PORT HAWKESBURY, N.S. -- In the four months before Lionel Desmond killed three family members and himself, the former soldier was supposed to receive therapeutic help to deal with post-traumatic stress disorder. But that never happened.

A provincial inquiry investigating the fatalities heard Tuesday from a key witness who revealed there had been some degree of miscommunication over how Desmond's file should have been handled during that critical period.

Between February and October 2016, Natasha Tofflemire was an intake nurse at the Operational Stress Injury Clinic in Halifax, which provides mental health treatment to clients referred by Veterans Affairs and the RCMP.

Tofflemire confirmed the clinic received a referral on Sept. 30, 2016, saying Desmond needed services in Nova Scotia because he had recently moved from Oromocto, N.B., where he had been receiving treatment from the OSI clinic in nearby Fredericton.

The document says Desmond, 32, had recently completed an intense, 11-week residential treatment program at Ste. Anne's Hospital in Montreal, but that he still required psychiatric follow-up at the OSI clinic in Halifax.

The referral also said Desmond required a therapist, ideally close to his new home in Nova Scotia's Guysborough County.

Tofflemire told the inquiry that when she contacted Veterans Affairs on Oct. 6, 2016, Desmond's case manager confirmed the former infantryman would be receiving treatment from a psychologist in Antigonish, N.S.

As well, Tofflemire said the case manager told her Veterans Affairs couldn't refer Desmond to the Halifax clinic for psychiatric treatment until it was confirmed he had a family doctor. The intake nurse said the case manager indicated she would look after that step.

At that point, the Halifax clinic placed Desmond's file "on hold," which meant nothing would happen until Veterans Affairs asked for more help. The federal department never called back, Tofflemire said, adding that she left her position about a week later.

Inquiry counsel Shane Russell then produced a document from the Fredericton clinic, dated Oct. 18, 2016. The document, from clinic psychologist Mathieu Murgatroyd, indicates that on that date, Tofflemire confirmed in a phone call that Desmond had secured a therapist in the community and "he would also be connected for psychiatric services in the community."

Tofflemire said she couldn't recall the conversation.

"I think this was a miscommunication between Dr. Murgatroyd and I," she told the inquiry.

Tofflemire said it was her understanding the Veterans Affairs case manager, Marie-Paule Doucette, was making arrangements for Desmond to see a psychiatrist in the Antigonish area, based on their talk on Oct. 6, 2016.

"It wasn't overly clear," she said. "That was still left open."

Tofflemire stressed that in the past, veterans from eastern Nova Scotia and Cape Breton would regularly turn down the opportunity to receive treatment in Halifax -- a three-to-five-hour drive away -- and instead seek help from local mental health professionals.

"This was an issue for many veterans in that community," she testified.

As for who would be helping Desmond, Tofflemire said she didn't know the name of the community therapist, adding that she was never told what happened with the plans for a community psychiatrist.

Last year, the inquiry heard that Desmond struggled to find help for his worsening PTSD symptoms after he left Ste. Anne's Hospital on Aug. 15, 2016. Psychologists and psychiatrists at St. Martha's Regional Hospital in Antigonish tried to help Desmond when he showed up at the emergency room a couple of times in the fall of 2016.

One psychiatrist, Dr. Ian Slayter, told the inquiry he was worried Desmond's case wasn't getting the attention it needed from Veterans Affairs. Slayter wrote a report, saying he wanted to help Desmond because of the complexity of his case, and "given that he seems to be falling through the cracks."

The report also stated Slayter was concerned about Desmond's "borderline delusions" regarding his wife's fidelity, though he rated Desmond's risk of suicide as low.

On Jan. 3, 2017, Desmond bought a rifle and killed his 31-year-old wife, Shanna, their daughter, Aaliyah, and his 52-year-old mother, Brenda, before turning the gun on himself.

This report by The Canadian Press was first published March 9, 2021.