The coroners inquest into the death of a man who died in the Royal Jubilee Hospital psychiatric unit is reaching the end as the jury hears from toxicologists and hospital managers who determined his cause of death and have since made systemic and operational changes to the unit.

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

While in the unit, he was apprehended by protection services officers after trying to leave the unit and placed in a seclusion room. Eight minutes later, nurses returned to find Spencer dead.

Black Press Media was not present Monday, when the courtroom heard a 2023 report from forensic pathologist Dr. Elizabeth McKinnon, who determined Spencer's cause of death.

According to Richard Neary, counsel for Spencer's mother, Mckinnon's report said Spencer died from cardiac arrest as a result of "physical restraint, hypertensive cardiovascular disease, schizophrenia and administration of sedating medication," which was later clarified to be Risperidone, an antipsychotic medication he had been taking for over a decade.

Neary said McKinnon testified there was only a small trace of Risperidone in his body at the time of his death so it may not have had a big effect. In a report she wrote in 2019, she didn't mention the medication at all.

Last week, the court saw video of protection officers punching Spencer three times while trying to apprehend him; the officers later testified to putting him in prone position in the seclusion room, where he was later found dead.

Kelly Reid, director of clinical operations for mental health and substance use for Island Health, said "everyone was very shaken up" on the morning of Spencer's death.

He said since it happened, there has been a change in leadership and more directors are available to handle specific wing and types of care at the hospital. He added there has also been more investment into mental health and substance abuse care within Island Health, though he did specify the changes did not come as a direct result of Spencer's death.

"In my experience, what often drives big service enhancement and improvement initiatives is that a number of things happen over time," Reid said. He said historically, changes would be recommended by a "quality council", which would investigate claims by patients that have been harmed in some form.

"There is never perfection in this business and we're still improving," he told the court room.

Once the jury has heard from all the witnesses, they will make recommendations for systemic changes to prevent similar deaths in the future.