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Canadian soldiers of the Princess Patricia's Canadian Light Infantry C Company in Kandahar City.

Louie Palu/The Globe and Mail

Veterans Affairs is not yet routinely reviewing suicides of former soldiers to identify lessons that might protect other vulnerable vets, despite an internal audit of cases that found troubling gaps at the department responsible for Canada's most chronically ill and injured veterans.

Government documents obtained by The Globe and Mail through access-to-information legislation show that a 2014 probe of 49 suicidal vets and 31 suicides uncovered instances where Veterans Affairs was not properly monitoring the distraught vets. Some weren't even screened for suicide risk in the first place.

Despite these findings – and internal calls for case-by-case reviews stretching back to at least 2010 – the federal department hasn't analyzed a single vet suicide since the 2014 audit, revealed Michel Doiron, assistant deputy minister of service delivery at Veterans Affairs. He pledged on Wednesday that a process for regularly scrutinizing suicides and attempted suicides will be introduced this year.

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Read more: Ottawa to pay for funerals of vet, family in Nova Scotia, but won't commit to probe

Read more: Remembering 31 Canadian Afghanistan war veterans lost to suicide

Roméo Dallaire: The war doesn't end when soldiers return home

"We've been looking into it since the fall," Mr. Doiron said in an interview. "We want to make sure that if there is something for us to learn from a [suicide] event, that we do learn it and we rectify accordingly."

Part of the problem, the 2014 probe found, was Veterans Affairs' own administrative database, which was primarily designed for processing disability and benefit claims and not for tracking health changes and suicide risk among former military members, states an internal Veterans Affairs' report that summarized findings from 10 medical and veterans experts involved in the audit.

"One barrier to care noted by several reviewers was missed opportunities to recognize prior suicidality in clients and arrange follow-up monitoring," the report notes. "This barrier was thought in part to be due to the business rather than clinical focus" of Veterans Affairs' database.

While the Canadian Forces are responsible for delivering health services to their military members, veterans fall under provincial medicare. Of the country's nearly 700,000 vets, about 120,000 receive services or payments from Veterans Affairs, often for serious physical injuries or mental illnesses, such as post-traumatic stress disorder.

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One of those ill vets was Lionel Desmond, who deployed to Afghanistan in 2007. Mr. Desmond's family said he was struggling with PTSD when he was released from the Forces in July, 2015. Last week, in a rural Nova Scotia home, police believe he gunned down his wife, Shanna Desmond, their 10-year-old daughter, Aaliyah, and his mother, Brenda Desmond, before killing himself.

The Nova Scotia government has launched an investigation of how the health system dealt with Mr. Desmond, a former infantryman with the 2nd Battalion of the Royal Canadian Regiment, based in Gagetown, N.B. Just two days before the shootings, the veteran sought help at St. Martha's Regional Hospital in the nearby town of Antigonish, family members said. They believe he didn't get adequate help at the hospital.

Rev. Elaine Walcott, a relative of the Desmond family, is calling on the military and Veterans Affairs to also investigate how they handled the chronically ill soldier. Neither Veterans Affairs nor the Forces has publicly committed to probing the Desmond case.

"There is a responsibility, systemically, for this to be examined," she said Tuesday, on the eve of funerals for the Desmond family. "This is an opportunity to put a lens on" mental-health care.

Mr. Desmond, 33, is among at least 72 soldiers and veterans who have killed themselves after serving on the Afghanistan mission, an ongoing Globe and Mail investigation has found. Most have only taken their own lives, but just before Christmas in 2015, Robert Giblin, a veteran of two Afghanistan tours, stabbed his wife, Precious Charbonneau, before they fell from a high-rise apartment in Toronto. Mr. Giblin's family said he suffered with PTSD.

Former veterans watchdog Pat Stogran, a retired army colonel, said it is "reprehensible" that formal suicide reviews are not yet commonplace at Veterans Affairs. He noted that he raised the issue during his ombudsman tenure, from 2007 to 2010.

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"There has to be a feedback loop to say where we are going wrong," Mr. Stogran said. "They should be taking substantial and very visible steps to fight this problem. It's life and death."

An expert group that reviewed, in 2010, a dozen vet suicides had also urged the department to routinely examine such deaths to better understand how to prevent other suicides. Yet no further investigation was done until 2014.

According to the access-to-information documents obtained by The Globe, the 2014 audit was conducted to identify suicide triggers, determine whether interventions were tried and to pinpoint measures to improve suicide prevention at Veterans Affairs.

The study's experts noted that valuable information was gained by examining the 80 cases of vets who had either died by suicide, attempted to, or thought about ending their life.

Most of the veterans had a chronic physical-health problem coupled with a mental-health illness. Many were also coping with other stress, such as difficulty finding a job or financial, relationship and legal troubles.

Seventy-nine per cent were males and most had been released from the military in recent decades. A dozen, though, had served in the Second World War or Korea.

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Of the 31 vets lost to suicide, the majority ended their lives at home, the probe showed. Their deaths occurred from 1961 to 2013.

Some "best practice" examples were found where front-line Veterans Affairs staff prevented suicides. Improvements in documenting suicide risk, compared with the 2010 review, were also noted.

The audit showed that the suicide profile of elderly vets differed from younger ones. These older former soldiers were less likely to have documented mental-health problems, but suffered with multiple chronic physical-health issues and social isolation.

Despite the audit's numerous insights, a presentation included in the documents indicates staff with the Veterans Affairs' service-delivery branch recommended against formal reviews of individual suicide cases. The presentation, prepared in June, 2015, acknowledges that data from the 2010 and 2014 studies have provided "significant information," but cautions that there are "professional, ethical and legal considerations for employees whose actions will be reviewed."

The recommendation then was for Veterans Affairs to periodically perform general examinations of suicide cases. That position has since changed.

Mr. Doiron said Veterans Affairs' newly hired chief psychiatrist, Alexandra Heber, was asked to look into the issue in September. He said he hopes that an official suicide-review process will be in place by the end of March. Currently, only administrative reviews are done to determine whether benefits are owed to families. Any lessons identified are shared within the department, Mr. Doiron said.

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Veterans Affairs and the Canadian Forces are working on a suicide-prevention strategy, which is expected later this year. Veterans Affairs recently added a tool to electronically record and track suicides and, in November, updated guidelines for dealing with suicidal veterans.

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