Desmond inquiry: ‘Desperately needed’ care absent in months before N.S. killings

PORT HAWKESBURY, N.S. — An inquiry that investigated why a former soldier in Nova Scotia killed three family members and himself in 2017 is calling on Ottawa and the province to change the way health records are shared and close gaps in the firearms licensing system. 

The much-delayed final report from the provincial fatality inquiry, released Wednesday, includes 25 recommendations aimed at improving support for veterans like Lionel Desmond.

“This has been an arduous and emotional process for everyone involved, but hopefully also a worthwhile one,” provincial court Judge Paul Scovil said in a statement delivered at the courthouse in Port Hawkesbury, N.S., where some of the public hearings were held.

During 53 days of hearings, the inquiry learned that the former infantryman was diagnosed with severe post-traumatic stress disorder and major depression in 2011 after he was involved in intense combat in Afghanistan in 2007.

Though he received four years of treatment while he was in the military, the inquiry heard that his mental health was still poor and his marriage was in trouble when he was medically released from the Armed Forces in 2015.

More importantly, the inquiry was told the 33-year-old former corporal did not receive any therapeutic treatment during the four months after he returned home to Upper Big Tracadie, N.S., in August 2016. The inquiry heard from several provincial health professionals who said they were unable to review Desmond’s federal health records once he returned to his home province.

“It is striking to me that once Cpl. Desmond transferred to Nova Scotia, it took many months to ramp up the care that he so desperately needed, this despite time being of the essence,” Scovil said.

On Jan. 3, 2017, Desmond legally purchased a semi-automatic rifle and later that day used it to fatally shoot his 31-year-old wife, Shanna, their 10-year-old daughter, Aaliyah, and his 52-year-old mother, Brenda, before he turned the gun on himself.

The judge said the inquiry also explored the unique challenges faced by rural residents and African Nova Scotians — Desmond was Black — when they try to seek mental health services.

Among other things, the inquiry recommends that Nova Scotia’s Health Department provide more virtual care to rural African Nova Scotian communities. As well, it calls on the department to hire more Black mental health providers to provide “culturally informed” care.

As for Desmond’s military health records, the report says the provincial government should encourage the federal government to ensure that federal employees diagnosed with PTSD or other health issues receive a copy of their health records, which should then be shared with provincial health authorities.

“That information needs to easily follow across federal and provincial boundaries,” Scovil said.

His report also found that key information about Desmond’s mental health was not shared with provincial firearms officers.

The inquiry heard that Desmond’s firearms licence was suspended in December 2015 after he was arrested in New Brunswick under the province’s Mental Health Act. At the time, his wife told police he had threatened to kill himself. The licence, however, was reinstated in May 2016 after a New Brunswick doctor signed an assessment form that declared his patient was “non-suicidal and stable.”

However, at the same time, Desmond was being treated at a federally funded clinic in Fredericton, where staff later determined his mental state had become unstable, as he was plagued by intrusive memories of brutal combat in Afghanistan. None of that information was shared with provincial firearms officials, as the clinic was not required to do so.

The inquiry’s report is recommending Nova Scotia’s chief firearms officer work with other provinces to ensure they can share notifications that indicate when police have concerns about certain people with firearms.

Firearms officers should also be given access to various police databases including the federal database known as PROS. And any time someone applies for or renews a firearms licence, firearms officers should be allowed to follow up with medical professionals who would be obligated to report any changes in the applicant’s health.

On another front, the inquiry dealt with issues of intimate partner violence, as many witnesses made it clear that Desmond’s marriage was in trouble even before he left the military.

During public hearings, Peter Jaffe, a psychologist at Western University in London, Ont., told the inquiry that Desmond presented 20 risk factors associated with domestic homicide, out of 41 factors developed by the Ontario Domestic Violence Death Review Committee.

The inquiry also learned that three hours before the killings, Shanna Desmond sought information from a women’s shelter about how to get a peace bond, though the inquiry did not hear any evidence of physical abuse.

The inquiry’s report includes several recommendations about intimate partner violence, including calls for a public information campaign.

One of Desmond’s sisters, Cassandra, said she wants to make sure the recommendations are implemented. 

“This is the step in the direction that we’ve got to continue to go with,” she said outside the courtroom. “This isn’t the last step of the journey.”

She said she appreciated the work that went into drafting recommendations that were “culturally focused,” but she criticized the report for failing to focus on the families that were left scarred by the tragedy.

“There’s still a large number of us still hurting after seven years of carrying the pain,” she said.

Shanna Desmond’s brother, Sheldon Borden, said the report was a failure because it says nothing about providing support for their parents, Thelma and Ricky Borden, both of whom are still living in the home where the killings took place.

“From where I stand, the system is continuing to fail,” he said outside the courtroom.

In Ottawa, Veterans Affairs Minister Ginette Petitpas Taylor said she had not read the report, but she confirmed the department was already making changes. As an example, she said that when a veteran seeks mental health support from Veterans Affairs, “those supports are approved immediately and put in place.”

That’s exactly what is recommended in the report.

The inquiry heard that Veterans Affairs appointed a case manager to handle Desmond’s transition to civilian life, but it took six months for the process to be completed. As well, the case manager was beset by delays and bureaucratic glitches as she struggled to find the help for her client during the last four months of his life.

The inquiry did not have the power to find fault in terms of criminal or civil liability, and its recommendations are not binding.

“No one person should have a finger pointed at them,” said Scovil. “The issue is systemic, up to and including the events on Jan. 3, 2017.”

This report by The Canadian Press was first published Jan. 31, 2024.

— With files from Sarah Ritchie in Ottawa and Keith Doucette in Halifax

Michael MacDonald, The Canadian Press