The almost two-week coroner's inquest into the death of a man who died in the Royal Jubilee Hospital psychiatric unit has now concluded.

The jury, who heard from witnesses and saw video evidence, has come out with nine recommendations to Island Health aimed at enhancing safety, oversight, and care quality in psychiatric emergency services.

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.

"The people did not know how to conduct themselves to help my son," Angela Spencer, Paul's mother, told reporters outside the courthouse. "There needs to be a lot more schooling and teaching how to help the security guards [who find themselves in a similar] situation that happened to my son."

On Sept. 20, the jury found that Spencer's death was accidental, with the cause of death being a combination of physical restraint, hypertensive cardiovascular disease, psychosis and the long-term use of risperidone, an antipsychotic medication.

The jury made seven recommendations to Island Health:

1. Increase representation of mental health workers in the PES;
2. Consider ways of to improve collection of evidence for the purpose of reviews and investigations;
3. Review policies and training regarding health risks to patients in "mental health distress" after being in a physical altercation or physical restraint;
4. Record video and audio in PES seclusion rooms;
5. Record audio from all security cameras in the PES;
6. Interview all persons involved in an incident resulting in an unexpected death;
7. Consider to ensure individuals are not left unattended in prone position following physical restraint.

Two additional recommendations were made for the Ministry of Health:

1. Considering investigating critical incidents through an independent party;
2. Reviewing the evidence act to ensure public accountability regarding investigations into "critical incidents resulting in unexpected deaths".

Island Health says they will "thoroughly review" the recommendations and issue a formal and public response to each recommendation, and take "appropriate action".

"As care providers, it is our obligation to learn from cases like this and take accountability to enhance the care experiences of our patients, clients, residents and their loved ones," noted a statement from Kathy MacNeil, Island Health CEO and president.

"Paul died a vulnerable person in hospital, and after Paul died the true facts around his death remained completely hidden for almost five years until this inquest, and that should be of grave concern to the public," noted Angela's lawyer Richard Neary in an emailed statement. "Now we hope and pray there is actually some action in response to those recommendations. It would be a travesty for our community and an insult to Paul鈥檚 memory and the work done by the jury if there were not."

Throughout the inquest, the courtroom heard about Spencer's health history, which included schizophrenia, galactosaemia and ankylosing spondylitis, and the circumstances before his death, where he was in a physical altercation with security officers who punched him three times before restraining him and leaving him in prone position in a PES seclusion room, where he died.