Police and health authorities need to develop a coordinated approach to dealing with people suffering from mental illness, said the jury at the coroner's inquest into the death of Coquitlam mom Colette Salemink.
Salemink died after her mentally ill son, Blake Salemink, who was on leave from Riverview Hospital, set fire to the family home in the spring of 2010.
Earlier this year after a trial, a B.C. Supreme Court judge found Blake Salemink not guilty by reason of mental disorder of arson and manslaughter, and the man has resided at the Colony Farm Psychiatric Hospital ever since.
The jury in the inquest, which concluded last Thursday, made 16 recommendations in order to prevent similar deaths in the future.
The jury recommended that Coquitlam RCMP, Port Moody Police Department and Fraser Health establish a memorandum of understanding that will coordinate the agencies' approach to dealing with people with mental illness.
As well, the jury said resources and information should be shared 24 hours a day and a copy of the recommendations should be used for training purposes for general duty officers.
The recommendations also include pairing police with psychiatric nurses, for a trial period, to deal with patients who have violated the conditions of their extended leave from mental health facilities. It also recommends police be given the power to temporarily revoke extended leaves when conditions are broken.
Communication between police and mental health services was highlighted in the report.
The jury said psychiatric doctors should be notified any time one of their patients has an interaction or incident that involves police, and that information about a person's leave conditions from a mental health facility be posted to the Canadian Police Information Centre, a database used by police.
In the weeks leading up to the fire, Blake Salemink's mental condition appeared to be deteriorating, his sister Erica told The Tri-City News last summer.
On April 13, 2010, a mental health warrant was drawn up that could have put her brother back in the hospital, however the document was never executed. Four days later, police were called to the Salemink residence after he threatened to hire a hit man from Mexico to kill his mother.
When officers arrived, Colette told them she did not believe the threat was serious and her son was not taken into custody.
On April 19, 2010 Blake piled some papers on the floor downstairs in their home and set them on fire. He then left the scene, crossed the U.S. border and was attempting to make his way to Mexico when authorities arrested him in Oregon.