'We failed him': Health officials testify on first day of Samwel Uko inquest

On Monday, a jury was selected and witness testimonies began for the coroner’s inquest into the death of Samwel Uko.

Uko, a 20-year-old football player from Abbotsford, B.C., was pronounced dead when his body was found in Wascana Lake in May of 2020.

He went to the Regina General Hospital for mental health issues twice on the day he died, according to his family.

In 2020, the Saskatchewan Health Authority publicly apologized in for the role it played in Uko’s death.

The inquest was originally scheduled for 2021, but COVID-19 protocols at that time forced its postponement.

The Ministry of Justice said the purpose of an inquest is to established who died, when and where that person died and the medical cause and manner of death.

“It is important to note that this is not a trial,” Robert Kennedy, who is presiding over the inquest, said in his opening remarks on Monday morning. He said no allegations or accusations against any party will be made throughout the process.

Six jurors were selected by the coroner on Monday morning. They will hear witness evidence throughout the week and may make recommendations at the end to try to prevent similar situations in the future.

Representatives from Uko’s family, the SHA and the Regina Police Service will be permitted to ask questions to witnesses throughout the inquest. The presiding coroner and the jury will also be able to ask questions.

WITNESS TESTIMONY BEGINS

The presiding coroner said approximately 25 witnesses are expected to be called to speak throughout the inquest.

The first witness to testify Monday morning was Daniel Ripplinger, a member of Regina Fire and Protective Services. He responded to the call for a water rescue at Wascana Lake on May 21, 2020, where Uko was seen by witnesses submerging himself into the lake and not coming out.

Ripplinger said he remembers seeing an SHA business card sitting with Uko’s belongings on shore. He said there was a handwritten phone number written on it.

Ripplinger said the fire team entered a boat into the lake and conducted a water recovery search. He said they reorganized their strategy throughout the search. He said a body was recovered after about an hour and 10 minutes. That was at 9:25 p.m.

“I was the individual that found the body,” Ripplinger said. “We snagged something with our equipment and slowly brought it to the surface.”

He said it was the body of Uko.

They brought Uko’s body to shore where he said EMS hooked Uko’s body up to a monitor and confirmed his death.

Ripplinger said he did not see any signs of visible trauma to the body when Uko was recovered from the lake.

Following the testimony from the first witness, Uko’s uncle said the family is very tense as the inquest gets underway.

“Listening to the first witness, who was the person who went and picked [Samwel] up from Wascana Lake, it’s very emotional for us. We’re still trying to process everything,” Justin Nyee, Uko’s uncle, said. “We’re hoping that as more witnesses come in, it will give us more clarity of what happened in his final hours.”

He said the family still has a lot of questions about what happened that day, including how decisions were made in the hospital that led to him being escorted out during his second visit.

CAUSE OF DEATH

On Monday afternoon, forensic pathologist Dr. Andreea Nistor testified. She conducted the autopsy on Uko testified on May 22, 2020.

Before conducting the examination, Nistor said she was informed the body of a young male was recovered from the lake.

“That can mean a lot of things. It doesn’t necessarily mean he drowned in the lake,” she explained.

Externally, she did not see any signs of injury such as bruises, cuts or scratches.

Nistor proceeded with the internal examination. She said there was pink coloured fluid in his airway and his lungs were “voluminous.”

She said the only drug in Uko’s system was over-the-counter allergy medication and it appeared he took a recommended dose.

“The conclusion was that, based on the circumstances that I was told and my autopsy findings with the foam in the airways, that the cause of death was consistent with drowning,” Dr. Nistor said.

She said in her opinion, the level of allergy medication was within a safe range.

“I don’t think that’s significant,” Dr. Nistor said.

‘WE FAILED HIM’

John Ash, an executive director of acute care with the Saskatchewan Health Authority (SHA), also testified in the afternoon.

He oversees the emergency departments at both Regina hospitals.

He said on May 22, 2020, he was made aware of the situation that had happened with Uko at the Regina General Hospital and decided an investigation was needed.

He said through reviewing video footage and hearing reports from staff, they identified Uko was not treated properly.

“We did not provide Samwel the care he deserved. We failed him,” Ash said.

Ash said the SHA has made changes for admitting patients as a result of Uko’s death.

He said Uko was ultimately turned away during his second visit on the day he died because the registration clerk could not confirm his identity. At that time, there was a policy in place that said clerks could admit people as “unidentifiable” but it was not followed in Uko’s case. Ash said that has been addressed and reaffirmed for staff.

He said there have been guidelines outlined for handing over patients brought to the emergency department voluntarily by police, as opposed to those who are under a mental health warrant. Uko was brought in voluntarily.

Another change is that patients experiencing a mental health crisis now cannot be discharged without being assessed by a physician.

“Any decision to remove anybody from the emergency department can only be made by a physician,” Ash said.

Ash said there wasn’t one thing that led to Uko being escorted away from the hospital, but rather several things and a lot of it came down to miscommunication.

During questioning from the SHA’s lawyer, Ash confirmed that Uko had received assessments from nurses and doctors during his first visit to the RGH on the day he died.

The inquest is scheduled to run from Monday until Friday, June 3 at the Ramada Plaza at 1818 Victoria Avenue.