Systemic failures and racism: Hearings for Desmond inquiry conclude in Nova Scotia
'These deaths were the tragic result of the failures of multiple service providers,' lawyer says
Systemic failures and racism were partly to blame for the tragic chain of events that led an Afghanistan war veteran to kill his family and himself in 2017, an inquiry heard Wednesday as it concluded its public hearings.
The provincial fatality inquiry was told Lionel Desmond served in Afghanistan as a rifleman during a particularly violent tour of duty in 2007 and was diagnosed with post-traumatic stress disorder and major depression in 2011.
Despite four years of treatment while he was still in the military, the inquiry heard Desmond required more help when he was medically discharged in 2015 and later took part in an intensive residential treatment program in Montreal in 2016.
Lawyer Tara Miller told the inquiry the deaths were preventable.
"These deaths were the tragic result of the failures of multiple service providers and institutions ... to share and take action on meaningful information in a timely way, or at all," said Miller, who represents Desmond's sister, Chantel.
Miller said those same institutions failed to provide mental health treatment to Desmond, who was Black, in a "culturally responsive manner," and to identify and address signs of intimate partner violence.
As Desmond was leaving the army in 2015, it was clear to those providing him with mental health services that he required a case manager to help him navigate the provincial health system, she said. But it took Veterans Affairs Canada six months to get that done.
As well, Miller noted health-care professionals at the provincial level were "significantly restricted" in what they could do because they did not have access to any meaningful federal records about the complexity of Desmond's mental health challenges.
"Without these records, none of the Nova Scotia health providers were set up for success in treating Cpl. Desmond," she said.
The former infantryman faced further challenges in August 2016 when he left the residential treatment program at Ste. Anne's Hospital in Montreal. A comprehensive discharge summary, which made it clear Desmond was a desperately ill man, did not include key findings about his mental health and risk factors associated with intimate partner violence, Miller said.
More importantly, the summary was never shared with health providers in Nova Scotia, she added.
"Despite the foreseeability of his need for extensive mental health treatment, and despite being ensconced in the Veterans Affairs system, Cpl. Desmond found himself seeking help from mental health providers (on his own)," Miller said.
While it's true that the sharing of health information is governed by privacy legislation, Miller said the rules state that health records should be made readily available to those within a patient's "circle of care." That wasn't done in Desmond's case.
On another front, Miller cited evidence presented by the Health Association of African Canadians, which reported that African Nova Scotians, like Desmond, face challenges accessing mental health care because of systemic racism in the health-care system.
"They were clear: for Cpl. Desmond to be properly treated ... there needed to have been culturally responsive care provided by clinicians trained in cultural competency," she said. "It's not clear if Cpl. Desmond received this care ... Certainly, none of the treatment providers were Black."
Rubin Coward, who describes himself as a community advocate, told the inquiry that family members made it clear that Desmond faced racism while serving in the military. He said that discrimination stood in the way of proper treatment.
"Complex PTSD is not only caused by war. Racism is a war that (Black, Indigenous and people of colour) are fighting," said Coward, who experienced racism while serving in the Royal Canadian Air Force in the early 1990s and was later diagnosed with PTSD.
"Treatment of people of colour for racism should, where possible, be carried out by (Black, Indigenous and people of colour) because they are ... culturally competent and sensitive to the fragile condition of such victims. These individuals, once traumatized, have lost their ability to trust."
The inquiry heard that on Jan. 3, 2017, Desmond legally purchased a semi-automatic rifle and used it later that day to kill his 31-year-old wife Shanna, their 10-year-old daughter Aaliyah, and his 52-year-old mother Brenda.
"As Cpl. Lionel Desmond battled to live with the legacy of the ... trauma he experienced in Afghanistan, his family battled along with him," Miller said.
"Aaliyah, Shanna and Brenda Desmond were the innocent and unintended victims of a war that impacted them daily after his return home, and for which they paid the ultimate price."
The man leading the inquiry, provincial court Judge Warren Zimmer, is expected to submit a final report with findings and recommendations later this year.
The inquiry heard from 69 witnesses during 55 days of hearings, which started in January 2020 but were delayed almost a year because of gathering restrictions imposed as the COVID-19 pandemic took hold a few months later.