment he received from professionals.

"If the professionals from the health and education sectors had built significant bridges, if his parents hadn't been left alone with their helplessness, maybe Riley's life wouldn't have been ruined," saysthe coroner's report.

"The fatal meeting with police is, in my eyes, the last stone he threw to get help."

Although the coroner wrote that shooting the teenager was justified given the circumstances, one of her top recommendations is an annual training program across Quebec to help officers better handle a situation involving people in crisis.

She also said the officers erred by not performing CPR on Fairholm after the shooting.

Fairholm's family has been critical of the Sret du Qubecand the BEI for a lack of transparency. None of the officers involved were charged in connection with the teenager's death.

Better training for 911 dispatchers

Six police officers arrived at the restaurant parking lot after a 911 call that included a detailed description of an armed man. It would later be revealed that Fairholm himself placed that call.

When asked to drop his weapon, Fairholmdidn't comply,the report states. Instead, he toldthe officers that he had been "planning this for five years."

Kamel wrote that she doesn't know whatFairholm meant by that, and she dismissed the notion that his death was a case of suicide by police.

"However, what appears to me to be a certainty is the fact that Riley is in crisis."

Fairholmwas brandishing the air gun, moving it in different directions during the seconds leading up to the shooting.

Fairholm's death also highlightsthe need for better training for 911 dispatchers, Kamel wrote. She saidthe amount of detailprovided by the callershould have raised suspicions that the caller was not a witness but actually theperson in distress.

That information, according to Kamel, could have better prepared the police officers.

'A real possibility' death could have been avoided

Between the ages of twoand 11, Fairholm suffered head traumafrom falling on three occasions.

A few years before his death, Fairholm's behaviour in school became increasingly "alarming," the coroner said, but staff failed to put a plan in place to help him.

Kamel also wrote that in the three yearsleading up to Fairholm's death, several professionals including his lifelong family doctor and mental health specialists monitored the teenager but failed to follow up with him.

The coroner's report includes observations from Alain D. Lesage, a psychiatric expert who wasmandated by the coroner to conduct a psychological autopsy.

After combing through several documents, including medical records and the police report, Lesage concluded that the teenager presented signs of severe distress, "constant risk of suicide and all of the signs of a major depression."

Dr. Lesage wrote that ifthe teenhad received appropriate help, there was "a real possibilityof modifying the trajectory of Riley's life."

"If a child needs a village to support it during difficult times, Riley, and I would dare say, his parents as well, wound up alone," Kamel wrote. "It's not enough to evaluate and medicate someone to ensure a safe followup. We need to talk to each other and build bridges."

Kamel's report also highlights the need for more mental health services for English-speaking Quebecers.

NO CPR administered after shooting

AfterFairholm was shot, none of the officers present performed CPR on him.

Although Kamel wrote that officers believed CPR was pointless, she pointed out that Fairholm'sstate didn't meet the criteria of what is referred to as a mortvidente, French for "obvious death."

The inquiry also found that the officers' first-aid kit was not fully equipped.

Even if it seems unlikely that CPR would have saved the teenager's life, the officers' inaction after the shooting represents a "grey zone" and a question that will always remain unanswered.

"I believe that the manoeuvre should always be provided," Kamel wrote, adding that it would have at least helped convinced Fairholm's family that police had tried everything possible to save him.

In total, she issued 10recommendations to different ministries within the Quebec government as well as the province's police training school.

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).

• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling on the website.

• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.

• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.