N.S. inquiry into killings by war veteran calls for better sharing of medical files

An inquiry that investigated why a former soldier in Nova Scotia killed three family members and himself in 2017 says health-care professionals could have done a better job of sharing Lionel Desmond’s complex medical history.

The much-delayed final report from the provincial fatality inquiry, released Wednesday, includes 25 recommendations aimed at improving support for Canadian veterans and their families, expanding health-care services for African Nova Scotians and strengthening the firearms licensing process.

“This has been an arduous and emotional process for everyone involved, but hopefully also a worthwhile one,” provincial court Judge Paul Scovil said in a written statement.

“The inquiry explored complex issues surrounding intimate partner violence, mental health services, support for veterans and access to firearms. But the evidence also led the inquiry into some areas that may have been less obvious.”

Scovil said the inquiry also explored the unique challenges faced by rural residents and African Nova Scotians — Desmond was Black — when they try to seek mental health services.

Among other things, the inquiry recommends that Nova Scotia’s Health Department provide more virtual care to rural African Nova Scotian communities. As well, the report calls on the department to hire more Black mental health providers to provide “culturally informed” 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 issues receive a copy of their health records, which should then be shared with provincial health authorities.

During 53 days of hearings, the inquiry learned the former infantryman was diagnosed with severe post-traumatic stress disorder and major depression in 2011 after he saw intense combat in Afghanistan in 2007.

Though he received four years of treatment while he was in the military, the inquiry heard that his mental health was still poor and his marriage was in trouble when he was medically released from the Armed Forces in 2015 and then took part in a residential treatment program in Montreal in 2016.

More importantly, the inquiry was told the 33-year-old former corporal did not receive any therapeutic treatment during the four months after he returned home to Upper Big Tracadie, N.S., in August 2016.

On Jan. 3, 2017, Desmond legally purchased a semi-automatic rifle and later that day used it to fatally shoot his 31-year-old wife, Shanna, their 10-year-old daughter, Aaliyah, and his 52-year-old mother, Brenda, before he turned the gun on himself.

Scovil’s report found that key information about Desmond’s mental health was not shared with provincial firearms officers and provincial health officials.

The inquiry heard that Desmond’s firearms licence 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 to kill himself. The licence, however, was reinstated in May 2016 after a New Brunswick doctor signed a medical assessment form that declared his patient was “non-suicidal and stable.”

At the time, Desmond was receiving treatment at a clinic in Fredericton, where staff determined his mental state had become unstable, as he was plagued by intrusive memories of brutal combat in Afghanistan.

None of that information was shared with provincial firearms officials, as the clinic was not required to do so.

As a result, the inquiry’s report is recommending Nova Scotia’s chief firearms officer work with other provinces to ensure they can share notifications that indicate when police have concerns about certain people with firearms.

Among other things, the report recommends the Nova Scotia government encourage the federal government to ensure that all new veterans are assigned a case manager as they transition into civilian life.

The inquiry heard that Veterans Affairs appointed a case manager to handle Desmond’s transition, but it took six months for the process to be completed. As well, the case manager was beset by delays and bureaucratic glitches as she struggled to find the proper help for her client during the last four months of his life.

On another front, the inquiry dealt with issues of intimate partner 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 inquiry that Desmond presented 20 risk factors associated with domestic homicide, out of 41 factors developed by the Ontario Domestic Violence Death Review Committee.

The inquiry also learned that three hours before the killings, Shanna Desmond sought information from a women’s shelter about how to get a peace bond.

The inquiry’s report includes several recommendations about intimate partner violence, including calls for a public information campaign, and to update risk assessments for front-line professionals.

The inquiry did not have the power to find fault in terms of criminal or civil liability, and its recommendations are not binding.