A coroner is criticizing the lack of child psychiatrists and a lack of training for educators following the second suicide in five months at a youth centre in the Laurentians.

Mathias Boivin, 16, killed himself at the Huberdeau youth centre in August 2014. According to the report, he was first admitted to the centre in 2011 for sexual behaviour problems, and was watched by a psychiatrist and criminologist at the Philippe-Pinel Institute.

A few weeks before committing suicide, Boivin was swallowing thumbtacks and ingesting hand sanitizer and laundry detergent.

Boivin was sent to the St. Jerome Hospital, but despite this, the coroner said he was barely supervised in the weeks before his death, and there was a lack of communication between staff and his treatment team.

In March 2014, 15-year-old Guillaume Bonnier-Crépeau also killed himself at the Huberdeau youth centre.

The coroner and this healthcare lawyer Jean-Pierre Menard noted that the Huberdeau facility didn't change anything to avoid a repetition.

“What is surprising immediately is that as soon as the first case happened, normally they should have stopped everything and analyzed what went wrong, and put in place strong measures to avoid the repetition of that. It is not what we saw here. They took several months to implement the recommendations and according to what we know, it seems to have been implemented after the second death. This is unexplainable,” said Menard.

The report urged Health Laurentians integrated social services centre to take the necessary measures to reduce waiting times for young people who need mental health treatment.

The coroner’s report showed that a young person in the Laurentians must wait on average 260 days to see a child psychiatrist.

Menard is calling on the government to hold a public inquiry into the matter.