A total lack of communication and coordination between health care professionals, provincial departments and civilian and military authorities let down retired Cpl. Lionel Desmond, and helped contribute to the tragic deaths of his family.

During the Desmond Fatality Inquiry on February 3 in Guysborough, the emergency room doctor who assessed retired Cpl. Desmond two days before he killed his mother, wife, and 10-year-old daughter before turning the gun on himself, testified that the veteran wasn’t considering suicide and not thinking about harming his family.

Dr. Justin Clark told the inquiry he met with Cpl. Desmond on December 1, 2017 and he received a score of 2, which on a scale of 1 to 5, indicated he required treatment as soon as possible.

Inside the emergency room, Cpl. Desmond told the physician, who at the time had only six-months experience in emergency rooms, that he was struggling with his post-traumatic stress disorder (PTSD) and that he had an argument with his wife that resulted in broken furniture when he checked himself into the hospital at 6:51 p.m.

Weeks prior, in October 2016, Cpl. Desmond checked himself in to St. Martha’s during a crisis situation – he had an appointment with Dr. Ian Slayter, who indicated his experience with nightmares and flashbacks since returning home from Afghanistan in 2007.

Dr. Clark testified he never saw Dr. Slayter’s notes from the psychiatric assessment in which Dr. Slayter suggested the former rifleman seemed aggressive and paranoid about his wife. He had been able to see a record of Cpl. Desmond’s previous emergency room visit, but the database didn’t include the meeting with Dr. Slayter, nor an instance in New Brunswick where he was suicidal.

Dr. Slayter also found Cpl. Desmond suffered from thoughts of jealousy that bordered on delusional.

Dr. Clark also indicated he was aware Cpl. Desmond had been prescribed several medications, including an anti-psychotic drug, but he couldn’t recall noticing Dr. Slayter’s files in the province’s Meditech system.

The inquiry counsel questioned whether a more fulsome electronic medical database would help emergency room doctors and pointed to information not included in Dr. Clark’s medical report; previous psychological assessments, private health clinic information, and medical records from the Canadian Forces.

Dr. Clark said knowing there were past reports and emergency room visits may have helped his assessment.

He also testified that after spending 21-minutes with Cpl. Desmond – concluding he was stable and had no suicidal or homicidal thoughts – the doctor contacted a psychiatrist for consultation because he was uncomfortable managing the situation on his own. That assessment happened shortly after 7:30 p.m. with Dr. Faisal Rahman.

Dr. Rahman also determined Cpl. Desmond showed no signs of suicidal or homicidal thoughts.

As to what happens next – there are conflicting accounts.

Dr. Clark testified Cpl. Desmond was kept for observation in the emergency room for the night, because his wife worked in the psychiatric ward – something Dr. Rahman agreed to – however, the inquiry heard from police Lionel had told his aunt he begged to be admitted to the third floor but was told there were no beds – an allegation the hospital continuously has denied.

After being discharged on January 2, the following afternoon, Cpl. Desmond killed 52-year-old Brenda, 31-year-old Shanna, and 10-year-old Aaliyah before the Afghanistan war veteran took his own life.

Then on February 10, the first civilian psychiatrist to meet with Cpl. Desmond after he was released from the military’s care testified that the Afghanistan war veteran’s complex mental illness deteriorated “due to a gap in treatment.”

Dr. Ian Slayter, who assessed the 33-year-old on two separate occasions in the fall of 2016, told the inquiry the former rifleman displayed symptoms of PTSD – but his mental health issues were far more complex – as he was also suffering from major depression, a probable traumatic brain injury, possible attention deficit disorder (ADD) and was “borderline delusional.”

Dr. Slayter has extensive experience studying suicide. Alongside his colleagues in 2010, he helped design a suicide risk assessment tool – which is why he considered Cpl. Desmond a “low risk” in late 2016 and early 2017.

Dr. Slayter said he was “surprised and horrified” when he learned Cpl. Desmond shot and killed his mother, wife and daughter before taking his own life.

He testified his first interaction occurred in an emergency room visit on October 24, 2016 as Cpl. Desmond was unable to leave the trauma and memory of combat behind, and was experiencing persistent problems with sleeping and nightmare – his wife did most of the talking.

“I thought he needed more trauma therapy,” Dr. Slaytor testified.

Cpl. Desmond informed the psychiatrist, while his PTSD symptoms were dwindling, his jealousy towards his wife Shanna and nightmares about her infidelity had been progressively getting worse.

However, Dr. Slayter testified he wasn’t informed about an incident a year prior in New Brunswick when Cpl. Desmond was suicidal and police had to intervene.

Through their first interaction, Dr. Slayter determined the former infantryman had not received any therapy since returning home from the Quebec-based, in-patient treatment centre for veterans suffering from PTSD, at Ste. Anne’s Hospital.

Suggesting Cpl. Desmond was “falling through the cracks” after returning home to Nova Scotia when the care he’d been receiving through the federal Veterans Affairs Department in New Brunswick stopped his services, Dr. Slayter told the inquiry that created barriers in accessing his medical records.

Melissa Grant, a lawyer representing the Attorney General of Canada, informed Dr. Slayter that Cpl. Desmond had a case manager within Veterans Affairs who was assisting him with locating the services he desperately needed, except, there were issues surrounding the location of receiving the treatment, Halifax or Cape Breton.

Dr. Slayter testified he believed Cpl. Desmond deserved a higher level of care – and agreed to meet with him until he received treatment through the military or Veterans Affairs.

The doctor noted that Cpl. Desmond’s “main role” in Afghanistan was retrieving bodies – often under fire, while watching for landmines, in poor visibility – which left him with “a lot of horrific memories.”

During a follow-up psychiatric assessment on December 2, 2016, that lasted approximately two-hours, Dr. Slayter concluded Cpl. Desmond was prone to angry outbursts and his jealousy seemed “over-emphasized” and “bordering on delusional” but he didn’t see anything concerning.

Dr. Slayter testified Cpl. Desmond would have benefitted from a neuro-cognitive assessment to determine if he had a brain injury, and to see if that was the cause of his problems processing information or difficulty following instructions or long conversations.

He never got the chance as Cpl. Desmond didn’t attend their follow-up appointment on December 21, 2016. He did book another appointment with Dr. Slayter on January 3, 2017, but later that day, he carried out the tragic triple murder-suicide in his wife’s family home in Upper Big Tracadie.

Dr. Slayter wanted Cpl. Desmond to receive help from an occupational stress injury clinic but before those services could be arranged, he asked the veteran to obtain his medical records from the Canadian Armed Forces and Veterans Affairs Canada; something the doctor admitted was difficult to accomplish.

Tara Miller, the lawyer representing Chantel Desmond, suggested the lack of communication could have been a barrier to his care, characterizing it as working in silos.

Dr. Slayter recommended to Provincial Court Judge Warren Zimmer that it’s crucial to have easier access to medical records from the military. Doctors can obtain medical records from any civilian hospital across the country within a day, but Dr. Slayter suggested there’s no easy path to get information from the military.

Adam Rodgers, the lawyer representing Cpl. Desmond’s estate, said it was a complex process for him to obtain those records, and claimed this was an unfair burden to place on any veteran.

By February 13, Provincial Court Judge Warren Zimmer told the inquiry that Veterans Affairs did not share key information on Cpl. Desmond’s mental illness; describing him as a former soldier struggling with severe PTSD, a major depressive disorder, and cognitive issues from head trauma.

Catherine Chambers, who was contracted by Veterans Affairs to consider becoming Cpl. Desmond’s therapist, heard for the first-time the severity of his mental-health issues – including his early release from an in-patient program specialized for veterans suffering with PTSD in August 2016, where clinicians noted he’d shown only “minor progress” after three-months.

Following Cpl. Desmond’s release from Ste. Anne’s Hospital in Montréal, no follow-up recommendations were carried out, including ongoing therapy, and undergoing brain scans and neuro-cognitive testing to indicate the level at which he could function.

Cpl. Desmond’s medical records indicate the scope of his mental illness; paranoia about the intent of doctors and nurses, sensory overload from noise, signs of poor cognitive function, worsening isolation, PTSD, major depression, and anxiety.

Chambers testified if she had been provided records of Cpl. Desmond’s previous treatment and recommendations for his continuity of care, she wouldn’t have agreed to assess him and instead referred him to in-patient care for PTSD.

According to Veterans Affairs case manager Marie Doucet’s notes recorded during the same time frame of Cpl. Desmond’s August 2016 discharge from the in-patient clinic in Montréal, he had cognitive limitations which required a neuro-psychological assessment.

Doucet also had concerns surrounding the lack of sound plan for Cpl. Desmond’s upcoming discharge and that he was returning to Nova Scotia and required support.

None of this information was provided to Chambers, who told the inquiry it “was crucial to have” and that “without cognitive wellness, community-based psychotherapy treatment is ineffective.”

The inquiry heard previous evidence about the benefits of moving to a “One Patient One Record” system of keeping medical records, under a more robust data collection system.

Another recommendation is that the military and the federal government provide more assistance and install better systems for sharing information with health care professionals requiring access to the medical records of veterans under their care.

These would be among the welcome recommendations from this inquiry.

It is inexcusable that Dr. Clark was unable to access notes and information from Dr. Slaytor and it isn’t a stretch to assume that Dr. Clark’s assessment would have been aided by knowledge of the incidents.

The inquiry has also exposed glaring shortcomings in the provincial Meditech system; a disturbing finding given that health care professionals are relying on this system to help treat Nova Scotians.

While the provincial health care system did not give Cpl. Desmond all the help he needed, the federal government and the military also failed him.

The military did not tell Cpl. Desmond’s psychiatrists about a suicidal incident in New Brunswick in which the RCMP was dispatched. That was vital information that went undisclosed.

Although contracted by Veterans Affairs to treat him, psychotherapist Catherine Chambers was kept in the dark by the department about the extent of Cpl. Desmond’s problems. She did not know about the scope of his mental illness; paranoia, sensory overload, poor cognitive function, isolation, PTSD, major depression, and anxiety.

Chambers was also not provided the notes of his Veterans Affairs case manager who said Cpl. Desmond had cognitive limitations which required a neuro-psychological assessment. The case worker also had concerns surrounding the lack of sound plan for his discharge.

The inquiry has yet to determine, but the Desmond family wants to know why and how the signature of Dr. Paul Smith in New Brunswick, allowed Cpl. Desmond to have his firearm licence re-instated, after which he purchased the murder weapon.

Yes there are privacy and intelligence considerations for the Canadian Forces to make before releasing information, but these are personal medical records, not classified documents. When it comes to helping their very own soldiers, the military should be far more forthcoming.

Questions must also be asked of the military’s doctors who are far more lenient vouching for veterans than they would be for civilians.

It is hard to explain why Veterans Affairs Canada provided such little information on Cpl. Desmond to a psychotherapist they contracted to care for him. Surely the department knew his therapy would have been greatly helped by more information.

These are the cracks in the system exposed by the Desmond Fatality Inquiry, and if anything at all can come from this horrible tragedy, hopefully it’s that changes can be implemented so that the next veteran in need, will be assisted as much as humanly possible.