'Ad hoc' monitoring failed to protect air force officer who took his own life: inquiry report

WARNING: This story contains distressing details about suicide. It also includes details of allegations of sexual assault which may be triggering.

A Canadian air force officer who took his own life after being charged with sexual assault was deemed by a military medical officer and a social worker to present a "moderate" suiciderisk but a military investigation has found there was little formal follow-up by his superiors.

A board of inquiry into the death of Maj. Cristian Hiestand said that the career pilot was placed on medical employment limitations shortly after being accused of two counts of sexual assault and was "restricted from possessing a personal weapon."

He was found dead in his home on Jan. 18, 2022.

One of the conditions of his release from custody the previous month was that he have no contact with several individuals at Canadian Forces Base Moose Jaw, Sask., where he was a pilot instructor.

According to court records, Hiestand was charged days after he'd ended a tumultuous, short-term relationship with a civilian woman.

The charges against him were laid by military police in provincial court in Saskatchewan less than a week after he broke off the relationship and within five days of authorities receiving a complaint from the civilian woman in question.

As a consequence of his release conditions, Hiestand was ordered to work from home.

'Anxiety, stress and hopelessness'

"Procedures and responsibilities regarding the supervision of Maj. Hiestand were devised on an ad-hoc basis," said the inquiry report, a copy of which was obtained by CBC News.

"There was no established standard operating procedure to supervise members who are working from home as a result of arrest and release conditions."

The investigation concluded that the arrangement, "due to his release conditions, increased his feelings of isolation and amplified feelings of anxiety, stress and hopelessness," given that much of his self-worth was closely tied to his status as an RCAF officer.

The support he did receive came from colleagues on the "basis of personal relationships," said the inquiry report. His friends told the inquiry thatHiestand would check in with thembut "no formal procedure was adopted," said the report.

Hiestand dropped out of sight in the daysbefore his death.

"Once Maj. Hiestand became unreachable, both his friends and the [chain of command] were unsure of what actions to take due to the uncertainty and confusion about the proper approach without invading Maj. Hiestand's personal space," said the report, dated July 29, 2022.

Only one person supporting him had suicide awareness training, the inquiry added.

The inquiry board recommended that all members of the training squadron receive suicide awareness training a proposalthe Department of National Defence says it is still studying.

A second recommendation involves developing a standard procedure to guide commanders on how to get subordinates into mental health counselling when necessary.

To some, it is startling that such procedures were not already in place in light of the suicidecrisis that gripped the Canadian military following the Afghan war almost a decade ago.

The Hiestand family has demanded answers and has questionedthe military police investigation, as well as the actions of Hiestand's superiors.

Retired lieutenant colonel Rory Fowler, a former military lawyer now in private practice, said medical staff met with Hiestand regularly in the first severalweeks after he was charged, but that ended during the Christmasbreak in 2022.

"When I read that he was assessed as a moderate risk, my immediate reaction was, 'Well, where was the action from the chain of command?'" said Fowler, who noted that Christmas was not the time to leave Hiestand on his own.

He said thatwhen all the factors are taken together, the military's approach toHiestand's case wasnot "appropriate."

Asked for a response to the board of inquiry's findings and Fowler's remark, the air force released a statement.

"This was a terrible tragedy and we mourn with Maj.Hiestand's family," says the statement.

"[Canadian Armed Forces] members experiencing crises are offered a range of mental health supports."

Actions of military policestill being investigated

Three professional standards and conduct complaints into the actions of military police officers in Hiestand's case are still under investigation almosta year after the complaints were laid. There's no indication of when they will conclude, the Department of National Defence said in a separate statement.

The family has asked for a Military Police Complaints Commission (MPCC) public interest hearing on the case.The watchdog agency turned down that request in a letterdated March 27, 2023, saying it is prepared to do a public interest investigation which isa step down from a hearing once the military has concluded its professional standards probe.

But on the question of whether the public would be served by a full inquiry, Tammy Tremblay, chair of the MPCC, wrote the circumstances and "the arguments set forward in your request do not warrant a Public Interest Hearing."

Fowler argued that the public interest isn't simply about how military police handled a single case of sexual assault and whether they rushed to judgment. He said it's abouthow they handle politically and socially charged cases in general.

"I wouldn't limit it to sexual misconduct," said Fowler. "That's the hot-button issue of the day. One could extrapolate this to [include] investigations that draw significant political and media scrutiny."

He added that sexual misconduct must be investigated and punished within the military but it's criticalthat the cases be handled fairly.

"Nobody disputes the importance of investigating allegations of sexual misconduct," he said. "It is of vital importance that those who are investigatingand those who are prosecuting don't rush to judgment."

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).

• Canadian Association for Suicide Prevention:Find a 24-hour crisis centre.

• This guide from theCentre for Addiction and Mental Healthoutlines how to talk about suicide with someone you're worried about.

• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling onthe website.

Support is also available for anyone who has been sexually assaulted:

You can access crisis lines and local support services through thisGovernment of Canada websiteor theEnding Violence Association of Canada database. If you're in immediate danger or fear for your safety or that of others around you, please call 911.