A Veterans Affairs internal review conducted after Lionel Desmond killed his family and himself in rural eastern Nova Scotia four years ago found 12 areas where the department could improve helping veterans with complex needs make the transition to civilian life.
The federal government had initially refused to disclose details of the review to a Nova Scotia fatality inquiry currently examining the murder-suicide involving the Afghanistan war veteran, but it subsequently relented and the review was publicly released this week.
While it determined there had been "no procedural errors" in the case, some of the barriers it identified have been echoed by previous testimony at the inquiry.
Among them is that Veterans Affairs case managers were in high demand when Desmond was released from the military in 2015. He had to wait six months to get a case manager.
On Wednesday, Marie-Paule Doucette, Desmond's case manager, testified she had a caseload of 35 to 40 clients within a year of being hired. On paper, case managers are only supposed to take on 25 veterans at a time, she said.
It's why she has to prioritize, she testified, and why veterans are expected to take some level of responsibility in managing their recovery.
"I have to pick and choose what I'm going to sit down with them to help them fill out," she said. "Because the time that I have to dedicate is already quite limited.
"So I'm not saying I don't care, I'm saying that I have to be realistic about what I have to prioritize."
Some recommendations adopted
On Jan. 3, 2017, Desmond bought a rifle, drove to his in-laws' home in Upper Big Tracadie, N.S., and killed his wife, Shanna, his 10-year-old daughter, Aaliyah, and his mother, Brenda. He then turned the gun on himself.
Veterans Affairs has adopted the review recommendations in at least five of the areas identified for improvement, a spokesperson told CBC in a statement. Descriptions of new policies covered most of the issues in another five areas.
One was the recruitment of more case managers, which the department said is ongoing. It's also investing in technology so that case managers spend less time on administrative tasks, the statement said.
"We are building a new suite of case management tools so that case managers have more time to work directly with veterans and their families."
The Veterans Affairs internal review notes that timely intervention of a case manager "is a factor to success and rehabilitation."
Desmond's transition predicted to be difficult
During his exit interview from the military in May 2015, Desmond was scored as being "moderate risk for unsuccessful transition" to civilian life. By the time he met his case manager that November, his chance of success had worsened — she scored him as having a "high risk" of not being able to transition.
That risk never changed during her interactions with him, Doucette testified.
Desmond had been diagnosed with severe post-traumatic stress disorder by a military psychiatrist in 2011, connected to what his fellow soldier described as "a brutal" seven-month tour of Afghanistan in 2007.
He underwent prolonged exposure therapy for trauma in the military, took medication and continued to see a psychiatrist and a psychologist at New Brunswick's Occupational Stress Injury clinic for veterans after he was released from the military.
Veterans Affairs paid for his in-patient treatment at a residential psychiatric facility, but he made minimal progress there between May and August 2016. The team there recommended he get a neuropsychological assessment done to see if he had a brain injury from a concussion, so therapy providers could take that into account in making a plan for him.
But when he was released from care, he never received any therapeutic treatment or a neuropsychological assessment. The difficulty in obtaining those was compounded by the fact that he moved from his home near CFB Gagetown in New Brunswick to live with his family in Nova Scotia where he had no follow-up resources.
Doucette tried to get a clinical care manager to help Desmond navigate finding new health-care providers, but that took three months due to a bureaucratic delay in her needing to take a course.
Veterans Affairs noted that delay in its internal review and since adopted the corresponding recommendation to offer the course on its record-keeping system on an "urgent basis" in the future.
Other recommendations that the review identified — and have since been adopted or addressed in policy — include:
Connecting a veteran to their local Veterans Affairs office before they relocate to another province and considering have a case conference with the new case manager were followed.
Better consultation around health-related travel, with its affect on family as in Desmond's case, his family's travel to visit him in Montreal at the in-patient facility was denied.
Holding interdisciplinary team meetings to "discuss and take action on" medical recommendations from an Occupational Stress Injury .
A new suicide prevention program.
The provincial inquiry is expected to meet in September so that all the parties can submit their recommendations to Judge Warren Zimmer for consideration.
The recommendations will look at preventing future deaths, focusing especially on whether the Desmond family had access to domestic violence support services, whether Desmond had access to appropriate mental services after his release from the in-patient facility and the policies that allowed someone with a complex mental illness to legally purchase a gun.