Warning: This story contains discussion of suicide.
The 911 call from a 17-year-old that led to his fatal shooting by Quebec provincial police was the last in a long list of cries for help that weren't handled properly and ultimately contributed to his death, according to a coroner's report.
Riley Fairholm, from Lac-Brome, Que., located in the Eastern Townships, was shot and killed during a police intervention in the parking lot of an abandoned restaurant on July 25, 2018.
He was holding an air gun at the time. The police intervention is said to have lasted just over a minute.
His death triggered an investigation by the Bureau des enquêtes indépendantes (BEI) — the province's police watchdog — as well as a coroner's public inquiry, presided over by Géhane Kamel earlier this year.
Several people testified during the inquiry, including the victim's mother, health professionals and police officers who responded to the call.
Kamel's report, which was made public on Wednesday, highlights the 17-year-old's struggles with mental health, how they affected his behaviour in school and the treatment he received from professionals.
"If the professionals from the health and education sectors had built significant bridges, if his parents hadn't been left alone with their helplessness, maybe Riley's life wouldn't have been ruined," says the coroner's report.
"The fatal meeting with police is, in my eyes, the last stone he threw to get help."
Although the coroner wrote that shooting the teenager was justified given the circumstances, one of her top recommendations is an annual training program across Quebec to help officers better handle a situation involving people in crisis.
She also said the officers erred by not performing CPR on Fairholm after the shooting.
Fairholm's family has been critical of the Sûreté du Québec and the BEI for a lack of transparency. None of the officers involved were charged in connection with the teenager's death.
Better training for 911 dispatchers
Six police officers arrived at the restaurant parking lot after a 911 call that included a detailed description of an armed man. It would later be revealed that Fairholm himself placed that call.
When asked to drop his weapon, Fairholm didn't comply, the report states. Instead, he told the officers that he had been "planning this for five years."
Kamel wrote that she doesn't know what Fairholm meant by that, and she dismissed the notion that his death was a case of suicide by police.
"However, what appears to me to be a certainty is the fact that Riley is in crisis."
Fairholm was brandishing the air gun, moving it in different directions during the seconds leading up to the shooting.
Fairholm's death also highlights the need for better training for 911 dispatchers, Kamel wrote. She said the amount of detail provided by the caller should have raised suspicions that the caller was not a witness but actually the person in distress.
That information, according to Kamel, could have better prepared the police officers.
'A real possibility' death could have been avoided
Between the ages of two and 11, Fairholm suffered head trauma from falling on three occasions.
A few years before his death, Fairholm's behaviour in school became increasingly "alarming," the coroner said, but staff failed to put a plan in place to help him.
Kamel also wrote that in the three years leading up to Fairholm's death, several professionals — including his lifelong family doctor and mental health specialists — monitored the teenager but failed to follow up with him.
The coroner's report includes observations from Alain D. Lesage, a psychiatric expert who was mandated by the coroner to conduct a psychological autopsy.
After combing through several documents, including medical records and the police report, Lesage concluded that the teenager presented signs of severe distress, "constant risk of suicide and all of the signs of a major depression."
Dr. Lesage wrote that if the teen had received appropriate help, there was "a real possibility of modifying the trajectory of Riley's life."
"If a child needs a village to support it during difficult times, Riley, and I would dare say, his parents as well, wound up alone," Kamel wrote. "It's not enough to evaluate and medicate someone to ensure a safe followup. We need to talk to each other and build bridges."
Kamel's report also highlights the need for more mental health services for English-speaking Quebecers.
NO CPR administered after shooting
After Fairholm was shot, none of the officers present performed CPR on him.
Although Kamel wrote that officers believed CPR was pointless, she pointed out that Fairholm's state didn't meet the criteria of what is referred to as a mort évidente, French for "obvious death."
The inquiry also found that the officers' first-aid kit was not fully equipped.
Even if it seems unlikely that CPR would have saved the teenager's life, the officers' inaction after the shooting represents a "grey zone" and a question that will always remain unanswered.
"I believe that the manoeuvre should always be provided," Kamel wrote, adding that it would have at least helped convinced Fairholm's family that police had tried everything possible to save him.
In total, she issued 10 recommendations to different ministries within the Quebec government as well as the province's police training school.
If you or someone you know is struggling, here's where to get help: