"DESPITE THE PAIR'S QUESTIONABLE BEHAVIOUR - VACUUMING AND WASHING LAUNDRY IN THE MIDDLE OF THE NIGHT, DESPITE THE PRESENCE OF A CHEMICAL BURN ON TAMMY'S FACE, NIAGARA REGIONAL POLICE AND THE HOMOLKA FAMILY ACCEPTED THE PAIR'S VERSION OF EVENTS;"
WIKIPEDIA ACCOUNT OF THE DRUG/RAPE RELATED KILLING OF TAMMY HOMOLKA BY HER SISTER KARLA AND PAUL BERNARDO;
MR. MARK SANDLER: AND AS I'M SURE IT HAS NOT BEEN LOST ON YOU, ONE (1) OF THE ISSUES THAT -- THAT HAS BEEN DISCUSSED HERE IS -- IS THE EXPRESSION, THAT'S USED IN THE MANUAL, "THINKING DIRTY".
DR. JAMES YOUNG: MM-HM.
MR. MARK SANDLER: FIRST OF ALL, WHO WAS RESPONSIBLE FOR THE USE OF THE PHRASE AND WHAT, IN YOUR VIEW, DID IT REFER TO?
DR. JAMES YOUNG: I DOUBT ANYONE WOULD WANT TO TAKE OWNERSHIP FOR IT NOW, BUT I CAN TELL YOU I WON'T TAKE OWNERSHIP. I DON'T KNOW WITH CERTAINTY. I MEAN, I SUPPOSE THE PERSON WHO USED IT THE MOST OFTEN WAS DR. CAIRNS, BUT I REALLY DON'T KNOW -- I DON'T KNOW WHERE IT CAME FROM WITH ANY CERTAINTY. WHAT WAS HAPPENING AT THAT POINT IN TIME --"
FORMER CHIEF CORONER DR. JAMES YOUNG TO THE GOUDGE INQUIRY;
During the course of the Goudge Inquiry I have been increasingly fascinated by the "think dirty" doctrine - and curious as to where it originated.
I was surprised to find that there was a "think dirty" link in Ontario with the notorious investigations of serial killers and rapists Paul Bernardo and Karla Homolka;
The "think dirty" connection relates directly to the drug/rape related death of Karla Homolka's sister Tammy, on December 24, 1990 - which was dismissed as "due to natural causes" by the local Coroner and the Niagara Regional Police Service;
Here is the Wikipedia account of the sordid Tammy Homolka story;
"By 1990, Bernardo was spending large amounts of time with the Homolka family, upon whom he had made a favourable impression," the account begins;
"He was engaged to the eldest daughter and flirting constantly with the youngest," it continues;
"He had not told them that he had lost his job at Price Waterhouse and instead was smuggling cigarettes across the nearby U.S.-Canadian border.
In time he had become obsessed with Tammy Homolka, peeping into her window and entering her room to masturbate while she slept.
Homolka had helped him by breaking the blinds in her sister's window to allow Bernardo access for his stalking.
In July Bernardo took Tammy across the border for more beer for a Homolka party; while there, Bernardo later told his fiancee, "they got drunk and began making out".
According to Bernardo's testimony at his trial, on July 25, 1990, Homolka laced spaghetti sauce with crushed valium she had stolen from her employer, Martindale Animal Clinic.
She served dinner to her sister, who soon lost consciousness.
Bernardo began to rape her while Homolka watched but after about a minute Tammy came to.
And over the summer, he plied Tammy and her friends with gifts, food, and sodas that had "a film and a few white flecks on the top".
Six months before their 1991 wedding, Homolka stole the anesthetic agent Halothane from the clinic.
On December 23, 1990, Homolka and Bernardo administered sleeping pills to the 15-year-old in a rum-and-eggnog drink.
After Tammy was unconscious Homolka and Bernardo undressed her and Homolka applied a Halothane-soaked cloth to her sister's nose and mouth.
Homolka wanted to "give Tammy's virginity to Bernardo for Christmas" as, according to Homolka, Bernardo had always been upset that she was not a virgin when they met.
With her parents sleeping upstairs, the pair filmed themselves as they raped her in the basement.
Tammy began to vomit. The pair tried unsuccessfully to revive her, then called 911, but not before they hid evidence, redressed Tammy, and moved her into her basement bedroom.
A few hours later Tammy Homolka was pronounced dead at St. Catharines General Hospital without having regained consciousness.
Despite the pair's questionable behaviour - vacuuming and washing laundry in the middle of the night, despite the presence of a chemical burn on Tammy's face, Niagara Regional Police and the Homolka family accepted the pair's version of events.
The official cause of Tammy Homolka's death was accidental - choking on her vomit after consumption of alcohol.
The pair subsequently filmed themselves with Karla wearing Tammy's clothing and pretending to be Tammy.
They also moved out of the Homolka house to a rented Port Dalhousie bungalow, to let her parents deal with their grief.
In response to public furor over the fact that police investigators had failed to arrest Bernardo in spite of blatant indications of foul play - and numerous promising leads that were not followed up over the years - the Ontario Government asked the Late Superior Court Justice Archie Campbell to review the investigation.
It is in Justice Campbell's 473-page report - published in June, 1996, I discovered that the then Chief Coroner, Dr. James Young, had initiated a "think dirty" policy -while the Bernardo fiasco was unfolding;
Justice Campbell found that the investigating Coroner, Dr. Joseph Rosloski, "faced with a puzzling and unexplained death, felt it his duty to come up with some kind of tidy answer and fell back on asthma as a cause of death without thinking it through as clearly as he might have and indeed without knowing how she died."
Campbell went on to conclude that:
"It was inappropriate for Dr. Rosloski to submit a final report sowing death by natural causes when there was a dramatic and unexplained second degree burn over much of Tammy's face, inappropriate to report that she died by means of natural causes when he did not know how she died, and inappropriate to list asthma as a cause of death when he had no evidence that asthma caused or contributed in any way to her death."
However, we are now aware that after Bernardo was arrested for "the Scarborough rapes" the Coroner's investigation into Tammy's death was re-opened by by Dr. Young and Deputy Chief Coroner Dr. Jim Cairns.
Tammy's remains were exhumed, a second post-mortem conducted, and the cause of death was re-classified as a homicide on the basis that Tammy died of aspiration of stomach contents while unconscious due to the administration of Halcion and Halothane.
Here is where "think dirty" comes in.
Justice Campbell notes in a section of his report called "The Coroner's system" that, "a number of changes have been made by the Chief Coroner's Office in the system of death investigation as it existed at the time of Tammy Homolka's death."
The first change that he enunciates in a list of eight changes is: "Training and reinforcement in the need for coroners to "think dirty" in the face of suspicious circumstances."
Campbell also zeroed in on the fact that a rape kit had not been administered in the post-mortem examination of Tammy Homolka "although the possibility of sexual activity was briefly considered");
"We know now that Tammy was sexually assaulted by both Bernardo and Homolka and Homolka. It is not certain that a rape kit would have revealed this fact had one been administered at the time of the post-mortem examination," Campbell wrote.
"Had a rape kit been administered and vaginal swabs and washings tested positive however it is clear that the investigation into the death of Tammy Homolka would have taken a different course."
"In encouraging coroners to 'think dirty,' Dr. Young's memorandum of June 6, 1994 concerning the investigation of potential female homicides committed by intimate partners emphasized the complexities of investigating female deaths and reminded coroners to approach all such investigations with a suspicious mind."
Dr. Young's June 6, 1994 memorandum - under the heading "Extracts From Chief Coroner's Report - is included as an Appendix in the Campbell report.
The very first paragraph refers to the importance of coroners "thinking dirty."
"In 1992, the Office of the Chief Coroner instituted a special three day course which is mandatory for all new coroners when they first embark on their Coroner work. This course stresses the importance of coroners "thinking dirty" and the necessity for the use of "team work" involving all the different agencies and disciplines responsible for a death investigation..."
There is no indication in the memorandum as to why new Ontario Coroner's were first taught to "think dirty" in this particular year.
One possibility: There would have been considerable public anxiety in the province - and in the Chief Coroner's Office - around this time; As Campbell notes: "Between May of 1987 and December of 1992, Paul Bernardo raped or sexually assaulted at least eighteen women in Scarborough, Peel, and St. Catherines and killed three women in St. Catherines and Burlington."
Bernardo was not arrested until February 17, 1993;
Now we get to the crunch;
Justice Campbell notes that Dr. Young's "think dirty" policy - in place as far back as 1992 - was applied in relation to "potential female homicides committed by intimate partners."
How and when did the "think dirty" policy become extended to investigations into the deaths of babies?
Perhaps there are some answers to this interesting question in Dr. Young's evidence to the Goudge Inquiry;
Here is what he had to say about it - under examination by Commission Counsel Mark Sandler;
MR. MARK SANDLER: And if I can take you to PFP057584. And this is in your document that's called the Coroner's Investigative Manual.
COMMISSIONER STEPHEN GOUDGE: There should be a binder that is --
MR. MARK SANDLER: There should be a separate binder that has the manual in it.
COMMISSIONER STEPHEN GOUDGE: A black binder.
DR. JAMES YOUNG: Yes, okay. Yeah.
CONTINUED BY MR. MARK SANDLER:
MR. MARK SANDLER: And if you can go to page 349 of the document. And I'm going to ask you very briefly about this because it has been dealt with fairly extensively in the evidence. And -- and I'm going to ask, really, just one (1) -- one (1) or two (2) questions arising out of it. his is the memorandum Number 631 dated April 10, 1995, to all coroners, pathologists, and chiefs of police in Ontario, re: the new protocol to be used in the investigation of the sudden and unexpected death of any child under two (2) years of age. And as I'm sure it has not been lost on you, one (1) of the issues that -- that has been discussed here is -- is the expression, that's used in the manual, "thinking dirty".
DR. JAMES YOUNG: Mm-hm.
MR. MARK SANDLER: First of all, who was responsible for the use of the phrase and what, in your view, did it refer to?
DR. JAMES YOUNG: I doubt anyone would want to take ownership for it now, but I can tell you I won't take ownership. I don't know with certainty. I mean, I suppose the person who used it the most often was Dr. Cairns, but I really don't know -- I don't know where it came from with any certainty. What was happening at that point in time --
MR. MARK SANDLER: Just -- just stopping there for a moment, because -- because I know you wouldn't want to leave this mis-impression. It certainly was -- was a phrase that you adopted and used in presentations yourself --
DR. JAMES YOUNG: Occasionally. I had a 'think dirty' side, yes.
MR. MARK SANDLER: Okay. And so I just interrupted you. So you were going to provide the Commissioner with the context in which the -- the phrase was used I take it?
DR. JAMES YOUNG: Well this -- this was the period worldwide when there was concern that -- that pediatric deaths weren't being properly investigated. And we were very aware and there were discussions, again, at any forensic meeting about the difficulties in investigating pediatric deaths, and the fact that they -- children died of different things than adults did; and the very difficult job of sorting out metabolic disorders, SIDS, cases of Shaken Baby, cases of subtle -- suffocation, of subtle child abuse, and dating of injuries, you know, to make sure that what was attributed to the death was -- was relevant. So they -- there was an awareness that the level of investigation of what the -- things that were important in a pediatric death are very different then the things that are important in a -- in a adult death and that the signs and symptoms are very different. But in order to do that, then you have to make the -- again, starting where do the problems mostly occur? The problems occur at the front end of an investigation. So the idea and the object was then that the investigating coroners and the police that are involved in these cases need to understand they can't walk into a situation, look at a scene -- first of all they need to go to the scene, which wasn't always being done, and they need to look at the scene with -- with a more careful observation then -- then just simply deciding that something -- well this looks like everything's fine, and it's a nice family, and therefore we'll -- we'll assume that everything's fine. Not that you're not going to end up back at that result, but what you have to do is go through the various possibilities in your mind and at the end of it you want to be able to conclude whether or not, in fact, this represents a suicide, an accident, a homicide, a natural or an undetermined death. But -- but don't fix on one (1), go through the list and try to in fact do it in an inquisitive na -- way. And that's really what it was meant to -- to do; is just simply awaken people to the fact that different and -- kinds of information and a different mind set needed to be addressed. It was not -- absolutely not, and it was never contemplated or discussed at any meeting I ever attended where the phrase was used, to mean that make cases -- make cases criminal matters when they aren't. That was not the intention. It was meant to awaken the - - the need to think in broader terms.
MR. MARK SANDLER: All right. And --
DR. JAMES YOUNG: In retrospect it's probably not the greatest phrase, but absolute -- until this Inquiry, no one ever raised it with us and said, It's a bad phrase. You know, it's the passage of time and the events here have cast a different light on it then was ever thought of at the time.
MR. MARK SANDLER: All right. So I -- I take it as implicit if not explicit on what you've just said, is that you recognize that -- that with the benefit of -- of what we've learned since, it might be advisable for the Chief Coroner's Office to -- to develop another phrase to communicate the same sentiment?
DR. JAMES YOUNG: Sure, sure. And that's how -- that's why we're always changing things and re -- you know, there's a lot of these memos that are reworked memos from the past, because as we get through and have experience, we take those experiences and change things.