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A young man pleaded for help as he was being led out of a hospital by security before taking his own life in a lake on the Saskatchewan legislature grounds.
The final moments of Samwel Uko's life are detailed in documents provided to his family as part of the Saskatchewan Health Authority's review into his care at Regina General Hospital in May. The family shared the review with The Canadian Press.
"As he was being escorted out of the facility, video footage shows him calling, 'I need help. I need help. I have mental-health issues,'" the review says.
Uko's body was discovered in Wascana Lake a short time later.
The health authority said it has formally apologized to Uko's family and it made a public apology at a news conference Thursday.
"I can't imagine the loss they feel and the suffering they continue to go through," said Scott Livingstone, chief executive the Saskatchewan Health Authority, adding Uko was "improperly denied care."
"For this I am deeply sorry."
Uko's uncle Justin Nyee called what happened to his nephew "insane."
"We are hurting, and we are angry at the same time because this shouldn't have happened," said Nyee, who lives in Calgary.
"After about 45 minutes they decided to kick him out of the hospital. He was not fighting, he was not cursing. All he was doing is telling them 'I need help.'"
Relatives say the 20-year-old man was visiting Saskatchewan from Abbotsford, B.C., and voiced concerns about being sick and people coming after him. He sought help at the Regina General Hospital.
The health authority's review says the young man went to the hospital on the morning of May 21 with "increasing depressive thoughts" and difficulty sleeping, but he denied thinking of self-harm.
It says he was connected with a mental-health clinic intake worker in the early afternoon and referred to an appointment with a psychiatrist within a week. He was told to contact a community outreach and support team or go back to the emergency room if he felt worse.
Hours later, the review says, he was brought back in by police. He had called 911 asking to go to hospital because he had mental-health issues.
The review says Uko was seated in a hallway between the registration and triage desks.
The desk clerk tried to get Uko to confirm he had been in for an earlier visit, but he did not, the review says. There was confusion over the last name he provided.
"The process for registration of an unidentified patient was not utilized."
The health authority says that after police left, a security officer consulted with a triage nurse and a decision was made for four officers to remove Uko. He was not registered or seen by the triage desk.
Video showed him calling for help on the way out.
"The honest truth is we spent too much time trying to obtain his identity and not enough time focusing on his care needs," Livingstone said.
Uko's death is to be the subject of a coroner's inquest to be held at a later date.
As a result of the review, the health authority said it has implemented a number of changes including improving the registration and triage process, better co-ordinating mental health supports in the emergency department and changing the process for removing someone from a facility.
"As an organization we failed Samwel," Livingstone said.
Nyee said he doesn't want his nephew's death to be in vain.
"There is a feeling of going forward and it will be good and better for someone else, to save someone else's life," Nyee said.
"I'm not saying the word satisfied, but we kind of understand in that sense they're trying to do the best they can to help the situation."
Ash said the purpose of the review was to allow staff to speak openly about what mistakes may have occurred as a way of improving the system.
"There have been no discussions about removal of staff. There's nothing that came out of the critical incident report that showed that there were any deliberate actions unrelated to trying to care for Samwel so right now there is nothing," Ash said.
This report by The Canadian Press was first published July 23, 2020
— With files from Bill Graveland in Calgary
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