Inquest into Brandon man's death after release from hospital 'taking too long'

The family of a man who died while out on a day pass from a Brandon psychiatric ward say the inquest into his death is taking too long.

'I was told we could expect to be court in spring of [2013] and here we are 3 years later,' mom says

Craig Kucher, 24, died in 2012 while out on a day-pass from a Brandon psychiatric ward. His family says the inquest into his death is taking too long.

The family of a man who died while out on a day pass from a Brandon psychiatric ward say the inquest into his death is taking too long.

"I was told we could expect to be in court in spring of [2013] and here we are three years later," Sharon Kucher told CBC News from Brandon. "It's very emotional."

Her 24-year-old son, Craig Kucher, died in 2012 after being struck by a train while out on a day pass from the Centre of Adult Psychiatry in Brandon. He was staying there involuntarily in the 10 days prior because he was in a delusional state. Craig battled with a host of mental health issues, including Asperger's, manic depression and obsessive compulsive disorder.

"I was really just shocked that he was being let go so quick. When he went to pack his bag I actually did say to the doctor, 'Are you sure this is the right course for him?' And they said, 'Yeah,' they felt it was right for him,'" she said. 

Reluctant, she took her son home. That day has haunted her ever since. Kucher said he was pleasant, they visited and made plans for his sister's birthday that night. A short while later, he said he was going out and he'd be back soon.  

"And we went, 'OK,'" she said. "About two hours later, I started making a comment to my husband that we should have asked where he was going because I expected he'd be home by now."

Another hour went by and he didn't show up. 

"I went on E-brandon [a local website] and on there had been a notice that there had been an accident on the rail road tracks and right away my instinct was, 'Oh my god, could it be my son?"

She called the nursing station at the hospital and staff confirmed Craig had been hit by a train. 

"The police pulled up just as I was throwing the phone at my husband and of course I was yelling and screaming," she said.

Kucher said her son died after falling from a train June 18, 2012. She said her son did not receive the care he needed in hospital. She cited records showing all he did was sleep and watch television. They also show he opted out of counseling sessions, she added.

"I have felt that he's been failed all through his life," Kucher said. "I feel that if there was a crack than he could slip through it, or if he found a crack than he could widen himself enough to slip through it." ​

Medical examiner ordered inquest 

The medical examiner could not conclusively state if Craig died by accident or suicide, and because he was still a patient at the hospital a mandatory inquest was called.​

The inquest will outline the circumstances surrounding Craig's death and what, if anything, can be done to prevent similar deaths in the future.

However, the process has been anything but expedient. It got underway October of 2015, three years after his passing. 

Hearings lasted three days and the judge's recommendations to the Prairie Mountain Health Authority are not expected until 2016.

Family identifies with Reid Bricker case

In the meantime, Kucher said she has reached out to Reid Bricker's family, identifying with their situation. 

Bricker, 33, went missing and is presumed dead by family following a discharge from a Winnipeg hospital in the middle of the night where he was under care for attempting suicide.

His disappearance has prompted calls for changes to discharge policies and the health privacy act. Kucher said her family is pushing for these changes, too, through the inquest. 

"I want to see medical records opened up," said Kucher.

In Craig's case, Kucher said doctors in both the emergency department and psychiatric ward relied heavily on health information the family provided. She said when a person presents with mental health issues, emergency staff, psychiatric staff and police should be able to access a person's complete mental health record immediately. 

"There should be a process to access all of the bigger picture," Kucher said.

Bricker had visited two other Winnipeg hospitals for attempting suicide, prior to the night he was seen at Health Science Centre — a piece of information hospital staff may not have known. Even though records are electronic, the Winnipeg Regional Health Authority confirmed if patients are seen at other hospitals, the record does not always detail what a patient was seen for.

Kucher is also calling on hospital release and discharge policies to be reviewed. She said like many mental health patients, her son was good at concealing his illness and convincing others he was OK, which the family believes led to his release on a day pass.

"I'm hopeful that some changes can be made and that some good can come out of a very awful situation that can maybe benefit others," she said.

"[It] can't bring back my son, but maybe [it] can help somebody else."


Jill Coubrough

Reporter, CBC News

Jill Coubrough is a video journalist with CBC News based in Winnipeg. She previously worked as a reporter for CBC News in Halifax and as an associate producer for the CBC documentary series Land and Sea. She holds a degree in political studies from the University of Manitoba and a degree in journalism from the University of King's College. Email:


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