Calgary hospitals needs to better track mentally ill patients once they leave medical facilities, says a report on the suicide of a woman with a long history of psychiatric problems.

In the report, released Monday, provincial court Judge Barbara Lea Veldhuis urged that there be a clear protocol for following up with mentally ill patients, especially those who miss medical appointments.

"Some patients may not be capable of taking personal responsibility for their mental health care," Veldhuis wrote. "There should be a clear procedure for reaching out to patients who may be high-risk for issues such as self-harm, non-adherence to treatment plans, forensic activity, poor medication management and other areas of concern."

Diane Yano, 44, of Calgary jumped to her death from the third floor of a parkade at the Peter Lougheed Hospital on Aug. 18, 2006.

Yano had been found not criminally responsible because of a mental disorder for drowning her two children, aged 3 and 5, in a bathtub in Fairmont, B.C. in 1999. She was also criminally charged for an alleged assault on a fellow patient at the Peter Lougheed Hospital about two weeks before her suicide.

Yano, who suffered from a major depressive disorder with psychotic episodes for most of her adult life, was an outpatient at the Calgary hospital's psychiatric unit.

The chemical engineer was admitted to the hospital on Aug. 3, 2006 because of depression and reportedly hearing voices that instructed her to harm herself and others. She had missed appointments in the months before her suicide, and "was left to her own devices until her admission in August 2006," Veldhuis wrote.

The judge noted that the Calgary Health Region has introduced new policies and renovated areas in hospitals where people could hurt themselves. But she also recommended better co-ordination between inpatient psychiatric care and continuing outpatient care, particularly to better manage high-risk patients such as Yano.

A judge cannot find fault in a fatality inquiry, but can make recommendations in an attempt to prevent similar tragedies.