MAURICE GAGNON; COMPLAINT AGAINST DR. CHARLES SMITH TO THE ONTARIO CORONER'S COUNSEL SUBMITTED ON BEHALF OF HIMSELF, HIS DAUGHTER LIANNE, AND HIS GRANDSON NICHOLAS (DECEASED);
One of important duties of a forensic pathologist is to fully document consultations with other specialists such as neuropathologists and anatomic physicists to ensure that decisions as to the cause or time of death are strictly within their expertise.
The Charles Smith Blog has learned, however, that former Ontario Ombudsman Claire Lewis, faulted Smith for failing to provide written reports from specialists he claims he consulted with on two occasions relating to his investigation of the death of 10-month old Nicholas Gagnon who died suddenly on November 30, 1995, in his family home in Sudbury, Ontario, while being cared for by Lianne Thibeault, his mother.
Lewis's report raises serious questions that go to the heart of Dr. Charles Smith's credibility: whether he can be believed when he claimed to have had two consultations with specialists in other fields - or whether he reached an opinion which would likely result in the laying of the most serious criminal charges based on areas beyond his expertise.
(Lewis refers to a letter sent to the Ontario's Deputy Chief Coroner by the lawyer for the Sudbury Children's Aid Society "which expressed concern that (Smith) was left to address the issues in the autopsy without the assistance of the other medical disciplines");
As I reported in the Toronto Star on February 26, 2001, Nicholas stopped breathing after bumping his head under a table and was pronounced dead at hospital.
Although a Sudbury coroner classified the death as sudden and unexplainable -- and somewhat consistent with sudden infant death syndrome -- Smith, after reviewing the initial autopsy report, decided the death was not accidental and had the body exhumed for a second autopsy.
Acting on Smith's opinion, Children's Aid Society officials moved to seize a then-unborn baby daughter from Thibeault.
Thibeault was unable to recover the child for about a month after it was born on June 27, 1998 and her name was not removed from the provincial child abuse registry until last March.
The baby was ultimately returned to her after Dr. Mary Case, an American pathologist reviewed all of the forensic and medical exhibits from Nicholas's autopsy at the request of Dr. David Chiasson, Chief Forensic Pathologist for Ontario, and concluded that, "I would not attribute this death to a head injury (as Smith had incorrectly opined) as there are no findings on which to make such a conclusion."
Case, a professor of pathology at St. Louis University in St. Louis Missouri, also stated in her opinion, dated March 6, 1999, "I would not attribute an asphyxial mechanism to this death anymore than I would a head injury," adding that she would consider both the cause and manner of death to be "undetermined."
After Maurice Gagnon, Thibeault's father, sued the local Children's Aid Society, Justice L. Gauthier said in her ruling, "It is unfortunate that the Society relied upon information which ultimately proved to be unsustainable...The persons who took important roles in the process provided flawed information."
Gagnon was troubled by the fact that although Smith had described himself as a medical doctor with specialization in anatomic pathology his investigation in his daughter's case appeared to be primarily neurological.
Gagnon had sought the medical opinion of Dr. William Halliday, a neuropathologist and professor of neuropathology at the University of Manitoba, who had participated in the investigation of numerous unexpected childhood deaths and had been involved with more than fifty "Shaken-Impact Syndrome" investigations.
Halliday's overall opinion on reviewing the case was that Smith's characterization of Nicholas's death as related to cerebral trauma resulting from non-accidental blunt force injury was "speculative and conjectural."
Halliday swore in an affidavit that he was personally aware that Smith relied on Hospital For Sick Children staff pediatric neuropathologists for matters relating to the nervous system, and like other anatomic pathologists "did very little of his own neuropathology."
Smith later rejected the suggestion that he had failed to consult a neuropathologist in an affidavit, saying, "Dr. Halliday notes that it would be ideal for a trained neuropathologist to perform the neuropathologic aspect of a pediatric autopsy, if such a person was available.""In this case such a procedure was undertaken," Smith continues in his affidavit. "The gross and microscopic neuropathologic observations were made by Dr. Venita Jay and me...Dr. Jay did not issue a written report, but communicated her opinion to me verbally."
Dr. Jay is on record as informing the Ontario College of Physicians and Surgeons of Ontario, in December, 2000, when contacted for her records of the "consultation" that, "I have no recollection of the above case at this time."
Moreover, as Gagnon pointed out, there was no mention of Dr. Jay in Dr. Smith's post-mortem report, and he concluded that if there had ever been a consultation, it would have to have been cursory, such as a chat in a corridor.
Ombudsman Lewis says in his report that, "the Deputy Chief Coroner (Dr. Jim Cairns) has advised my office that he discussed the autopsy report of (Smith) when it was completed and the(Smith) told him that he had this consultation."
"The Deputy Chief Coroner did not know if this was a "hallway" consultation or a written report and he did not question this at the time," Lewis continued. "There was no written report of this consultation."
But Lewis says elsewhere in his report that in late November and early December 1998, "The (Children's Aid Society became aware that the colleagues of the Director of the Ontario Pediatric Forensic Pathology Unit (Smith) for Sick Children, were not providing the information that was supportive of his position."
"The pediatric neuropathologist with whom he said he consulted (Jay) responded to a subpoena explaining that although she may have been involved in a peripheral, incidental way, she had no specific recollection of the case," Lewis continued. "She said she had no information in her possession or control to contribute to the case."
Lewis was clearly troubled by the Smith's failure to document any "consultation" with Dr. Jay - and by a second failure by Smith to document a significant consultation - one Smith said he had with a radiologist during the investigation of Nicholas's death.
"He (Dr. Smith) noted that the original radiographs were reviewed by the Acting Chief and the neuroradiologist, Department of Diagnostic Imaging, HSC (Hospital for Sick Children), who, he said, affirmed the presence of the split skill sutures...," Lewis wrote in his report.
The existence of split sutures would have buttressed Smith's opinion that this was a non-accidental death because they tend to be an indication of brain swelling.
"There is no written report of this consultation," Lewis added. "This is the first of two occasions when there was no written report of a significant consultation."
"This is a matter that concerned me and I will address that later."
Lewis later notes that he was informed by the Chief Coroner's office (The CCO) that, "in a similar case scenario, the first thing the CCO would look for if there is reference to a head injury is a written neuropathological opinion - and that a case conference would be held to assess the case with all the parties involved (including all of the doctors who were consulted).
He suggests that written reports should be the norm whenever someone else's medical advice is relied on to form any significant opinion.
That begs the question whether the consultations actually occurred in the Thibeault case;
Harold levy;
