Desmond Fatality Inquiry concludes, judge to present recommendations

PORT HAWKESBURY: A federal lawyer has defended the role of Veterans Affairs Canada in the lead up to the triple murder-suicide that rocked the small, tight-knit, historically Black community of Upper Big Tracadie on Jan. 3, 2017.

Lori Ward told the court on April 19 that it wouldn’t be right to blame Veterans Affairs Canada for the deaths of retired Cpl. Lionel Desmond, his 52-year-old mother Brenda, his 31-year-old wife Shanna, and their 10-year-old daughter Aaliyah.

“It would be so easy to lay everything at the feet of Veterans Affairs,” Ward said in her final submission to the inquiry. “There’s a narrative that is perpetuated about an uncaring bureaucracy.”

The inquiry, which saw testimony from 69 witnesses over 53 days, spanning the past 27 months, was investigating what caused Desmond, who was a former infantryman, to kill his mother, his wife, and his daughter before turning the gun on himself.

The inquiry’s mandate is to determine the circumstances under which these deaths occurred, as well as some specific issues, including, but not limited to: whether Desmond and his family had access to the appropriate mental health and domestic violence intervention services leading up to their deaths; whether health care and social services providers who interacted with the Desmond family were trained to recognize the symptoms of Occupational Stress Injuries or domestic violence; and whether Desmond should have been able to retain, or obtain a licence, enabling him to obtain or purchase a firearm.

Desmond was diagnosed with major depression and severe post-traumatic stress disorder after serving in Afghanistan in 2007 with the 2nd Battalion Royal Canadian Regiment’s India Company. He was deployed to Kandahar just one month after the birth of his daughter.

A then 24-year-old rifleman, he was in direct combat with the Taliban as they ramped up their guerilla campaign in one of the Canadian military’s bloodiest combat missions. He was medically discharged from the Canadian Armed Forces in July 2015, after receiving four years of treatment.

Highlighting the work of Desmond’s appointed case manager, Marie-Paule Doucette, Ward suggested she tried to utilize every resource possible to help him deal with his stress by using compassion and empathy.

Ward advised that his case manager drove Desmond to the airport for his intensive treatment program at Ste. Anne’s Hospital in Montréal, made a “special request” to ensure he received funding to cover the cost of the travel, and at one point, met with him in-person during her vacation.

“Lionel Desmond has access to the best care at this time,” she said.

However, during the last four months of his life, Desmond didn’t receive any therapeutic treatment, in spite of Doucette’s efforts, and the required functional assessment and a neuropsychological assessment never happened.

Ward suggested Doucette would have her hands tied in her efforts to support her client because Desmond would routinely decline offers of assistance if he had to drive 500 kilometres round trip to Halifax, which resulted in his mental health deteriorating between August 2016 and January 2017.

“To say there was a gap in his treatment upon his discharge from Ste. Anne’s and his relocation to Guysborough, Nova Scotia, would be an understatement,” Allen Murray, the inquiry’s lead counsel told the inquiry on April 19. “The depth and complexity of his mental health challenges can’t be overstated.”

During that critical four month period, Desmond pursued help from two local hospitals, Guysborough Memorial Hospital and St. Martha’s Regional Hospital in Antigonish, but the doctors he met with weren’t able to view his federal health records, which provided a more clear representation of his mental well being.

Despite federal privacy laws, Ward insisted Desmond “could have easily obtained his own health records,” even with a mild cognitive impairment.

Ward also challenged Nova Scotia psychiatrist Dr. Ian Slayter’s comments that Desmond, who he accepted as a patient in 2016, appeared to be falling through the cracks in the health care system.

“In fact, (he was) far from falling through the cracks at Veterans Affairs,” she said. “Mr. Desmond’s decision to decline treatment (in Halifax) and to try to find community supports in rural Nova Scotia amounted to a huge crack that Ms. Doucette and others were doing their best to have him navigate clear of.”

Regardless of that debate, Murray suggested Desmond had fallen into a treatment void that left him unable to recover from a downward spiral.

Desmond was in contact with 40 mental-health professionals from the time he was diagnosed with PTSD and major depression in 2011 until his death in 2017.

“What the inquiry has heard is that, repeatedly, professionals may not have fully grasped the numerous red flags for the risk of serious domestic violence or domestic homicide,” he said. “His actions were the products of a damaged psyche and a tortured soul. It’s a story of missed opportunities. It’s a story of information that was siloed and went unshared. It’s a story of many caring professionals who wanted to help, but ultimately could not.”

On the final day of public hearings, the inquiry heard systemic failures and racism were partly to blame for the tragic chain of events that led to the Afghan war veteran carrying out the triple murder-suicide in 2017.

Despite receiving four years of treatment after being diagnosed with PTSD while he was still in the military, Desmond would require additional help when he was medically discharged in 2015.

Tara Miller, who represented Chantel Desmond and was joint counsel for Aaliyah, told the inquiry on April 20, these were preventable deaths.

“These deaths were the tragic result of the failures of multiple service providers and institutions to share and take action on meaningful information in a timely way, or at all,” Miller stated.

The institutions, Miller said, failed to provide mental health treatment to a Black man in a “culturally responsive manner,” and to recognise and address signs of intimate partner violence.

In addition to it taking Veterans Affairs six months to find Desmond his case manager, Miller highlighted how health care professionals at the provincial level were, “significantly restricted,” in what they could do as they didn’t have access to his federal records.

“Without these records, none of the Nova Scotia health providers were set up for success in treating Cpl. Desmond,” she said. “Despite the foreseeability of his need for extensive mental health treatment, and despite being ensconced in the Veterans Affairs system, Cpl. Desmond found himself seeking help from mental health providers (on his own).”

The rules state records should be made readily available to those within a patient’s circle of care, something that wasn’t done in Desmond’s case, Miller said.

Miller also alluded to evidence presented by the Health Association of African Canadians, which reported African Nova Scotians, like Desmond, face challenges accessing mental health care because of systemic racism in the health care system.

“They were clear. For Cpl. Desmond to be properly treated, there needed to have been culturally responsive care provided by clinicians trained in cultural competency,” Miller said. “It’s not clear if Cpl. Desmond received this care, certainly, none of the treatment providers were Black.”

In the afternoon on Jan. 3, 2017, Desmond legally purchased a semi-automatic SKS 7.62 carbine and would use it hours later as the murder weapon in the tragedy.

“As Cpl. Lionel Desmond battled to live with the legacy of the trauma he experienced in Afghanistan, his family battled along with him,” Miller said. “Aaliyah, Shanna, and Brenda Desmond were the innocent and unintended victims of a war that impacted them daily after his return home, and for which they paid the ultimate price.”

The provincial fatality inquiry that started witness testimony in Guysborough on Jan. 27, 2020, has had to deal with numerous delays caused by the COVID-19 pandemic, including long adjournments due to public health restrictions, and a change in venue to the Port Hawkesbury Justice Centre.

As the proceedings have reached their conclusion, Warren K. Zimmer, the presiding provincial court judge for the inquiry, will file a written report with the provincial court containing his findings and recommendations, which is expected sometime this fall, however, Zimmer’s report will not contain any findings of legal responsibility.