Scathing suicide inquiry finds gaps, shortcomings at Royal Military College


OTTAWA — Members of a board of inquiry into three suicides at the Royal Military College of Canada have reported facing troubling delays and obstacles in obtaining key information and evidence during their nearly year-long internal investigation.

A censored copy of the board of inquiry’s final report was provided to reporters this week and confirmed that officer cadets Harrison Kelertas, Brett Cameron and Matthew Sullivan took their own lives in separate incidents in 2016.

The scathing report also uncovered numerous gaps, shortcomings and worrying practices at the 142-year-old college in Kingston, Ont., where future generations of military officers are groomed, when it came to suicide prevention.

Those included the use of “suicide watches” with other students — even though studies showed such watches raised the risk of suicide among the watchers and had been previously flagged as a concern by the military’s medical branch.

In an interview with The Canadian Press, the military’s chief of personnel acknowledged that there were shortcomings at the university and said senior commanders were committed to fixing them as quickly as possible.

But Lt.-Gen. Charles Lamarre rejected suggestions that officials at the college in Kingston, Ont., could have done more earlier to keep Kelertas, Cameron or Sullivan from taking their own lives.

“Folks were doing their best with what they knew at the time, and they thought they were doing the best that they could,” Lamarre said during a telephone call from National Defence headquarters.

“That’s why it’s so important to actually go through and do this critical self-examination and to put in place the changes that can prevent reoccurrence and that’s what’s taken place.”

The board of inquiry report had been eagerly anticipated by the families of the three young men, who had expected it last year and expressed frustration and anger that its release was delayed, thereby depriving them of closure.

Some had worried that the report was being delayed because officials were trying to whitewash the findings to hide any wrongdoing or negligence at the college or within the military chain of command.

Military officials have rejected such allegations, saying the investigation was extremely complex, involving dozens of witnesses and tens of thousands of pages of documents — all of which needed to go through a final legal review.

The three families have been briefed separately on the inquiry’s findings over the past week, but have so far declined to comment.

The report reveals that the board of inquiry faced challenges accessing information and evidence, particularly from the Canadian Forces National Investigation Service, which investigates major crimes in the military.

“Despite early indication(s) by the CFNIS that the deaths were suicides,” the report reads, “and that suicides are not investigated by the CFNIS, it took over six months for the board to access critical evidence held by the CFNIS.”

It was also told at one point to file an access to information request and given blacked-out material “despite the authority of the board to receive unredacted evidence.”

Despite previously defending the lengthy delay in releasing the report, Lamarre acknowledged the board’s challenges getting information were “wrong” and promised officials were committed to preventing future problems.

While the exact circumstances around the three suicides were blacked out in the report provided to the media, for privacy reasons, the board identified a number concerns when it came to the risk of suicide among RMC students.

Those included stigma, specifically student fears that asking for help would affect their future careers, which has also been identified as a concern within the overall military population.

The board was also particularly concerned that RMC commanders regularly ordered students to act as a “suicide watch” or “buddy watch” when fellow officer cadets were deemed at risk of trying to take their own lives.

Two such suicide watches were ordered at RMC in the first half of 2016, even though studies had shown they increased the risk of suicide among the watchers and the military’s medical branch recommended against their use.

Asked about the suicide watches, Lamarre said: “It says right there in the board of inquiry that there’s a recognition that best practices and standards were not well understood throughout the cadet wing or the college itself.

“And again, that’s one of the key recommendations: to standardize these things to make sure they understand what they are.”

RMC was also found to be missing an overarching suicide-prevention strategy, which exist in other universities given that suicide is the leading cause of death among young Canadians. The absence of such a strategy was found to make it more difficult for students to access support services.

Officials also didn’t know what constituted a suicide attempt or how many there had been and, “unlike Queen’s University,” didn’t have procedures for to help students during their arrival at the college and other “transitions.

Finally, the report raised concerns about how college staff dealt with suicides after they occurred, saying there was an “underestimation and misunderstanding of the effect of suicide on staff, friends and survivors of suicide loss.”

It was unclear from the report how many, if any, of the issues raised by the board of inquiry related to Kelertas, Cameron and Sullivan, as the sections related to their time at RMC were largely blacked out.

All told, the board made 78 recommendations to address the many issues raised in the report.

But Lamarre said the vast majority were already being addressed following a special review of the college that was order by defence chief Gen. Jonathan Vance last year and through the military’s new suicide-prevention strategy.

“There is a desire to make sure that all those things are being addressed,” he said.

“The fact that three different initiatives are speaking to the same thing … I think it’s a good indicator that folks are paying attention and trying to correct things where they can.”

— Follow @leeberthiaume on Twitter.

Lee Berthiaume, The Canadian Press