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Lionel Desmond (far right) was part of the 2nd battalion, of the Royal Canadian Regiment, based at CFB Gagetown and shown in this 2007 handout photo taken in Panjwai district in between patrol base Wilson and Masum Ghar in Afghanistan.

The Canadian Press

Afghanistan war veteran Lionel Desmond was holed up in his house having fleeting homicidal thoughts and binge drinking beer alone to cope with severe post-traumatic stress disorder and depression when he made the first desperate call for help to Veterans Affairs Canada.

He had just been released from the military in the summer of 2015, and a Veterans Affairs case manager was supposed to help him co-ordinate the transition to civilian life and connect him with the support and care he needed, but no one had contacted him. After five months and several more calls without a response, Mathieu Murgatroyd, a clinical psychologist who was treating Mr. Desmond at the Operational Stress Clinic in Fredericton, called VAC on his behalf. Dr. Murgatroyd told a coroner’s inquest earlier this year that he had been concerned that Mr. Desmond was becoming unstable and needed co-ordinated support. A case manager made a call to Mr. Desmond the next day, but it took a month for them to actually connect.

On Jan. 3, 2017, the former corporal shot and killed his young daughter, wife, mother and himself in the small rural community of Upper Big Tracadie in rural Nova Scotia.

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In the years since the triple murder-suicide, VAC had not made anything public about its handling of Mr. Desmond’s case owing to privacy legislation. But a coroner’s inquest in Nova Scotia has shone a light on cutbacks and bureaucratic hurdles within VAC that led to systemic failure in the treatment of the Afghan war vet.

Among the bureaucratic obstacles were privacy concerns that prevented VAC from sharing detailed information about Mr. Desmond’s medical history among a contracted private therapist and health care providers in provincial systems; a shortage of case managers owing to cutbacks in the department; and delays transferring his file when he moved to a Montreal in-patient facility and then back to Nova Scotia.

The inquest will reconvene on Sept. 13, and closing arguments are expected later this month. Provincial Court Justice Warren Zimmer, who is presiding over the inquiry, will produce a report and recommendations. However, they will only be provincial in scope because Ottawa rejected the Desmond family’s request for a joint provincial-federal public inquiry.

The 42 days of testimony that the inquest has already heard have provided a window into the lives of thousands of soldiers whose mental health was impaired by their combat experiences in Afghanistan. They have also shown significant gaps in how the federal and provincial governments help veterans with PTSD. With the Taliban’s resurgence in Afghanistan, some vets are facing renewed struggles.

“It is inexcusable that we do not have a system that supports our veterans when they come home from combat, when they have legacy injuries from serving our country and they do not have the resources and support to help them in a way that’s meaningful,” said Tara Miller, counsel for Mr. Desmond’s sister Chantel Desmond, and the estate of his mother, Brenda Desmond. She is also joint council to present concerns related to Mr. Desmond’s daughter, 10-year-old Aaliyah Desmond.

In addition to revealing administrative barriers at VAC, the inquiry has also shown a need for ways to share medical records that respect veterans’ privacy and provide enough information to give treatment providers a full account of their patient so that more soldiers don’t fall through the cracks like Mr. Desmond did, Ms. Miller added.

In the coming weeks, Ms. Miller said, counsel will formulate closing arguments centred on identifying pragmatic solutions for the systemic issues that came out of the testimony.

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More than 40,000 members of the Canadian Armed Forces served in Afghanistan during the NATO-led mission, Canada’s largest deployment since the Second World War. Of those, 22,134 are clients of VAC, and 9,600 are receiving disability benefits for a mental health condition directly attributable to their service in Afghanistan.

A year and a half after Mr. Desmond was medically released from the military, in the late afternoon of Jan. 3, 2017, he bought a rifle and a box of bullets from a hunting store in Antigonish. He changed into camouflage clothing as if he were going into battle. His wife had recently told him she wanted a divorce.

He parked his Ford Escape with its veteran licence plate up a remote logging road in the woods, about a kilometre behind the family home of his wife, Shanna Desmond. He slashed the tires of her red Dodge pickup truck parked in the driveway, then went in the back door and shot and killed Shanna, a newly graduated nurse. He shot his mother and daughter – likely unintended victims who happened to be there, RCMP Corporal Gerard Rose-Berthiaume said at the inquest. Then he turned the gun on himself.

Without adequate support after Mr. Desmond left the military, it was like he brought the war home to his family, Ms. Miller said. “That’s exactly what happened here with Shanna and Aaliyah and Brenda. They were the unintended victims of this battle that came home on home soil. They got caught in the crossfire,” Ms. Miller said.

Justice Zimmer ordered an internal review into VAC’s treatment of Mr. Desmond to be entered as evidence at the coroner’s inquest after lawyers for the Attorney-General of Canada said it wasn’t relevant and refused to provide it. The review found that Veterans Affairs made no procedural errors, but it cited 18 “opportunities for improvement,” many of which Josh Bueckert, a spokesperson for the federal agency, told The Globe and Mail VAC has been working on. Hiring more case managers was one of them, he said.

VAC has more than doubled the number of case managers since 2015 to provide more timely access, and implemented a new screening tool in 2019 to triage high-risk veterans, spokesperson Emily Gauthier said in an e-mail. The case manager ratio is now 31.8 veterans per case manager, compared to VAC’s target of 25:1.

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“VAC is working to lower the case-manager ratio,” Ms. Gauthier said. “We continue to recruit case managers.”

In the months before the deaths, Mr. Desmond also faced another delay from VAC as his mental health continued to deteriorate and he became increasingly controlling of his wife.

After attending a VAC in-patient clinic in Montreal in the summer of 2016, Mr. Desmond returned to rural Nova Scotia. His caregivers in Montreal and his case manager had decided he needed a VAC clinical case manager to increase the amount of help he was getting to meet his basic needs and navigate everyday life in his rural community. But Mr. Desmond had to wait three months for his clinical case manager to complete training on administrative software. In that time, he also went two months without mental-health treatment.

In VAC’s review of Mr. Desmond’s death, the department found that training for clinical case managers should be “done on an urgent basis for cases that require immediate support.”

Other “opportunities for improvement” VAC identified in its internal review include more timely transfer of files to case managers after a veteran relocates. Mr. Bueckert said a new, clearly defined file-transfer process has been in effect since June.

The coroner’s inquest also heard that a psychologist and occupational therapist at the VAC-funded in-patient clinic in Montreal had recommended that Mr. Desmond receive a neuropsychological evaluation when he returned to Nova Scotia to determine his cognitive capacities and identify the support he needed. However, his case manager, Marie-Paule Doucette, told the inquest she wanted to get Mr. Desmond set up with the clinical case manager first, and had not known that would take three months.

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VAC’s internal review recommends that files of veterans who have case managers be reviewed regularly to ensure medical recommendations are taken into consideration.

Mr. Bueckert said quarterly quality assurance reviews are now taking place.

Because VAC did not share detailed information about Mr. Desmond’s medical history with health care providers, including about his increasingly fraught relationship with his wife, none of the people trying to help him in the days and weeks before he killed his family members and himself knew the extent of his mental health issues.

Roland Lawless, a veterans’ advocate who is president of the Veterans Memorial Medical Centre Society, a non-profit that plans to provide mobile outreach services to veterans in rural areas, says privacy protection laws need to be relaxed when lives are at stake.

“It’s a tragedy that should never have happened,” Mr. Lawless said. “A big bungle of privacy kept everybody out of the loop until the big bomb went off.”

Special to The Globe and Mail

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