'Bureaucratic barriers' delayed care for veteran with PTSD who shot family and himself, inquiry hears

The Veterans Affairs case manager assigned to Lionel Desmond faced "significant bureaucratic barriers" that resulted in the months-long delay in getting him clinical services in Nova Scotia after he was discharged from an in-patient psychiatric facility, a provincial fatality inquiry heard Tuesday.

Marie-Paule Doucette testified that both she and the care team at Ste. Anne's Hospital in Montreal felt it was a priority that the Afghanistan veteran with complex PTSD get connected to mental health professionals in his home community, especially given that he showed only "minimal progress" during his 2½ month stay in the summer of 2016.

On Jan. 3, 2017, Desmond shot his wife, Shanna, his 10-year-old daughter, Aaliyah, and his mother, Brenda, before he turned the gun on himself.

Doucette is one of the last witnesses expected to testify at the fatality inquiry.

The presumption of the tragedy's preventability is at the heart of the hearings underway in Port Hawkesbury, N.S., as evidence is gathered to make recommendations about how to prevent future deaths.

The bureaucratic hurdle that kept Desmond from having a clinical care manager — someone to help with his transition to life after the military and in-patient care — was that Veterans Affairs only intermittently offered a course that would teach her how to use the electronic system to submit her notes.

That delay occurred even though Doucette spoke to Helen Luedee, the clinical care manager, on Aug. 16, 2016 — one day after Desmond was released from hospital.

They wouldn't get to meet until Nov. 30, 2016.

"I personally, as not [Veterans Affairs Canada], but as an individual working [there], thought that the delays were a bit, well, that there were significant bureaucratic barriers and it complicated the process," Doucette told the inquiry. 

Veterans Affairs appears to agree.

Internal review suggests change

An internal review conducted by the federal department following the deaths found that none of its employees made "any procedural errors," but in its suggestions for improvement, it noted that the course that held up Luedee's appointment with Desmond "should be done on an urgent basis for cases that require immediate support."

Doucette could not say whether that suggestion for improvement has been adopted.

Desmond was first diagnosed with severe PTSD by a military psychiatrist in 2011, connected to a seven-month tour in Afghanistan in 2007. 

Despite treatment in the years since his diagnosis, he never recovered. Doucette testified that Desmond's psychologist in Fredericton told her that he hoped to stabilize the veteran's mental health through in-patient care. 

Afterward, he hoped that Desmond would be stable enough to begin trauma therapy at New Brunswick's Occupational Stress Injury Clinic. 

But Desmond's home in Oromocto, N.B., sold while he was at the psychiatric facility in Montreal. He chose to move back to Nova Scotia immediately after his release. 

"It's not the ideal scenario when someone goes to treatment — and Ste. Anne's had expressed that they accept people in treatment when they know there's a team available to work with them upon release," Doucette testified Tuesday.

"It's out of the ordinary to release someone from in-patient treatment to no resources."

Doucette said that she chose to stay on as his case manager temporarily after his move so that there would be some continuity of care.

When asked whether she would do anything differently, Doucette noted that she doesn't believe she could have predicted the events of Jan. 3, 2017.

But she said that it has prompted a change in her practice. Although she left Veterans Affairs Canada in 2019 to practise in the community, she said she now is more direct in how she asks clients about conflict and violence in their relationships.

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