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Fredy VillanuevaThe Canadian Press

Senior investigators from two Quebec police forces went out of their way to avoid asking a fellow officer to explain why he shot an unarmed Montreal teen, a long-awaited coroner's report into the death of Fredy Villanueva has concluded.

A series of "human factors," including poor decision-making by an aggressive officer and belligerent behaviour by Mr. Villanueva's brother, Dany, led to a scuffle and the legally justified but unnecessary shooting of Fredy Villanueva by Constable Jean-Loup Lapointe, Justice André Perreault found.

"Fredy Villanueva was not the victim of a murderous police officer," Justice Perreault concluded in an exhaustive report released Tuesday. "Nor was he a thug who fell from the bullets of an officer because he was armed or threatening the life of police. The explanation for why he died is so much dumber than that."

Mr. Villanueva, 18, "just had the bad reflex or lousy judgment to try to end the altercation by getting in between the two."

Fredy Villanueva's mother, Liliane Maribel Madrid, took some solace in the judge's conclusion that her son had no ill-intent. In a brief statement to reporters, she partly echoed the judge's words: "My son Fredy was not a thug. My son Fredy died for nothing. He didn't deserve the bullets Lapointe fired into him."

While the judge had some criticism for nearly everyone at the scene of the confrontation early on a sunny Saturday evening in August, 2008, the most scathing portion of his report was reserved for the subsequent investigation, territory that was not part of his mandate but he said coloured every aspect of his report.

He said investigators from both the Montreal police and the Surêté du Québec avoided interrogating the two officers involved in the shooting while they were left together and met with their union. Procedures to seize the officers' pistols were not followed and there was "harmful confusion on the type of investigation being conducted," the judge said. Senior officers said they did not want to know what happened the night of the shooting.

Meanwhile, the young civilian witnesses of the shooting were kept in isolation and two were even questioned on their gurneys as they were treated for gunshot wounds. A third person was arrested for no obvious reason, the judge said. He concluded the treatment was unequal and unjust and hindered his fact-finding mission.

Many of Mr. Villanueva's family and friends, as well as their lawyers, have maintained the investigation was rigged to clear the officers.

"I can certainly understand their skepticism toward the process intended to find the truth," the judge wrote, saying investigators broke many of their own rules for investigating homicide and for handling police-involved shootings.

The judge said he had to take care to avoid reaching unfavourable conclusions against the two officers solely because the investigation was so badly botched.

"Actually the only investigation into this case was the one done by the coroner-judge," said Alain Arsenault, a lawyer who represents Jeffrey Sagor Métellus, a young man who was part of the melee and was shot in the back a second after Mr. Villanueva was shot.

Last May, Quebec created an independent civilian oversight body to investigate incidents involving a police shooting of civilians. The investigative unit will oversee all police shootings in the province and gather evidence to determine whether an officer should be charged.

The special unit will be headed by a civilian with no previous ties to a police force. The individual will oversee the work of 12 investigators, many of whom will be retired police officers.

Under the former system, an outside police force would investigate officers involved in the death or injury of a civilian.

In his account of events around the shooting, the judge said he did not believe Constable Lapointe's contention he feared Fredy Villanueva was trying to take his pistol.

However, the judge concluded the officer had other grounds for fear, including that he was under physical attack by two men, with two others looming nearby. He had also lost sight of his partner.

The judge noted the officer had other options, such as disengaging from confrontation over such a minor offence, but he admitted he has the benefit of hindsight and a much fuller picture than Constable Lapointe had that evening.

Constable Lapointe fired four shots in less than two seconds, killing Fredy Villanueva and wounding two men.

The judge had praise for only one actor in the confrontation. He said only Constable Stéphanie Pilotte, Constable Lapointe's partner, seemed to avoid escalating the confrontation.

"If every person involved had shown as much levelheadedness as Constable Pilotte that evening, Fredy Villanueva would still be alive," said Justice Perreault.

The judge made 22 recommendations. He suggested officers should have clear guidelines to avoid physical confrontation with people they do not intend to arrest, and better training to stop shooting when a threat has passed. He also said the government should reconsider whether patrol officers should have firearms capable of firing eight shots in a second.

Officials, including the director of the Quebec police college and the chief of the Montreal police, Marc Parent, were quick to say they have already adopted many of the recommendations and improved officer-involved investigations. The rest will be reviewed by the province.

With a report by Rhéal Séguin in Quebec City