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Officers at Canada’s oldest military college and the military’s medical community had little understanding of suicide risks, or even how many students were attempting to kill themselves, in 2016 when three young officer cadets took their own lives, a team of investigators says.

The three-member board of inquiry into the deaths of 22-year-old Harrison Kelertas, 20-year-old Brett Cameron and 19-year-old Matthew Sullivan, which released its report to the families this week, found that the Royal Military College of Canada (RMCC) in Kingston, Ont., had no comprehensive suicide-prevention plan, and no clear protocols to follow when a suicide was attempted.

The deaths of the three young men shook the Canadian Forces and prompted a visit by senior staff in November, 2016. The findings of that visit led General Jonathan Vance, the Chief of Defence Staff, to take the college under his direct command and resulted in 79 recommendations aimed at improving the culture at RMCC, most of which have already been enacted, says Lieutenant-General Charles Lamarre, the head of military personnel.

But two years ago, the new report of the board of inquiry says, there was little understanding of what was causing young people to contemplate suicide.

The RMCC “has many elements aimed at suicide prevention but does not have the overarching suicide prevention strategy required for effective implementations of these elements,” says the report of the board headed by Colonel François Messier. In addition, the report says, the RMCC chain of command “could not state, with a degree of certainty, the number of attempted suicides that occurred between January to June 2016.”

Lt.-Gen. Lamarre said much has changed at the college since the tragedies two years ago. A permanent medical clinic was created that can handle mental-health issues, and every officer cadet must undergo resiliency training in their first year. In addition, the military and Veterans Affairs Canada launched a joint suicide-prevention strategy in 2017 after large numbers of suicides were being reported among soldiers and veterans.

But two years ago, the report says, there was a lack of understanding across the armed forces about the “signs, triggers and stressors” of suicide – and that was also true at RMCC as young men were taking their own lives.

OCdt. Kelertas was from Hudson, Que., and was an internationally competitive fencer. He died in a college dormitory on April 28, 2016.

OCdt. Cameron was from London ,Ont., where he was a member of the air cadets and was passionate about music and flying. He was in the same RMCC squadron as OCdt. Kelertas and was found dead at the college on May 7, 2016.

OCdt. Sullivan was the top cadet in his unit in Saint John before becoming a student at RMCC. He had been placed in a holding unit at the college and was waiting to be medically released after developing depression and anxiety. He died on Aug. 11, 2016, the day after arriving back in Saint John.

The board of inquiry report released this week is heavily redacted to remove any of the details of the deaths of the young men.

But it goes on at length about the importance of not using officer cadets to supervise their classmates who are under suicide watch.

It also talks about the treatment of cadets who are in the holding unit waiting for release. “For ill and injured [officer cadets], a long and uncertain period of transition from holding platoon back to civilian life constitutes a stressor for which RMCC does not mitigate,” the report says. Academic failure, it says, must be recognized as a suicide risk.

In addition, it says, the school does not have the necessary protocols to provide information and support for those bereaved or affected by suicide or a suicide attempt, even though those affected are at higher risk of dying by suicide themselves.

In total, the board made 53 findings aimed at preventing future suicides at RMCC.

In a written response, Gen. Vance agreed with all but two. He said the Canadian Forces' health-services team, rather than RMCC as recommended by board, should track and report attempted suicides. And he said it would be impossible to follow the board’s recommendation that the mental-health history of all candidates for RMCC be verified.

Gen. Vance said it was with “extreme sorrow” that he now considered the investigation into the deaths of the three young men closed and “if possible to do so, suicides will be prevented for good at RMCC.”

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