Blue Line

N.S. avoids public scrutiny in high profile deaths:’How can we hope for change?’

HALIFAX — Lionel Desmond suffered rages from post-traumatic stress. He told relatives he struggled to access mental health services. Then he killed his family and himself.

June 22, 2017  By The Canadian Press

Six months later, no public inquest aimed at preventing similar deaths is on the horizon — frustrating Desmond family members and repeating a familiar pattern for other Nova Scotians who’ve sought fatality inquiries.

Debbie Stultz-Giffin has followed the Desmond case since January, when the former soldier killed his wife, mother, daughter and himself in Upper Big Tracadie.

She sees links with her own fruitless calls for a public inquiry into the death of her 87-year-old mother, Dorothy Stultz. She died after a violent shove by a male resident with dementia in a nursing home on March 1, 2012.

“Again we are looking at other vulnerable individuals in a situation where if an investigation doesn’t happen, how can we hope for change?” she says of the Desmond case.


The Stultz death wasn’t made public until The Canadian Press discovered it last year among nine deaths classified as “homicides” by the medical examiner over the past decade — none of which have led to a fatality inquiry.

Meanwhile, since 2010 the province has had six non-natural deaths in its jails in cases that would trigger mandatory public inquests in most other Canadian jurisdictions.

Alberta held 24 public fatality inquiries last year, including one into the hanging death of Corp. Shaun Collins, an infantry soldier diagnosed with PTSD who had done two tours of Afghanistan.

Dr. John Butt, the former medical examiner for both Nova Scotia and Alberta, said in an interview that “without question” Nova Scotia should use its existing law to order a judicial inquiry into the Desmond case.

He also said the province should bring in reforms similar to Alberta’s, where a doctor, a lawyer and a layperson on a board would provide a recommendation for a discretionary cases like the Desmond murder-suicide.

He also called for Nova Scotia to create mandatory inquests for non-natural deaths in prisons.

“I can’t believe a province doesn’t have mandatory inquests under certain circumstances,” he said.

In the latest prison death, 42-year-old Jason LeBlanc died in a Cape Breton jail cell in January last year from an opiate overdose shortly after being arrested for an alleged parole violation.

Police reports said he told a prison nurse he’d taken five “nerve pill(s)” and appeared intoxicated, which has raised questions about why he wasn’t sent to a health facility for monitoring.

His father, Ernie LeBlanc, made repeated calls for a public inquest. Instead, he received a shortened version of an internal report by the Justice Department admitting corrections staff hadn’t followed procedures.

In Ontario’s system, inquests into such non-natural deaths in jails are mandatory, and last year the province held 43 inquests into various types of deaths.

Amina Oakley, a Markham, Ont., lawyer who represents families at inquests, says there has been a decline in the number of discretionary cases ordered by the Office of the Chief Coroner in Ontario, but urges Nova Scotia not to follow that trend.

“It’s critical because this is an issue that is coming back to the forefront because we have all of these soldiers coming back from overseas … Clearly all the public has an interest in knowing if there’s a better way to treat these veterans so we don’t have such terrible loss,” she said.

In Manitoba, six public inquests were held by judges, while British Columbia held seven.

In Nova Scotia, the last judicial inquiry was ordered in 2008 in the case of Howard Hyde, a musician with mental illnesses who died after an altercation with jail guards and a series of taserings in police custody.

There’s been nothing similar since.

Even in provinces that routinely hold inquests, cases like that of Lionel Desmond’s require a discretionary decision by the coroner or a review board, based partly on whether it could help prevent similar deaths.

But the prevention of future tragedies is precisely why Desmond’s twin sisters have confirmed they support an inquiry overseen by a judge that looks at health care for troubled veterans.

They told The Canadian Press their brother said he sought help in vain at St. Martha’s hospital in Antigonish before the murder-suicide.

“His exact words were, ‘They didn’t have my records.’ … That’s my understanding,” said Chantel Desmond. “He didn’t want to leave.”

That was on Jan. 2, the day before Desmond killed himself, 31-year-old Shanna, their 10-year-old daughter and his mother Brenda Desmond, 52. A senior medical official in Nova Scotia has challenged the statement that Desmond, who had done two tours of Afghanistan, was turned away from hospital care.

Archie Kaiser, a Dalhousie University law professor with expertise on mental health issues, says the Desmond case is a clear example of where the medical examiner or the province’s justice minister should use their power to call an inquiry.

He argues the case fulfills provisions in the Fatalities Investigations Act allowing for an inquiry when “in the public interest or the interest of public safety,” as it would provide insight into the treatment of veterans and into the issue of domestic violence.

“The complex relationships between employment-related PTSD for soldiers … the difficulties associated with reintegration into society and the availability of supportive services appear to be implicated,” he said.

Dr. Matthew Bowes, the province’s chief medical examiner, said he’s reluctant to call public inquiries if there are other means to examine the issues — even if they’re behind closed doors.

He says he wants to wait and see the results of the Nova Scotia Health Authority’s quality review — which are internal studies done by medical staff for educational purposes.

These reviews provide no open testimony, do not result in a written report on the facts of the case, and the health authority itself determines, in consultation with the families, who gets a copy of its action plan and recommendations.

Such studies also have been unsatisfactory to some families who’ve initially called for public inquests.

“Private investigations … opens up the gate for things to be overlooked, swept under the carpet and dismissed. It’s just not a healthy situation for everyone involved,” said Stultz-Giffin.

She received a brief report in her mother’s death — after an outburst of publicity about the case — from Health Department investigators that she said “left me feeling flat. There weren’t any real answers.”

Still, Bowes says that when he came to the province 14 years ago, senior bureaucrats told him “that judicial reviews as part of public policy renewal really ought to be more of a decision on the part of the minister.”

Nova Scotia’s new justice minister, Mark Furey, who has the power to call for a fatality inquiry, has declined requests for an interview on the topic of an inquest.

Meanwhile, Stultz-Giffin will be wishing the Desmond family well in their quest for an open inquiry even as her own hopes for such a process have long faded.

“It’s a societal issue and as a society we need to discuss these very types of issues,” she said.

– Michael Tutton

News from © Canadian Press Enterprises Inc. 2017

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