A newly established mental health crisis response team was called to assist before Rodney Levi was fatally shot by police last year, but didn't respond in time.
On Friday, a coroner's inquest jury issued a series of recommendations to avoid similar deaths in the future, including revamping the way the unit is dispatched.
Levi, of Metepenagiag Mi'kmaq Nation, was shot twice in the chest by RCMP Const. Scott Hait outside a home southwest of Miramichi on June 12, 2020.
Hait testified at the inquest that concluded last week that Levi wouldn't drop two kitchen knives and told the officer he was suicidal. Const. Justin Napke attempted to use a Taser on Levi three times.
CBC News requested an interview with someone from Horizon Health about the unit and the jury's recommendations, but no interview was provided. Horizon issued a two sentence statement that only said it is aware of the recommendations and would review them with unspecified partners.
The shooting occurred during a period of increased attention on police use of force and calls for shifting resources to mental health workers who can respond instead of police.
Team includes social workers, nurses
Horizon Health announced the Miramichi-based unit in January 2020, six months before Levi's death. It includes specially-trained mental health social workers and nurses who can respond to a broad area around the city.
A witness testified the unit, which operates between noon and 8 p.m., could take 15 to 30 minutes to deploy once contacted. In Levi's case, it didn't respond after being requested by police.
Michael Johnston, a lawyer assisting with the inquest, told the jury and presiding coroner John Evans that RCMP dispatchers contacted the unit and provided cell phone numbers for the two officers at the scene with Levi.
"There was no answer, because presumably the officers were tied up," Johnston told the jury on Oct. 5.
It wasn't clear what time the unit was contacted about Levi or what time it attempted to call the officers.
The five-member inquest jury recommended the unit be dispatched alongside other emergency services for mental wellness checks.
The jury also recommended the unit be dispatched similar to police and fire calls. A central dispatch centre takes calls and dispatches those services over radios.
The jury also called for the unit to become a 24-hour service.
The recommendations, if implemented, could affect more than just the Miramichi unit as there are similar teams in the Moncton, Fredericton, Saint John and upper river valley regions.
Mary Ann Campbell, a psychology professor at the University of New Brunswick Saint John and director of the Centre for Criminal Justice Studies, helped establish the crisis response unit in Saint John last October as a three year pilot project.
It works from the Saint John police headquarters, which Campbell said helps with collaboration between clinicians and police.
She welcomed some of the jury's recommendations, saying the way the units are dispatched can be improved so that 9-1-1 operators can determine if the team may be required.
Campbell said the recommendation to make the units operate 24 hours a day sounds reasonable, but may not be practical given funding and challenges filling staff positions in health care. The Saint John team operates from 11 a.m. to 11 p.m.
It's always difficult to know how a call might have turned out had the service been there or not. - Mary Ann Campbell
Campbell said there's evidence that when such teams respond with police or in place of police, there are good outcomes. However, Campbell said there are calls that require a police response given safety issues.
"It's always difficult to know how a call might have turned out had the service been there or not," Campbell said.
While the inquest jury requested someone from the unit be called to testify about how it works, no one was. Details of what unfolded were provided by various other witnesses.
The inquest heard a recording of radio traffic between Hait, the first responding officer, and RCMP dispatchers. In the recording, Hait could be heard requesting an ambulance and for the mobile mental health unit to be deployed. He testified it appeared to be a potential mental health issue.
After arriving at the scene around 7:16 p.m., Hait radioed "it's pretty calm." At 7:27 p.m., an officer yells over the radio "shots fired, shots fired."
A juror asked Alberta-based RCMP Staff Sgt. Leonard McCoshen, who testified about the Mounties' use of force training, why the officers seemed to escalate the situation when things initially appeared calm and knowing the mobile crisis unit had been called.
"I wasn't there, and I don't exactly know what was happening," McCoshen told the jury, saying their actions were based on their risk assessment of the situation.
He said he doesn't know what the body language was like or what exactly was being said in the few minutes police were there.
He wouldn't answer a juror's question about whether he would have handled the situation any differently.
The jury determined Levi's manner of death was homicide. Crown prosecutors determined in January the responding officers wouldn't face criminal charges. The jury's determination doesn't affect that decision.