Inquiry judge tackles bureaucracy that prevented officials from sharing veteran's history

The judge overseeing the Lionel Desmond inquiryquestioned the layers of bureaucracy that kept health, military and public safety institutions from sharing information about the Afghanistan veteran who ended up killing three members of his family and then himself in 2017.

While Judge Warren Zimmer has been tasked with making recommendations to prevent future deaths, he's twice gotten witnesses to tell him they would have made different choices had they known the full scope of Desmond's mental illness.

In each case, the information existed just not on a public database where it could be shared.

Zimmer delved into that theme as he questioned Lysa Rossignol, the acting chief firearms officerfor New Brunswick's provincial firearms office, onThursday at the inquiry in Guysborough, N.S.

He read her a referral request sent to Ste. Anne's Hospital in Montreal, which was made by Desmond's psychiatrist and two other treating clinicians on Dec. 15, 2015. The request readthat his doctors "strongly recommend" that he be admitted for in-patient treatment at the residential program for veterans with PTSD,given he had a severe and complex version of the illness, as well as major depression.

He "continues to struggle with disabling symptoms of PTSD that affect his social and occupational" ability to function, the letter said.

Zimmer told the chief firearms officer he wanted her to have a full picture of other medical information that might have been available to her during her review of the veteran's firearms licence.

The review was triggered by Desmond's suicideattempt in Oromocto, N.B., on Nov. 27, 2015, less than a month before the referral request would sent to Ste. Anne's.

Policy change

His licence wasfully reinstatedafter a two-week waiting periodin May 2016, around the same time he entered that facility. In the interim, Dr. Paul Smith had signed a medical form for the firearms office, which noted that Desmond was stable and non-suicidal.

The judge asked whether Smith's note would have been enough for the firearms office, if it had known about the referral to Ste. Anne's.

"If our office had been privy to this letter, it would have changed the outcome of his licence [being reinstated]," Rossignol said.

The judge agreed: "I think that your answer to me was self-evident," he replied.

Other lawyers questioned why Rossignol and the area firearms office were satisfied with Smith's report, with Tom Macdonald, the lawyer for the Borden family, saying it was a one-sentence note.

The New Brunswick chief firearms office adopted a new medical form in February 2017, just a month after Desmond shot his wife, Shanna, their 10-year-old daughter, Aaliyah, and his mother, Brenda. He then turned the gun on himself.

The more detailed form came was "driven by" the tragedy, the then-director of New Brunswick's firearms program, Derek Eardley, told Macdonald.