Two families in Guysborough County, N.S., became forever bound by tragedy after an Afghanistan veteran with a complex mental illness — and a history of conflict in his marriage — crept through the woods on Jan. 3, 2017, slashed his wife's tires and went into her family home without warning.

In the moments that followed, Cpl. Lionel Desmond fatally shot his wife, Shanna, his 10-year-old daughter, Aaliyah, his mother, Brenda, and then himself.

Those deaths — and the presumption of their preventability — have coloured the first 17 days of testimony at the fatality inquiry in Guysborough, N.S. When combined, the 20 witnesses described how layers of bureaucracy and the use of many different databases across government prevented health, military and public safety institutions from sharing information.

Numerous lawyers told CBC News about the recommendations they expect will target that issue.

Information sharing

Two witnesses testified that if Veterans Affairs had shared more of Desmond's medical history, they would have made different decisions. The former soldier was diagnosed with complex post-traumatic stress disorder in 2011 following a seven-month tour of Afghanistan four years earlier. He got treatment within the military and through Veterans Affairs, but "made minor progress" in his recovery.

He was medically discharged from the military in 2015.

In one case, Lysa Rossignol, the acting chief firearms officer for New Brunswick, who reviewed Desmond's gun licence, said she wouldn't have returned the gun to him if she'd known he was about to go to a psychiatric facility to treat his complex PTSD.

In another, therapist Catherine Chambers said if she had known the extent of Desmond's PTSD, she would have told Veterans Affairs that she couldn't successfully treat him in the community — and that he needed to return to an in-patient program.

A collage of Lionel Desmond, his wife Shanna, mother Brenda and daughter Aaliyah and his military comrades. (CBC)

Judge Warren Zimmer, who is overseeing the inquiry, agreed that she ought to have been given more information, as he read from a report prepared by Veterans Affairs in August 2016 upon Desmond's early release from St. Anne's Hospital in Montreal. It contained notes about the depth of his illness: his paranoia about his doctors and nurses, sensory overload from noise, signs of poor cognitive function, the desire to isolate himself, as well as other symptoms of PTSD, major depressive disorder and anxiety.

It also noted that he'd made little progress.

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

The lawyer for Lionel Desmond's estate said he's confident that the inquiry will recommend a better system to share information between federal and provincial agencies, given what the judge has heard so far.

"The local caregivers that saw Cpl. Desmond in the last few weeks of his life did a very good job with him and did their very best," Adam Rodgers said in an interview. "But they were limited by the lack of information that they received from Veterans Affairs Canada … and so, one of the key recommendations is certainly going to be an improvement in the information flow between the federal Veterans Affairs [department] and the provincial mental-health organizations.

"I think that's going to be a critical recommendation."

Veterans Affairs tight-lipped

Veterans Affairs has been tight-lipped throughout the inquiry and did not respond to questions. But a department spokesperson and the lawyer for the attorney general of Canada said that Veterans Affairs witnesses will be called at later sessions.

Some of those witnesses are expected to testify when the inquiry resumes in May, according to several lawyers.

Framed photos of Shanna and 10-year-old Aaliyah Desmond are displayed in the Borden family home, where they were killed on Jan. 3, 2017. (Eric Woolliscroft/CBC)

Allen Murray, inquiry co-counsel, said that he expects to call clinicians from the Operational Stress Injury Clinic, a Veterans Affairs-funded program for former soldiers with PTSD, who treated Desmond in New Brunswick.

In this session, however, he and his co-counsel, Shane Russell, focused on another mandate of the inquiry — the circumstances surrounding Lionel Desmond's release from St. Martha's Regional Hospital on Jan. 2, 2017, in Antigonish, N.S. — and whether the clinicians who saw him there or in the community were trained to recognize PTSD and the warning signs of domestic violence.

Neither of the two psychiatrists who saw Desmond before he killed himself and his family believed he would harm himself or anyone else, according to their testimony. One had seen him only days before.

While Dr. Ian Slayter, who saw him about three weeks before, felt that Desmond had "fallen through the cracks" as he transitioned from military care to the provincial system and needed immediate therapy, he testified that the veteran showed none of the signs of being homicidal.

That's a statement that's been echoed by virtually all of doctors and nurses who testified about seeing Desmond in the last two years of his life — they described him as seriously ill but not violent.

These doctors, nurses and therapists relied on their clinical judgment and a suicide assessment tool in making decisions, which included releasing him from hospital the day before he shot his family and himself.

Murray acknowledged that it's hard to know what sort of recommendations he might suggest to help other doctors presented with someone like Lionel Desmond.

"That's a hard question," he said. "The consistent sort of impression of Lionel Desmond late in his life … was that he didn't give off any signs or signals necessarily that he was in the place that he ultimately was.

"So I think it's something that we will continue to consider — and it's something that ultimately I hope we will be able to make some useful recommendations about."

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

Support for families

One of the inquiry's mandates has been to look at whether Desmond and his family had access to domestic violence intervention and support.

It's a theme that the lawyer representing Desmond's mother and his daughter says she would like to see more of in future sessions. Tara Miller said veterans' families across the country have told her how frustrated they are that when their soldiers first returned home they were given little education about how to support them and how to get help themselves.

"Those family members play a really valuable role in helping support their reintegration, if you will, back into the civilian world, but oftentimes [soldiers] don't have the language to describe what's going on inside of them," she said. "So I'm curious when we get to this [and] hear from Veterans Affairs witnesses ... about what exactly are the supports that are offered to the Shanna Desmonds of the world and the Brenda Desmonds of the world."

In the opinion of Shanna's brother, Sheldon Borden, there were no such supports.

The Borden family

When Shanna's husband returned home from the in-patient program in Montreal in August 2016, she was given nothing, Borden said.

"They saw the aggression, there's lots of doctor reports of how aggressive Lionel was, but that's his PTSD, that's his sickness," Borden said. "And they basically just said, 'OK you're cured,' like it was like a celebrity rehab.... 'You're cured and go home with your family.'"

The Bordens have standing in the inquiry.

Borden himself followed his brother-in-law Lionel Desmond into the Canadian Forces. But like his brother-in-law, he says, he now has PTSD from the racism he experienced in the air force.

And although he said that he's receiving support for that within the military, he does not believe his brother-in-law did — and it's an area that will be explored at future sessions of the inquiry when it sits again.

The inquiry is meant to learn about the facts of what happened and to make recommendations to prevent further deaths from occurring. It is not meant to lay blame.

The next session is slated for May 18.

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