Saturday, December 29, 2007

A Glimmer Of understanding: The Fatal Decision; Part One;



How could Dr. Charles Smith have had such a disastrous impact on Ontario's criminal justice system?

Thanks to the evidence of Dr. Ernest Cutz at the Goudge Inquiry I finally have a glimmer of understanding as to how this came about.

The die was cast with the fatal decision to appoint Dr. Smith - a man with no formal qualifications in forensic pathology - as head of the new Ontario Pediatric Forensic Pathology Unit to be located at the Hospital for Sick Children, in 1991.

The proverbial light bulb lit up in my head when I got the glimmer when Commission Counsel Jennifer McAleer asked Cutz if he had any concerns with respect to the choice of Dr. Smith to head a new pediatric forensic pathology unit to be located at the Hospital.

(Before the Unit was established in 1991, autopsies on children in criminally suspicious cases were done at the coroner's office while those done on children who died of natural causes were done at the hospital. But with the establishment of this unit, all autopsies were done at Sick Kids.)

Cutz replied that he would not have recommended Smith for the job because he had not been trained to handle handle matters like "bullet wounds, knife wounds, any kind of act of violence, rape and those kind of things," which forensic pathologists handle on a daily basis.

"(They) have a lot of experience...whereas we practically never do it, and so we have no experience," Cutz said."

That made perfect sense to me.

As an anatomic pathologist, Dr. Smith was trained to diagnose disease and gain other clinically significant information through the examination of tissues and cells.

He simply didn't have the in-depth training and experience which is necessary to determine the cause and time of death and related matters in the context of the criminal and civil justice systems.

Dr. Cutz testified that Smith had "no strong research background" when he began working full-time at the hospital in 1981.

Under questioning by lawyer Peter Wardle, who represents several individuals and familes affected by Smith, as to whether any one at the hospital was actually assisting him - - or whether he was just learning from the cases - Cutz replied that there was "no formal sort of teaching."

To the contrary, Cutz explained that, "(We) we were all 15 available to provide assistance as needed, but basically 16 he was left to develop his skills and knowledge on his own."

Cutz said it would be fair to say that Smith's training at the hospital before being appointed to head the unit "was really derived from on-the-job experience" - and that it would not be unfair to say that he was "self-taught."

This humble Bloggist simply cannot understand why the Province would not have insisted that the person appointed to head the new Unit - with its huge responsibility in investigating children's deaths - should have the highest professional qualifications, training, and experience as a forensic pathologist.

It is no answer to say that Canada did not have any systems in place for qualifying people to work in this complex medical specialty - other countries did.

The province and the Hospital should have scoured the world to find a fully qualified individual who was up to the task - rather than hiring Smith and placing him in a position in which he was way over his head.

The shocking extent of Dr. Smith's ignorance was communicated by my former Toronto Star colleague Theresa Boyle in her account of Dr. John Butt's testimony at the Goudge Inquiry on Nov. 21, 2007.

Butt participated in the independent review of Dr. Smith's cases called by former Chief Coroner Dr. Barry McLellan.

The story appeared under the heading: "Smith lacking the basics, probe told."

"A controversial doctor at the centre of a public inquiry showed a surprising lack of understanding of how rigor mortis affects a body – something even a student of medicine should know, a British Columbia pathologist has testified," the story began.

"This is of concern because it's very basic information that one would expect a medical student to have a good grasp on," Dr. John Butt testified yesterday.

He was commenting on Dr. Charles Smith, who had conducted an autopsy on a 3-year-old girl known only as Katarina who died suddenly in 1995 in Toronto.

The girl's mother was later found not criminally responsible because of mental disorder for the death.

In court proceedings, Smith had commented that rigor mortis starts in the small muscles behind the eyes and mouth and slowly continues downward, affecting the whole body.

Butt said Smith was wrong on this basic point, noting that the stiffening of muscles that occurs after death starts in the smaller ones and moves to the larger ones.

"It has nothing to do with the condition of the body top-to-bottom," he said.

Butt is one of a number of internationally respected pathologists who have reviewed Smith's case file and found serious errors.

This prompted the province to call a public inquiry into pediatric forensic pathology in Ontario.

Smith was once deemed the top pediatric forensic pathologist in the country and he headed the forensic pathology unit at the Toronto Hospital for Sick Children.

The inquiry has been told that while Smith was educated as a pediatric pathologist, he lacked training in forensic pathology.

Meantime, Butt said Smith made another mistake in Katarina's case when he determined the cause of death to be asphyxia.

"It was my opinion that there was little information pathologically upon which to make this conclusion," he said, adding that the pathology in this case was too weak to point to an exact cause of death.

In parentheses, Smith had also written the word "filicide," which means the deliberate act of a parent killing her own child.

But the inquiry has heard that it's not a pathologist's job to weigh in on the manner of death, but rather just to give an opinion on the cause of death...

Dr. Jack Crane, a fully qualified forensic pathologist who reviewed several of Dr. Smith's cases for the independent review ordered by former Chief Coroner, Dr. Barry McLellan, told the Goudge Inquiry: "People who dabble in it (forensic pathology) can get themselves in -- into difficulty, into problems."

He certainly got that right.

Next: A Glimmer of Understanding: The Fatal Decision: Part Two;