When Pharus Bobbie thinks about her father, Ronald, she remembers a caring, kind and energetic man, not a psychiatric patient.

"He loved me more than life itself, more than anybody," she said.

But Pharus Bobbie says an inquest into the 59-year-old's death saw her father only as an illness and it missed an opportunity to make real change at the Selkirk Mental Health Centre.

The inquest report, released last week, looked into the drowning death of Ronald Bobbie when he was an involuntary resident at the psychiatric facility in Selkirk, Man. He had been a patient at the centre for 12 years after he was found not criminally responsible for arson offences when he disappeared from the unit and later drowned in the Red River, just north of the Redwood Bridge in Winnipeg, in 2014.

Provincial court Judge Lindy Choy, who was in charge of reviewing the evidence, said evidence at the inquest gave no indication that any inappropriate decisions were made at the time of Ronald Bobbie's death.

Choy's one recommendation was that nursing staff should be "equipped to enable effective monitoring of patient ingress and egress." While Choy didn't give specifics, she wrote that could include physical changes to the ward, an increase in staffing or both. 

That hasn't brought any healing to his family and won't tackle the issues that lead to his death, Pharus Bobbie said.

"[He was] just an illness, like that's pretty much all I got out of that [inquest] was that he was an illness that was created and it based everything on that," she said.

"I didn't find anything about how he cared about his daughter; he always wanted to be with his daughter. Like nothing like that, nothing that the hospital did anything wrong."

Ronald Bobbie was diagnosed with rapid-cycling bipolar disorder but the inquest report said there was no indication he was a risk to himself or the public.

The report said in early 2014, he was doing better overall and his treatment team were hoping to move towards reintegrating him into the community. The discussions contemplated having him live in Winnipeg or with Pharus Bobbie in Dauphin, Man.

Pharus Bobbie said she was in conversations about how to take the steps to take care of her father, but nothing seemed to be happening. It was frustrating for her, other family members and for her dad.

"I could have done a better job if they would have let me and it hurt because I have to live with the fact that I first thought what could I have done better? What could I have done better to get my dad out of there?" Pharus Bobbie said. "But it's nothing I could have done because [he wasn't] in my custody."

Daughter questions use of day passes

As Ronald Bobbie's condition improved he was granted more privileges and would often go visit his family. Sometimes he would leave to visit his family even if he wasn't granted the day passes.

The inquest also heard that Ronald Bobbie had disagreements over his treatment plan and wasn't going to therapy, instead going to visit his family. That meant his privileges to see his family were revoked.

When he couldn't visit her, Pharus Bobbie said her father's condition would worsen and he would get depressed.

"To take off and to just go see his daughter and to be punished it broke his heart," she said.

"Then it was longer, he had to wait longer to see me."

The inquest looked into whether patients should get passes to leave the facility, but Pharus Bobbie said that wasn't the issue with her father. Her concern was that passes were used as leverage and it was detrimental to his recovery.

During the inquest she voiced those concerns, as well as other surrounding how much medication he was on, whether there were too many patients and communication with his treatment team. But Choy wrote in the report that she couldn't look at those concerns — only the issues of passes.

"The family's frustration with the withholding of privileges for the purposes of controlling behaviour is certainly understandable, but I view this as a necessary aspect of his treatment plan," Choy wrote.  

Family, patients not being heard

Pharus Bobbie said she feels like she wasn't heard and the inquest just prolonged her family's grieving.

"I think a lot of patients aren't being heard and I don't think a lot of families are being heard and I really don't think that there is enough being done for patients at that hospital," she said.

Most of her life her father was institutionalized, and she questions whether that was even the right decision.

"It bothers me that someone who can kill someone with their own hands can be released, but my dad had to watch me pretty much through glass, sometimes in a room, for years," she said.

The inquest is done and Pharus Bobbie said she's disappointed and doesn't expect much to change. But now she wants to make sure that her children learn about their grandfather, who he was as a man and father, not as a psychiatric patient.  

"My kids won't have a grandpa and I won't have my dad to be by my side," she said.

"He was my best friend, too. He always listened, he didn't interrupt. He didn't judge me. I could always open up to him about things."