The sister of a police shooting victim was disappointed that an inquest did not result in more specific recommendations to prevent a similar tragedy from happening in the future.

A jury in a coroner’s inquest into the 2019 police shooting death of Kyaw Naing Din, an immigrant from Myanmar, made only three recommendations on Tuesday, Mar. 8, at the inquest’s conclusion.

Kyaw Naing Din, died in the family home he shared with his siblings on Colemore Street, after a police officer fired three shots during a mental health call.

The 54-year-old had been diagnosed with schizophrenia, and had been frequently taken to hospital by police before the fatal event on Aug. 11, 2019.

The five person jury presented Donita Kuzma, the presiding coroner, a unanimous verdict.

Recommendations included that the Provincial Health Services Authority have case management representatives in regular contact with clients who have mental health issues – including their family and/or support circle – to establish and build a relationship with the client and provide a continuity of care.

That the Minister of Health and Addictions, the Minister of Public Safety and Solicitor General, and the Provincial Health Services Authority, provide more funding for resources to develop, implement, and maintain supports for first responders attending mental health incidents.

Finally, that the Minister of Education develop a teaching module for mental health and addiction awareness with the assistance of the Ministry of Mental Health and Addictions to destigmatize mental illness.

The week-long inquest started Monday, Feb. 28 and heard from: Kyaw’s sister, Yin Yin Din; the four police officers who responded to the call, including Const. Matthew Wagner who pulled the trigger; chief civilian director of the Independent Investigations Office of B.C., Ronald MacDonald; Supt. Wendy Mehat, with the Ridge Meadows RCMP detachment; and others.

Din, speaking for family members, said they all felt that the recommendations by the jury were shallow and weak.

She was hoping that the jury would recommend that in the future when somebody is suffering from mental health crisis, police should incorporate the family members who could deescalate the situation. She testified during the inquest that it was her belief that if the police officers had waited five more minutes for her siblings to arrive on scene, the whole incident would not havehappened.

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Din was also disappointed that the jury did not make any recommendations on the systemic racism that, she believes, exists in mental health care, after she testified that the Din family made a request to have Kyaw take his daily medication at the pharmacy, but was denied the request by his psychiatrist, who said it would be too expensive for them.

She would also have liked the jury to be a bit more specific in their recommendations.

Din family lawyer, Neil Chantler, said even though they would have been keen to see some targeted recommendations on police use of force with mental health calls, or on the issue of first responders dealing with language barriers, Kuzma had stressed to the jury to keep the recommendation list short, saying sometimes short lists are more effective as inducing change than long ones.

Chantler was ultimately happy with the themes that the jury touched on, like the need for better response to mental health calls.

“I think we all recognize, including the police officers, including members of the health care community who testified, in an ideal world, someone trained in mental health, a psychiatric nurse, for example, would attend every call like this,” he said.

He was also happy the jury called for better mental health care in the community, after hearing evidence during the inquest that Kyaw did not have adequate support which led to him not taking his medications.

Although Kyaw had family to support him, there are still times when family can’t fill the role played by health workers, Chantler explained.

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“We need to find a place in between what we have now and the institutionalized care we had in decades past. And, we’re not there yet,” said Chantler.

He would like people to live at home and in the community, but still be regularly checked on by a psychiatric nurse who is a part of their health-care team to make sure they are well, having their needs met, and that they are taking their medication.

Chantler was very pleased that the jury recognized the problem with stigma surrounding mental health, saying that the inquest heard evidence that stigma affects decisions by everyone in the system from health care providers, dispatchers at 911, police officers responding to mental health calls. Mental health, said Chantler, is not treated the same as physical health and it is treated as a “lesser-than type of illness” that is handled with fear, apprehension and with some degree of mystery.

“We need to get past that,” he said, adding that education is the key.

Din said it feels like her family will never have justice for their brother.

The best thing to come out of the inquest, she said, was that the public can now see what happened.

Din was pleased about the recommendation for more funding for mental health care, hoping others will receive the benefits of the daily pharmacy dispensing program.

However, she is pessimistic the recommendations will make a difference, saying she has often heard that inquests might recommend more funding, more training.

“But they never get implemented.”