11/14/2012 06:51 EST | Updated 01/14/2013 05:12 EST

Inquest hears of poor communication between police, doctors before fatal arson

BURNABY, B.C. - Health professionals caring for a mentally ill British Columbia man in the months before he burned down his mother's house, killing her, didn't know he had assaulted his mother and then later threatened to murder her, a corner's inquest has heard.

Likewise, the police officers responding to those calls had no way of knowing Blake Salemink was on leave from a psychiatric hospital on strict conditions that he live at his mother's home, rendering any attempts to remove him, even temporarily, ineffective.

The story emerging at a coroner's inquest of Blake Salemink's troubled life and Colette Salemink's sudden death two years ago is one of communication gaps between two services — the police and the mental-health system — that ended with a fatal fire at their home in Coquitlam, east of Vancouver, on April 19, 2010.

Blake, then 23, was charged with arson and manslaughter in his 59-year-old mother's death, but earlier this year, a judge found him not criminally responsible because of his mental illness.

Blake has what's known as schizoaffective disorder, which the inquest heard is essentially a combination of schizophrenia and bipolar disorder. He had previously been cared for at Riverview Hospital, a psychiatric facility in Coquitlam, but was on extended leave at the time, allowing him to live in the community under certain conditions.

His conditions included attending medical appointments, taking his medications and living at his mother's house.

It was at that house in November 2009 that Blake assaulted his mother, the inquest heard. The police didn't contact Blake's team at Riverview, other than a single email from an RCMP officer, who sent it to an unidentified staff member at the hospital.

The email didn't reach Blake's doctors for a full month, and even then, it was inaccurate. The email suggested it was a relatively mild incident that involved pushing and shoving, when, in fact, he left his mother with bruises on her face.

Blake's psychiatrist, Dr. Rohan Ramsundhar, only knew the full extent of the assault when he saw documents from the B.C. Coroners Service after the deadly fire.

"Had I known that he had assaulted his mother at the very beginning, I would have issued a warrant of apprehension and he would have been taken to the hospital pronto," Ramsundhar told the inquest Wednesday.

"You would like to see more information shared between police and mental health?" asked the coroners service lawyer, Rod MacKenzie.

"Absolutely," Ramsundhar replied.

If Blake was recalled to the hospital, Ramsundhar could have changed his treatment, sought to change the man's conditions or even asked that he be committed to a psychiatric facility against his will.

Instead, Blake returned to his mother's house. Things did not improve.

A week before the fire, Colette phoned Sue Bateman, a psychiatric nurse who was Blake's primary therapist. Colette, who also had schizoaffective disorder but was stable when medicated, told the nurse she'd had enough.

"She reports that her health can't endure his behaviour any more and she wants him out," Bateman wrote in her notes at the time.

Bateman told the inquest Blake resisted attempts to find him new housing, because he didn't want to pay rent. She said she told Colette the best option was to seek a restraining order.

"She said she was apprehensive about doing that because she could relate to him, because they have the same illness and she was worried about him being homeless," Bateman told the inquiry.

And two days before the fire, Colette called the police after Blake threatened to hire a hit man to murder her. That incident wasn't shared with Blake's doctors, either, the inquiry heard.

Meanwhile, police dealing with Blake did not have access to the full picture of Blake's mental health.

Information isn't automatically shared between police and mental-health authorities, said Const. Erica Saurette, who works on the RCMP's community response team.

Electronic police databases don't include mental-health information such as patients' release conditions, and doctors aren't automatically notified if police come into contact with patients. Police don't have any power to arrest someone breaking their psychiatric release conditions, said Saurette.

MacKenzie, the coroners service lawyer, suggested this arrangement may be a problem.

"There was a condition that he reside with his mother. Police took him away and they didn't know he was to reside from his mother," MacKenzie wondered aloud as he questioned Saurette.

"Maybe if they had known, they could have advised the mental health people."

The inquest was scheduled to enter its third and final day on Thursday, after which the jury will be asked to make recommendations to prevent other deaths. The jury cannot assign blame.

Note to readers: This is a corrected version. A previous version incorrectly spelled the first name of Dr. Rohan Ramsundhar.