The Bermuda Hospitals Board is yet to offer condolences to the family of a mentally ill man who hanged himself while a patient at MWI, his lawyer said.

Victoria Pearman told an inquest on Friday that Shandal Richardson's relatives believed he was under constant supervision at the Mid Atlantic Wellness Institute (MWI) in March 2008.

She delivered closing arguments into the hearing, which began in August.

"At the end of the day the constitution of Bermuda is about preservation of life," she told coroner Juan Wolffe. "We have lost a life. We have lost a man a family man with a wife and children."

"Right up to today no one down there has said anything to offer their condolences. Whether it's your fault or not, say you're sorry for their loss."

According to Ms Pearman "something went horribly wrong" after Mr. Richardson was referred to MWI on March 4, 2008 after trying to stab himself in his Warwick home. He was found hanging 16 hours later.

Ms Pearman said Mr. Richardson had been seen by a doctor in that period. He was determined to be suffering from a mental disorder and in need of observation in case his condition got worse.

Only hours later he was taken out of the constant observation room and placed in a routine one.

"Witnesses said it seemed he had calmed down, he didn't appear volatile. But I know this court cannot believe people in danger of committing suicide are always volatile and actively looking to find something to use to kill themselves," said Ms Pearman.

"Maybe in hindsight he should have been kept in the observation room, where family believed he would stay."

She urged Mr. Wolffe to look into why nursing staff failed to use available tools a vulnerability assessment and video surveillance which could have helped with their evaluation of the client.

Nurse Michael Looby said he only looked at the camera two or three times throughout his day shift, Ms Pearman said. That night, nurse Marlene Taylor said she only looked at the camera every five to 20 minutes.

"When you look at the camera, you have to take heed to what you see," she said. "If you have someone you know comes in as an attempted suicide and then see someone on the camera with their bed mattress lying upwards on the floor, how can you say that it didn't trouble you?" she asked.

Ms Pearman also questioned why it allegedly took night staff 15 minutes to respond.

She urged the coroner to use his examination to give the family closure and to prevent someone else from dying.

Bermuda Hospitals Board lawyer Allan Doughty said: "It is not the function of the coroner to determine and question (if there was) criminal or civil liability.

"At no time was it said Mr. Richardson wasn't under care of doctors and nurses."

He said it would be a "high bar to hit" for someone to prove that Mr. Richardson's death was caused by neglect of any sort.

Mr. Wolffe will deliver his ruling on January 7.