Family members broke down in tears and questioned why a suicidal man was moved from a safe room at the Mid-Atlantic Wellness Institute (MWI) 24 hours into a planned 72-hour observation period.

An inquest into his death heard father-of-three Shandal Richardson was admitted to the mental health facility March 4, after a King Edward VII Memorial Hospital doctor deemed him to be suicidal.

Family members saw him placed in a room with only a bare mattress and urinal bucket before they left that evening.

Mr. Richardson was found dead at MWI in the early hours of March 5, 2008. He had a bedsheet tied in a noose around his neck and the other end tied to a bedpost and was in a separate room from the one he was admitted to.

Yesterday his wife, Denise Richardson, alleged the mental health facility failed in its duties to her husband.

"He was in the hands of MWI for his safety," she said. "It is the only facility on the Island where he can go for that care. I feel they did not do their job.

"He was supposed to be there for 72 hours and he passed away within 24 hours. Why?

"A nurse's aide involved in the situation said when a new nurse came on shift there was no mention of his condition and they treated him as a normal patient," she alleged. "Why?"

Mrs. Richardson continued "A new video monitoring system was turned off on March 3 and no one knew it was off until March 6. Why?

"Someone should have been monitoring my husband

"A nurse heard a disturbance and went to the window [of his second room]. The bed was upright. Why did she return to her desk and call another person?"

Bermuda Hospitals Board attorney Allan Doughty asked for the statement of the nurse Mrs. Richardson had referred to be read into record.

In it, the nurse indicated that she called another nurse when she heard the noise because it was against policy for an individual nurse to enter a room with two patients so she needed another person with her.

Through tears, Mr. Richardson's cousin, Shakera Richardson also questioned the care he received. She told the court she had called MWI on March 6 and spoke with a nurse called Mike, whose surname she could not recall. She alleged the nurse told her Mr. Richardson would not have been able to commit suicide if properly supervised but was moved to another room because a nurse on duty did not know he was suicidal.

>She added that she had spoken with Mr. Richardson on the evening of March 4 while he was at MWI. She said she urged him to be strong and look to the future and visiting her while she studied in England. He repeatedly told her it was "too late". When she asked him if he was thinking of taking his life he replied "It's not that, the family want me gone."

She did not report her conversation to any staff at MWI.

Mrs. Richardson told Magistrate Juan Wolffe the ordeal began early March 4 when her husband sprang out of bed and ran to the kitchen. When she heard things clattering she ran after him and found him with a large kitchen knife pressed against his chest. She tussled with him until she got control of the knife, but said she never feared for her own safety as she knew he would never hurt her.

She then called the Police as well as his mother, Olivia Carter.

Mrs. Richardson told the court her husband had been hearing voices in the weeks leading up to his death and had previously been treated at MWI as an outpatient for mental issues and seizures.

She acknowledged that at the time of his death he was no longer taking medicine proscribed to him by MWI doctors.

When Police arrived at Mr. Richardson's house at Scenic Hills, Southampton on March 4 he was taken to KEMH. He was then seen by Emergency Room doctor Peter Kabatz who said it was his determination "there was a risk of suicide" and Mr. Richardson should be taken to MWI. He told the court he spoke with Bermuda Hospitals Board resident psychiatrist Dhammika Herath and told him the information he had on the patient.

Mrs. Richardson said she spoke to her husband for the last time on March 4, 2008 when she called him at MWI at approximately 8 p.m. They spoke about the children and she said she would speak to him soon. She told the court he replied "I don't think so." She did not report her conversation to any staff at MWI.

She received a call in the early hours of the morning from MWI informing her that her husband had been found hanging at the facility. He was pronounced dead at KEMH at 3.09 a.m. on March 5. The cause of death was recorded as suicide.

The family is being represented by Victoria Pearman and the inquest will resume on Friday.