Death of Thomas Audet: coroner Géhane Kamel asks for more money for the DPJ
Thomas Audet died on June 18, 2016.
Coroner Géhane Kamel recommends that the Quebec Ministry of Health and Social Services change the way its youth protection departments (DPJ) operate and inject more money in order to avoid tragedies such as death of Thomas Audet, which occurred in Alma on June 18, 2016.
The two-year-old toddler died after sustaining several injuries. He had been on the DPJ's waiting list for three weeks when he passed away in the apartment where he was living with his mother and stepfather at the time.
In order to shed light on the events and prevent such a situation from happening again, Coroner Kamel had been mandated by the Chief Coroner of Quebec in February 2022 to preside over a public inquiry.
The hearings took place over five days in September and October 2022, at the Chicoutimi courthouse. Thomas Audet's paternal grandparents, who called for the inquest to be held, were heard, as were the child's parents and his stepfather at the time of death.
Coroner Kamel's report was eagerly awaited by the family. The 26-page document contains a series of recommendations. Among them: the implementation, within the DYP, of an exceptional measure indicating that all children aged five and under who are the subject of a report must be the subject of an evaluation without deadline and daily monitoring of the situation.
The coroner in Thomas Audet's file
After the report of May 17, 2016, a worker from the DYP, which is grouped under the bosom of the Integrated University Health and Social Services Center (CIUSSS) of Saguenay-Lac-Saint-Jean, assigned a code 3 to the file of Thomas. This code means that an intervention was required within four working days.
Throughout the often emotionally charged hearings, Coroner Kamel noted the importance of promoting professional practice within DYPs. The lack of staff has been raised on several occasions by those involved in the file and certain managers.
Among her recommendations, the coroner reiterates the importance of working on recruitment and retention youth protection personnel, in particular by ensuring ratios adapted to the needs of the target clienteles.
She goes back to the starving budgets granted to the DYPs and questions the functioning of the coding system when reporting.
Still on the subject of requests to the Quebec Ministry of Health and Social Services, Géhane Kamel addresses the subject of contingency measures.
She points out that 'it is imperative to precisely define the breaking point for which the number of reports received is considered excessive and decisive for the implementation of these emergency measures.
The College of Physicians of Quebec (CMQ) is also targeted by the requests of the president of the public inquiry into the death of Thomas Audet.
During the investigation, it was revealed that a first pediatrician assessed little Thomas and saw fit to hospitalize him so that he could undergo further examinations. There was then a suspicion of abuse. A fellow pediatrician who was on call at the time assessed the child at the hospital.
During his testimony before coroner Kamel, this pediatrician said he remembered very well the consultation he had had with Thomas Audet a month before his death.
A skeletal x-ray allowed to see that the toddler had suffered a fracture to the left tibia. Swelling was noticed in the right hand and seemed unexplained, in the opinion of the doctor in question. He also observed that Thomas' social context seemed precarious.
During the examination, marks left by a tear in the pinna of the ear were seen by the doctor. He also noted bruises on the dorsal side of the penis. At that time, the mother had no explanation for the origin of this injury.
Three years after the death of the toddler, the family had organized a tribute ceremony in the cemetery of Saint-Ambroise.
Thomas Audet spent the night in the hospital and the doctor who had examined him was not called back in the evening or during the night. He advised the team taking over that there was suspicion of abuse and asked them to be vigilant about mother-child contact. Despite everything, the pediatrician who was on duty the next day concluded that the injuries were accidental in nature due to the age of the child (toddler) and discharged him without notifying the DPJ.
< p class="e-p">In light of these events, Géhane Kamel recommends that the CMQ remind its members of section 39 of the Youth Protection Act, which provides that “any professional who, by the very nature of his profession, provides care or any other form of assistance to children and who, in the exercise of his profession, has reasonable cause to believe that the security or development of a child is or may be considered to be in danger […] is required to report without delay the situation to the director of youth protection.
During the public hearings, the coroner heard 26 witnesses and analyzed 72 exhibits and annexes. Many of the exhibits were subject to a publication ban.
The Sûreté du Québec is also flayed in passing by the report of coroner Kamel. She writes that, during the investigation, she made a request for expertise on a blanket found on Thomas's bed. The results revealed that the blanket matched the child's DNA.
While this would not have changed the outcome as to the cause of death, further investigation meticulous investigation by the Sûreté du Québec in 2016 would have had the merit, if the parents had been questioned, of understanding the source.
Thomas Audet died of blunt abdominal trauma. If the stepfather of the child at the time, Maxime Patry, was first singled out, charges filed against him by the Director of Criminal and Penal Prosecutions (DPCP) were withdrawn after the retraction of a key witness. The DPCP had a year to file new charges against him, but chose not to.
However, the evidence gathered during the The investigation cannot determine the probable cause of the injuries sustained by the child, the statement released by the Coroner's Office said.
From the outset, at the start of these hearings, I recalled that it takes a village to take care of a child. The responsibility for children in Quebec does not fall solely on institutions, it is a collective responsibility for which each of us, as citizens, should have a concern and an interest in acting on their behalf. Finally, the death of a child is an unbearable ordeal for a family. It is deplorable that this same family had to wait six years before obtaining answers about the death of little Thomas, writes Géhane Kamel.
She continues by pointing out that transparency and support remain the best remedies to put a balm to such a great mourning. Public bodies would do well to adopt a more sensitive approach to this difficult but necessary transition for families. In this sense, it would be more than desirable for the organizations that take charge of these tragedies to be able to humanize their practices and not wait for a public coroner's inquest to offer support and condolences to bereaved families.
< p class="e-p">Interrogated by Radio-Canada on Monday afternoon, the Minister of Social Services, Lionel Carmant, was waiting to read the report before commenting.
The great – Thomas Audet's paternal parents, including grandfather André Simard, said they were disappointed in an interview on Monday afternoon that responsibility for the death of the child had not been established.
André Simard is still against the intervention of the DPJ.
One responder decided it was going to stay a code three. And it's a bit part of the DPJ's way of doing things that, when they've made a decision, forget it, they'll never change it, he lamented on Monday.
As for Maxime Patry's lawyer, Me Jean-Marc Fradette, he admits that there was negligence in the apartment where Thomas Audet lived, but he believes that everything the system failed.
It's for sure that the DPJ is a little blamed, although I find that the blame is a little cutesy. [The coroner] also says the doctors should have lit more, talked to each other and made a disclosure, he mentioned.
With information from Gilles Munger< /em>