Assessment forms for a mentally ill man were not filled out by Mid-Atlantic Wellness Institute (MWI) staff before he hanged himself in his hospital room.

The news emerged yesterday during an inquest hearing into the death of father-of-three Shandal Richardson.

Mr. Richardson, 35, was admitted to the mental health treatment facility on March 4 last year after trying to stab himself with a knife at his Southampton home.

He was deemed to be a suicide risk by an Emergency Room doctor at King Edward VII Memorial Hospital (KEMH) before being admitted to MWI where he was placed in the acute care Somers' Annexe.

According to his admission notes, which were read to the inquest yesterday, he was brought in on a stretcher, motionless and predominantly mute, apart from the occasional effort to mutter to relatives. He was noted to be "distressed and confused."

The inquest has previously heard that Mr. Richardson was initially placed in a room at MWI used for "observation and seclusion", which only had a bare mattress and a urinal bucket. However, he was moved to a different room before his death in the early hours of the next day, March 5, when he tied one end of a bedsheet around his neck and the other to a bedpost.

MWI chief operating officer Patrice Dill told the inquest during a previous hearing that Mr. Dill had not been recommended for constant one-on-one observation. However, his family has claimed that he was supposed to be under constant observation for 72 hours after admission and could not have killed himself if this had been done.

Reading out documents relating to Mr. Richardson's admission and treatment, Ms Dill explained that Bermuda Hospitals Board resident psychiatrist Dhammika Herath was of the opinion that the patient required detention and assessment for his own protection and that of others.

Ms Dill was asked by Coroner Juan Wolffe if someone looking at the document could determine that Mr. Richardson should be placed in the seclusion and observation room at the hospital.

"From reading this? No," replied Ms Dill.

She was also quizzed by the Coroner over two documents in Mr. Richardson's file that had not been filled out. The first of these was a "vulnerability assessment" which Ms Dill said is usually done on arrival at the unit in collaboration with the patient, if they are fit to do so.

She agreed with the Coroner that this is "quite an important document" that covers areas such as the patient's history and past admission to MWI.

"Given the problems that Shandal was presenting with, would it have been hospital policy, would it be a form that would have been expected to be filled out as soon as possible?" inquired the Coroner.

"Yes," replied Ms Dill.

"Are there any circumstances by which this form would not be filled out?" he asked.

"Yes," she replied. "If a client is acting out and is combative and mute so that direct engagement with the client is not possible it would be difficult to get information to complete the form. It would all be based on observations."

Ms Dill agreed that the form would assist staff in deciding if a patient should be placed in seclusion and what level of monitoring and investigation they needed. She was also questioned about a document entitled "treatment plan" which, she said, would usually be completed by the nurse in the unit upon admission but was not completed in Mr. Richardson's file.

Again, the Coroner asked if the form would speak to whether Mr. Richardson should be kept in seclusion, and what level of monitoring he should receive. Ms Dill replied that it would document observations pertaining to his treatment plan.

Ms Dill also read a document relating to Mr. Richardson's past psychiatric history, which indicated that he'd undergone treatment in the community for a depressive illness and marital problems and had been seen at MWI two months prior to his death "but did not follow up with medication or doctor's appointments".

Coroner's Officer Lyndon Raynor asked if Mr. Richardson's death sparked the Bermuda Hospitals Board to conduct an internal inquiry.

She replied that it did. However, when Sgt. Raynor asked about the outcome of the inquiry, BHB lawyer Allan Doughty objected to the question, saying it went beyond the jurisdiction of the Coroner's court to get into this issue.

Coroner Mr. Wolffe opted to ask a general question instead as to whether there was a review of policies and procedures by the BHB. Ms Dill said there was.

The purpose of the inquest is to determine where, how and when Mr. Richardson died, although the Coroner can also make recommendations. It is due to continue on October 20.

l This newspaper referred to Shandal Richardson as schizophrenic in an article on September 17, based on a comment made by the Coroner at a hearing the previous day. The deceased's mother Olivia Carter has asked us to point out that her son never received a formal diagnosis of schizophrenia.