Following a week of testimony, a seven-person inquest jury has classified a Victoria man's death as a suicide.
The jury was asked to look into the death of Rhett Mutch, 20, who was fatally shot in 2014 when he charged at police officers with a knife.
The jury also made a dozen recommendations to improve police responses to people in a mental health crisis, as well as added support for young people transitioning out of care.
Among the recommendations: funding to make a mental crisis response team available round the clock, more frequent de-escalation training for police officers, and the possibility of having police wear cameras on their bodies to record events.
They also recommended that an early intervention and safety plan be created when police receive multiple crisis calls from a single source, and that all police officers be encouraged to participate in care services after a critical incident.
Mother sought help for son
During the inquest, one officer who responded to the police call described the events that led to the young man's death. The officer said those events seemed to take place "in a heartbeat."
But Mutch's mother, Marnie, described the tragedy as one rooted in a lifetime of difficulty getting help for her troubled son.
Mutch died in his mother's living room in November of 2014. He was fatally shot when he charged at police officers with a knife.
The inquest was called to look for ways to prevent similar deaths in the future.
Mutch told the inquest that the final moments of Rhett's life began when she called 911 out of "sheer frustration" that her son was not receiving help for his problems.
Rhett, who was not allowed to be at the home by court order, had broken in. He was in a state of crisis, picked up a kitchen knife, and threatened to harm himself.
"I just did not have any other option," Mutch said.
History of behavior problems
The day Rhett died was far from the first time police had been called to the Mutch home.
The inquest heard Rhett's behavior problems started when he was a boy. He would fly into what his mother described as "rages" — massive temper tantrums that often included physical violence.
Rhett received some counselling when he was about six years old, but Mutch said the outbursts continued.
Around age 11, Rhett was accepted into a more intensive in-patient program in Victoria, but there was a two-month wait list.
Mutch testified that she hit a breaking point and called child protective services looking for respite for herself.
"I did what I needed to do to get help," she told the inquest.
But as a result of that call, Rhett was removed from the home. In the turbulent years that followed he bounced between foster care and his mother's home.
Mutch testified that she felt her treatment by the Ministry of Children and Family Development was punitive and did little to help her or her son.
"I wanted it to work," she said. "I wanted to be like every other family."
By the age of 13, the inquest heard Rhett was expressing suicidal thoughts.
Through all of the turmoil, Mutch testified that her son never received a diagnosis for mental health issues.
Final downward spiral
In his later teen years, Mutch said her son was doing well. Following a stay in a youth shelter, he moved to his own apartment with the help of a rent supplement from the ministry.
But after he aged out of the system, Mutch said he received less support and ran into money troubles. In the months before he died, Rhett tried to live at home, but the rages continued.
In the spring of 2014, Rhett destroyed his mother's laptop during a fit. Mutch said she opted to lay charges because she was assured her son would be required to get counselling as part of his sentence.
That counselling was ordered as part of a 12-month sentence to be served in the community.
But according to testimony from Rhett's probation officer, he had only recently been referred to a counselling program at the time of his death — seven months later.When Mutch had called police for help controlling Rhett's behavior in the past, officers came to the door and spoke with him. The situation always ended peacefully.
The jury for the inquest heard testimony from a range of witnesses over a week.