Fredy Villanueva, 18, died in August 2008 as two young police officers tried to break up an illegal dice game in a park.
The botched police operation led to the death and ultimately triggered widespread rioting in that part of the city, creating international headlines.
Quebec court Judge Andre Perreault wrote in a report released Tuesday that Villanueva's death was a "result of a multitude of circumstances of human nature, which, if considered on its own, cannot logically justify this result."
"Fredy Villanueva did not deserve to die," the coroner wrote.
The long-awaited report includes about 20 recommendations for police, the provincial academy where officers are trained, the City of Montreal and the province's Health and Education departments. The recommendations target better education and training.
Perreault, the ad-hoc coroner who oversaw the 106-day inquest, heard from 47 witnesses. Proceedings wrapped up this past June, after legal wrangling by the city and the policeman's brotherhood had led to numerous delays.
The death occurred on Aug. 9, 2008, as police tried to question the teen's older brother, Dany. Officers Jean-Loup Lapointe and Stephanie Pilotte were trying to put an end to the illegal gambling game and arrest Dany Villanueva when things degenerated.
In the ensuing scuffle, Fredy Villanueva was shot and killed by two bullets fired by Lapointe, while two other people were injured by other bullets.
The young officer, who testified he had never discharged his weapon in the line of duty before that day, told the inquest he was afraid for his life and his partner's and thought he was going to be disarmed.
Perreault said he didn't believe Lapointe's claim that Fredy Villanueva was trying to get his pistol, but could understand the officer's concerns.
In hindsight, Lapointe could have backed away, Perreault noted. But the coroner also said Dany Villanueva's resistance toward police also intensified the confrontation.
Perreault said neither Fredy Villanueva nor Lapointe deserves the way they've been portrayed.
"Fredy Villanueva was not the victim of a killer cop," Perreault wrote. "But he (Villanueva) doesn't merit being remembered as a thug who tried to disarm a police officer or threatened that officer or his partner."
Perreault praised Pilotte's ability to show calm and restraint during the sequence and noted if everyone had acted similarly, Fredy Villanueva might be alive today.
The coroner was particularly critical of how the post-shooting investigation was handled, calling it incomplete.
The inquest showed that proper procedures were not followed by police.
The officers were not separated and not even questioned right after the incident. They were allowed to meet with a union rep and were not immediately disarmed. There were also lengthy delays in the filing of incident reports and Quebec provincial police never met with either officer.
Perreault noted there was "harmful confusion regarding the type of investigation" police conducted during the probe.
A provincial police investigation eventually cleared the two officers and no criminal charges were ever laid. In Quebec, another police force is called in to investigate when there is a death or injury during an operation.
Villanueva's family and supporters have claimed in the past the entire process was set up to clear the officers.
Perreault said procedures were clearly different for the officers and the civilians.
"I must concede that it may well be that some of my conclusions are coloured by this inequity," Perreault wrote. "In this sense, I understand the skepticism of the relatives of Fredy Villanueva when it comes to the search for the truth."
Villanueva family lawyer Peter Georges-Louis said while the coroner did not have the power to say police should stop investigating police, it's clear it must.
Quebec plans to change the way it handles police-related incidents, with the creation of an independent body expected to come into force sometime next year.
Perreault said the death was avoidable — a banal situation that happens time and time again that simply escalated.
"Thousands of offences as trivial as playing dice in a park are subject to annual police interventions that all go well, even when the police and citizens do not agree on whether the offence has indeed been committed," Perreault noted.
Villanueva's mother, Lilian, reiterated that her son didn't deserve his fate.
"My son Fredy died for nothing," she said in a tearful statement at a news conference.
Perreault's recommendations include many for police and the province's police academy to review, such as when to use force and when a firearm should be removed from its holster. Also, police should look at whether to intervene in a situation where they are badly outnumbered.
The coroner also suggested the province's Education Department teach, starting in high school, how to deal with police officers and the consequences of not co-operating.
Perreault also suggests the city look at social programs and an action plan for the multicultural neighbourhood.
Mayor Denis Coderre, who was a federal MP for the area in 2008, said his administration will do everything it can to help people in Montreal North.
Meanwhile, Montreal police Chief Marc Parent says public security is at heart of its actions and they welcomed Tuesday's report, saying the force will work to implement recommendations and that some already have been instituted.
Parent said he stands behind the work of his officers and has no issue with Lapointe continuing as a police officer with an elite tactical unit.
"I think that police officers do a job that's not always easy," Parent said. "To put myself in the place of an intervening officer to know what is the level of tolerance one has in a stressful situation — we're all human and we each interpret the threat differently."
But lawyer Alain Arsenault, who represents one of the shooting victims, said police should reconsider whether Lapointe be allowed to continue as a police officer.
"Should I keep this officer? Should he be allowed to have a firearm? Should he be allowed to stay in the tactical unit?," Arsenault said.
"The veritable police investigation was really the one conducted by the coroner."
Civil suits launched by the Villanueva family and the two shooting victims were suspended pending the outcome of the coroner's report. Given the coroner's report, Georges-Louis says these suits will proceed.
"We believe that Lapointe acted poorly given the circumstances and his perception (of the situation) was completely false," Georges-Louis said.
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