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Anita Cenerini holds a portrait of her son, Private Thomas Welch, at her home in Winnipeg on Oct. 26, 2016. Pte. Welch died by suicide three month after returning from Afghanistan.

LYLE STAFFORD/The Globe and Mail

The military needs to improve how it deals with grief-stricken families after a soldier dies, as too many have to fight to find out what led to their loved one's death, concludes a new report from the Canadian Forces ombudsman.

The report, released on Tuesday, includes several recommendations for improving how information is shared with families after a death and for enhancing the military's board of inquiry system, which examines what factors contributed to a serious injury or fatality, including suicide.

Gary Walbourne, the National Defence and Canadian Forces Ombudsman, found that the military's engagement with families varied wildly from case to case. Many families felt they had to hound the military for information, while some believe they've never been told the whole story.

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Related: Infantry soldier's story reveals gaps in Canadian Forces' inquiry system

"Families should not have to chase after information they have a right to access – whether the death happened during operations or not – they should be assisted in their efforts to obtain it," the ombudsman's report states.

In several instances, the lack of timely, concrete information added to a family's confusion about the military's system for investigating deaths and ultimately made the grieving process harder.

"It just brings [healing] to a full stop if they feel, for some reason, there is some information they should be entitled to but are not receiving," Mr. Walbourne said in an interview. "It leaves doubt in their mind. Those type of things manifest."

The case of Private Thomas Welch, chronicled in The Globe and Mail on Monday, illustrates why this issue matters, Mr. Walbourne said.

The 22-year-old soldier took his own life in May, 2004, just three months after returning from the Afghanistan war. Yet, nearly 13 years later, his family is still waiting for answers from the military.

Pte. Welch, an infantryman with the 3rd Battalion of the Royal Canadian Regiment, was the first Canadian soldier to kill himself after serving in the volatile operation, a Globe investigation discovered.

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The Forces confirmed last week that no board of inquiry was conducted to examine what factors contributed to the young soldier's death and whether there were lessons to help prevent other suicides. Only a lesser summary investigation was done, and its findings were never shared with the family.

The investigation report, which the military retrieved from the government's Library and Archives Canada after The Globe made several inquiries last year, will soon be presented to the family, a military spokesperson said.

The long wait for answers has been heart-wrenching, said Pte. Welch's mother, Anita Cenerini. She repeatedly asked for information, but received scant details. Eventually, the struggle for truth wore her down.

"The passage of time doesn't change anything when an injustice has occurred," she said Monday. "I never got closure."

Boards of inquiry into military suicides were not mandatory in 2004, but had been carried out in other cases.

Rules were changed in August, 2008, making inquiries the standard in deaths by suicide. But practices for sharing information with families remain inconsistent and the robustness of the internal probes varies.

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Several families of soldiers lost to suicide have told The Globe they felt marginalized by the inquiry process – and even targeted for blame in some cases. More than 70 Afghanistan war veterans have killed themselves after serving in the mission, the newspaper's continuing probe of military suicides has found. Many were dealing with post-traumatic stress disorder or other mental illnesses related to their deployments.

Suicides have been at the heart of many boards of inquiry in recent years. Of the 54 inquiries held over a two-year span ending in June of 2016, 35 involved suspected suicides.

The internal inquiries, which are not open to the public or media, used to take several years to conclude, but improvements have been made and most final reports are completed between nine months to a year after the death review is ordered, the ombudsman's report notes.

The ombudsman's review of how bereaved families are handled by the military was done in collaboration with the Canadian Forces. Mr. Walbourne wants the military to provide families with more and better information on its board of inquiry process and grief-support programs. He proposes developing guidelines for commanding officers to meet with families who want to know what happened to their loved one.

Mr. Walbourne's review also found that more training is needed for military workers appointed to the role of designated assistants, who help support families after a soldier's death.

Moreover, many of the guides and reference materials that the assistants rely on to help families are outdated or missing pertinent information, the ombudsman discovered. The resources are also not located in one place.

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Mr. Walbourne recommends establishing a permanent military working group to ensure that policies, guides and training are updated and responsive to families' needs.

The military's top commander supports the ombudsman's findings and recommendations. In a letter to the ombudsman dated Feb. 17 and included in the report, General Jonathan Vance said he wants to make sure that families receive "the best possible support at their most vulnerable time."

"We learned a great deal during the Afghanistan campaign and have improved our processes considerably." Gen. Vance wrote. "However, there is more work that can be done."

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