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An inquest into the suicide of a Vancouver police constable four years ago has returned 12 recommendations aimed at better hospital communication on mental health files as well as improved police training and psychological assessment.
The recommendations include mandatory annual psychological check-ins for officers and explicit action to curb rumours within the Vancouver Police Department.
Const. Nicole Chan took her own life on Jan. 27, 2019, amid an investigation into complaints she had made about inappropriate relationships with two senior officers.
Over the seven-day inquest, jurors heard from 30 witnesses and lawyers who raised questions about Vancouver Police Department and Vancouver General Hospital policies.
The inquest heard that Chan was found hanged from her bedroom door the day after she had been taken to hospital – but was not admitted – amid a mental health crisis.
The night before her death she had been frantic about the investigation into her complaints, had threatened to take her own life, and had fabricated a noose from a dog leash and hidden knives inside her home, the inquest heard.
Several witnesses testified that she had felt blackmailed into sex by Sgt. Dave Van Patten, a human resources officer and her superior, and was upset that she had been placed on stress leave and felt ostracized in the department while he was allowed to keep his job.
Read more: VPD officer who died by suicide worried ‘rumour mill’ would destroy her career, inquest hears
Van Patten had allegedly recorded intimate images of Chan that were on another officer’s phone and threatened to send them each of their spouses if she did not agree to a sexual relationship with him, the inquest heard.
The inquest heard that Chan’s boyfriend at the time of her death, along with police officers and paramedics, had great concerns about Chan being discharged from the hospital, given her history of suicide attempts.
One officer testified Chan, as an experienced officer, would know what to say to get released. The treating Psychiatrist Dr. Kiran Sayyaparaju testified he did not have all the information and Chan denied trying to take her life. He testified he could not legally hold her against her will.
Chan was ultimately released after about an hour and 20 minutes, was taken home by Vancouver police. She took her own life several hours later.
The coroner’s jury was tasked with determining the facts around her death and making recommendations, but does not have the power to find fault or assign guilt.
Several of the jury’s recommendations were aimed at Vancouver General Hospital and its mental health Access and Assessment Centre.
The jury recommended that procedures be put in place to ensure admitting doctors have direct contact with police, paramedics or family and friends in attendance when someone presents to the facility.
Two officers involved in Chan’s case wanted to speak with the admitting psychologist but were unable to, the jury said.
It also recommended the hospital ensure doctors’ ability to access patients’ historical information from all sources, noting testimony suggesting better access to Chan’s file might have helped her assessment.
It also recommended that the Access and Assessment Centre develop a process to make sure the attending doctor can take phone calls from community health providers, after hearing evidence from witnesses that connecting with attending physicians this way is difficult.
The jury also asks the minister of health to consider integrating a database containing medical records of patients who have suicidal ideations across all health authorities.
The majority of the recommendations were directed at the Vancouver Police Department and Chief Constable Adam Palmer.
The jury called for mandatory psychological clinical interviews as a part of every officers’ recruitment.
It additionally called for annual psychological check-ins to be mandatory for all officers, noting that major crime and forensic units do this but other officers do not.
It also recommended the department ensure that respectful workplace training is “mandatory, rigorous, in-person and on a regular basis” for all officers.
It cited testimony from Sgt. Corey Bech who said there was little interactive training with respect to workplace harassment, and that VPD supervisors don’t get specific training.
Furthermore, it said the department’s respectful workplace policy should explicitly “recognize rumors and gossip as an example of unprofessional behavior.”
It cited Bech’s testimony that rumours and gossip about Chan’s situation were swirling in the department, and included allegations that she was having an affair with Bech.
The jury also recommended that promotions within the department come with formal administration training, and that officers in the human resources department get specific HR training.
It cited testimony from a VPD HR officer who said they were assigned to the section without any formal education in human resources management.
Finally, it called for a human resource or peer support case representative to be in regular contact with all staff who have mental health issues and their family, if they permit it, to build “relationship and provide continuity of care.”
Following the release of the recommendations, Vancouver Police Chief Adam Palmer released a statement offering condolences to her family and friends, and lauding her as someone who devoted her career to helping people in their time of need.
“That she died alone, of suicide, and when she herself was in need, is something that will stay with us always,” Palmer said.
“Her life and career were tragically cut short, however, Nicole’s death has highlighted the importance of our conversations about mental health and accountability in policing. These conversations are never over.”
Palmer went on to say the VPD would take time to review the jury’s recommendations, but remained “committed to ensuring Nicole’s death continues to lead to positive change within policing and for anyone struggling with their mental health.”
Read more: ‘Please help me be a survivor’: VPD officer who died by suicide pleaded for help in letter
Over the course of the inquest, the jury heard that a New Westminster Police Department criminal investigation had recommended sexual assault charges against Van Patten, but that the BC Prosecution Service elected not to proceed with them.
A separate Police Act investigation ultimately found Van Patten and a second officer, Sgt. Greg McCullough, had committed misconduct. Van Patten was dismissed while McCullough was given a 15-day suspension and later retired.
Chan’s family has also filed a civil suit naming several officers, the province and the Vancouver Police Board.
— with files from Global News’ Rumina Daya
If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 9-1-1 for immediate help.
For a directory of support services in your area, visit the Canadian Association for Suicide Prevention at suicideprevention.ca.
Learn more about preventing suicide with these warning signs and tips on how to help.