Jonathan Pomares, the 40-year-old man who brutally murdered his two children, before taking his own life in Tétreaultville on Oct. 22, 2019, should not have been discharged from the Institut universitaire en santé mentale de Montréal (IUSMM) seven days earlier, a coroner has found.

The report of the coroner Stéphanie Gamache, made public Tuesday, describes a lack of training and communication between the various stakeholders of the health network involved in Pomares's case.

In addition, the lack of guidelines and resources trained to deal with suicide attempts in a context of a breakdown prevented a more appropriate intervention in this case, she wrote.

The coroner's recommendations include asking the Ministry of Health and Social Services to create an evaluation grid for such cases and to train all health-care workers and professionals on an ongoing basis in the CIUSSS du Centre-Sud-de-l'Île-de-Montréal and de l'Est-de-l'Île-de-Montréal, which were involved in this case.

She also recommends training on when to lift confidentiality rules that prevented the transmission of information between professionals on the real risk presented by Pomares.

Finally, she invited the Secrétariat à la condition féminine to extend the creation of crisis cells specialized in such interventions, which already exist in other regions, to the two CIUSSSes concerned.

Pomares's ex-wife had told him that she wanted to end their relationship on Oct. 12.

The next day, Pomares, who had previously stopped drinking excessively, consumed a large quantity of alcohol in combination with several ibuprofen tablets. Informed of this fact, his ex-wife contacted 911.

He strongly resisted being taken to the hospital and had denied any attempt at suicide, Gamache wrote. But the psychiatrist who saw him at Notre-Dame Hospital judged that he was in severe breakdown and that he was a high risk to himself and unpredictable to others.

On Oct. 14, because of his place of residence, he was transferred from Notre-Dame to the IUSMM psychiatrc hospital where, once again, the psychiatrist who assessed him thought it necessary to place him in protective custody.

LACK OF INFORMATION

However, on Oct. 15, a second psychiatrist at the institute decided to discharge him based solely on the discussions he had had with Pomares. Pomares was permitted to go and live with a friend and consult a psychosocial worker.

Gamache felt that this psychiatrist did not have the full picture of his situation since he had not been able to communicate with his ex-wife, she wrote.

Although surprised that he was discharged without her knowledge, Pomares's ex-wife agreed that he could stay with the children, Hugo and Élise, aged seven and five, respectively.

On Oct. 22, the day of the tragedy, Pomares went to pick up the children at the end of their school day as agreed, and was supposed to make them supper while waiting for their mother's arrival, around 9:30 pm.

When she arrived, she found the bodies of her children and that of her ex-husband, who had hanged himself.

This report by The Canadian Press was first published in French on April 12, 2022.