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Pomares case | A tragedy that “probably” could have been avoided, concludes the coroner



The double murder committed by Jonathan Pomares on his two children before killing himself, in Montreal in October 2019, could “no doubt” have been avoided if a crisis unit had been set up, concludes coroner Stéphanie Gamache in its report released on Tuesday.

“When someone has nothing left to lose, destruction essentially takes over. So the loss of control over someone can precisely tip over into violence and homicidal gestures, ”summarized Mand Gamache at a press conference in Montreal.

Mr. Pomares committed suicide after killing his children, Élise, 5, and Hugo, 7, in the family residence in the Tétreaultville district on October 22, 2019.


Hugo, Élise and their father Jonathan Pomares

About ten days earlier, he had made suicidal remarks and gestures when the children’s mother had told him of her intention to separate.

Poorly assessed risks

In the context of separation, a suicide attempt can be an “extreme expression” of control comparable to domestic violence, and constitute “a homicidal risk factor according to the scientific literature”, underlines Ms.and Gamache in his report.

However, these risks have not been correctly assessed, shows the lawyer in her meticulous reconstruction of the events.

Thus, although the first evaluation of Mr. Pomares at Notre-Dame Hospital recommended preventive confinement, a note indicating the absence of domestic violence had also been entered in the file, on the grounds that there was no had any manifestation of physical violence in the couple.


Coroner Stephanie Gamache

The coroner mentions a dozen other factors that were not fully taken into consideration by the successive interveners, including Mr. Pomares’ alcohol problems, his anxiety-depressive history, his aggressiveness towards the paramedics which led him to the hospital and the presence of a knife in the couple’s bedroom.

This myriad of signals, some of which dated back many years, should have prompted the establishment of a crisis unit to create a safety net around the family, believes the coroner.

If there had been a better understanding of the situation and the risk factors in a context like this, there are actions that could have been taken.

Coroner Stephanie Gamache

Such “concrete actions” would “undoubtedly have made it possible to avoid this horrible tragedy”, she notes in her report.

While acknowledging that steps have been taken “in the right direction”, Mand Gamache makes several recommendations so that health system workers receive training on domestic violence, as well as on the conditions for lifting the confidentiality of files with relatives and other workers.

If all these recommendations are followed, “I hope that a tragedy like this will not happen again,” she said on Tuesday.

call for respect

The lawyer began her presentation with a call for respect “in order to preserve the privacy of the family affected by this horrible tragedy”.

The children’s mother, referred to as “the ex-spouse”, is not named in the report. Mand Gamache offered him his condolences, his respect and his empathy.

This woman who wants to stay away from media attention shows immense courage and resilience.

Coroner Stephanie Gamache

The coroner wanted to conclude her speech by talking about the two children, “because we must give them a voice since they are full victims of domestic violence”.

Young Hugo was “curious, energetic” and “loved playing sports, especially soccer”, while little Élise was empathetic, “loved to talk a lot” and “loved sweets and her stuffed animals”.

“The children both got along and were very close,” said Ms.and Gamache courtesy of their mother.

Ten days in October 2019

October 12

The wife of Jonathan Pomares, in a relationship with him for 16 years, announces the end of their relationship. He reacted with heavy drinking and suicidal remarks.

October 13

Mr. Pomares shaves his head and swallows ibuprofen tablets with alcohol. His ex-spouse calls 911. When paramedics arrive, the man denies any suicide attempt, and is so aggressive that the police have to intervene. The psychiatrist who assesses him at Notre-Dame Hospital prescribes preventive confinement.

October 14

Transferred to the University Institute in Mental Health of Montreal (IUSMM), Mr. Pomares is evaluated by a second psychiatrist, who deems it necessary to extend preventive custody.

October 15

A third psychiatrist assesses Mr. Pomares and discharges him since, according to the patient’s statements, he presents no imminent danger to himself or others.

October 17

Mr. Pomares meets with a social worker who, not having access to the IUSMM notes, concludes that there has been no suicide attempt and considers the suicide risk low. An appointment is made for October 24.

October 22

Mr. Pomares does not show up for work. His ex-spouse, believing him to be well supported in his post-hospitalization follow-up, confirms his desire for a definitive separation. Returning to the family home around 9 p.m., she discovers her two children bloodied and lifeless, and their father hanged.

Need help ?

If you need support, if you are having suicidal thoughts or if you are worried about someone close to you, contact 1 866 APPELLE (1 866 277-3553). A suicide prevention worker is available to you 24 hours a day, seven days a week.

You can also visit the website

The Crime Victims Assistance Centers provide assistance to loved ones of crime victims following traumatic events: 1-866-le CAVAC (1 866 532-2822) or

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