VANCOUVER -- When 46-year-old Tricia Beck was seen by a mental health team on Friday, Feb. 7, she was crawling on the floor, had multiple bruises and a black eye, and was incoherent. But despite multiple calls to police, no one came that day to take the mother of six to the hospital.

Now police say the doctor and nurse who checked on Beck at her BC Housing-run apartment in Vancouver should have called paramedics.

Media Relations officer Sergeant Aaron Roed said the team made calls to the non-emergency line for police. 

"They should have called BC Ambulance immediately to get her to hospital," he said. "This really comes down to she didn’t get the medical treatment that she dearly did need."

Beck struggled with mental health issues and addiction. The psychiatrist who saw her decided she needed to go to the hospital under the Mental Health Act, according to a review of the circumstances surrounding Beck’s death by the Vancouver Coastal Health Patient Care Quality Office. The review said they sought the assistance of police because she had not agreed to go voluntarily. 

Sgt. Roed said the team used a document called a Form 4, which allows for involuntary admission to hospital, but he said it doesn’t require police enforcement.

"When they call the non-emergency police line, it does go into a queue with a lower priority level, as it wasn’t an emergency with a Form 4," Sgt. Roed said. 

When the mental health team left to do the paperwork, they asked BC Housing staff to keep an eye on Beck. Later in the afternoon, when police still hadn’t arrived, housing staff also reported they called 911. Roed confirmed the call, and said the staff wanted to know when police would arrive because they were going to be off shift.

"There was no additional information to elevate this to a more urgent situation," Sgt. Roed said. When asked whether the fact 911 was called should have indicated a more urgent status, he replied 911 calls are also prioritized by dispatchers.

The review found Car 87, a mobile team including a police officer and a nurse, was not immediately available to respond either as it was attending other calls. Sgt. Roed said he doesn’t know what their call load was on that specific day, but added they have a busy schedule and also prioritize calls. 

When an officer came by the next day, there was no response at Beck’s unit. On Sunday, when Car 87 arrived, they found her dead inside.

"We are working with Vancouver Coastal Health and we will be recommending in future they always call BC Ambulance to attend with Form 4, so they can be transported to the hospital," Sgt. Roed said. "We want to express our condolences to the family. They lost a mother, a daughter, and she didn’t get the medical attention she needs and for that, we’re very sorry."

In the patient care review, Vancouver Coastal said its staff were not contacted by BC Housing or police to indicate that police had not been able to attend right away, and were not aware Beck had not been picked up and taken to the hospital.

"It is best practice to stay with certified patients until emergency services arrive, however competing priorities do not always permit this option,” the review said. “I am sorry that nobody stayed with Tricia until police arrived and we sincerely apologize for that."

CTV has requested interviews with Vancouver Coastal Health and BC Housing regarding Beck’s death.

BC Housing told CTV Beck’s subsidized housing building on Jackson Avenue does not have staff on site 24 hours a day, but rather from Monday to Friday. 

The organization said while Housing Minister Selina Robinson is not giving on-camera interviews at this time, they are looking at what the roles and responsibilities of their staff allow for within their working hours, in hopes of making improvements. 

Canadian Mental Health Association BC Division CEO Jonny Morris told CTV the immediate reaction to Beck’s story is one of concern, and compassion for her family.

"And I think the...moral imperative here to look at what can be done differently in individual cases like this, but also at a systemic level, to ensure that we don’t ever see a loss of life when someone is in a psychological, or a psychiatric, or a mental health, or a substance use emergency," Morris said. 

He said we need to think about treating a mental health crisis the same way we treat other urgent medical situations. 

"The need for an urgent, emergency response is required, particularly when in many ways, so many folks rely on emergency resources in a mental health system that has been systemically underfunded for a very long time," Morris said, and added often the first point of contact for people in crisis is the police or the emergency department. "That’s why we have fairly drastic measures like the Mental Health Act legislation in place that, especially in those crisis moments, need to get enacted rapidly and quickly, because it can often be a matter of life or death."

Morris said there’s also an opportunity to find ways to improve coordination and create "failsafes" in the system so that people don’t fall through the cracks. 

Vancouver Coastal said it is making changes to prevent this kind of situation in the future, including letting the mental health team know to call 911 when clients are certified and need to get to hospital, and creating a procedure when someone needs to go to the hospital under the Mental Health Act and police are unavailable.

Beck’s family still has questions, including how she died. Her death is still under investigation by the coroner and the Major Crime Section of the Vancouver Police.