The judge overseeing an inquiry in a triple murder-suicide involving a former Canadian war veteran it is almost impossible to determine if the deaths could have been prevented.
Judge Paul Scovil presented his report and 25 recommendations on the Lionel Desmond hearings.
Desmond served two tours in Afghanistan and suffered from severe PTSD. When he moved back home to Nova Scotia, he went four month without treatment due to difficulties accessing his medical records from the military.
He shot and killed his wife, daughter and mother before turning the gun on himself in Upper Big Tracadie, N.S. in 2017.
“This has been an arduous and emotional process for everyone involved, but hopefully also a worthwhile one,” Judge Scovil said.
Scovil stated health care professionals could have done a better job sharing Desmond’s medical history and his mental state.
“The overarching question here is whether the Desmond family’s tragic deaths could have been predicted or prevented,” said Judge Scovil. “At the end of the day, it is impossible to say with certainty that had my recommendations been in place when Corporal Desmond left the military, no suicide or homicides would have occurred. But we can say they could have possibly helped avert the tragic events of January 3, 2017.”
The inquiry last 56 days over seven years and heard from 70 witnesses. It was delayed by COVID 19 and a change in judges over that time.
Desmond Fatality Inquiry – Recommendations
Recommendation 1: It is recommended that the Province of Nova Scotia advocate the Federal Government to have a case manager assigned to Veterans transitioning out of the Canadian Armed Forces.
Recommendation 2: That the Rapid Access and Stabilization Program be funded by the Province of Nova Scotia to include all regions in Nova Scotia.
Recommendation 3: That the Province of Nova Scotia liaise with federal agencies to ensure individuals diagnosed with Post Traumatic Stress Disorder or other health issues be provided a copy of their health records to be ingested into Nova Scotia records.
Recommendation 4: That the Nova Scotia Health Authority and the Nova Scotia Department of Health and Wellness assess the availability of neuropsychological assessments in the province and, if needed, take steps to ensure they are more readily available.
Recommendation 5: That the Nova Scotia Health Authority continue to update its Suicide Risk Assessment & Intervention policy and tool based on the most up-to-date evidence on suicide risk assessment and continue to train staff engaged in mental health on the SRAI policy and tool and be provided adequate funding by the Province of Nova Scotia to do so.
Recommendation 6: That the Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority partner with appropriate community organizations to provide more comprehensive virtual care to rural African Nova Scotian communities.
Recommendation 7: That the Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority take steps to recruit Black and diverse mental health providers to provide culturally informed and responsive care with an emphasis on training in the areas of psychosocial services, occupational stress, and general mental health and addictions with appropriate provincial funding.
Recommendation 8: The Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority should recruit and provide educational scholarships for Black registered nurses and nurse practitioners with appropriate provincial funding.
Recommendation 9: The Network of Black Mental Health Providers built from the work of the Nova Scotia Mental Health and Addiction Strategy should be supported and adequately resourced by the Province of Nova Scotia.
Recommendation 10: The Province of Nova Scotia should ensure that funding for the Men’s Helpline through the provincial 211 system continue, and work to increase public awareness of websites that provide information for those who encounter intimate partner violence.
Recommendation 11: That the Province of Nova Scotia embark on a public information campaign across multimedia regarding avenues to access programs relating to intimate partner violence. Further, that any campaign be aware of, and refer to, African Nova Scotian needs and cultural identity.
Recommendation 12: Ensure that frontline professionals in multiple systems such as health, mental health, education, social services, and the justice system, are up to date with current information about intimate partner violence, the dynamics in these relationships, the impact of intimate partner violence on children and the potential for lethality in these cases. This should include an awareness of risk factors, risk assessment, safety planning and risk management strategies.
Recommendation 13: That Nova Scotia institute a police standard requiring all police agencies to utilize an intimate partner violence risk assessment tool in all calls and investigations involving domestic conflict where concerning behaviour regarding an intimate partner is present irrespective of the existence of a criminal charge.
Recommendation 14: That the Nova Scotia Departments of Justice and Community Services review the High-Risk Case Coordination Protocol to deal with cases in which there is no criminal offence but there is concerning behaviour related to the intimate partner.
Recommendation 15: That Nova Scotia’s Chief Firearms Officer work with other provinces to ensure that processes are in place to notify when clients of this and other provinces are involved in events that create FIPs and to ensure that information is shared in a timely manner.
Recommendation 16: That police officers in Nova Scotia receive additional training on proper Uniform Crime Report coding.
Recommendation 17: That the Province of Nova Scotia advocate with the Federal Government to have federal policing agencies provide firearms officers access to the federal police database (PROS).
Recommendation 18: That the Province of Nova Scotia ensure all steps be taken to have expedited access by the Chief Firearms Officer to various police databases, including PROS, Versades and Niche.
Recommendation 19: That the Province of Nova Scotia encourage the Federal Government to proclaim in force those provisions of Bill C-71, an Act to amend certain Acts and Regulations to firearms, s.c. 2019, c.9, related to licence verification and business record keeping.
Recommendation 20: That the Province of Nova Scotia advocate the Federal Government to add under section 16(a) of the Application for a Possession and Acquisition Licence under the Firearms Act a provision that applicants must disclose any employment restrictions regarding firearms or weapons.
Recommendation 21: An applicant for a firearms licence or a renewal of a firearms licence should be required to give an enduring consent and direction to the Office of the Chief Firearms Officer to allow follow-up with a medical practitioner at any time during the period that the licence is valid and in effect and to require the medical practitioner to report changes in the health status of the applicant.
Recommendation 22: The Office of the Chief Firearms Officer should, in appropriate cases, place certain licences under review and seek additional medical information, if necessary, to ensure that applicants who have been granted licences are continuing to meet eligibility requirements and are maintaining good mental health.
Recommendation 23: The Office of the Chief Firearms Officer should receive additional funding to facilitate additional and ongoing checks of the mental health status of licensees.
Recommendation 24: That the Province of Nova Scotia liaise with other provinces and the Federal Government to improve the transfer of health records into each others record databanks.
Recommendation 25: To ensure that the recommendations from this Inquiry are not lost in the passage of time, the Province of Nova Scotia should create a formal implementation committee comprising of senior government officials from relevant departments to oversee the implementation of the Inquiry’s recommendations. This committee should have at minimum a five-year mandate and liaise with appropriate federal departments.
