A Quebec coroner has issued a final report into the violent deaths of three people who were shot at random in the Montreal area by a mentally ill man in 2022, recommending the province look at creating a dedicated court to deal with mental-health cases.

Coroner Géhane Kamel made several recommendations Thursday including transforming the province's mental-health review board into a specialized tribunal as is the case in Ontario, which would allow police, medical professionals and prosecutors to be involved in files.

Kamel's report follows an inquiry last year into the August 2022 murders of André Lemieux, 64, Mohamed Belhaj, 48, and Alex Lévis Crevier, 22, as well as the death of Abdulla Shaikh, the 26-year-old killer who died in an exchange of gunfire with police at a Montreal motel.

"An administrative tribunal specializing in mental health … would have the particular benefit of ensuring the homogeneity of decisions and dedicated experience of decision-makers," Kamel wrote in a 58-page report.

Currently in Quebec, the Commission d’examen des troubles mentaux determines the risk of those found not-criminally responsible, but other matters must go through the courts, meaning prosecutors, police and mental health experts often work in silos.

The new body would help ensure conditions are abided by and help police understand when to apply certain measures, like a provincial law that allows people whose mental state presents a danger to be arrested and hospitalized. The inquiry heard that despite frequent calls from family members raising concerns, applying the measure isn't easy.

Shaikh, who had a history of mental-health problems, had no criminal record despite some brushes with the law. He was diagnosed with schizophrenia around 2018 and had two lengthy stays in hospital. His family said he was not taking his medication as prescribed and had been scheduled to get more medication a few days after his death.

Quebec's mental-health review board ruled in March 2022 that Shaikh, who was under the supervision of a mental-health hospital, posed a "significant risk" to public safety but could continue living in the community.

A board decision cited his psychiatrist saying that Shaikh suffered from "denial and trivialization of behavioural disorders, violence and psychiatric pathology" but had shown improvements over the previous six months.

The final report included roughly two-dozen recommendations for various groups including police, Crown prosecutors, regional health boards and the provincial Health and Justice Departments.

Kamel found there were several red flags in Shaikh's case that included lengthy court delays for cases where he was charged, a lack of co-operation from Shaikh with front-line mental-health workers and a lack of followup after his file was closed, other than quarterly psychiatrist visits and medication monitoring.

The coroner said there is a shortage of mental-health resources in general, and specifically of monitoring for people who fall under the provincial mental health review board and either refuse or are reluctant to receive help.

Shaikh had two ghost guns — homemade firearms — in his possession, and Kamel concluded that the killings had been planned, for reasons only the deceased shooter knows. Kamel said his behaviour was not typical of someone in psychosis but rather a personality disorder.

The coroner's inquest heard that within a one-hour period in Montreal on Aug. 2, 2022, Shaikh shot and killed Lemieux and Belhaj, who were both outside. Then he travelled to Ontario to visit the Toronto Zoo and Canada's Wonderland before returning to Quebec to murder Lévis Crevier, who was skateboarding on the street in Montreal's northern suburb of Laval.

This report by The Canadian Press was first published Feb. 29, 2024.