The mother of a man who died at the Mid-Atlantic Wellness Institute (MWI) yesterday appealed for answers.

In a statement to the inquest into the death of Shandal Richardson, his mother Olivia Carter said: "All I want to know is what happened to my son. Why wasn't he given the care he needed?

"Was he given any medication? Was he sleeping at the time? Was he moved from room to room and why, and who moved him? I need to have those questions answered for peace of mind and closure. I want to know how he died."

The inquest into the father-of-three's death began yesterday at Magistrates' Court with Juan Wolffe presiding.

Mr. Richardson was found dead at MWI in the early hours of March 5, 2008. He had a bedsheet tied in a noose around his neck and the other end tied to a bedpost.

The previous day, March 4, he was admitted to the emergency department of King Edward VII Memorial Hospital after a 911 call by his wife.

Police and an ambulance attended the family home at Scenic Hills, Southampton, after reports he was trying to self-harm with a knife.

Robert Powell, a registered general nurse, said he arrived at the house to find Mr. Richardson looking "very scared".

"His eyes were wide and he looked very frightened," said Mr. Powell. "I did not see any signs of aggression at all. I just saw somebody who was very, very frightened."

In a statement to the inquest, Bermuda Hospitals Board resident psychiatrist Dhammika Herath said: "I was informed that when Mr. Richardson was admitted to emergency he was behaving in an agitated state at his house, that he had attempted to stab himself with a knife."

After examining him he recommended the 35-year-old be treated at MWI, where he had been treated in the past for mental health problems and seizures.

Dr. Herath said Mr. Richardson was "muttering to himself and muttering to unseen persons".

"He also admitted to hearing voices talking about him," he added.

Ms Carter said her son, a security guard, first started having seizures in 2001-2. As time went on he became increasingly withdrawn and expressed fears "his life was being threatened".

In early 2008, she said her son then claimed "cameras were in his house and were watching him".

Chitra Rao, a Canadian forensic pathologist, said a post-mortem on Mr. Richardson found no evidence of foul play.

In a statement read to the inquest, Dr. Rao said the bedsheet left a ligature mark five centimetres long on his neck, four centimetres below his right earlobe.

Dr. Rao said: "There was no evidence of any struggle. The cause of death is death by hanging in an institution."

Susan Grosse, a locum to the Government Analyst, reported traces of cannabis use in the autopsy results on Mr. Richardson's blood, vitreous humour and liver.

The inquest also heard from his GP, Fiona Ross. She said he had appeared distraught in the run-up to his death and had expressed concerns about people trying to harm him.

The inquest is expected to last until Wednesday. Allan Doughty is the lawyer for Bermuda Hospitals Board, with Victoria Pearman acting for the family.