After four days, 25 witness testimonies, and four hours of deliberation, the jury of the inquest into the death of Samwel Uko gave their recommendations.

The 20-year-old from Abbotsford, B.C., died on May 21, 2020, while in Regina visiting his aunt. Uko had sought help at the Regina General Hospital for mental health issues twice. His second visit ended when he was forcibly removed by hospital staff. An hour later, his body was found in Wascana Lake.

According to a forensic pathologist and the jury, Uko died by drowning. However, how he died was undetermined, meaning the jurors were not able to decide whether it was accidental or suicide.

The jury listed 20 recommendations to prevent similar deaths from happening.

• Consultation with staff, OHS, external mental health organizations and other stakeholders regarding emergency room layout.
• Incorporate patient dignity into daily staff huddles, emails, meetings, etc.
• Provide mental health training to all SHA staff, including non medical staff
• Provide cultural diversity training on topics including institutional racism, unconscious bias and micro aggression
• All emergency department staff being trained in de-escalation tactics
• Incorporate interview questions and processes to incorporate topics like mental health, diversity and biases
• Gather staff input from all staff regarding communication of new policy
• Allow staff paid time to review policy
• Incorporate all possible means to distinguish medical staff from non-medical staff
• Have a psychiatric nurse on staff 24
• Have two triage nurses staffed at triage at all times
• Ensure patient identity is confirmed at every point of contact
• Examine possibility of adding one point of authority between triage, protective services and registration
• Have a police officer in emergency 24/7
• Ensure police officers fill out a patient form regardless of reason of handoff
• Provide a visual aid to explain the emergency room process
• Explore one on one training at registration desk
• Educate public on Stop The Line policy and emergency room process
• Provide mental health pamphlets
• Inform registration clerks they have the ability to pass along any information they deem important

Justin Nyee, Samwel’s uncle, said that he and the family feel relief.

“I am happy for those six jurors who made the recommendations, (they) were all on point,” he said. “There is not a single point that I don’t agree with. Everything they said of those 20 points, I agree with every single one of them.”

Throughout the week, the family wore ‘Justice for Samwel Uko’ t-shirts. Nyee said justice wasn’t achieved through the inquest, but it was a good first step.

“It was something that we were hoping for, and it comes to us as a good step.”

Taban Uko, Samwel’s father, said he is hoping change happens.

“I hope the hospital will take these recommendations seriously so this will not happen again.”