The system failed Lionel Desmond and his family. These changes may prevent another tragedy

Though Lionel Desmond finished his tour of Afghanistan in August 2007, the trauma of the war would rage inside him and inside his home for the next decade.

It culminated on Jan. 3, 2017, when he fatally shot his wife, his mother and his daughter before taking his own life.

A Nova Scotia fatality inquiry has spent the last two years examining what led up to that evening. All of those involvedin the hearings hope to close the gaps they uncovered and prevent a similar tragedy from happening to another military family.

There are many such families in this country.

Roughly 400 soldiers are medically released from the Canadian Forces each year due to mental illness, and upwards of 70 per cent of them have partners and children, according to federal figures.

The evidence heard over 53 days may help those families by answering the questionsguiding the inquiry:

• Did Lionel Desmond have access to appropriate mental health care?

• Did his wife, Shanna, his daughter, Aaliyah, and his mother, Brenda, have access to appropriate domestic violence intervention?

• Did the many health-care professionals and police officers who saw the family have the necessary training and information to spot the risk of intimate partner violence?

• Should a man with profound and complex PTSD symptoms, recently released from an in-patient psychiatric program, have been able to legally purchase a firearm?

The short answer is no.

But the nuances present an overarching question the lawyers will answer in their final submissions to Judge Warren Zimmer on April 19: What must bechanged?

Happy-go-lucky to a soldier 'destroyed'

By all accounts, Desmond was known as a helpful, happy-go-lucky young man.

That side of him shone through in military training and before his tour of Afghanistan in early 2007, his friend and fellow soldier, Cpl. Orlando Trotter told the inquiry. Desmond wanted to be a good partner and father.

But the seven-month tour was "like going to hell," Trotter testified in February 2021. Desmond's job there involved navigating landmines in order toretrieve bodies, creating memories that would repeat in his mind for years.

"You take somebody like him and put him in a war zone and [say], 'Take this rifle, and that guy over there, shoot him.' I would say it destroyed him," Trotter testified. "You have to have a certain type of personality to go into battle, and he just wasn't one of those guys."

What they saw overseas destroyed the lives of many serving with 2nd Battalion Royal Canadian Regiment at the time.

Desmond's battalion arrived at a point of high Canadian casualties. It replaced a regiment in the months following Operation Medusa,a deadly offensive that saw 12 Canadian soldiers killed.

Their own battalion would lose 10 people when a vehicle drove over an improvised explosive device, Trotter told the inquiry, and many within the battalion of 300 to 400 soldiers himself among them have since been diagnosed with PTSD.

Desmond is one of eight from that battalion to have died by suicide since returning home, according to Trotter's evidence.

His death is the only known murder-suicide of the group.

A diagnosis of complex PTSD

A military psychiatrist diagnosed Desmond with complex PTSD and major depression in 2011, after his symptoms reached a point where he struggled to perform his duties and were a source of conflict in his marriage.

He experienced flashbacks and nightmares about the bodies he'd retrieved, and he often felt numb and struggled to connect with his family and friends, his military psychiatrist Dr. Vinod Joshi told the inquiry.

"His long-term prognosis is guarded in light of poor response to treatment."-Dr. Vinod Joshi, military psychiatrist

Despite medication, group therapy and individual psychotherapy, Desmond never made a full recovery.

When he experienced stress in his life, he would relapse.

One of those sources of stress was his marriage, which had been affected by his PTSD and a separation, as Shanna was in Antigonish, N.S., studying for her nursing degree while he was still posted to CFB Gagetown in New Brunswick.

"His long-term prognosis is guarded in light of poor response to treatment," Joshi wrote in a psychological progress report in October 2012.

Desmond had his exit interview from the military in May 2015; he had been medically released.

Difficulttransition to civilian life

Desmond was referred to the Occupational Stress Injury Clinic in New Brunswick, a program funded by Veterans Affairs, but he missed appointments as he began spending more time with family in Nova Scotia.

He was struggling.

Part of that struggle is one that evidence suggests iscommon among new veterans finding a new identity outside of an institution that has provided the structure of their adult lives.

It's something that can be compounded by financial trouble.In Desmond's case, he was awaiting disability compensation and a military pension to kick in. Even when that happened, he still used the food bank at times.

One of the people meant to help him with this transition was a case manager with Veterans Affairs Canada, but Desmond's first contact with a case manager was six months after his release.

That delay is an issue the inquiry has limited powers to change, given that the inquiryis provincial in scope. But the federal departments involved, including Veterans Affairs, have had representatives at the proceedings and have pledged their support.

The department also launched an internal review after the murder-suicides, and a spokesperson told CBC News in June 2021 that it was actively recruiting for more case managers.

In May 2016, Desmond was sent to Ste. Anne's Hospital nearMontreal to try to stabilize his ongoing PTSD symptoms, including his struggle to manage his emotions. At that point, he had disclosed to medical practitioners that he was having nightmares about his wife cheating on him and that, in those dreams, he would kill her in retaliation.

When he left the hospital in August, his case conference report said he'd made "minimal progress."

Falling through the cracks

While he was in treatment, his home sold in Oromocto, N.B.That prompted his decision to move back to Nova Scotia immediately following his release from hospital and live with Shanna and Aaliyah, who were living with his in-laws in Guysborough County, N.S.

This period the five months after Desmond's release is one that the inquiry returned to repeatedly and one that will certainly be an area that the recommendations will try to address.

Because, as Zimmer said, Desmond "fell through the cracks." He went from the intense structure of an in-patient program to receiving no therapeutic treatment for the final months of his life.

Part of the reason for this is because he'd been seeing a team in New Brunswick and it took months for Veterans Affairs to arrange for his care in Nova Scotia.

But it's also becauselayers of bureaucracy prevented him from getting his medical files from his time in the military and as a veteran at Ste. Anne's.

Dr. Matthew Bowes, the province's chief medical examiner, noted that he himself could not get access to Desmond's military medical records, despite later testimony that there is a procedureallowing their request.

But if that procedure didn't work for someone with the education and authority of a provincial medical examiner, we can't rely on it to work for someone in a vulnerable position, Bowes said.

If it doesn't work in practice, it doesn't work at all.

That medical information, when combined, highlighted not only the extent of Desmond's illness, but also a pattern of risk to his family.

It included reports ofnightmares, shouting, police visits, firearms being removed from the home and requests for him to leave the family home for a night to cool off.

If the six doctors who saw Desmond between August 2016 and Jan. 2, 2017 had access to that history, they mighthave seen that risk and made different decisions, a domestic violence expert told the inquiry.

Instead, on Jan. 2, 2017,Desmond was released from St. Martha's Hospital emergency room where he'd spent the night after his wife had asked him to leave.

The next day,he bought a semi-automatic rifle using a firearms licence that was twice reinstated after two different doctors cleared him for mental fitness at different points in the previous five years.

He then drove to his in-laws' house, slashed the tires on his wife's car and walked inside the home.

Six gunshots later and four people would be dead: Shanna, 31, Aaliyah, 10, Brenda, 52, and Lionel, 33.

Preventing this from happening again

There is vast room for improvement in how government institutions treat veterans, people with mental illness and families at risk of domestic violence.

In Desmond's case, the transition from the military health-care system to the civilian one created numerous hurdles. It's anarea that the judge and lawyers Tara Miller and Adam Rodgers say they expect to address.

All three have noted that there needs to be better communication between the military and civilian health-care systems and an easier way for a soldier to access their military health records.

"When somebody is released, either medically or they're retiring from the military, they should walk out of the door that day with their medical records on a disc or a USB stick," said Miller, a lawyer representing the estates of Brenda and Aaliyah Desmond. "The fact that there is a process that they have to apply and wait and submit forms to get their medical records, the bureaucracy and the administration slows all that down."

WATCH | Lawyer Tara Miller shares her recommendations for change:

Lawyer at Desmond inquiry says changes are needed for veterans leaving military health-care system

2 years ago

Duration 5:31

Tara Miller, a lawyer at the Desmond inquiry, says soldiers leaving the military should be given a copy of their health records the day they are released. To do so, will make sure civilian doctors have a better picture of what treatment the patient might need.

Rodgers, who represents Lionel Desmond's estate, said he expects he'll make a recommendation to take that idea a step further: to connect veterans with a family doctor as soon as they leave the military.

"This inquiry is not designed to lay blame, so we're not focusing too much on who did what improperly, but it's clear that there were major gaps in the transition from the military to the provincial health system," he said in an interview.

Gun safety

Another gap the judge returned to this week will also certainly be part of his final recommendations making it mandatory for doctors to report a change in a patient's mental health if they've previously cleared them to be fit enough for a firearms licence.

Doctors in New Brunswick twice signed off on Desmond's medical form needed as part of a firearms licence review. That form has already changed so that it requires more information from a doctor than a simple yes or no and the form in Nova Scotia is also more robust.

But Zimmer noted that there are laws that force doctors to take away someone's driver's licence if they become a public safety risk. The same could be true for firearms, he suggested.

Inquiry counsel Allen Murray echoed the judge's sentiment.

"A medical practitioner provides an opinion that is it's a snapshot in time," he said in an interview. "And, of course, the person's physical or mental health can change."

Support for families

The presumption of preventability in the deaths of the Desmond family is outlined, too, in the risk factors that are considered to predict a heightened risk of domestic homicide.

TheOntario Domestic Violence Death Review Committee has identified 41 such factors and considers there to be a heightened risk if seven are present.

In the Desmonds' relationship, there were 20.

"If somebody had done a thorough risk assessment" with either partner in the last month of their lives, they should have seen that pattern,testified Peter Jaffe, director ofthe Ontario-based Centre for Research and Education on Violence Against Women & Children.

That's a gap that Miller hopes to close. She plans to recommend ways to make it easier for family members to share information with health-care providers.

"What can we do to enhance, to strengthen, to make robust domestic violence interventions and to support the families along that journey," she said.

"Lionel Desmond brought ...the battle home with him. And that meant that those people at home with him entered that war unwittingly with him as they struggled to support him and move forward."

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