VANCOUVER -- Six months after 46-year-old Tricia Beck died alone in her BC Housing-run apartment in Vancouver, a review of the circumstances surrounding her death has led to an apology from Vancouver Coastal Health.

Beck’s family still has no idea how the mother of six died. While the response they received from Patient Care Quality Office review dated Aug. 6 did not answer that question, it did confirm what a BC Housing worker told them anonymously after their daughter’s death: that she appeared to be extremely unwell in early February, but even after a visit from a mental health team, she was ultimately left alone.

Beck’s mother Karen Smithers said she only read the review through once because “my heart hurts."

“I guess there’s this piece of me that didn't want to believe that she could be treated this callously,” Smithers told CTV News. “It’s disgusting and I’m angry.”

The letter explains how Beck was being followed by Raven Song Primary Care and Strathcona Mental Health teams. She had struggled with mental health issues and addiction.

The team was first called on Feb. 6 by BC Housing staff, reporting “erratic” behaviour from Beck. An outreach visit was scheduled for the following morning at 10:30 a.m., “as it was the end of the day." If housing workers had concerns prior to the mental health team visit, they were to call 911.

On Friday, Feb. 7, a nurse and psychiatrist from the Strathcona Mental Health team visited Beck, according to the review.

“Her room was in disarray and Tricia had multiple bruises and a black eye. She was crawling on the floor and was not able to communicate clearly,” it said.

The doctor made the call for Beck to be taken to the hospital under the Mental Health Act, with the assistance of police, because she had not agreed to go voluntarily. The team left to do the paperwork, leaving BC Housing staff to keep an eye on her. They also made a non-emergency call to police at 12:13 p.m.

By 3 o’clock, the review found police had not arrived and Tricia’s door was now closed. Another non-emergency call was placed, and the nurse was told Beck’s call was next in line. Housing staff also reported they called 911. Police have never said they received a 911 call in relation to Beck on the day she is believed to have died.

When Car 87 (a mobile team including a police officer and a nurse) finally received the request regarding Beck, they were responding to other calls and were not available to attend until the next day.

However, on Feb. 8, Car 87 did not attend. Instead, another officer came by and went to Beck’s suite, but left after getting no response.

“VCH staff were not contacted by housing or police to indicate that police had not/could not attend to the call,” the review said. “VCH staff were not aware that Tricia had not been picked up and taken to hospital by the VPD.”

There also is no specific explanation offered as to why someone with the health authority or one of the mental health teams did not follow up with Beck’s building or police, or why BC Housing staff eventually left Beck unmonitored.

Her body was found in her suite on Feb. 9 after police broke open her locked door.

“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, and added it was not apparent to staff that Beck was dying. “I am sorry that nobody stayed with Tricia until police arrived and we sincerely apologize for that.”

Beck’s father Bill asked why, if his daughter was in such bad shape that she had to be forced to go to the hospital, that someone didn't make sure she went.

“Everybody dropped their end of rope and went home,” he said. “It was 4 o’ clock on a Friday afternoon.”

Smithers is especially troubled by the knowledge a doctor and nurse saw her daughter crawling and bruised, but left her in the care of others, who also failed to keep monitoring her.

“If they had just been human beings and got her to the hospital, and my daughter had died in the hospital with people trying to save her, this would be a non-issue,” she said. “Was she laying there crying and asking for her mom?”

The review also noted the building manager said police response time had increased in recent years, often taking several hours or even days, and a 911 call didn’t always mean a quicker response.

“This is (sic) systemic issue that crosses between VCH and VPD and one we will look into solutions to,” the review said. “We regret that VCH staff did not escalate their non-emergent call to police to that of an emergent call and that follow up was not arranged when the mental health team were leaving for the day.”

Vancouver Coastal said it is now making changes to prevent this kind of situation in the future, including letting the mental health team know they should call 911 when clients are certified and need to be brought to hospital, and creating a procedure for when someone needs to go to the hospital under the Mental Health Act and police are not available.

Smithers said their apology “isn’t worth anything”.

“I want someone to be held responsible for my daughter’s death,” she said. “This has destroyed a whole family.”

Beck’s death is also being investigated by the coroner and the Major Crime Section of the Vancouver Police.