After hearing from two dozen witnesses, the jury at an inquest in Regina has delivered 20 recommendations on how the Saskatchewan Health Authority can prevent deaths similar to that of 20-year-old Samwel Uko, who drowned in Wascana Lake in 2020 after being removed from Regina General Hospital.
Following the completion of the inquest, Uko’s uncle, Justin Nyee, spoke on behalf of the family saying that he agreed with the recommendations and was glad that “the truth is coming out, and people are listening to it, and people know that he wasn’t treated nicely at the hospital.”
“This was only because he was Black,” Nyee said in impassioned remarks to reporters, leading to tears as he talked about remembering his nephew.
“He didn’t deserve to die.”
Nyee said he was relieved to see the notes addressing racism included in the list of 20 recommendations.
“Six people … saw what we saw,” he added.
Uko, a football player from Abbotsford, B.C., died on May 21, 2020, while in Regina visiting his aunt.
He sought help at Regina General Hospital for mental health issues twice that day. His second visit ended when he was forcibly removed by hospital staff.
His body was found in Wascana Lake an hour later.
The jury had been tasked with providing suggestions to the health authority following five days of the public inquest at the Ramada Plaza hotel in Regina, as well as determining the manner and cause of his death.
While the family had originally said they believed he died by suicide, the jury said he died by drowning from undetermined circumstances.
Nyee said the family accepted that finding.
The jury’s recommendations, delivered Friday afternoon, included the provincial health authority providing mental health and cultural diversity training to all staff.
The jury also recommended all staff in the emergency department be trained in de-escalation tactics.
Security footage showed Uko had been forcibly removed from the Regina General Hospital while he screamed that he had mental issues.
Other key recommendations included:
- The SHA consulting with staff, architects and organizations about the layout of the emergency room.
- The health authority taking steps to ensure the correct number and type of staff are available, including a police officer and a psychiatric nurse available 24 hours a day, seven days a week.
- The health authority requiring one-on-one training at the registration desk and reassessing intake interviews questions to incorporate diversity and mental health aspects.
Uko’s father said he hopes the provincial government and Saskatchewan Health Authority take the recommendations seriously.
The family said they are continuing to pursue a civil court case against the SHA.
Uko’s family held a press conference Friday morning, hours before the recommendations were delivered, sharing how difficult, frustrating and draining the inquest has been for them.
Nyee said the young man’s death has been devastating for his family.
Speaking to reporters, Nyee directed their attention to Uko’s mother, Joice Guya Issa Bankando, whom he said he has known for 22 years, since she married his brother, Taban Uko.
“The last two years, I have seen a turnaround of 360 degrees. She is not the person I met and I knew for the last  years,” said Nyee, who has been translating the inquest for Uko’s parents over the course of the week.
Bankando has rarely been inside the inquest chambers over the last two days.
“We try to shield her from what’s going on,” said Nyee.
She was taken to hospital after her blood pressure spiked before the family’s Wednesday press conference, he said.
“She’s being eaten alive inside. Like she’s taking a lot. A lot. And the impact on her … it’s hard to see how this has affected her life,” said Nyee.
“She’s [the] kind of a person who’s present with you, but she’s not there. You can see … that she’s here, but she’s not with you. This is the effect [of] losing her son.”
The jury heard from a range of witnesses over the course of the week, including Regina General Hospital workers who were present at the emergency room during Uko’s second visit.
Nyee voiced his frustration with them on Friday.
Some of the security guards who removed Uko, as well as the triage nurse on duty, testified that they didn’t hear what he said when he was screaming as he was being pulled out of the ER.
Uko can clearly be heard in the video recording of the incident, saying, “Leave me alone! I have mental issues!” The witnesses who testified were visible in the video.
“He did everything correct,” Nyee said. “Suddenly everyone … working in the ER is deaf. ‘We did not hear him cry for help,’ the nurse said. ‘I did not hear him cry for help.’
“Everyone has seen the video.… How many times he was saying, ‘I need help?'”
The Saskatchewan Health Authority says communication issues and lack of clarity around Uko’s registration information led to his removal from the emergency room.
Blame lies with staff, family says
Nyee said he wants those who made mistakes in handling Uko that day to be fired.
“The blame goes to all the staff who was working that day,” Nyee said.
“They admitted their mistake. They admitted their error. But what do you do to correct it?”
Changes have been made around removing people from the hospital since Uko’s death. The manager in charge of security at Regina General Hospital testified this week that security now will not remove anyone until they are seen by a doctor first.
The changes don’t go far enough, Nyee said.
“What about accountability? People who refused him help … they are still in the same position. They are still working in the same hospital.”
Nyee believes Uko did not get the help he needed because he was a Black man. If the registration clerk on duty that day was a Black woman, Uko would still be alive today, his uncle said.
“She would look at him like her brother, her son, her nephew, as a human being — because she will see herself in him, she would have to try her best to help him.”
In addition to accountability for those who were involved, Nyee said the family wants to see consistent diversity training for Regina General Hospital staff. They also want its hiring process to reflect the diversity of Canada.
Throughout the inquest, members of the education and advocacy group Black in Sask. have been present to support and help speak for Uko’s family.
During Friday morning’s press conference, Vibya Natana, an anti-racism and youth development advocate for Black in Sask., implored everyone to recognize that Uko’s treatment has an effect on the whole community.
“Racism, anti-Black racism specifically, impacts everyone in our community. If this is able to happen to one person, what’s to say it could not happen to someone again?” Natana said.
“The onus is on all of us to make sure that we are not only fighting for justice in our communities.
“We are again asking that everyone consider … the impact that this is having — yes on the family, but on our society at large.”
If you or someone you know is struggling, here’s where to get help:
This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you’re worried about.
For more stories about the experiences of Black Canadians — from anti-Black racism to success stories within the Black community — check out Being Black in Canada, a CBC project Black Canadians can be proud of. You can read more stories here.