According to the B.C. Coroners Service, all three individuals died shortly after leaving Abbotsford Regional Hospital, which is run by the Fraser Health Authority. The inquest is scheduled for May 16, 2016.

BCSS program and development coordinator Ana Novakoviccalled attention to a number of previous government reviews of similar deaths. She emphasized those were followed by recommendations that failed to prevent the three being examined next year.

“Since 2008, there have been three other coroner’s inquests into deaths involving improper monitoring and discharge of mentally ill patients in hospitals under Fraser Health Authority’s jurisdiction,” Novakovic told the Straight. “A number of improvements were recommended as a result of these inquests, but it seems that they are either inadequate or have not been implemented.”

According to a BCSS analysis, those earlier cases concerned Ross Allan, who died in April 2008, Jasdeep Sandhu, who died in October 2008, and Patricia Reed, who died in February 2011. According to their respective inquest verdicts, all three were admitted to Fraser Health hospitals for mental-health reasons and died while in the care of those facilities or shortly after discharge.

BCSS executive director Deborah Conner said she’s worried the review scheduled for May 2016 will find the three people who are the subjects of that inquest—Brian Geisheimer, Sebastien Abdi, and Sarah Charles—died under similar circumstances.

“My question would be: was there a treatment plan when these people were released?” Conner said.

In a phone interview, Stan Kuperis, director of mental health and substance use for Fraser Health, listed a number of mental-health-care reforms implemented in recent years. These include improved patient-transfer protocols, for example, and revised policies for discharging patients. In addition, Kuperis emphasized that Fraser Health pays close attention to coroners’ investigations.

“We have responded to all those recommendations within previous coroner’s inquests and have put changes into place in response,” he said.

According to Conner, the most troubling aspect of this series of events is that when it comes to mental health, Fraser Health is actually among the best B.C. service providers.

“There are similar problems everywhere,” she said. “It could very easily be happening in all the other regions.”

According to Fraser Health, during the 2013–14 fiscal year, its 12 hospitals throughout the Lower Mainland saw 30,305 emergency mental-health visits.

On August 19, the Straight reported that the number of emergency mental-health visits Vancouver General Hospital and St. Paul’s Hospital see together in one year is projected to surpass 10,000 before the end of 2015. That’s up from 6,520 in 2009.

Those hospitals—operated by Vancouver Coastal Health and Providence Health Care, respectively—have also dealt with high-profile incidents that followed patients leaving a facility after they were admitted for a mental-health issue.

In December 2012, for example, Nicholas Osuteye attacked three women two days after he was discharged from St. Paul’s Hospital. In February 2012, Mohamed Amer stabbed an elderly man the same day he was released from St. Paul’s. And in January 2012, Jerome Bonneric was charged with assault shortly after St. Paul’s let him go. (An external reviewof the Amer case resulted in 22 recommendations for service improvements.)

In a telephone interview, Dr. Bill MacEwan, head of psychiatry at St. Paul’s Hospital, explained how staff work to try to ensure nobody admitted for mental-health reasons leaves on their own or without a support system in place.

“The three key things for any individual that we always try for is a place to live, follow-up care, and support, where support can be a variety of things, from family to a mental-health team,” he said. “To get those three variables covered, that’s the general approach that we take.”

MacEwan stressed that’s not always easy, especially when an individual has no fixed address.

“It’s harder to track somebody and find somebody and follow up with care if you don’t know where they live,” he said. “For those individuals, to have them go into care, that becomes more difficult. Sometimes it’s a shelter.”

Conner said the problem is not insurmountable and primarily persists on account of a lack of political will.

“It’s not like we don’t know what has to happen,” she said. “Programs have been around for a long time. They have proven to be effective, and they have academic rigour. They just needed funding and consistency.”

In 2010 (the last year for which statistics are available), hospitals only fully implemented 26.3 percent of coroners’ recommendations, according to a department annual report.

The B.C. Ministry of Health did not make a representative available for an interview.

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The article was originally published in print and online at Straight.com on August 26, 2015.