In his report into whether veterans are given enough information about why they are granted or denied disability benefits, Guy Parent found the government is failing.
And failure so early on in the process can have a domino effect that Parent says he intends to study over the coming years.
"There are so many systematic issues in dealing with Veterans Affairs Canada, it's a good question to say where to start," he said in an interview.
"We needed to start somewhere and I think this is a good point."
The decision letter is used by veterans to map out their own care as well as their dealings with the department and any confusion clouds the process, Parent said.
The report released Monday reviewed a sample of 213 disability benefit decision letters sent between 2001 and 2010 and found that none clearly stated the reasoning behind the decision.
About one in five gave enough detail for veterans to attempt to deduce the rationale, but the remainder came up entirely short.
Parent says providing information to support a decision is fundamentally different from simply providing a reason for a decision.
Failing to provide supporting information for decisions is at odds with the Veterans Bill of Rights and other federal laws, the report said.
"It troubles me to think that many veterans may be wrongly assessed and do not pursue the matter further because the letter did not reveal where the department’s decision might have been flawed," Parent wrote.
"It is equally unacceptable for veterans to exercise their appeal rights without having been provided with a clear explanation of the decision."
The report found that decision letters aren't adequate because there are flaws in the process used to generate the letters and there's also a misconception about what constitutes adequate reasons for decisions.
Parent said he doesn't think the department is deliberately trying to confuse former soldiers.
"It's a matter of people working individually as opposed to systematically," he said.
The department was first alerted to a problem with communicating decision- making in 1998, when it was raised by the auditor general.
An internal evaluation flagged it again in 2004-2005 and in August 2010, it was raised once more.
Monday's report made four recommendations.
It said the way the letters are generated needs to be improved and that reasons for decisions need to be in plain English, not medical or legal terms.
The report also said manuals need to be reviewed to make sure adjudicators are aware of what has to be in the letters and a quality assurance system must be in place.
A spokeswoman for Veterans' Affairs Minister Steven Blaney said he welcomes the report and intends to act quickly.
"Cutting red tape and providing hassle-free services to our veterans is minister Blaney's top priority," Codie Taylor said in an e-mail.
In the interview, Parent said he expects Blaney to comment directly on the report on Tuesday.