MONTREAL -- The death of Jules Boutin was "preventable," the coroner said in her report on the death of the 13-year-old who was hit by a school bus two years ago in Sainte-Agathe-des-Monts in the Laurentians, just over an hour north of Montreal.

On Sept. 12, 2019, at the end of the school day, Boutin was crossing the street near the Polyvalente des Monts when he was hit by a bus making a left turn.

He was pronounced dead shortly after at the hospital.

Coroner Julie Blondin released her report Thursday morning, in which she made a series of recommendations.

She concluded that the driver of the bus likely did not see the teenager and that there was no evidence to suggest that there was any fault in her driving. Witnesses indicated that she was driving slowly and stopped at her mandatory stop at the intersection.

The police reconstruction of the accident scene did not determine the exact location of the collision or what may have happened.

The driver was not using her cell phone, according to the inquest.

At most, the coroner is suggesting the possibility of a distraction on her part.

The mechanics of the bus are not at issue and it is a "flat nose" bus, which offers better visibility than older buses with longer hoods.

The coroner offered several suggestions to prevent further loss of life in similar circumstances.

She urged the Société d'assurance-automobile du Québec (SAAQ) to improve the driver training program for heavy trucks, such as buses. She also suggested that buses be equipped with specialized equipment to improve the visibility of their drivers: 360-degree cameras and automatic emergency braking systems were mentioned.

Changes have already been made at the school and the school service centre. A crossing guard position has been created and a fence now surrounds the school grounds. 

-- This report by The Canadian Press was first published in French on Sept. 9, 2021.