“Too little too late.” We conclude with these harsh words towards the Sûreté du Québec and its research activities the report of the coroner Luc Malouin on the deaths of Norah and Romy Carpentier in July 2020.
• Also read: “I think my family has been abandoned”: strong statement from Norah and Romy’s mother at the end of a public inquiry
• Also read: Carpentier Public Inquiry: Insufficient staff to respond to research requests during holidays
After 19 days of public inquiry, 51 witnesses and 713 documents submitted as evidence, Me Luc Malouin published on Tuesday morning its investigation report into the murder of Norah and Romy, killed by their father Martin Carpentier.
Photo credit Pierre-Paul Biron
It seems clear to the coroner that the management of the Sûreté du Québec misjudged the situation and struggled to take measures to maximize the chances of recovering the girls after the accident that killed their father on the evening of March 8th July “overturned”, found alive, 2020.
“In the hierarchical authorities of the SQ, we have forgotten the idea of the urgency of the situation. […] Children are probably somewhere in the forest without food and water. It is urgent to find them,” emphasizes Luc Malouin, believing that “the police hierarchy must seriously question its model of intervention in an emergency.”
Maximize the opportunities
In his 85-page report, the coroner notes many elements that, if handled differently, could have made a difference.
Because if the SQ had concluded in the weeks following the tragedy that it was all over on the morning of July 9, a dozen hours after leaving the road, the coroner sees things differently.
SCREENSHOT / VAT NEWS / QMI AGENCY
“I believe that Mr. Carpentier took action toward the end of the day [du 9] given the constant impasse in which he found himself,” Me Malouin stated.
Keep in mind that some witnesses at the inquest believed that a quicker search would have made it possible to find the little girls alive.
Me Malouin doesn’t go that far, but admits that “the opportunities would have been maximized”.
“Clear lack of trained staff”
So what was missing?
First of all, the SQ should have treated the case from the first hours according to the “worst possible scenario” and spoke of a disappearance and fear for the little girls. Me Malouin also makes it one of his 11 recommendations. (see box)
“I must note that somewhere in the police hierarchy, someone has forgotten the Police Practice Guides, which has led to unnecessary delays in the continuation of the case,” he laments.
Archive photo, Annie T. Roussel
These delays then delayed the entire process of initiating the research. It was only the morning after the serious Me Malouin accident that the first special police officers entered the forest at 10 a.m.
Then the first research areas were targeted without adhering to the rules of practice. And after changes in the structure of the specialized research unit, the numbers were clearly insufficient, notes Me Malouin.
Photo Stevens LeBlanc
“I must note that in July 2020 this unit was unable to respond to the urgency that existed in this case. The lack of trained staff is evident,” the report said.
These are the elements that lead too quickly and without maximizing all investigative and research techniques to the end of the day on July 9th and, unfortunately, to the death of Norah and Romy Carpentier.
“Organizational pride”?
And given these problems, particularly staffing issues, why hasn’t the SQ asked for help? Coroner Malouin wonders whether the police were not displaying “organizational pride” at this point, unfortunately to the detriment of public protection.
“For some reason the SQ decided to go it alone. The strategic decisions of managers have certainly affected the smooth conduct of research,” writes Luc Malouin, emphasizing that “the time of organizational pride and union protectionism is over.”
Members of the Quebec Association of Search and Rescue Volunteers (AQBRS), wildlife officers and SPVQ police officers could have quickly helped after Norah and Romy’s disappearance.
Communication problems
Luc Malouin’s report also proposes the rapid activation of a media alert with less restrictive criteria than the AMBER alert when the disappearance of a child is reported.
Archive photo
“Especially since it was possible to use prime time,” the coroner reported on the morning of July 9th.
“The sooner we ask the public for help, the more likely we are to find missing people,” he says.
Remember that an AMBER alert was issued by the Sûreté du Québec, but it was not published until 3:23 p.m. the day after the accident.
Upcoming reactions
The coroner will hold a press conference later in the day on Wednesday to present his findings and answer questions from the media.
Photo credit Pierre-Paul Biron
The girls’ mother, Amélie Lemieux, who was present on all days of the hearing, could respond tomorrow after the coroner’s outcome.
As for the Sûreté du Québec, which was seriously damaged by the Malouin report, its management had not yet responded at the time of writing.
However, Public Security Minister François Bonnardel reiterated his confidence in the provincial police on Tuesday morning.
“There is a very clear observation: when it comes to missing children, time is of the essence. The Sûreté du Québec has already responded to several recommendations or findings regarding its rescue and search teams. I have full confidence in them,” the minister stressed, saying he expects the SQ to “implement” the Malouin coroner’s recommendations.
Recommendations from Luc Malouin
– Modification of the Administrative Directive “Runaways, Disappearances, Kidnappings” ENQ, CRIM.-36, to provide for the presence of two investigators in each disappearance of a child under 13 years of age;
– to remind all officials, investigators and police officers of the importance of always considering the disappearance of a child under 13 years of age as the worst-case scenario and acting accordingly;
– Equip vehicles and police officers with the technology necessary to share information collected during a police operation;
– Training emergency services police officers, both Pool 1 and Pool 2 police officers, in accordance with national search and rescue standards and ensuring that skills and experience are maintained in accordance with national standard CSA Z1620-15;
– Establish simple and effective partnership and cooperation protocols with other police forces, wildlife officers and volunteers of the Quebec Association of Search and Rescue Volunteers (AQBRS) and distribute these protocols to all officers;
– In the event of an enforced disappearance, particularly if it involves a child under 13 years of age, to issue a media alert quickly after the disappearance;
– Establishment of a unified command post from the start of a land search operation;
– assign a ground research technician to this command post to act as a liaison between researchers and investigators;
– To provide comprehensive feedback at the end of each day;
– Better creation of all farm registers, both for investigative work and for land research;
– Provision of two ground search technicians if additional personnel are added after initial searches.
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