The head of an inquiry into the death of a Halifax teacher's aide has made 34 recommendations to improve the youth court system and toughen the law overseeing teens awaiting trial.

"Tragedy highlights problems, yet, at the same time, it can ignite the fires of social change and advancement," retired chief justice Merlin Nunn said in releasing his findings Tuesday on the case of Archie Billard.

Theresa McEvoy died instantly in the crash.

Spiralling Out of Control: Lessons Learned From a Boy in Trouble, Nunn's 381-page report, says the teen should never have been allowed out of custody two days before the fatal crash.

Billard — who faced 27 charges related to a string of car thefts — was driving a stolen car on Oct. 14, 2004, when he slammed into Theresa McEvoy, a 52-year-old mother of three, at an intersection in west-end Halifax.

McEvoy was driving back to school after having lunch with one of her sons.

Billard, who had a fondness for stealing Chrysler Neons, fled the scene. He told police he was so high on marijuana he didn't know how fast he was going. Police figured it was in excess of 100 km/h.

Billard was convicted of criminal negligence causing death, and earlier this year received an adult sentence of 4½ years in prison. He's at the youth jail in Waterville, N.S.

Billard's life was "spiralling out of control" and into a crime spree, Nunn said.

"None of our responses seemed to be effective in stopping him. They should have."

The inquiry was convened to look into several key questions, all revolving around why a Windsor court released the teen when there was a warrant out for his arrest in Halifax.

'The system, as it existed at the time, did fail'-Inquiry commissioner Merlin Nunn

The inquiry heard from 47 witnesses, including Halifax police and RCMP officers, court workers, Crown attorneys and also Billard's mother.

Nearly 12,000 pages of documents were entered as exhibits.

Cites information breakdown

Nunn found key information didn't get relayed, there was a computer breakdown and a lack of clear procedures. He also cited bail limitations in the Youth Criminal Justice Act.

Billard's mother, Trudy Lushman, told the inquiry she had no control over her son's behaviour, and the youth criminal justice system gave him too many chances.

Between January 2004 and his appearance in Windsor court the following October, Billard was arrested six times.

In Windsor, the Crown attorney had not made arrangements for Billard to be picked up on the Halifax charges. In addition, there was no working fax machine at the Windsor courthouse and no connection to a central court database.

In the end, Nunn didn't blame any individuals involved in Billard's case.

"The system, as it existed at the time, did fail," he wrote.

Recommendations target quick action

Nunn's 34 recommendations aim to improve the delivery of youth justice programs in Nova Scotia, toughen the federal youth justice act, and better co-ordinate services to youth outside the court system.

Nunn's recommendations include:

• Amend definition of violent offence in Youth Criminal Justice Act to include conduct that endangers or is likely to endanger someone's life or safety.
• A youth should appear in court by the next scheduled appearance date or within a week of arrest.
• Police should be trained to understand the court system and procedures of the justice of the peace.
• Creation of a director of youth strategy and services to co-ordinate all programs for at-risk youth.
• Education to fund specialists to identify at-risk kids in schools.
• Justice Department should set up audit section to ensure court staff are following rules.
• Court staff in Windsor should have a working phone, fax and computers.
• New courthouses should have separate facilities for youth court matters.
• A fully funded bail supervision program should be created for youth in the Halifax Regional Municipality.

Weeks after the car crash, McEvoy's family demanded that the province hold an inquiry into her death, saying it would give her sons answers to why their mother died.

The estimated cost of the inquiry is $1.5 million.