About a dozen friends and family members gathered in a Medicine Hat courtroom Wednesday, hoping to get answers about Glenn Piche's 2013 death while in a psychiatric unit.
Judge Fred Fisher was clear at the start of the proceedings the inquiry is not meant to lay blame in the death of Piche but recommendations could be made to prevent future deaths.
The inquiry is scheduled to last three days.
"It's a bit overwhelming I guess. There's just a lot of things I didn't know were going on at the time," said Trina Larsen, one of Piche's four daughters, three of whom were in the courtroom.
Larsen said she is hoping her family can get some answers around her father's death.
"I think that's what we were all looking for, and a lot of it is being explained," she said. "As much as it's hard to hear, it's good to hear so that maybe in the end we can have some closure for our family. And hopefully there will be some changes. From what I've heard today, there needs to be changes."
Medical records not passed on
Court was told that despite Piche's psychiatrist — Dr. Aditi Patel — asking for his past medical records upon visiting him on June 19, 2013, the first day he was in hospital, she had not received those files by the time Piche took his own life the next day
If those files had been made available to her, she would have seen a series of suicidal attempts and threats dating back to 2003, including two earlier stays at the hospital in 2013, one in March, and the other only two weeks before his last admission.
Instead, Patel told the court she relied on the information she had at hand, which was that Piche's family said he was suicidal but Piche adamantly denied that. He only admitted to having been in the psychiatric unit once before, in 2005, and he appeared "calm, cool and collected" on June 19, 2013, according to Patel's recollection and notes.
"He thought that these were false accusations and he had no intention of hurting himself and he should be able to leave," Patel said.
Piche had been placed on a 30-minute watch instead of more high-risk watches at closer time intervals. Initially Patel had thought 15-minute intervals would be more appropriate, but changed her course of action when Piche pleaded for longer intervals.
"He pleaded and he explained that he did not want to be in the hospital but if I'm going to keep him he should be allowed some freedoms," Patel said.
At the time of Piche's death, those checks were carried out by security officers with no medical training. Today, only trained nurses are permitted to conduct mental health checks.
Family says improvements needed
The family also took issue with how many people had to be relied on to pass the right information to the next person who would care for Piche. Court heard from the arresting RCMP officer who passed off information to the hospital peace officer, then to an emergency room physician, then to his admitting doctor and then to Patel, the psychiatrist.
"Miscommunication from one section, to the next, to the next, to the next, that has to be changed," said Julie Piche, his sister-in-law. "You can't throw someone in the hospital and say 'OK you have him now' without understanding what the previous person had witnessed and is concerned about."
Court also heard that while some of the rooms in the psychiatric unit have video cameras for observation by nurses and security, Piche's room did not.