The inquest into the death of a 43-year-old man who died while in care of a psychiatric unit at Royal Jubilee Hospital (RJH) started on Monday Sept. 10. A jury of seven will hear a number of witness testimonies to eventually make recommendations for systemic changes to prevent similar deaths in the future.

Paul Spencer was involuntarily admitted to Psychiatric Emergency Services (PES) at RJH just past midnight on Sept. 27, 2019, after being apprehended by police due to concerns about his mental health.

Just hours later, Spencer was pronounced dead.

His mother, Angela Spencer, told the court about her son's life, the details of what happened before he died, and the morning she found out her son was dead when she got a call from one of the PES doctors.

"I screamed my head off. I could not believe [it] and then [the doctor] started to say things like, 'We didn't taser him'. And I thought, 'Why are you talking about tasering?' I got confused. 'He had agitated delirium,' and I thought, 'What on earth was that?' And I was very, very confused, perplexed. I was really,
really upset," she told the court. "I didn't have time to kiss him goodbye."

She explained the night before he had unexpectedly left the home with a suitcase, and she called the Saanich Police Department for help.

Paul's family doctor, Brook Nero, spoke about Paul's history of health issues which includes diagnoses of schizophrenia and psychosis, Galactosaemia, which prevents the body's ability to convert galactose to glucose, which Nero said can affect brain function, and ankylosing spondylitis, a type of arthritis which restricted Paul's head movements.

Despite his schizophrenia, both Angela and Nero said Spencer wasn't aggressive or violent, nor was he addicted to drugs or alcohol. He did, however, endure paranoia which caused multiple hospitalizations, including his last.

"He was a very likeable man. Intellectually, he was slow, but he made up for that with honesty, integrity," said Nero.

Const. Shauntelle Nichols of the Saanich Police Department said she found Spencer at a bus stop near the hospital after he called her and told her his whereabouts.

"He was in a state where he was paranoid and scared. There was a lot going on with him," said Nichols. "[At first] he didn't want to go to the hospital. He didn't want to tell me where he was, [but] he wasn't aggressive by any means."

Nichols detailed apprehending him under the Mental Health Act, taking him to the hospital and admitting him to PES. She said he was calm and "very cooperative" over the entire process.

The court saw video of Spencer being handed off from Nichols to Charlotte Ewington, a psychiatric nurse at PES, who then spoke with him and helped admit him into the unit. She said he was "settled" and "calm in nature" when they went through the admittance process.

"You can see [in the video] that I drop my paper, and he instantly picks it up and hands over to me. So even that's an indication that he does have some kind of reality-based nature within him," Ewington told the court on the second day of the inquest. She mentioned that though he was "unwell", he showed no signs of anger or aggression.

During what was a normal-seeming night for Ewington, she said she went for her break, and when she returned, another nurse had notified her that Spencer had died in a seclusion room after an incident with security guards.

Ewington said the nurse told her that Spencer had suddenly tried to leave. Security was called and performed a "takedown" of him before he was placed in a seclusion room. The nurse told her that when nurses went to sedate Spencer, they found him dead in a prone position in the seclusion room.

She did say that the information she received from the nurse may have been inaccurate after receiving new details about the case as a result of the inquest.

The inquest will continue through the week and the jury will hear from a number of medical professionals, security guards, and others who are involved in the case.