Coroner Juan Wolffe ruled the death of mentally ill Shandal Richardson as suicide but made several recommendations regarding practises at the Mid Atlantic Wellness Institute where the father of three died.

Mr. Richardson was admitted to MWI on March 4, 2008 after trying to stab himself with a knife at his Southampton home.

He was deemed to be a suicide risk by an Emergency Room doctor at King Edward VII Memorial Hospital before being admitted to MWI where he was placed in the acute care Somers' Annexe.

Initially Mr. Richardson was placed in a room at MWI used for "observation and seclusion", which only had a bare mattress and a urinal bucket. However, he was moved to a different room before his death, meanwhile another patient who attacked nurses was put in the seclusion room.

In the early hours of March 5, 2008 he hanged himself using bed sheets he attached to his upturned bed.

His family claimed he would not have been able to kill himself had he been properly monitored.

Mr. Richardson was taken from the seclusion room within hours of being admitted to make way for another patient deemed to be more of a security risk.

He was then placed in another room under "routine monitoring" rather than constant one-on-one observation.

During the course of the inquest the Magistrates' Court heard that video monitoring equipment in the room where Mr. Richardson was moved to was not working at the time.

The court also heard that when a nurse was alerted to Mr. Richardson's plight she had to call for back up as MWI policies do not allow staff members to enter a room alone, instead they must enter in pairs. Though the nurse did say if she had seen the patient trying to hang himself she would of gone in alone. At the time the view into his room was obstructed.

The inquest also heard that a "vulnerability assessment" which is usually done on arrival at the unit in collaboration with the patient had not been done.

Mr. Wolffe will deliver a full report of his recommendations to the Minster of Health and MWI head within two weeks but yesterday outlined some of the report.

He recommended that MWI should have more than one seclusion room; there should always be more than one staff member at the Somers Annex; video equipment in patients' rooms should always be turned on; and contemporaneous notes on patient care should be completed before the end of a shift.

Mr. Wolffe also apologised for several adjournments, which caused the inquest to span three months, adding that it had made it more difficult for the family.

Family members declined to go into detail after the Coroner gave his brief statement but Mr. Richardson's wife, Denise Richardson, said: "We are happy with what we have heard today. We want to wait until we have read the full report before we comment. But we are happy with some of his recommendations."