The former soldier who killed himself and his family were victims of "systemic failures" that failed to detect escalating domestic violence and created barriers to accessing mental health care, the province's chief medical examiner told the inquiry into the Desmond family's fatal shooting.

Dr. Matthew Bowes was the first witness called at the opening of the fatality inquiry into the deaths of Lionel Desmond, his wife Shanna, 31, their 10-year-old daughter Aaliyah and his 52-year-old mother Brenda — and the person who compelled the province to call the inquiry in the first place.

Desmond shot his family members before turning the gun on himself in his wife's family home in Upper Big Tracadie, N.S ., on Jan. 3, 2017.

Desmond had been diagnosed with post-traumatic stress disorder (PTSD) soon after returning home from an eight-month tour in Afghanistan in 2007. He received treatment while in the Canadian Forces in Montreal and in New Brunswick, and sought help in Nova Scotia as a veteran.

Bureaucracy and barriers

Bowes said his own investigation found that there were problems in transferring information from doctors who treated Desmond in different provinces — and that records held by Department of Defence and other federal agencies might not have filtered down to his clinicians in Nova Scotia.

"That may have been a barrier to Mr. Desmond's mental health care," Bowes said.

While the counsel for the attorney general of Canada said that civilian doctors can apply for those records and access to information requests should be granted within 30 days, unless an extension is requested, Bowes said that the perception is that it's much more difficult.

He himself couldn't obtain those records as the provincial medical examiner, noting that someone with acute mental illness may not be functioning at a level where they can manage extra bureaucracy.

"I think that the ultimate test of a system is not whether we think it's reasonable, but it's how the clients actually experience it," Bowes said. "And from what I was able to get, is that Mr. Desmond experienced difficulty with it."

Nightmares

Lawyers for doctors who saw him in Fredericton and in Guysborough, N.S., and Antigonish, N.S., told the inquiry that Desmond continued to experience nightmares and flashbacks for 10 years after his return from a theatre of war.

And Bowes said his investigation before calling the inquiry suggests that if Desmond were not suffering from PTSD, major depressive disorder and other illnesses, he would not have killed his family.

Dr. Matthew Bowes, the chief medical examiner, testified at the Desmond Inquiry Monday. (Brett Ruskin/CBC)

He said he hopes there will "be some tremendous good that comes out of this inquiry" in changing how the province manages mental health and domestic violence services.

"Mr. Desmond showed warning signs [of domestic violence] that were not picked up," by his clinicians, he said. "If we're able to draw lessons from the deaths of Mr. Desmond and of his family, it may help hundreds or thousands of people who work in jobs that are stressful."

It's also critical to close the policy gap that allowed Desmond to obtain a firearms licence, Bowes said.

"The fact that a gun was placed in this man's hands is a failing," he said. "I think that most people would agree that someone with mental health issues should not have access to a gun."

Domestic violence

He said he also felt compelled to call the inquiry because Nova Scotia needs more information about intimate partner violence in order to prevent future deaths.

"There can be no discussion about domestic violence deaths unless we know how many there are and where they occur," he said. "And all discussions of prevention involve reducing that number — so if we don't have a number" we don't have a benchmark.

He had reservations, however, about recommending a fatality inquiry, given that its scope will be limited to Nova Scotia when two institutions critical to what happened — the Department of Defence and Veterans Affairs — are at the federal level and wouldn't be included.

Desmond, shown in 2007, had been diagnosed with PTSD within years of returning home from Afghanistan. (Trev Bungay/Facebook/The Canadian Press)

He told Judge Warren Zimmer that he worried that recommendations wouldn't prompt change in those higher levels of government, to which one of Desmond's sisters nodded her head in the gallery and quietly said she agreed.

Unlike a public inquiry where findings carry legal weight, a fatality inquiry leads to recommendations and lays no blame on institutions or people.

That's one of the reasons the Desmond family has continued to call for a public inquiry at the federal level, hoping to create changes within the Department of Defence and Veterans Affairs.

The inquiry is expected to probe whether:

Desmond had access to mental health services.

He should have been able to obtain a firearms licence.

The health-care providers who treated him were trained to recognize PTSD or signs of domestic violence.

The inquiry had been scheduled to begin Nov. 18 , but was adjourned as Shanna Desmond's family had recently dismissed their lawyer and the replacement needed time to prepare.

It's expected to run for five weeks given the extraordinary volume of evidence: 58,000 files, numbering about 120,000 pages.

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