The sister of a mentally ill woman killed by police says that new recommendations made in a coroner’s inquest might have saved her life.

Sylvia Klibingaitis, 52, Michael Eligon, 29, and Reyal Jardine-Douglas, 25, all had mental health disorders and were holding knives or scissors when they were shot by police. An inquest into their deaths spanned three months and heard from dozens of witnesses.

The jury returned Wednesday with 74 recommendations, including that officers should consider mental state, not just behaviour, when a person is advancing with a sharp weapon. Currently, officers are trained to react to behaviour when they face an “imminent threat,” regardless of whether the person is in crisis.

“It is beyond my wildest dreams that I ever thought I would be in a situation where one of my family members was in crisis and would be killed, especially Sylvia,” said an emotional Anita Wasowicz, her sister. “She was a very kind, loving person.”

The jury returned a verdict of homicide in all three cases, which in an inquest means another person’s actions caused the death but does not carry any criminal implications. The Special Investigations Unit cleared the officers of wrongdoing.

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Many of the recommendations suggested changes to police training, such as emphasizing verbal de-escalation techniques. If an emotionally disturbed person is not responding to a police challenge such as “Drop your weapon!” officers should stop yelling and try another strategy, the jury advised.

“When officers are dealing with a situation in which a person in crisis has an edged or other weapon, the officers should, when feasible … try to communicate with the person by verbally offering help and understanding,” the jury wrote.

One officer should take the lead in de-escalation, and police should wait as long as possible to fire their guns. Training should emphasize that there is no fixed distance at which shooting is necessary, the jury recommended.

Wasowicz said outside coroner’s court that she was pleased with the recommendations but they did not go far enough. There is still a “chasm” between the police response to emotionally disturbed people carrying weapons and those without weapons, she said.

But she said some of the recommendations might have saved her sister, who died on Oct. 7, 2011, after calling 911 and telling the dispatcher she had a knife and was going to kill her mother.

“If de-escalation and more distance and time was provided to Sylvia as opposed to the immediate screaming … that could have perhaps saved her life,” she said.

Wasowicz and her sisters represented themselves in the inquest because the cost of a lawyer would have surpassed $30,000, she said. She smiled as she spoke warmly about her sister “Sylvie,” who wrote poetry, loved going out for dinner and sang in her church choir.

The jury also recommended that Mobile Crisis Intervention Teams, which consist of a psychiatric nurse and a specially trained officer, be expanded to all divisions of the city and be available beyond their current 11 a.m. to 9 p.m. hours.

Some recommendations were also made for Taser use, because the police chief had recommended that the conducted-energy weapons be made more readily available in situations where emotionally disturbed people have knives.

The jury called for a study to be commissioned to determine whether Tasers are more dangerous for the mentally ill. It also advised that road sergeants, who carry Tasers, should be dispatched to the scene as soon as possible when an emotionally disturbed person has a knife.

Outside the courtroom, Toronto Police Association president Mike McCormack said police already try to de-escalate situations and wait as long as possible before firing their guns.

While McCormack promised the police would consider all the recommendations, he said the “police challenge” — a statement such as “Drop the knife!” — was a tried-and-true method. He also acknowledged cost would be a factor in adopting many of the recommendations, including making MCITs available 24 hours a day.

“We don’t operate in a vacuum. We have to look at the realities. We have to look at who’s going to be paying for this training and make sure … it doesn’t impact police officers on the street,” he said.

But he said the police supported a recommendation to evaluate adopting new equipment, such as armour that protects against sharp weapons and cameras worn on the body.

Peter Rosenthal, lawyer for Eligon’s family, agreed with Wasowicz that the recommendations might have saved the lives of the three victims in the inquest.

“I think this is an excellent verdict by a jury that really studied the matter. If their recommendations had been in place, I believe Michael Eligon would be alive today — and so would other people,” he said.

Eligon escaped from Toronto East General Hospital, where he had been admitted for a psychiatric stay, on Feb. 3, 2012. Surrounded by officers on a quiet neighbourhood street, he was wearing only a hospital gown and carrying two pairs of scissors when he was shot.

The jury also recommended that actions be taken to prevent elopement from emergency rooms, such as locked rooms or constant observation by nurses.

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Jardine-Douglas died on Aug. 29, 2010, after his sister called 911 to admit him for a mental health assessment. He pulled a knife on an officer who boarded a bus he was riding.

Outside court, Jennifer Chambers, coordinator of a mental health advocacy group called the Empowerment Council, called the jury “brave” and “thoughtful.” She praised a recommendation for further study of how well police officers’ training is working in the field.

“I think that’s very important because the training that they do at the Toronto Police College is actually very good. So our concern is what happens when it gets to the street,” she said.

Chambers also supported a recommendation to stop automatically handcuffing people when they are apprehended under the Mental Health Act. But the goal should to be to avoid that contact in the first place, she said.

“I think that dealing with people’s crises before they come into contact with police is the real solution," she said.

Ten key recommendations

Here are 10 key recommendations out of 74 the inquest jury put forward.

1. Officers should take into account whether a person is in crisis and not just his/her behaviour when encountering a person with a weapon, when feasible and consistent with public and officer safety.

2. If an emotionally disturbed person has failed to respond to a standard police command (such as “Stop, police!” or “Drop the weapon!”), officers should be trained to stop shouting those commands and try different defusing strategies.

3. Train officers to co-ordinate among themselves so that one officer takes the lead in situations involving emotionally disturbed people.

4. Officers must continue de-escalation attempts and refrain from firing their guns for as long as possible, consistent with public and officer safety.

5. The Ministry of Community Safety and Correctional Services should commission a study of Tasers to determine if there are any special risks associated with the use of this device on emotionally disturbed people.

6. Expand the availability of Mobile Crisis Intervention Teams to make them available in all divisions of the city and to operate beyond their current 11 a.m. to 9 p.m. hours.

7. The Ministry and the Toronto police should evaluate the adoption of improved equipment such as body armour that protects from sharp weapons, body-worn cameras and shields.

8. Officers should not handcuff emotionally disturbed people being apprehended under the Mental Health Act unless their behaviour warrants handcuffs.

9. Create spaces/environments within the emergency department that reduce the risk of elopement, including locked units and procedures for monitoring patients.

10. The Ministry of Health and Long-Term Care should increase funds to mental health crisis hotlines and services, and increase advertising campaigns to promote awareness of these services.