The six-person jury that heard a week's worth of evidence into the police shooting death of Steven Rigby has called for 10 changes, including greater availability of less-lethal weapons for police and more training spots for future psychiatrists in Saskatchewan.
Rigby, 27, died in a police shooting on the outskirts of Saskatoon on Dec. 22, 2018, after a struggle with mental illness and severe alcoholism that was laid bare in painful detail at a coroner's inquest into his death this week.
The inquest heard he had spoken of provoking police to shoot him — what's commonly referred to as "suicide by cop" — before his encounter with police. Three Saskatoon police officers who testified during the inquest said Rigby pointed his weapon at police before he was shot.
"I did not want to shoot Steven," said former officer Nathan Lynchuk. "This was a guy who needed help, not a guy who needed to see the end of his life happen that way. He deserved more than that."
Rigby was committed to a mental health facility in Saskatoon but then quickly discharged two days before the shooting. His family said he never got the help he needed.
The inquest, which began Monday, was not a criminal process. Its six jurors — four men and two women — were asked to come up with practical recommendations to prevent deaths like Rigby's in the future.
They also deemed Rigby's death a suicide. Their other choices were ruling it a homicide, accident, the result of natural causes or "undetermined."
While the recommendations delivered Friday are not binding, Carey Rigby-Wilcox, Rigby's mother, said she's confident they will all be implemented.
"I would love for someone to say, 'we started a program in honour of Steven.' You know, a bed or room or something. Because Steven was tired and he didn't want anybody to go through the struggles and the obstacles that he had to go through to get help," she said.
"I just hope people look back and reflect on the mistakes, the gaps, the cracks in each system and try to make it better and do that as quick as possible."
The inquest jury called for an audit of the Saskatoon Police Service's crisis negotiation team, which was involved on the night of Rigby's death.
They also tasked senior officials at the police service to investigate remote surveillance technology to help improve communication between critical incident sites and police headquarters in downtown Saskatoon.
The negotiators in the Steven Rigby incident never made it to the site on the southwest boundary of Saskatoon where Rigby was shot. Instead, they spoke to him over the phone on his car's Bluetooth speaker.
In another communication-themed recommendation, the jury called on the RCMP and the Saskatoon Police Service to increase the amount of training and resources devoted to the communications system that patches police radios from both agencies.
The inquest heard about gaps in knowledge between the two police services. At one point, as Rigby was dealing with both police services, he was given conflicting commands, witnesses said.
Regular testing of the patch has already increased since the Rigby incident, a lawyer for the RCMP said.
The psychiatrist who discharged Rigby said some of his prior health information — including a suicide attempt that landed him in a separate Saskatchewan hospital five months earlier — was not available to her at the time she assessed him in December 2018. She said that would have been helpful to her work.
The jury called on the Saskatchewan Health Authority to beef up resources to centralize health records so that doctors can more easily obtain information about patients.
The Saskatchewan Health Authority and the University of Saskatchewan were asked to increase the number of annual training spots for aspiring psychiatrists in the province. One witness, a psychiatrist, said there are currently only five to eight spots available per year.
"Do you know how many lawyers are pumped out a year?" said an incredulous-sounding coroner's counsel, Robin Ritter. "Way too many."
Mental wellness also figured in the recommendations. The jury called for more on-staff psychologists at the RCMP and Saskatoon Police Service and mandatory check-ins with a psychologist for officers at both police agencies as soon as possible after a critical incident.
Rigby-Wilcox attended each day of the inquest, constantly scribbling notes in a journal.
After all witnesses had been questioned, Scott Spencer, the lawyer for the Saskatchewan Health Authority, turned to the Rigby family and expressed his condolences over Rigby's death.
Here are the recommendations in full:
1. To the Saskatoon Police Service and RCMP: Increase training and resources into centralized communications systems between Saskatoon Police Services and RCMP.
2. To the Saskatoon Police Service and RCMP: Task seniors administrators and officers to audit and administer mental health training for officers and staff. For example, roles and responsibilities under the Mental Health Services Act.
3. To the Saskatoon Police Service and RCMP: Consider a mandatory and expedited (within one to two weeks) discussion/check-in of involved officers with a psychologist after a critical incident. Psychologists should also be included in critical incident debriefs.
4. To the Saskatoon Police Service and RCMP: Increase the number of psychologists on staff to assist with critical incidents.
5. To the Saskatoon Police Service: Increase training and availability of less-lethal weaponry.
6. To the Saskatoon Police Service: Task senior administrators and officers with investigating technological remote surveillance for improving site communication with Saskatoon police headquarters.
7. To the Saskatoon Police Service: Task senior administrators and the crisis negotiation team with auditing their procedures, roles and responsibilities as well as recording equipment for alternative means of recording voice calls in which standard equipment is not available.
8. To the Saskatchewan Health Authority and University of Saskatchewan: Increase annual training spots for psychiatrists.
9. To the Saskatchewan Health Authority: Increase allocated resources into centralizing health records with e-health for ease of access by physicians, psychologists and psychiatrists.
10. To the Saskatchewan Health Authority: Assess the viability of a program between social workers and the SHA in relation to educating and assisting individuals suffering from concurrent disorders on a needed basis.
If you're experiencing suicidal thoughts or having a mental health crisis, help is available.
For an emergency or crisis situation, call 911.
You can also contact the Saskatchewan suicide prevention line toll-free, 24/7 by calling 1-833-456-4566, texting 45645, or chatting online.
You can contact the Regina mobile crisis services suicide line at 306-525-5333 or Saskatoon mobile crisis line at 306-933-6200.
You can also text CONNECT to 686868 and get immediate support from a crisis responder through the Crisis Text Line, powered by Kids Help Phone.
Kids Help Phone can also be reached at 1-800-668-6868, or you can access live chat counselling at www.kidshelpphone.ca.