The jury made robust recommendations, calling on changes to Island Health's Psychiatric Emergency Service (PES) to prevent similar deaths.
After a nearly two-day deliberation, the jury presiding over the coroner’s inquest into the 2019 death of a psychiatric patient in a Victoria hospital has come to the verdict that Paul Spencer’s death was accidental, but made fulsome recommendations for system change, mostly towards Island Health., after he tried to leave.Nearly five years to the date, Spencer was brought to the hospital by a Saanich Police officer after his mother called police when he left home while suffering from delusions.
There was video of this altercation provided as evidence to the inquest. CHEK News applied for it to be made public, but the presiding coroner denied that request after Island Health lawyers fought to keep it from being published. Following the altercation, Spencer was placed face-down on a bed in a seclusion room, un-monitored for several minutes. When staff came back, Spencer was dead.
On Friday, the jury made nine recommendations in relation to Spencer’s death. Seven were directed towards Island Health. Finally, the jury recommended to Island Health that patients not be placed in the prone position and left unattended after being restrained.
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