Samwel Uko's uncle says he recently found out his nephew visited the Regina General Hospital not once, but twice on the day he died.
The second time, he was escorted out by security just a couple of hours before he was found dead in Wascana Lake.
The 20-year-old from Abbotsford, B.C., was in Regina visiting an aunt when he died on May 21.
Justin Nyee, Uko's uncle from Calgary, said he found out more details about his nephew's final hours in a phone call with the Saskatchewan Health Authority this week.
Prior to that call, he thought Uko had reached out for medical help once, not twice.
"We were shocked at first and then we are upset and we are angry because … he went twice," said Nyee. "Everyone knew this person had a mental health issue, but for whatever reason they decided not to help him.
"It doesn't make any sense."
On the morning of May 21, Uko asked his cousin to take him to the hospital, but he had to be left alone due to COVID-19 measures. Over the course of the next few hours, Uko met with four nurses and one doctor.
Nyee said the doctor diagnosed Uko with depression, referred him to a mental health clinic, and released him from the hospital at about 10:45 a.m.
'Red flags' ignored, says uncle
At 1 p.m., Uko received a call from someone from a mental health clinic who interviewed him until about 2:30 or 3.
Nyee found out that when Uko was asked if he thought about killing himself, he said yes. He even disclosed to the mental health worker that he had made one failed attempt.
"At the end she decided that his condition was mild … nothing to worry about," said Nyee. "I told them there were a lot of red flags in his answers. How come she did not pick that up?"
At about 5 p.m., Uko called 911 to say he was having mental health issues and needed help. He was found on the side of the street by police officers. They escorted him to the hospital and stayed with him for about 40 minutes before leaving.
About 15 minutes after that, the nurse who was talking to Uko called security and he was kicked out of the hospital.
There is no record of his second visit to the hospital. The only proof he was there was CCTV footage from the lobby where he was sitting.
Nyee said he asked the health authority if the situation was handled according to procedure. He was told it wasn't, he said.
He asked if Uko was fighting, cursing or arguing with hospital staff. Someone from the SHA said Uko wasn't doing anything, but was escorted out because he could not provide his name.
Uko's body was found at about 7:30 that night.
Uko's care under investigation: SHA
According to Nyee, the SHA is reviewing Uko's second visit to the hospital. That review is expected to take three to four weeks.
Nyee said his family is going to have a meeting soon and will likely get a lawyer who can represent them in talks with the SHA.
He said he wants to prevent another Black person from dying because they could not get adequate help.
"I always try not to interject race into the problem, but yes, this looks to me as if they did not care because he was a Black kid," said Nyee.
"Nobody is hearing our problems and it's out there. We face it like anyone else, and bringing this to light helps other people too."
Today, it's his nephew, Nyee said. "But we don't know tomorrow who it's going to be.… We have to work to avoid that for the next person."
The Saskatchewan Health Authority said Uko's case is a "critical incident," defined as "a serious adverse health event including, but not limited to, the actual or potential loss of life … related to a health service provided by, or a program operated by, a health care organization."
"We again wish to convey our sincerest condolences to the family and friends of this young man," a spokesperson said in an email to CBC. "This situation is heartbreaking for everyone involved."
The SHA said it is communicating with Uko's family as his care is reviewed. The agency would not respond to specific questions on the case because it is under investigation.
