An investigation into why a former soldier in Nova Scotia killed three members of his family and himself in 2017 finds that medical professionals could have done a better job sharing Lionel Desmond’s complex medical history .
The much-delayed final report of the provincial death inquiry, released Wednesday, includes 25 recommendations aimed at improving support for Canadian veterans and their families, expanding health services for African Nova Scotians and strengthening the firearms licensing process.
“This has been an arduous and emotional process for everyone involved, but we also hope it is worth it,” provincial court Judge Paul Scovil said in a written statement.
“The investigation explored complex issues surrounding domestic violence, mental health services, support for veterans and access to firearms. But the evidence also led the investigation into some areas that could have been less obvious.”
Scovil said the survey also explored the unique challenges faced by rural residents and African Nova Scotians — Desmond was Black — when trying to seek mental health services.
Among other things, the inquiry recommends that the Nova Scotia Department of Health provide more virtual care to rural African Nova Scotian communities. Additionally, the report calls on the department to hire more Black mental health providers to provide “culturally competent” care.
As for Desmond’s military health records, the report recommends that the federal government ensure that federal employees diagnosed with PTSD or other health conditions receive a copy of their health records, which should then be shared with provincial health authorities.
“This information needs to be able to easily cross federal and provincial borders,” Scovil said. “Individuals, professionals and others, should carefully consider the need to air concerns about individuals and work with those whose consent is necessary to ensure the flow of information.”
During 53 days of hearings, the inquest heard the former infantryman was diagnosed with severe post-traumatic stress disorder and major depression in 2011 after witnessing intense combat in Afghanistan in 2007.
Although he received four years of treatment while in the military, the investigation found that his mental health was still poor and his marriage was in trouble when he was released from the armed forces for reasons medical reasons in 2015 and subsequently participated in a residential treatment program. in Montreal in 2016.
More importantly, the investigation found that the 33-year-old former corporal did not receive any therapeutic treatment in the four months following his return home to Upper Big Tracadie, Nova Scotia, in August 2016.
“I am struck by the fact that once Corporal Desmond was transferred to Nova Scotia, it took several months to escalate the care he desperately needed, even though time was of the essence,” said Scovil.
On January 3, 2017, Desmond legally purchased a semi-automatic rifle and used it later that day to fatally shoot his 31-year-old wife, Shanna, their 10-year-old daughter, Aaliyah, and her 52-year-old husband. . his elderly mother, Brenda, before turning the gun on himself.
Scovil’s report reveals key information about Desmond’s mental health was not shared with provincial firearms controllers and provincial health officials.
The inquest heard Desmond’s firearms license was suspended in December 2015 after he was arrested in New Brunswick under the province’s Mental Health Act. At the time, his wife told police he had threatened suicide. However, the license was reinstated in May 2016 after a New Brunswick doctor signed a medical assessment form declaring his patient “non-suicidal and stable.”
At the time, Desmond was receiving treatment at a Fredericton clinic, where staff determined his mental state had become unstable as he was plagued by intrusive memories of brutal combat in Afghanistan.
None of this information was shared with provincial firearms officials because the clinic was not required to do so.
As a result, the inquiry report recommends that Nova Scotia’s chief firearms officer work with other provinces to ensure they can share notifications of when police have concerns about certain people possessing guns fire.
Among other things, the report recommends that the Nova Scotia government encourage the federal government to ensure that all new veterans are assigned a case manager as they transition to civilian life.
The inquest heard the Department of Veterans Affairs appointed a case manager to manage Desmond’s transition, but it took six months for the process to be completed. Additionally, the case manager struggled with delays and bureaucratic issues as she struggled to find the right help for her client during the last four months of his life.
On another front, the investigation focused on issues of domestic violence, as many witnesses made it clear that Desmond’s marriage was in trouble even before he left the military.
Dr. Peter Jaffe, a psychologist at Western University in London, Ont., told the inquest that Desmond had 20 risk factors associated with domestic homicide, out of 41 factors developed by the Ontario Death Review Committee due to domestic violence.
The inquest also heard that three hours before the murders, Shanna Desmond had requested information from a women’s refuge about how to obtain a peace bond.
The inquiry’s report includes several recommendations on domestic violence, including calls for a public information campaign and updating risk assessments for frontline professionals.
The inquiry does not have the power to find fault in matters of criminal or civil liability and its recommendations are not binding.
“No one should be singled out,” Scovil said. “The problem is systemic, up to and including the events of January 3, 2017.”