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Howard Hyde, who died 30 hours after being stunned with a Taser in a Halifax jail, is seen here in an undated family photo. ((Canadian Press))

An inquiry into the jail-cell death of Howard Hyde, a mentally ill Nova Scotia man, has found it was accidental and not caused by excited delirium or being jolted with a Taser.

Anne Derrick, the provincial court judge who led the 11-month inquiry, released a final report Wednesday that says Hyde's accidental death in Halifax in November 2007 was caused by a struggle with jail guards.

Derrick's 462-page report says the restraint techniques used by the guards may have interfered with Hyde's ability to breathe.

"The only useful approach is to understand that Mr. Hyde died because of physiological changes in his body brought on by an intense struggle involving restraint," Derrick wrote. "He did not die because he was mentally ill."

Hyde's story attracted national attention because Halifax police had jolted him with a Taser stun gun up to five times about 30 hours before he died.

A medical examiner concluded the cause of death was excited delirium, a condition characterized by increased strength, paranoia and suddenly violent behaviour marked by profuse sweating and an elevated heart rate.

Jolts made things worse

Derrick's report says the repeated jolts from the stun gun did not cause Hyde's death.

But she recommends against using conductive energy weapons such Tasers on emotionally agitated people, except as a last resort.

"I have found on the evidence that use of the CEW on Mr. Hyde worsened the situation," Derrick wrote.

The report contains 80 recommendations, calling for bureaucratic changes in the provincial health and justice departments, more funding for all levels of mental health care and more training for police.

"I believe that the report is a blueprint and a guide to assist us as to how we should treat the mentally ill in the criminal justice system and the health system in our province," said inquiry lawyer Dan MacRury.

The probe into the death of the 45-year-old Dartmouth man was the longest fatality inquiry in Nova Scotia's history.

During the hearings, which wrapped up in June, Derrick learned Hyde had long taken medication to cope with schizophrenia.

On the night of Nov. 21, 2007, however, Hyde's common-law wife, Karen Ellet, called a crisis hotline to complain he had assaulted her while in a psychotic state.

Police were dispatched and Hyde was arrested, but not before Ellet told them her husband had not been taking his medication and required psychiatric help.

Despite her plea, Hyde was never given the help he needed. The inquiry heard from multiple witnesses who testified that a psychiatric assessment would have helped the man. A series of snafus, misunderstandings and overlapping jurisdictions got in the way.

"Without the significant amount of funding that's required to do what we need to do in terms of providing assistance to people who live with mental illness, nothing's going to change," said Stephen Ayer, Schizophrenia Society of Nova Scotia executive director.

Scuffle at police station

Police officers testified they had to bring Hyde before a judge, because he was facing allegations of domestic abuse, but the booking process quickly spiralled out of control inside the Halifax police station.

A surveillance camera captured the moment when an officer told Hyde a utility knife would be used to remove a knot from the drawstring in Hyde's shorts, saying, "I just have to cut off one of those balls there."

At that point, Hyde sprinted toward the booking counter, where he was tackled and stunned with a Taser.

Officers involved in the scuffle testified Hyde displayed incredible strength as he fought them off, eventually vaulting over the counter and running toward a hallway, where he was again shocked with a stun gun as police struggled to control him.

Police testified that Hyde went limp and his heart stopped after he was stunned with a Taser. Paramedics revived him and took him to hospital, where he received anti-psychotic medication and a recommendation for a psychiatric assessment.

There was more confusion at the hospital, however, over who would handle the assessment, since police were saying Hyde had to be brought before a judge.

Hyde was released from hospital in the morning with a doctor's note scrawled on a health information transfer form, saying he should be returned to the emergency department if the court failed to provide him with an assessment.

Again, there was confusion as to how those instructions would be carried out.

Police testified they didn't have the jurisdiction to detain Hyde, and the sheriff's deputies at the court said they weren't allowed to disclose health documents to the Crown or defence lawyers.

Put in jail without medication

In the end, Hyde was transferred from the court to the Central Nova Scotia Correctional Facility — without medications and without an assessment.

The inquiry heard that early on Nov. 22, Hyde tried to escape from a correctional worker, because he believed there were "demons" at the end of a long, windowless hallway. Two struggles ensued. Hyde died in a holding cell amid a tangle of guards.

A medical examiner concluded the cause of death was excited delirium with three contributing factors: the restraint technique used by guards and Hyde's obesity and heart disease.

Kevin MacDonald, a lawyer representing Hyde's sister, Joanna, told Derrick the cause of death was likely a guard's restraint method, which he said left Hyde on his stomach, struggling to breathe.

MacDonald has called for a ban on the use of stun guns and an overhaul of police restraint techniques.