Craig Kucher inquest report calls for clearer protocols in psychiatric patient releases

The death of a man on a two-day leavefrom a Brandon psychiatric ward was likely an accident and not suicide, but clearer protocols should be put in place for patients and those caring for them on releasefrom hospital, a Manitoba judge ruled.

An inquest report into the death of Craig Kucher, 24, who died in June 2012 after he fell from a train, was released Wednesday morning.

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

Judge Donovan Dvorak ruled that the position Kucher was in when he was hit by the train suggests the incident was more accident than suicide, even though the autopsy report listed delusional disorder as a significant condition contributing to the death.

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

Kucher was in the psyciatric ward involuntarily for10 days before his death because he was in a delusional state. He battled a host of mental health issues, including Asperger's, bipolar disorderand obsessive compulsive disorder.

"The leave of absence provided to Mr. Kucher on June 18, 2012,was appropriate and medically justified," Dvorak said in the report. "Mr. Kucher's condition had improved significantly."

The report also concluded there was nothing to suggest he might harm himself or anyone else.

Kucher's family told CBC News late last year that they felt their son did not receive the care he needed in hospital.

Craig Kucher inquest report calls for clearer protocols in psychiatric patient releases

8 years ago

Duration 1:56

The death of a man on a two-day leave from a Brandon psychiatric ward was likely an accident and not suicide, but clearer protocols should be put in place for patients and those caring for them on release from hospital, a Manitoba judge ruled.His mom, Sharon Kucher,said at the time that records showed all he did wassleep andwatchtelevision. They also show heopted out of counselling sessions, she added.

"I have felt that he's been failed all through his life,"she told CBC News."I feel that if there was a crack then he could slip through it, or if he found a crack then he could widen himself enough to slip through it."

Dvorak made three recommendations in the report:

• Ensure that clear protocols are in place at mental health facilities that would ensure the person taking responsibility for a patient being released knows what is expected of them;
• Ensure protocols are in place that would ensure the patient is aware of the doctor's expectations in terms of co-operation with treatment; and
• Written copies of information should be provided to the patient and the person or persons taking the patient into care.

Prairie Mountain Health, the health authority in charge of the Brandon Regional Health Centre,said in a statement Wednesday afternoonthey are pleased with the findings outlined in the inquest report and will be moving forward with implementing the recommendations.

Kucher family disappointed with report

Kucher's family told CBC News they were disappointed by the report.

"I feel the judge must have just stayed right to task of what had happened in my son's last hours, not looking at the overall picture and not taking advantage of the opportunity to make things better as a whole for all mentally challenged patients," SharonKuchersaid on Wednesday.

She said she took the weekend to read and process the 14-page report and was pretty upset that it did not amount to much in the end.

Kucher said she'd like to see unified record-keeping implemented among all medical professions as it would allow for easier access to information.

"I had hopes that it would address the medical issues and the medical ways of recording outcomes and visits and stuff like that, so that it would be easier access for all medical personnel," she said.

She said the reportlikely won't prevent similar incidents from taking place in the future.

"It was an accident. The fact that he had a mental illness and had been involuntarily admitted to CAP (Centre for Adult Psychiatry)really didn't have a lot of bearing on the circumstancesof his death," she said.

She still maintains that he shouldn't have been released on a temporary leave in the first place and suggests other parents be really aware of the treatment their children are receiving.

"Somehow you need to get out there and let medical personnel or police or jail systems or anybody know what works for your child or young adult," Kucher said. "It's tiring, it's consuming, it's emotional, but you need to keep going and be there."

"We just hope that we could use this as an opportunity to see a bigger picture and help more mentally ill adults," she said.

Kucher remembered as loving

"Craig was a loving computer geek," she said of her son, who was a college graduate. "He was right into computers.

"He was quick to give you hugs or words of comfort," she added. "He loved to run. He was into soccer. He worked in the oilfields for a while."

His three sisters plan to include him in all of their big events, such as weddings, Kucher said. She also plans to advocate for people with mental illness on Craig's behalf.

"We've planted a tree for him," she said. "Our family is growing. We've got grandchildren to look forward to. He'll be a part of our lives and be in our hearts forever."