Ottawa ignored calls to probe veteran suicides despite troubling 2014 audit
Veterans Affairs is not yet routinely
reviewing suicides of former soldiers to identify lessons that might
protect other vulnerable vets, despite an internal audit of cases that
found troubling gaps at the department responsible for Canada’s most
chronically ill and injured veterans.
Government
documents obtained by The Globe and Mail through access-to-information
legislation show that a 2014 probe of 49 suicidal vets and 31 suicides
uncovered instances where Veterans Affairs was not properly monitoring
the distraught vets. Some weren’t even screened for suicide risk in the
first place.
Despite these findings – and internal
calls for case-by-case reviews stretching back to at least 2010 – the
federal department hasn’t analyzed a single vet suicide since the 2014
audit, revealed Michel Doiron, assistant deputy minister of service
delivery at Veterans Affairs. He pledged on Wednesday that a process for
regularly scrutinizing suicides and attempted suicides will be
introduced this year.
“We’ve
been looking into it since the fall,” Mr. Doiron said in an interview.
“We want to make sure that if there is something for us to learn from a
[suicide] event, that we do learn it and we rectify accordingly.”
Part
of the problem, the 2014 probe found, was Veterans Affairs’ own
administrative database, which was primarily designed for processing
disability and benefit claims and not for tracking health changes and
suicide risk among former military members, states an internal Veterans
Affairs’ report that summarized findings from 10 medical and veterans
experts involved in the audit.
“One
barrier to care noted by several reviewers was missed opportunities to
recognize prior suicidality in clients and arrange follow-up
monitoring,” the report notes. “This barrier was thought in part to be
due to the business rather than clinical focus” of Veterans Affairs’
database.
While the Canadian Forces are
responsible for delivering health services to their military members,
veterans fall under provincial medicare. Of the country’s nearly 700,000
vets, about 120,000 receive services or payments from Veterans Affairs,
often for serious physical injuries or mental illnesses, such as
post-traumatic stress disorder.
One of
those ill vets was Lionel Desmond, who deployed to Afghanistan in 2007.
Mr. Desmond’s family said he was struggling with PTSD when he was
released from the Forces in July, 2015. Last week, in a rural Nova
Scotia home, police believe he gunned down his wife, Shanna Desmond,
their 10-year-old daughter, Aaliyah, and his mother, Brenda Desmond,
before killing himself.
The Nova Scotia
government has launched an investigation of how the health system dealt
with Mr. Desmond, a former infantryman with the 2nd Battalion of the
Royal Canadian Regiment, based in Gagetown, N.B. Just two days before
the shootings, the veteran sought help at St. Martha’s Regional Hospital
in the nearby town of Antigonish, family members said. They believe he
didn’t get adequate help at the hospital.
Rev.
Elaine Walcott, a relative of the Desmond family, is calling on the
military and Veterans Affairs to also investigate how they handled the
chronically ill soldier. Neither Veterans Affairs nor the Forces has
publicly committed to probing the Desmond case.
“There
is a responsibility, systemically, for this to be examined,” she said
Tuesday, on the eve of funerals for the Desmond family. “This is an
opportunity to put a lens on” mental-health care.
Mr.
Desmond, 33, is among at least 72 soldiers and veterans who have killed
themselves after serving on the Afghanistan mission, an ongoing Globe
and Mail investigation has found. Most have only taken their own lives,
but just before Christmas in 2015, Robert Giblin, a veteran of two
Afghanistan tours, stabbed his wife, Precious Charbonneau, before they
fell from a high-rise apartment in Toronto. Mr. Giblin’s family said he
suffered with PTSD.
Former veterans
watchdog Pat Stogran, a retired army colonel, said it is “reprehensible”
that formal suicide reviews are not yet commonplace at Veterans
Affairs. He noted that he raised the issue during his ombudsman tenure,
from 2007 to 2010.
“There has to be a
feedback loop to say where we are going wrong,” Mr. Stogran said. “They
should be taking substantial and very visible steps to fight this
problem. It’s life and death.”
An
expert group that reviewed, in 2010, a dozen vet suicides had also urged
the department to routinely examine such deaths to better understand
how to prevent other suicides. Yet no further investigation was done
until 2014.
According to the
access-to-information documents obtained by The Globe, the 2014 audit
was conducted to identify suicide triggers, determine whether
interventions were tried and to pinpoint measures to improve suicide
prevention at Veterans Affairs.
The
study’s experts noted that valuable information was gained by examining
the 80 cases of vets who had either died by suicide, attempted to, or
thought about ending their life.
Most
of the veterans had a chronic physical-health problem coupled with a
mental-health illness. Many were also coping with other stress, such as
difficulty finding a job or financial, relationship and legal troubles.
Seventy-nine
per cent were males and most had been released from the military in
recent decades. A dozen, though, had served in the Second World War or
Korea.
Of the 31 vets lost to suicide,
the majority ended their lives at home, the probe showed. Their deaths
occurred from 1961 to 2013.
Some “best
practice” examples were found where front-line Veterans Affairs staff
prevented suicides. Improvements in documenting suicide risk, compared
with the 2010 review, were also noted.
The
audit showed that the suicide profile of elderly vets differed from
younger ones. These older former soldiers were less likely to have
documented mental-health problems, but suffered with multiple chronic
physical-health issues and social isolation.
Despite
the audit’s numerous insights, a presentation included in the documents
indicates staff with the Veterans Affairs’ service-delivery branch
recommended against formal reviews of individual suicide cases. The
presentation, prepared in June, 2015, acknowledges that data from the
2010 and 2014 studies have provided “significant information,” but
cautions that there are “professional, ethical and legal considerations
for employees whose actions will be reviewed.”
The
recommendation then was for Veterans Affairs to periodically perform
general examinations of suicide cases. That position has since changed.
Mr.
Doiron said Veterans Affairs’ newly hired chief psychiatrist, Alexandra
Heber, was asked to look into the issue in September. He said he hopes
that an official suicide-review process will be in place by the end of
March. Currently, only administrative reviews are done to determine
whether benefits are owed to families. Any lessons identified are shared
within the department, Mr. Doiron said.
Veterans
Affairs and the Canadian Forces are working on a suicide-prevention
strategy, which is expected later this year. Veterans Affairs recently
added a tool to electronically record and track suicides and, in
November, updated guidelines for dealing with suicidal veterans.
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