System failures preceded Afghan War veteran’s murder-suicide: Desmond inquiry final report

PORT HAWKESBURY, N.S. — Cpl. Lionel Desmond came home from the Afghan War in 2008 a tormented man.

As his life spiralled over the following nine years, the help he needed didn’t follow him in large part due to the siloing of health records between Veterans Affairs Canada and provincial and federal institutions.

On Wednesday, the Desmond Fatality Inquiry released its final report into all that led up to Desmond shooting his wife Shanna, mother Brenda and ten-year-old daughter Aaliyah in their Upper Big Tracadie home on Jan. 3, 2017.

“It is a story of mental health systems encased in silos built over cracks,” wrote Judge Paul Scovil in his 207-page report.

Despite having a non-fault finding mandate, the report finds plenty of fault — not in individual mental health or Veterans Affairs case workers but in systemic gaps that saw the help Desmond needed not follow him after he checked himself out of an in-patient occupational stress injury program at Ste. Anne’s Hospital in Quebec in August 2016.

He brought back to Upper Big Tracadie severe post-traumatic stress disorder and major depressive disorder, which were taking an increasing toll on himself and his marriage.

Already overburdened health-care providers in Antigonish didn’t have access to Desmond’s health records when he began seeking help.

“To say that there was a gap in his treatment upon his discharge from Ste. Anne’s Hospital and his relocation to Guysborough, Nova Scotia would be an understatement,” reads the report.

“Cpl. Desmond came to Nova Scotia with no services or treatment plan in place. Nothing was arranged for ongoing psychological counselling, medication compliance monitoring, social supports, or neuropsychological testing. Cpl. Desmond’s relationship with his wife was troubled and continued to deteriorate.”

If anyone could have seen them, the signs were all there that his wife, daughter and mother were in  growing danger.

Desmond had told health professionals of dreams of hurting his wife and of recurring violent nightmares. He’d threatened Shanna with his own suicide via text message, then denied it to the police.

As his life fell apart and Shanna’s career as a nurse took hold, Desmond developed unfounded paranoia about her faithfulness to him. He became prone to sudden outbursts of anger.

“(The murder-suicide) seems entirely predictable and preventable with hindsight,” Dr. Peter Jaffe, one of Canada’s pre-eminent experts on intimate partner violence, told the inquiry.

“This hindsight is clear in the context of all the information available about the serious risks that Cpl. Desmond was presenting and the history that could have been known to professionals as well as family and friends.”

Meanwhile, the provincial chief firearms officer didn’t have access to police or medical records that would have pointed to Desmond’s mental spiral.

So, after checking himself out of a voluntary overnight stay at St. Martha’s Regional Hospital in Antigonish on Jan. 3, 2017, he was able to buy a Russian-made SKS-AR rifle with which he would kill his family and himself that evening.

The report has 25 recommendations that include:

• Better sharing of records between federal and provincial health-care providers
• Better training of health-care providers and police in the hallmarks of intimate partner violence
• The chief firearms officer have better access to police and health-care records
• More extensive training and recruitment of African Nova Scotian health-care providers, and
• The creation of an implementation committee composed of senior government officials to ensure the report’s recommendations are implemented.

“Based on the evidence presented in this inquiry, it is clear that the institutions, health-care professionals and community members involved could have done a better job sharing information about Corporal Desmond’s medical history, as well as his physical and mental state in the days leading up to Jan. 3, 2017,” Scovil said as he released his report at the Port Hawkesbury Justice Centre on Wednesday.

“(Health-care information) needs to easily follow an individual across federal and provincial boundaries.”

As the media gathered outside the courtroom, Sheldon Borden reminded everyone that the same government that sent his brother-in-law off to war is still failing the family. His parents, Ricky and Thelma Borden, still live in the Upper Big Tracadie home in which their daughter and granddaughter were murdered because they can’t afford to leave.

“The first way to begin to help the families heal is to help the family relocate,” said Borden.

“I shouldn’t have to be on the news asking you in big institutions to pay for my niece’s or my sister’s or my aunt Brenda’s funeral. I shouldn’t have to ask these big institutions to pay for the cleaning. Initially they said ‘no’ because they can only provide support for the member. What about support for the families?”

Cassandra Desmond, Lionel Desmond’s sister, said after receiving the report of the fatality inquiry she had fought for that her efforts will turn to ensuring its recommendations are implemented.

“The fight continues,” she said.

After the report’s release, Nova Scotia Justice Minister and Attorney General Brad Johns committed to working with the federal government to implement the recommendations.

“We will also carefully consider how Judge Scovil’s recommendations interconnect with our actions in response to the April 2020 mass casualty and recommendations contained in the Mass Casualty Commission Final Report,” said Johns.

“Much work is underway across government to improve mental health services, raise awareness of and address intimate partner violence, and improve public safety in response to that report.”

Scovil was appointed to take over the inquiry last summer after Johns refused the request of Judge Warren Zimmer, who had hosted the inquiry, for more time to prepare the final report. In a letter sent to lawyers involved in the inquiry expressing his own frustration with the Department of Justice after his term was ended, Zimmer attributed delays to the pandemic, the immense amount of documents and that, unlike the Mass Casualty Commission, he did not have a large staff to assist him.

Zimmer said in the letter it was his intention to have a copy of the report available by last August.

Desmond Fatality Inquiry Recommendations

1. Province advocate the federal government to have a case manager assigned to veterans transitioning out of the Canadian Armed Forces. 

2. The Rapid Access and Stabilization Program be funded by the province to include all regions in Nova Scotia. 

3. Province liaise with federal agencies to ensure individuals diagnosed with post-traumatic stress disorder or other health issues be provided a copy of their health records to be “ingested” into Nova Scotia records. 

4. The Nova Scotia Health Authority and Nova Scotia Department of Health and Wellness assess the availability of neuropsychological assessments in the province and, if needed, take steps to ensure they are more readily available. 

5. The Nova Scotia Health Authority continue to update its suicide risk assessment and intervention policy and tool based on the most up-to-date evidence on suicide risk assessment and continue to train staff engaged in mental health on the policy and tool and be provided adequate funding by the province to do so. 

6. The Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority partner with appropriate community organizations to provide more comprehensive virtual care to rural African Nova Scotian communities. 

7. The Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority take steps to recruit Black and diverse mental health providers to provide culturally informed and responsive care with an emphasis on training in psychosocial services, occupational stress and general mental health and addictions with appropriate provincial funding. 

8. The Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority should recruit and provide educational scholarships for Black registered nurses and nurse practitioners with appropriate provincial funding. 

9: The Network of Black Mental Health Providers built from the work of the Nova Scotia Mental Health and Addiction Strategy should be supported and adequately resourced by the province. 

10: The province should ensure that funding for the Men’s Helpline through the provincial 211 system continue and work to increase public awareness of websites that provide information for those who encounter intimate partner violence. 

11. The province of Nova Scotia embark on a public information campaign regarding avenues to access programs relating to intimate partner violence. Further, that any campaign be aware of, and refer to, African Nova Scotian needs and cultural identity. 

12. Ensure that frontline professionals in health, mental health, education, social services and the justice system are up to date with current information about intimate partner violence, the dynamics in these relationships, the impact of intimate partner violence on children and the potential for lethality in these cases. This should include an awareness of risk factors, risk assessment, safety planning and risk management strategies. 

13. Nova Scotia institute a police standard requiring all police agencies to utilize an intimate partner violence risk assessment tool in all calls and investigations involving domestic conflict where concerning behaviour regarding an intimate partner is present, irrespective of the existence of a criminal charge. 

14. The Nova Scotia Departments of Justice and Community Services review the high-risk case coordination protocol to deal with cases in which there is no criminal offence but there is concerning behaviour related to the intimate partner. 

15. Nova Scotia’s chief firearms officer work with other provinces to ensure that processes are in place to notify when clients of this and other provinces are involved in events that create FIPs and to ensure that information is shared in a timely manner. 

16. Police officers in Nova Scotia receive additional training on proper uniform crime report coding. 

17: The province advocate with the federal government to have federal policing agencies provide firearms officers access to the federal police database. 

18. That the province ensure all steps be taken to have expedited access by the chief firearms officer to various police databases, including PROS, Versades and Niche. 

19. The province encourage the federal government to proclaim in force those provisions of Bill C-71, an Act to amend certain Acts and Regulations to firearms, s.c. 2019, c.9, related to licence verification and business record keeping. 

20: The province advocate the federal government to add under section 16(a) of the Application for a Possession and Acquisition Licence under the Firearms Act a provision that applicants must disclose any employment restrictions regarding firearms or weapons. 

21. An applicant for a firearms licence or a renewal should be required to give an enduring consent and direction to the Office of the Chief Firearms Officer to allow follow-up with a medical practitioner at any time during the period that the licence is valid and in effect and to require the medical practitioner to report changes in the health status of the applicant. 

22. The Office of the Chief Firearms Officer should, in appropriate cases, place certain licences under review and seek additional medical information, if necessary, to ensure that applicants who have been granted licences are continuing to meet eligibility requirements and are maintaining good mental health. 

23. The Office of the Chief Firearms Officer should receive additional funding to facilitate additional and ongoing checks of the mental health status of licensees. 

24: The province liaise with other provinces and the federal government to improve the transfer of health records into each other’s record databanks. 

25: To ensure that the recommendations from the inquiry are not lost in the passage of time, the province should create a formal implementation committee composed of senior government officials from relevant departments to oversee the implementation of the recommendations. This committee should have at minimum a five-year mandate and liaise with appropriate federal departments

If you or someone you know is in need of mental health support:

• Check out the Canadian Mental Health Association at www.cmha.ca to find resources in your area.  
• Call the Nova Scotia provincial crisis line anytime at 1-888-429-8167. 
• Call 211 or visit 211.ca to get help anytime in over 100 languages and to connect to the services for you need
• The Kids Help Phone provides confidential support at 1-800-668-6868 or text CONNECT to 686868