System failed Gagetown soldier who killed family: inquiry report

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A judge overseeing the horrific case of a former Base Gagetown soldier and Afghanistan War veteran who killed three family members isn’t pointing the finger at any of the many professionals who interacted with him but blames systemic problems for the tragedy.

Judge Paul Scovil released his final 25 recommendations at the Desmond Fatality Inquiry in Port Hawkesbury courthouse in Nova Scotia on Wednesday, close to where the tormented former soldier, Lionel Desmond, had lived.

On Jan. 3, 2017, Desmond shot his wife Shanna, their 10-year-old daughter Aaliyah, and Desmond’s mother Brenda, before turning the gun on himself at their home in Upper Big Tracadie, Guysborough County, near Cape Breton.

He had served a lengthy tour in Afghanistan from January to August 2007, where “he witnessed many difficult things,” the judge said, and returned from the central Asian country “a broken man.”

In 2011, Desmond was finally diagnosed as suffering from severe post-traumatic stress disorder.

A preventable tragedy?

Before and after his discharge in the military, there were at least 40 health, mental health, Canadian Armed Forces, Veterans Affairs and police officials who interacted with Desmond about his “prolonged and complex mental health” problems, the inquiry found.

“This has been an arduous and emotional process for everyone involved,” Judge Scovil said. “The overarching question here is whether the Desmond family’s tragic deaths could have been predicted or prevented. At the end of the day, it is impossible to say with certainty that had my recommendations been in place when Cpl. 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.”

Among his findings, Scovil recommended better training for health professionals and police officers to understand the warning signs of domestic violence.

No one person should have a finger pointed at them. The issue was systematic.

Judge Paul Scovil

Desmond’s relationship with his wife, a nurse who he’d married shortly after high school, was turbulent and prone to periods of separation. She had continued living in Guysborough Country throughout his military service, which began in 2004 to support his family. Before his military service, he was described as a team player and funnyman. After his tour of duty, he often thought of killing himself.

Delays in treatment

The judge highlighted a key delay in Desmond’s mental health treatment, after he was released from the military on medical grounds in 2015 but still lived in Oromocto, near the base. After speaking with health-care professionals, it took six months to assign a case manager to oversee his treatment.

Once Desmond moved back to his home province in the summer of 2015, he encountered more delays seeking treatment.

“It was striking that once Cpl. Desmond transferred to Nova Scotia that it took many months to ramp up the care that Cpl. Desmond needed,” the judge wrote.

“No one person should have a finger pointed at them. The issue was systematic. Up to and including the aftermath of Jan. 3, 2017, Cpl. Desmond was forward-looking as far as therapy and counselling. We can only speculate as to what changed with that attitude just before Cpl. Desmond walked into the Leaves and Limbs Sports and made his fateful purchase.”

On Jan. 3, 2017, only a day after he had checked himself out of St. Martha’s Hospital in Antigonish where he’d been treated by a psychiatrist, he went into the sports store and legally purchased a Russian SKS-AR rifle. That evening, at around 6 p.m., he killed his family.

Family members pushed for inquiry

The evidence showed that Desmond first killed his wife, shooting her in the neck, chest and stomach. His mother, Brenda, described as a hard-working single mom who’d raised Desmond and four other siblings on her own, frantically called her brother, George Desmond, to tell him what had happened. Lionel Desmond then turned the gun on her, before killing his daughter too.

He then put a bullet through his head.

The young girl’s aunt, Chantel Desmond, dropped by shortly after 6 p.m. to visit with her niece and tell her that her regular tutoring class, scheduled for later that evening, had been cancelled. Instead, she found a bloodbath.

The inquiry, which took nearly six years to reach its conclusion, happened in large part because Desmond’s surviving family members had pushed for it.

Ordered by Nova Scotia’s minister of justice in 2018, it sat for 56 days over several years, due in part to delays related to the pandemic.

Scovil’s report and recommendations were based on a review of the evidence, including testimony from 70 witnesses and 377 documents entered as exhibits during the proceedings.

His final report contained no findings of legal responsibility because fatality inquiries are governed by the Fatality Investigations Act and are different than public inquiries, which traditionally focus on uncovering facts and can make findings of legal responsibility.

No evidence of being turned away from hospital

The judge said there wasn’t evidence to support the family’s contention that he was turned away from treatment at St. Martha’s Hospital or that he hadn’t received proper treatment. He said the doctor and psychiatrist who dealt with Desmond at the hospital had limited information about his past and couldn’t have known he would go on a murderous rampage.

Scovil found the institutions, health-care professionals and community members could have done a better job-sharing information about Desmond’s medical history, as well as his physical and mental state in the days leading up to these deaths.

It was clear that the dissemination of information regarding Cpl. Desmond was lacking among institutions, health care professionals and members of the community with concerns.

Judge Paul Scovil

This type of information would also have been important for firearms officers, he said. These officials are tasked with evaluating applications for firearms and must decide based on the information before them whether to grant a possession and acquisition licence for a weapon, or to place such a licence on review and, if need be, have a firearm removed from a gunholder’s possession.

“In this inquiry it was clear that the dissemination of information regarding Cpl. Desmond was lacking among institutions, health-care professionals and members of the community with concerns, but no real idea of where to go with these concerns, or even if they should,” the judge wrote in his report.

“Health-care information needs to easily follow an individual across federal and provincial boundaries and within provinces. Individuals, professionals, and others need to take a close, hard look at the need to share concerns, and to work with those whose consent is needed to insure information flow.”

The judge also made several recommendations to improve access to health care for Black Nova Scotians, particularly in rural communities.