The Lionel Desmond fatality inquiry will end in recommendations for change rather than blame, but Judge Warren Zimmer made it clear Thursday that Veterans Affairs failed the former soldier when he left military care.

Zimmer read reports about the Afghanistan veteran's complex mental illness and yearslong struggle to find successful treatment into evidence — noting that Desmond's plan to transition into the community gathered dust for months.

In the meantime, Desmond grew more ill.

Clinicians released him from an in-patient program for veterans with post-traumatic stress disorder (PTSD) in August 2016, reporting that he'd shown just "minor progress" after three months.

He left early, it said, because he wanted to spend time with his daughter before she returned to school in September. The caseworker who prepared the report worried about him returning to live with his wife and daughter, because he'd had conflict there in the past.

He did return home, however, but would leave on occasion when he had angry outbursts and his wife Shanna asked him to sleep elsewhere. The last time she asked him to leave was on New Year's Eve, 2016, three days before he would kill her, his mother, their daughter and then himself.

Framed photos of Shanna and 10-year-old Aaliyah Desmond are displayed in the Borden family home, where they were killed. (Eric Woolliscroft/CBC)

His medical reports note the range of his illnesses: paranoia about the intent of doctors and nurses, sensory overload from noise, signs of poor cognitive function, worsening isolation, PTSD major depression and anxiety.

Upon his release from St. Anne's hospital in Montreal, his team recommended ongoing therapy — and that he undergo brain scans and neuro-cognitive testing to see at what level he could function. Doctors noted that he showed many signs of post-concussion syndrome.

None of that follow-up happened.

Instead, he met with Catherine Chambers, a trauma therapist assigned to him by Veterans Affairs, on Dec. 2, 2016.

As the judge read these reports out loud, Chambers quietly began to cry in the witness box.

The judge seemed to understand why.

He said he read her all this information about Desmond to make a point: that it was available, that Veterans Affairs didn't give it to her when it hired her, and that the information might have changed the way she handled Desmond's case.

"It's important to appreciate that all of this information was sitting there [with Veterans Affairs] and you had none of it," he said. "I think it's important for people to understand what was available."

Catherine Chambers, a trauma therapist, works extensively with veterans with PTSD and met Desmond in late 2016. (Laura Fraser/CBC)

Chambers agreed that the information would not just have been helpful, but critical — if she had known the level of care Desmond had received before and, in her opinion, still needed, she would have told Veterans Affairs that she could not help him in the community.

He needed more in-patient treatment, she told the judge, and ongoing therapy.

Instead, "he kept getting passed off," Zimmer said.

The lawyer for the Attorney General of Canada said she couldn't speak to the judge's comments on behalf of Veterans Affairs.

Veterans Affairs Canada did not respond to direct questions, but instead sent the following statement:

"The evidence heard today was the evidence of one witness. There will be witnesses from VAC and other federal entities who will provide evidence to the Inquiry on these matters in due course," said Alex Asselin, a spokesperson for the department.

Asking for divorce

Veterans Affairs had hired Chambers to do an assessment of Desmond and consider becoming his therapist.

She said that she believed Desmond's caseworker got in touch in October, but she and Desmond didn't connect until the end of November. They met twice in the last month of Desmond's life — and she agreed that he had complex PTSD and said he'd likely need years of therapy to overcome the trauma he'd experienced.

But she testified said that he deeply loved his wife and hoped to create a happy home life together.

Then, in the hours before Desmond killed his family and himself, he called Chambers and said his wife had asked for a divorce.

Earlier evidence suggested that she'd only asked him to leave for a night or two, something which had happened before when the Afghanistan veteran's symptoms of PTSD turned into yelling matches and, sometimes, fists slamming against furniture.

But Chambers told the inquiry he spoke to her on Jan. 3, 2017, to tell her about a car crash he'd gotten in to with Shanna and that it had led to a fight and to her request for a divorce.

When questioned by other lawyers about whether Shanna told her husband she wanted to end their marriage on another day — perhaps Jan. 2 — Chambers said it was possible but unlikely.

She said that she told Desmond that she would help him find safe housing and navigate this transition, that he didn't have to deal with this alone.

He promised her, she said, that if he thought he might harm himself or anyone else, that he would go to the hospital.

Desmond was part of the India Company, 2nd battalion, Royal Canadian Regiment in Afghanistan in 2007. (Facebook/The Canadian Press)

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