A days-long inquest into the death of a woman fatally shot in Mission, B.C. has resulted in nine recommendations ranging from reviews of training processes to a re-examination of existing bylaws.

Lisa Dudley, 37, died of gunshot wounds to the head and neck in September 2008 in an air ambulance parked in a field near her home.

The inquest held nearly 10 years later included Dudley's last words, and testimony from the officer who was called to her home the night she was shot, but never went inside.

Among the jury's recommendations are that RCMP Dispatch Services review its procedures and training to ensure that all employees thoroughly document all details reported by a complainant. They are also to be reminded that all calls are recorded and can be made public through requests under the Freedom of Information Act.

On the first day of the inquest, it was made public that a Mountie responding to a call reporting the sound of gunshots laughed with a police dispatcher. Cpl. Michael White, who was a constable at the time, and another officer went to investigate the report in the quiet neighbourhood, but did not get out of their vehicles or contact the person who made the call for further information.

The call was played during the inquest, and the corporal was asked whether he thought the report was funny. 

"No, it's not funny. I was just skeptical," he said.

His skepticism came from the unusually high number of shots reported – six – and because only one person had called it in. White parked his car, filed a report then moved on to another call less than half an hour later, unaware that Dudley was dying inside the home.

The neighbour who made the call spoke at the inquest, saying he felt those he spoke to did not seem interested. He teared up recalling he'd learned Dudley was found four days later and died of her injuries.

The jury in the inquest also recommended Mounties consider implementing a policy on following up with complainants in cases where someone may be seriously injured, such as shootings and stabbings. If the policy is already in place, the verdict read, the RCMP should explore increased training.

Police should also consider implementing a system of mandatory routine review and training on its First Response Investigations Policy within all levels of the RCMP, and explore increasing exterior lighting for unmarked police cars operating on rural roads, the jury recommended.

They also recommended the District of Mission review its bylaws regarding the visibility of residential addresses from the street.

To BC Emergency Health Services, the inquest verdict suggested air ambulances should be better equipped to allow patient care during transport. Directing its final recommendations to the minister of public safety, the jury suggested a review of the First Responder Investigation Policy including mandatory follow-up for all police agencies operating in the province.

It was also suggested the ministry look at implementing mandatory training when it comes to responding to complaints of instances such as shootings, where there is a potential of serious injuries.

In Dudley's case, first responders only returned to the scene after a concerned neighbour took matters into his own hands. Stuart Young, who testified this week in the inquest, knocked on her door.

Not getting a response, he went to the back of the home, where noticed a glass door was shattered. Looking through, he saw through her sitting on a chair in the corner of the room.

Dudley's partner Guthrie McKay was shot three times and died, but Dudley was paralyzed and tied to the chair. They were gunned down in a hit organized by one of Dudley's ex-boyfriends.

During the inquest, her family learned her final words – that she loved her mom. 

The parting phrase was uttered to a paramedic, who was not permitted to tell Dudley's mother what she'd said.

The goal of coroner's inquests is not to lay blame but to determine the events that led to a death and make recommendations to prevent similar deaths in the future.

With files from CTV Vancouver's Jon Woodward and The Canadian Press