Canada

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

Although Lionel Desmond completed his tour of Afghanistan in August 2007, the trauma of the warfare would rage inside him — and inside his house — for the subsequent decade.

It culminated on Jan. 3, 2017, when he fatally shot his spouse, his mom and his daughter earlier than taking his personal life.

A Nova Scotia fatality inquiry has spent the final two years analyzing what led as much as that night. All of these concerned within the hearings hope to shut the gaps they uncovered — and forestall an identical tragedy from taking place to a different navy household.

There are various such households on this nation.

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 companions and youngsters, in accordance with federal figures.

The proof heard over 53 days might assist these households by answering the questions guiding the inquiry: 

  • Did Lionel Desmond have entry to applicable psychological well being care?

  • Did his spouse, Shanna, his daughter, Aaliyah, and his mom, Brenda, have entry to applicable home violence intervention?

  • Did the various health-care professionals and cops who noticed the household have the mandatory coaching and data to identify the chance of intimate companion violence?

  • Ought to a person with profound and sophisticated PTSD signs, lately launched from an in-patient psychiatric program, have been in a position to legally buy a firearm?

The brief reply is not any. 

However the nuances current an overarching query the attorneys will reply of their remaining submissions to Choose Warren Zimmer on April 19: What should be modified?  

Shanna, 31, and Aaliyah, 10, might have used extra assist as Lionel transitioned from the navy, proof suggests. (Fb)

Blissful-go-lucky to a soldier ‘destroyed’

By all accounts, Desmond was often known as a useful, happy-go-lucky younger man.

That aspect of him shone by in navy coaching and earlier than his tour of Afghanistan in early 2007, his pal and fellow soldier, Cpl. Orlando Trotter instructed the inquiry. Desmond needed to be a superb companion and father.

However the seven-month tour was “like going to hell,” Trotter testified in February 2021. Desmond’s job there concerned navigating landmines in an effort to retrieve our bodies, creating recollections that may repeat in his thoughts for years.

“You are taking someone like him and put him in a warfare zone and [say], ‘Take this rifle, and that man over there, shoot him.’ I might say it destroyed him,” Trotter testified. “You must have a sure sort of character to enter battle, and he simply wasn’t a kind of guys.” 

Cpl. Orlando Trotter served alongside Lionel Desmond in Afghanistan in 2007. (Nova Scotia Courts)

What they noticed abroad destroyed the lives of many serving with 2nd Battalion Royal Canadian Regiment on the time. 

Desmond’s battalion arrived at a degree of excessive Canadian casualties. It changed a regiment within the months following Operation Medusa, a lethal offensive that noticed 12 Canadian troopers killed.  

Their very own battalion would lose 10 folks when a car drove over an improvised explosive machine, Trotter instructed the inquiry, and plenty of throughout the battalion of 300 to 400 troopers — himself amongst them — have since been identified with PTSD.

Desmond is considered one of eight from that battalion to have died by suicide since returning house, in accordance with Trotter’s proof.

His loss of life is the one recognized murder-suicide of the group.

Lionel was a part of the India Firm, 2nd battalion, Royal Canadian Regiment in Afghanistan in 2007. (Fb/The Canadian Press)

A prognosis of complicated PTSD

A navy psychiatrist identified Desmond with complicated PTSD and main melancholy in 2011, after his signs reached a degree the place he struggled to carry out his duties and had been a supply of battle in his marriage.

He skilled flashbacks and nightmares concerning the our bodies he’d retrieved, and he typically felt numb and struggled to attach together with his household and buddies, his navy psychiatrist Dr. Vinod Joshi instructed the inquiry. 

His long-term prognosis is guarded in gentle of poor response to remedy.– Dr. Vinod Joshi, navy psychiatrist

Regardless of treatment, group remedy and particular person psychotherapy, Desmond by no means made a full restoration.

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

A kind of sources of stress was his marriage, which had been affected by his PTSD and a separation, as Shanna was in Antigonish, N.S., learning for her nursing diploma whereas he was nonetheless posted to CFB Gagetown in New Brunswick.

“His long-term prognosis is guarded in gentle of poor response to remedy,” Joshi wrote in a psychological progress report in October 2012. 

Desmond had his exit interview from the navy in Could 2015; he had been medically launched.

Troublesome transition to civilian life

Desmond was referred to the Occupational Stress Harm Clinic in New Brunswick, a program funded by Veterans Affairs, however he missed appointments as he started spending extra time with household in Nova Scotia. 

He was struggling.

A part of that battle is one which proof suggests is frequent amongst new veterans — discovering a brand new identification exterior of an establishment that has offered the construction of their grownup lives.

It is one thing that may be compounded by monetary bother. In Desmond’s case, he was awaiting incapacity compensation and a navy pension to kick in. Even when that occurred, he nonetheless used the meals financial institution at occasions.

One of many folks meant to assist him with this transition was a case supervisor with Veterans Affairs Canada, however Desmond’s first contact with a case supervisor was six months after his launch.   

Lionel Desmond is proven right here on this household picture, together with his mom, Brenda, left, and daughter, Aaliyah. (Submitted by Cassandra Desmond)

That delay is a matter the inquiry has restricted powers to alter, provided that the inquiry is provincial in scope. However the federal departments concerned, together with Veterans Affairs, have had representatives on the proceedings and have pledged their assist.

The division additionally launched an inside evaluation after the murder-suicides, and a spokesperson instructed CBC Information in June 2021 that it was actively recruiting for extra case managers. 

In Could 2016, Desmond was despatched to Ste. Anne’s Hospital close to Montreal to attempt to stabilize his ongoing PTSD signs, together with his battle to handle his feelings. At that time, he had disclosed to medical practitioners that he was having nightmares about his spouse dishonest on him — and that, in these goals, he would kill her in retaliation. 

When he left the hospital in August, his case convention report stated he’d made “minimal progress.”

Falling by the cracks

Whereas he was in remedy, his house bought in Oromocto, N.B. That prompted his resolution to maneuver again to Nova Scotia instantly following his launch from hospital and reside with Shanna and Aaliyah, who had been residing together with his in-laws in Guysborough County, N.S. 

This era — the 5 months after Desmond’s launch — is one which the inquiry returned to repeatedly and one that may actually be an space that the suggestions will attempt to handle. 

As a result of, as Zimmer stated, Desmond “fell by the cracks.” He went from the extreme construction of an in-patient program to receiving no therapeutic remedy for the ultimate months of his life. 

A part of the explanation for it is because he’d been seeing a workforce in New Brunswick and it took months for Veterans Affairs to rearrange for his care in Nova Scotia. 

However it’s additionally as a result of layers of paperwork prevented him from getting his medical recordsdata from his time within the navy and as a veteran at Ste. Anne’s. 

Dr. Matthew Bowes, the province’s chief medical expert, famous that he himself couldn’t get entry to Desmond’s navy medical information, regardless of later testimony that there’s a process permitting their request.

But when that process did not work for somebody with the schooling and authority of a provincial medical expert, we won’t depend on it to work for somebody in a susceptible place, Bowes stated.

If it would not work in observe, it would not work in any respect.

Dr. Matthew Bowes, Nova Scotia’s chief medical expert, testified that he felt systemic failures contributed to the deaths of the Desmond household. It is why he compelled the federal government to name an inquiry. (Brett Ruskin/CBC)

That medical data, when mixed, highlighted not solely the extent of Desmond’s sickness, but additionally a sample of threat to his household.

It included studies of nightmares, shouting, police visits, firearms being faraway from the house and requests for him to depart the household house for an evening to chill off. 

If the six docs who noticed Desmond between August 2016 and Jan. 2, 2017 had entry to that historical past, they could have seen that threat and made totally different choices, a home violence skilled instructed the inquiry. 

As a substitute, on Jan. 2, 2017, Desmond was launched from St. Martha’s Hospital emergency room the place he’d spent the night time after his spouse had requested him to depart. 

The following day, he purchased a semi-automatic rifle utilizing a firearms licence that was twice reinstated after two totally different docs cleared him for psychological health at totally different factors within the earlier 5 years. 

He then drove to his in-laws’ home, slashed the tires on his spouse’s automobile and walked inside the house. 

Six gunshots later and 4 folks could be lifeless: Shanna, 31, Aaliyah, 10, Brenda, 52, and Lionel, 33.

A collage reveals the Desmond household and Lionel’s navy comrades. (CBC)

Stopping this from taking place once more

There may be huge room for enchancment in how authorities establishments deal with veterans, folks with psychological sickness and households liable to home violence. 

In Desmond’s case, the transition from the navy health-care system to the civilian one created quite a few hurdles. It is an space that the decide and attorneys Tara Miller and Adam Rodgers say they count on to handle. 

All three have famous that there must be higher communication between the navy and civilian health-care techniques — and a neater means for a soldier to entry their navy well being information.

“When someone is launched, both medically or they’re retiring from the navy, they need to stroll out of the door that day with their medical information on a disc or a USB stick,” stated Miller, a lawyer representing the estates of Brenda and Aaliyah Desmond. “The actual fact that there’s a course of that they’ve to use and wait and submit varieties to get their medical information, the paperwork and the administration slows all that down.”

WATCH | Lawyer Tara Miller shares her suggestions for change: 

Lawyer at Desmond inquiry says modifications are wanted for veterans leaving navy health-care system

Tara Miller, a lawyer on the Desmond inquiry, says troopers leaving the navy must be given a duplicate of their well being information the day they’re launched. To take action, will be certain civilian docs have a greater image of what remedy the affected person may want. 5:31

Rodgers, who represents Lionel Desmond’s property, stated he expects he’ll make a suggestion to take that concept a step additional: to attach veterans with a household physician as quickly as they go away the navy.

“This inquiry is just not designed to put blame, so we’re not focusing an excessive amount of on who did what improperly, however it’s clear that there have been main gaps within the transition from the navy to the provincial well being system,” he stated in an interview. 

Gun security

One other hole the decide returned to this week may even actually be a part of his remaining suggestions — making it necessary for docs to report a change in a affected person’s psychological well being in the event that they’ve beforehand cleared them to be match sufficient for a firearms licence.

Medical doctors in New Brunswick twice signed off on Desmond’s medical kind wanted as a part of a firearms licence evaluation. That kind has already modified in order that it requires extra data from a physician than a easy sure or no — and the shape in Nova Scotia can be extra sturdy.

However Zimmer famous that there are legal guidelines that power docs to remove somebody’s driver’s licence in the event that they grow to be a public security threat. The identical might be true for firearms, he instructed. 

Inquiry counsel Allen Murray echoed the decide’s sentiment. 

“A medical practitioner gives an opinion that’s … it is a snapshot in time,” he stated in an interview. “And, after all, the particular person’s bodily or psychological well being can change.”

Lionel is proven right here together with his daughter, Aaliyah, in Toronto. By all accounts, he deeply cherished the woman. (Submitted by Cassandra Desmond)

Help for households

The presumption of preventability within the deaths of the Desmond household is printed, too, within the threat elements which are thought-about to foretell a heightened threat of home murder. 

The Ontario Home Violence Loss of life Evaluation Committee has recognized 41 such elements and considers there to be a heightened threat if seven are current. 

Within the Desmonds’ relationship, there have been 20. 

“If someone had accomplished an intensive threat evaluation” with both companion within the final month of their lives, they need to have seen that sample, testified Peter Jaffe, the Ontario-based Centre for Analysis and Schooling on Violence In opposition to Girls & Kids.

Framed photographs of Shanna and 10-year-old Aaliyah Desmond are displayed within the Borden house, the place they had been killed on Jan. 3, 2017. Thelma and Ricky Borden, Shanna’s dad and mom, nonetheless reside there. (Eric Woolliscroft/CBC)

That is a niche that Miller hopes to shut. She plans to suggest methods to make it simpler for relations to share data with health-care suppliers.

“What can we do to boost, to strengthen, to make sturdy home violence interventions … and to assist the households alongside that journey,” she stated.

“Lionel Desmond introduced … the battle house with him. And that meant that these folks at house with him entered that warfare unwittingly with him as they struggled to assist him and transfer ahead.”

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