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coroner’s inquest

When Erica Salemink was growing up, it was her mother who helped her memorize songs for the school musical or consoled her when she didn't qualify for the provincial diving tournament.

But as she testified at a coroner's inquest Thursday, photos of her smiling mother on display, Ms. Salemink shared not just those warm memories but one of utter tragedy.

Colette Salemink died in April, 2010, at the age of 59 after her mentally ill son, Blake, set their Coquitlam, B.C., home on fire. He was eventually found not criminally responsible by reason of mental disorder.

"It pains me to think of – this is where I'll crack – what she's missing out on," Ms. Salemink told the inquest, her eyes welling up with tears, her voice breaking for the first time. Her four-week-old son was in the room as she testified.

She added, soon after, "I have often thought about what my mom must have been thinking when she woke up to her house on fire. And did she know Blake intentionally set it? It tears my heart apart thinking about the fear she must have felt and the pain she endured. It must have been unbearable for her."

Ms. Salemink, 35, was the final witness at the three-day inquest. Where much of the earlier testimony focused on policy – lack of communication between RCMP and mental-health officials was a recurring theme – Ms. Salemink dedicated her 20-minute statement to the human side, to her mother. At one point, she shared a story about the gold cross her mother used to wear, an item Ms. Salemink has held on to, soot and all.

She said her mother was stressed in the weeks leading up to her death. Blake, who was being treated for a combination of schizophrenia and bipolar disorder, was becoming increasingly difficult to deal with.

The police had been called to the home several times, the inquest has heard. Colette was assaulted about five months before the fire. Two days before the blaze, Blake had threatened to hire a hitman to kill her, she told police.

However, one of the conditions of his extended leave from a mental-health facility was that he reside at his mother's home. Ms. Salemink said her mother was worried about what would happen to Blake if she threw him out. "She was trying to figure out a way to do the right thing for both her and Blake," she said. "I still don't know what is the right thing we were supposed to do at the time."

Ms. Salemink said she last spoke with her mother the night before the early-morning fire. She said her mother planned to get a restraining order against Blake that very day.

When asked what more could have been done to help the family, Ms. Salemink said more resources need to be available to those suffering from mental illness. At one point she referenced a Surrey RCMP program in which an officer is teamed with a psychiatric nurse so they can respond to mental-health calls together. Coquitlam does not have such a program.

Ms. Salemink said it could often prove difficult getting help for her brother after hours or on weekends. All she and her mother could do was wait until Monday or the next appointment.

The fire was set on a Monday morning.

Blake, now 25, resides in a mental-health facility. His psychiatrist at the time of the fire testified Wednesday that he had no idea the situation between Blake and his mother had grown so violent. The psychiatrist, Dr. Rohan Samsundhar, called for better communication between RCMP and mental-health officials.

The jury came back with 16 recommendations Thursday evening. For one thing, it said Coquitlam RCMP and mental-health officials should create a co-ordinated approach. For another, it said if a person is on extended leave from a mental-health facility, information about any dealings with police should be sent to that person's psychiatrist.

The jury said the Coquitlam area should implement a program in which a police officer and nurse respond together to mental-health calls, and urged the province to start a similar program for the entire Lower Mainland on a trial basis.

The jury also said if a caregiver no longer wishes to care for a patient, that person's wishes should be adhered to within 24 to 36 hours.

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