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David Mitchell arrives at a coroner's inquest into the death of his son Angus Mitchell after a lunch break in Burnaby, B.C., on Thursday November 14, 2013. His 26-year-old son was shot and killed by police during a shootout on a rural road in Maple Ridge in 2012 after fatally shooting two people in a sushi restaurant and wounding his former landlord.

DARRYL DYCK/THE CANADIAN PRESS

Changes are needed to the way psychiatric assessments are conducted, reported, and initiated, says a coroner's jury charged with looking into the police killing of a man who fatally shot two people and injured another just weeks after he was cleared by psychiatrists after walking into a medical clinic with a gun.

Angus Mitchell, 26, was shot dead by RCMP in May 2012, three months after he was arrested under the Mental Health Act. He was released after he was deemed not to meet the criteria for involuntary admission to a psychiatric hospital.

Among their seven recommendations Friday, jurors suggested when a person is arrested under the act, the psychiatrist assessing the person should make every effort to contact family or next of kin.

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"Collateral information could be helpful to a more complete assessment, affording psychiatrists any history not willingly supplied by the patient," the jury foreman told the inquest.

Jurors heard that when psychiatrist Dr. Brent Gould completed Mr. Mitchell's assessment in February 2012 at the Royal Jubilee Hospital in Victoria, Mr. Mitchell was adamant family members not be contacted to obtain more information.

Dr. Gould testified that due to privacy issues, he did not contact any family or next of kin and relied primarily on the information Mr. Mitchell provided. Mr. Mitchell was released later that day.

But Mr. Mitchell's father, David Mitchell, testified that had Dr. Gould been aware of his son's troubled past he would likely have come to a different conclusion regarding his son's mental health.

"There are only certain reasons when I can breach the confidentiality of the patient," said Dr. Gould.

The jury also recommended that when a firearm is involved, physicians should be required to report psychiatric assessments performed on people arrested under the Mental Health Act to the chief firearms officer. The firearms license in question would then be suspended pending further investigations.

Mr. Mitchell's February 2012 psychiatric assessment was not reported to firearms officers, and he did not lose his firearms license.

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On May 27, 2012 Mr. Mitchell killed a sushi restaurant owner and an employee. Two days later, he shot and injured his former landlord.

The RCMP's Lower Mainland Emergency Response Team issued a public warning on May 30. A region-wide manhunt for Mr. Mitchell ensued, and a witness tipped off police to his location.

When Mr. Mitchell fired at RCMP officers, police returned fire, killing him.

Other jury recommendations were made to the chief firearms officer, as well as the commanding officer of the RCMP and all municipal police chiefs.

The final jury verdict will be forwarded to the chief coroner of the province, who may bring them to attention of appropriate parties. Copies will be available to the public.

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