A public inquest began Monday into the death of Alain Magloire, a 41-year-old homeless man who was shot and killed by Montreal police on Feb. 3, 2014.

The coroner’s inquest is trying to determine why the father of two, who suffered from serious mental health issues, was shot four times by police in downtown Montreal. The officers were never charged.

The coroner will seek to determine how it happened and look to prevent any similar incidents in the future.

The incident began when Magloire got in an argument at a youth hostel on St-Hubert St. near Berri St. and used a hammer to smash the window at the reception desk.

Hostel staffer Alex Witter called 911.

When police arrived, they caught up with him in front of the bus terminal on Berri, where he waved the hammer at them. They called for an officer equipped with a Taser, but it didn’t arrive soon enough.

Before the Taser could be used, Magloire began running toward the officers.

A patroller stopped him by running him over with his cruiser. Magloire got up and lunged toward an officer.

That's when he was shot with four bullets. Magloire died on location.

An investigation by Surete du Quebec police concluded no excessive force was used in the shooting.

Magloire was a father of two, had a Master’s degree in biochemistry and used to work with children with disabilities. He also suffered from mental illness.

His brother, Pierre Magloire, said, “As a society, we’re expecting a change. Everyone’s talking about it; everyone’s looking for something to change.”

According to retired coroner Denis Boudrias, the real question is how the system might have failed Magloire, who had serious needs for psychiatric care.

“What was done for Alain Magloire in the welfare system, the hospital system, what's been done for him, what could have been done for him,” he said.

The coroner, Luc Malouin, will look into how police deal with people who have mental health problems. At the end of the inquest, Malouin will make recommendations for future emergency police interventions.

The public hearings are expected to last until Jan. 22.

This is not the first time police actions have been questioned when dealing with the mentally ill. At least four homless men with mental health issues have been shot by Montreal police since 2011.

In 2011, Mario Hamel, a homeless man using a knife to open garbage bags, was shot and killed in a police foot chase. In that incident a stray bullet from a police officer killed Patrick Limoges, who happened to be bicycling in the area.

In January 2012, Farshad Mohammadi was killed in the Bonaventure metro station

Following those deaths two coroners have recommended more police officers carry stun guns, but at the time of Magloire’s death Montreal’s police force only had 70 Tasers, and fewer than 300 officers trained in their use.

The coroner investigating Mohammadi’s death said each patrol car downtown should have a stun gun, and that better training to recognize mental illness could have saved Mohammadi's life.