Final Report in Desmond Fatality Inquiry Reveals 25 Key Recommendations


The Honourable Judge Paul Scovil has released his final report in the Desmond Fatality Inquiry, including 25 recommendations meant to improve supports for Canadian Veterans and their families, to expand access to health-care services for African Nova Scotians, and to strengthen the application and licencing processes for firearms.

The Inquiry proceedings resumed in Port Hawkesbury, N.S., today for the release of the report, which is now available on the Inquiry website. A complete list of Judge Scovil’s recommendations are broken out here.

“This has been an arduous and emotional process for everyone involved, but hopefully also a worthwhile one,” Judge Scovil said.

The Inquiry sat for 56 days over several years, due in part to delays related to the COVID-19 pandemic. Judge Scovil’s report and recommendations are based on an exhaustive review of the evidence that was established during those hearings, including testimony from 70 witnesses and 377 documents entered as exhibits during the proceedings.

His final report contains no findings of legal responsibility; fatality inquiries are governed by the Fatality Investigations Act and are different than public inquiries, which traditionally focus on uncovering facts and can make findings of legal responsibility.

On January 3, 2017, the bodies of Lionel Desmond, a veteran of the war in Afghanistan, his wife Shanna, their 10-year-old daughter Aaliyah, and Mr. Desmond’s mother Brenda, were found in a home in Upper Big Tracadie, Guysborough County, N.S. It was believed that Corporal Desmond took the lives of his family members before he took his own life.

In 2018, the former Minister of Justice directed that an Inquiry be held to determine the circumstances under which these deaths occurred, including:

  • the circumstances of Lionel Desmond’s release from St. Martha’s Hospital on January 2, 2017;
  • whether Lionel Desmond had access to appropriate mental health services, including treatment for Occupational Stress Injuries;
  • whether Lionel Desmond and his family had access to appropriate domestic violence intervention services;
  • whether health care and social services providers who interacted with Lionel Desmond were trained to recognize the symptoms of Occupational Stress Injuries or domestic violence;
  • given Nova Scotia administration of the Canadian Firearms Program, whether Lionel Desmond should have been able to retain, or obtain a licence, enabling him to obtain or purchase a firearm;
  • what restrictions, if any, applied to accessing federal health records of Lionel Desmond, by provincial health authorities or personnel; and
  • any recommendations of the Judge about the foregoing matters.

“Based on these terms, the Inquiry explored the complex issues surrounding intimate partner violence, mental health services and support for Veterans, and access to firearms,” said Judge Scovil. “But the evidence and witness testimony also led the Inquiry into some areas that may have been less obvious at the beginning of this journey – issues related to the accessibility of healthcare, including mental health services, in rural communities, the unique health care needs of African Nova Scotians, and problems with the continuity, completeness and privacy of an individual’s medical records.”

Judge Scovil found that the institutions, health-care professionals and community members involved could have done a better job sharing information about Corporal Desmond’s medical history, as well as his physical and mental state in the days leading up to these deaths. 

This type of information would also have been important for firearms officers. These individuals are tasked with evaluating applications for firearms and must decide based on the information before them whether to grant a Possession and Acquisition License for a weapon, often referred to as a PAL, or to place a PAL on review and if need be, have a firearm removed from an individual’s possession.   

“The overarching question here is whether the Desmond family’s tragic deaths could have been predicted or prevented,” said Judge Scovil. At the end of the day, it is impossible to say with certainty that had my recommendations been in place when Corporal Desmond left the military, no suicide or homicides would have occurred. But we can say they could have possibly helped avert the tragic events of January 3, 2017.”

As per the Fatality Investigations Act, Judge Scovil’s final report and recommendations have been filed with the Provincial Court. A copy was also provided to the Minister of Justice.

For additional background on the Desmond Fatality Inquiry, as well as archived webcasts and transcripts of past proceedings, please visit

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