BURNABY — The jury in a British Columbia coroner’s inquest into the deaths of a family of four in Prince Rupert in 2023 has found that they died of homicide and suicide, and recommended that police be informed when someone they have brought to hospital under the Mental Health Act is released.
The jury found on Tuesday that 38-year-old Christopher Duong died of self-inflicted wounds to the neck, while Janet Nguyen, 35, and the couple’s sons aged two and four, were all found to have died by homicide on June 13, 2023. Nguyen was found to have died of ligature strangulation, while the boys were asphyxiated.
They were found dead in bed together, three days after Duong was detained by police under the Mental Health Act but then released a few hours later.
The jury issued nine recommendations, including suggesting to the Ministry of Health that hospital admission forms be changed to allow an apprehending police officer to be contacted when a person is released from involuntary admission.
A social worker told the hearing last week that he didn’t narrow a five-day window to contact the family to 24 hours after Duong’s apprehension, because of his belief that Duong was still in hospital.
The recommendations that were read aloud by a juror at the inquest in Burnaby, B.C., said it heard that if police and ministry staff had been told of Duong’s release, “such an update would have triggered a different response.”
Police had apprehended Duong on June 10 after he was found driving around Prince Rupert on B.C.’s north coast at 2 a.m., with Nguyen and their boys, saying they had to keep driving or they would be killed in a “hit.”
The family was found dead three days later at the Prince Rupert home of Nguyen’s parents. Nguyen had an electrical cord around her neck; Duong had cut wounds to his arms, legs and neck; and the two boys had teddy bears arranged at their feet.
Other recommendations to the Ministry of Health included expanding the number of hospitals offering psychiatric and mental health services, as well as investigating ways to improve followup on discharged patients who had been involuntarily admitted.
The Northern Health authority was recommended to boost recruitment of psychiatric nurses.
The jury advised Prince Rupert Regional Hospital to review “the physical setup of the seclusion rooms, (which) was such that it approached torture,” while a doctor had testified that they were uncomfortable keeping patients there for extended periods. The hospital was also told to consider changing authorization routines for the discontinuation of tests on involuntarily admitted patients.
RCMP were meanwhile recommended to review police training regarding communication with the Ministry of Children and Family Development.
The jury recommendations say ministry staff “were not informed of the presence of bladed weapons,” when Duong was detained.
“Witnesses stated that this information would have changed their assessment of the situation and their response time,” the jury found.
RCMP were also advised to look into ways to ensure the preservation of former officers’ notebooks.
The final recommendation was that the Ministry of Children and Family Development train social workers on admission, duration and release criteria for patients admitted to hospital involuntarily.
RCMP Cpl. Matthew Blumberg, a crime scene investigator, testified last week that a video “last will and testament” was found on Duong’s and Nguyen’s phones.
The inquest heard that Duong was rumoured to have been involved in the Prince Rupert drug trade, while a notice of civil claim filed by B.C.’s director of civil forfeiture in 2015 describes Duong as a “violent gang member and drug trafficker” who was well known to police.
But Blumberg told the inquest there were “no outstanding suspects” in the deaths, and there was no evidence of any outside party being involved at the scene.
A coroner’s inquest is a non-fault-finding inquiry that aims to determine facts related to a death, make recommendations to prevent similar deaths and to ensure public confidence in the process.
This report by The Canadian Press was first published Feb. 10, 2026.
Canadian Press Staff, The Canadian Press
