Nearly a year after former soldier Lionel Desmond killed his family and then himself, Nova Scotia's chief medical examiner is recommending an official inquiry be conducted to prevent more such deaths.
Dr. Matthew Bowes said Thursday that many questions have been raised since the tragedy.
"The purpose of this, of course, is to look for some tangible connection between the deaths and the appearance of a failure of policy or practice which, if corrected, is likely to prevent future deaths of this same type," he said.
Desmond, 33, was a veteran of the Afghanistan war and had post-traumatic stress disorder (PTSD). He killed his mother Brenda Desmond, 52, his wife Shanna Desmond, 31, and their 10-year-old daughter, Aaliyah Desmond, before killing himself in the couple's Upper Big Tracadie home in Guysborough County on Jan. 3.
Bowes said he was struck by the fact that many government agencies "touched on Mr. Desmond's life" and wondered whether they could have done more to prevent the tragedy.
"It's not like Mr. Desmond was unknown and this happened out of the blue — there was a trajectory," he said. "There was touch points in our system and I think it would be very valuable to look at how those things occurred and how we might, in retrospect, have done it differently."
Former MP Peter Stoffer, who now works as a veterans advocate at Trauma Healing Centers, said it's good that the province is looking into the matter.
"There's an awful lot of unanswered questions as to why someone who wore the uniform of Canada would do a terrible act," said Stoffer. "It's one thing to kill yourself, but to take three other people with you, that is horrible."
Stoffer said care for veterans is a federal responsibility, not provincial. He called on the Department of National Defence and the Department of Veterans Affairs to help with the inquiry.
"Hopefully with the provincial inquiry being called, they can access any and all federal information from DND and DVA to assist the inquiry," he said.
He said key questions are what happened in the transition period when Desmond left active service, what services he and his family received from DVA once he'd left, and if there were any gaps in that care.
Beyond Nova Scotia
Two of Desmond's sisters, twins Chantel and Cassandra, have campaigned for an inquiry, saying their brother did not get the help he needed.
"It's about time," Chantel Desmond said Thursday.
"We're fighters and we're not going to give up," she said. "I think they really felt it would get nowhere and get swept under the rug but this is just the beginning."
Desmond said she's hopeful the inquiry will shed light on "what the province did, and what they didn't do" as well as the federal government's mistreatment of veterans.
"It took my family to go through it," she said. "I lost my family and now I'm worried about trying to help other families."
Reaches 'well beyond' Nova Scotia
Dr. Bowes said even if the inquiry doesn't address all the issues that led to the deaths, anything that can be learned is valuable to "make our systems better."
He added: "I am mindful of the fact that this is an important issue, that this has a scale that reaches well beyond Nova Scotia's borders and the scale of the response to that issue does not seem to be satisfactory yet."
Veterans Affairs Minister Seamus O'Regan told CBC News the federal government will work with the province.
"We are prepared to make available necessary information on matters including: federal care provided to veterans and their families; how veterans' operational stress injuries are addresses; and the continuity of care provide to veterans," he said in a written statement.
"While we are committed to offering the fullest support available, we will also need to see the terms of reference before we can respond more fulsomely."
National Defence response
In a statement, the Department of National Defence said it intends to work with the province and Veterans Affairs to provide support during the inquiry, but noted the details of how that will work need to be developed.
"Our leadership is committed to ensuring that its members are mentally and physically strong and resilient, and prepared for the demands of military life," said spokesperson Jessica Lamirande in an email.
"This is why we also continue to work with our colleagues at VAC [Veterans Affairs Canada] to improve the delivery of services to those transitioning to civilian life," she wrote.
Last fatal inquiry held a decade ago
Bowes said it's not clear in what capacity the federal government would co-operate when it comes to an inquiry.
"I'm hoping that both levels of government [including provincial] will co-operate fully … and that both levels of government can learn from any errors or lapses or mistakes that were made to prevent this tragedy from ever happening again."
The inquiry will be conducted under the Fatality Investigations Act, a rarity in the province. The last time a fatality inquiry was held in Nova Scotia was the Hyde inquiry almost 10 years ago.
More details about the Desmond inquiry and the appointment of a judge to oversee it will be announced in the new year.