Dr. Charles Randal Smith: An indictment By His Peers;

On December 8, 2006 a historic meeting was held at the Chief Coroner's office in Toronto on Grenville Street in Toronto.

Among those present were Dr. Michael Pollanen, Ontario's chief pathologist, and the international team of external examiners who had been retained to probe the cases selected as part of the Chief Coroner's review.

These are top people chosen because of their proven status in the world of forensic pathology - unlike Dr. Charles Smith who enjoyed a reputation largely of his own making;

This would be the first opportunity for the examiners as a group to attempt to develop a consensus on some of the cases involving the work of Dr. Charles Smith on which they had reviewed individually.

The memorandum summing up this meeting - introduced during the first week of the inquiry - is a glaring indictment of Dr. Smith's work.

For example, here are some of the comments on individual cases: (The names of the case are not important for this exercise);

Bear in mind that these tend to be the most serious cases known to the criminal law: Murder, manslaughter and infanticide - all involving the deaths of infants.

The types of cases where one would have expected the most thorough, well-documented death investigations, which could be carefully scrutinized by others, say in court, at a later date.

Case A: All agreed that although there were no major technical difficulties, the general consensus was that the interpretation of injuries was unbalanced;

Case B: Discussion surrounding primary data as insufficient to give a definitive independent review of the case; All agreed that the initial autopsy report was insufficient in detail which may have been medically relevant to the time of death;

Case C: All agreed that Dr. Smith's opinion on the cause of death in this case should have been assigned as "unascertained;"

Case D: All agreed that there were serious issues in this case concerning Dr. Smith's testimony which contradicted his autopsy report. Whilst the autopsy report details the injuries, the cause of death is vague and imprecise. There are significant issues surrounding the timing of the injuries and the time of death as noted by Dr. Smith;

Case E: Shaken baby case: Panel found that using the criteria in place at the time the cause of death would have been given as trauma; (But, all agreed that this would not be considered a balanced view by today's standards);

Case F: All agreed that the opinion given by Dr. Smith as to the mechanism of injury, by any reasonable standard , is grossly erroneous. Although the cause of death in testimony accords with that in the autopsy report, the issue in this case relates to the mechanism of injury and therefore the testimony is inaccurate and misleading;

Case G: All agreed that the conclusions noted by Dr. Smith relating to the cause of death are largely unreliable;

Case H: All agreed that Dr. Smith provided an unbalanced interpretation of the mechanism of the lethal injury. Discussion focused on the judge's ruling that has anticipated many of the current issues with pediatric head injury;

Case I: All agreed that Dr. Smith's cause of death was insufficient based on the evidence available; Ignored histology indicating natural disease, indicated non-existing head fracture and no consideration to the surrounding environment at the time of death. Agreed that the cause of death was not asphyxia as Dr. Smith had reported;

Case J: All agreed that Dr. Smith's findings concerning cause of death were not supported by any evidence;

(These were just some of the cases under review);

What a stunning indictment of the legendary Dr. Charles Randal Smith; He couldn't even get the most fundamental tasks entrusted to forensic pathologists: The cause of death and the time of death - let alone the mechanism of death!

And what a stunning indictment of the Coroner's system during many of the Smith years: Smith's erroneous, often undocumented opinions became cast in stone for use against innocent parents and caregivers because the people entrusted to supervise his work for the protection of the public were not doing their job.

The external examiners "general observations" recorded at that meeting are also instructive:

o: The panel was hindered by a "lack of commentary" in autopsy reports. "Thus in the absence of court testimony, some of Dr. Smith's opinions needed to be reconstructed from other documents)e.g. police reports and Coroner's statements";

0: The panel indicated that Dr. Smith's diagnosis of shaking injury in cases with skull fractures of scalp bruises was not reasonable;

0: Professor Crane indicated that Dr. Smith frequently made the erroneous presumtpive diagnosis of "asphyxia" based on the presence of intrathoracic petechiae. This was thought to represent an untenable view that was outside the mainstream of forensic pathology;

0: The panel indicated that Dr. Smith's diagnosis of head injury based on inferring the presence of cerebral edema from the brain weight was untenable and outside the mainstream of forensic pathology;

0: The panel indicated that Dr. Smith was too definitive in excluding accidental mechanisms of injury, such as falls as potential explanations of childhood head injury;

0: Professor Crane noted that, in some cases, there were serious discrepancies between the autopsy report and the court testimony. This included altering the cause of death, or presenting new findings that were not recorded in the autopsy report;

0: General Commentary by Professor Whitwell on head injury cases: Despite this, Dr. Smith did also make inappropriate or unbalanced diagnoses of head injuries based on histologic artefacts, or non-standard anatomical evidence (e.g. (e.g.) increased brain weight, hypoxic encephalopathy) that was not fully determinative of cranocerebral cases;

Winnipeg researcher Kirsten Kramar has pointed out that pathologists are among the most powerful witnesses in the criminal justice system because of the customary deference paid to them by police.

“Although the Coroner’s office is careful to state that the question of culpability is a matter for the police, a cause of death finding essentially determines which course of action the police will take," Kramar noted.

"Similarly, Crown prosecutors will claim that it is up to the police to lay charges which they then simply prosecute," she continued.

But, the police will almost invariably determine whether or not a criminal charge will be laid based on the autopsy report from the forensic pathologist…”

Dr. Smith's erroneous cause of death findings were all the more lethal, no pun intended, because of the stature lavished personally on him by the other actors in the criminal justice system - even though both he and the forensic pathology he practiced were so tragically flawed.

Harold Levy;