The Hospital For Sick Children's Irreparable Breach Of An Important Public Trust;

"AFTER A COLOSTOMY, FECES LEAVE THE PATIENT'S BODY THROUGH THE STOMA, AND COLLECT IN A POUCH ATTACHED TO THE PATIENT'S ABDOMEN WHICH IS CHANGED WHEN NECESSARY."

FROM WIKIPEDIA DEFINITION OF COLOSTOMY;

After a colostomy, feces leave the patient's body through the stoma, and collect in a pouch attached to the patient's abdomen which is changed when necessary.

One of the most devastating examples of Dr. Charles Smith's incompetence involved an infant at the Hospital for Sick Children in Toronto who was forced to undergo a colostomy because of Dr. Smith's mistaken diagnosis.

The example was provided to the Inquiry by Dr. Ernest Cutz who testified that he had been told about the case by Dr. Barry Shandling, a Surgeon at the Hospital.

Dr. Cutz said he learned that the operation was necessary because Smith had concluded from a biopsy that a newborn child was lacking ganglion cells - an indication that the intestines may not be functioning properly.

However, it was ultimately determined after the fact that the ganglions had been present all along and that the operation was therefore surgically unnecessary.

Cutz told Commissioner Stephen Goudge that, "I think Dr. Shandling was very concerned because he has to explain this to the parents."

Wikipedia describes a colostomy as, "a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall, leaving the patient with an opening on the abdomen called a stoma."

"This opening is formed from the end of the large intestine drawn out through the incision and sutured to the skin," the definition continues.

"After a colostomy, feces leave the patient's body through the stoma, and collect in a pouch attached to the patient's abdomen which is changed when necessary.

This humble Bloggist finds it unthinkable that such an operation would have to be conducted on a newborn infant because of a mistaken diagnosis.

I also find it unthinkable that the Hospital did not inform the College of Physicians and Surgeons - the governing body of the medical profession in Ontario, that the botched diagnosis and unnecessary surgery on an infant had occurred.

(If the Inquiry had not been called, it is unlikely that this horrific incident involving Dr. Smith - and the Hospital's suppression of it - would ever have seen the light of day);

There were so many other incidents in which Dr. Smith apparently erred that some of his colleagues sent an anxious letter to his then-department head, the late Dr. Larry Becker, which is detailed in an earlier Blog.

The Blog, which ran under the heading, "Goudge Inquiry: Stunning Revelations: Smith removed from non-forensic duties at Hospital For Sick Children in 1997 after colleagues complained about errors" is worth repeating in light of subsequent evidence called at the Inquiry.

"The Goudge Inquiry heard the stunning revelation Monday that Dr. Charles Smith's errors were not confined to his work on coroner's autopsies," the Blog began.

"Several of his colleagues at the Hospital for Sick Children - including pathologists and Surgeons - had complained in 1997 that Dr. Smith had made errors in his interpretation of histological samples on four cases handled as a surgical pathologist on the hospital's staff.

In short, he misinterpreted what he observed under the microscope in each of the four cases.

Dr. Jim Cairns, who was Director of Investigations for the Chief Coroner's Office at the time, also revealed that the Hospital ultimately curtailed his responsibilities in surgical pathology and reduced his salary accordingly - until reinstating him at a later date.

Cairns also delivered the startling revelation that the Hospital for Sick Children did not inform the Chief Coroner's office, about the serious problems that the Hospital had encountered with Smith's work - and the remedial steps it had been forced to take - (including a requirement that he take continuing education courses);

Moreover, Dr. Cairns testified that Dr. Smith had fallen seriously behind in his paper work on hospital matters (just as he had problems delivering his forensic reports in a timely manner H.L.)

While leading Dr. Cairns evidence, Commission Counsel Linda Rothstein introduced into evidence a letter from Dr. Laurence Becker, Smith's superior at the hospital, "re surgical complaints."

"Since my return from the pathology conference in Orlando I have come across four (4) recent cases of Dr. Smith's in which there are diagnostic discrepancies. I am outlining the events below as I understand them," the letter begins.

Cairns informed Rothstein that, "these are issues where other colleagues at the hospital are saying that he is not interpreting histological slides appropriately, and that "one of the fundamental things about a pathologist is the ability to diagnose things down the microscope."

Cairns said he "very much" agreed with Rothstein that it would have been relevant for himself and other members of the (Chief Coroner's office) to know that Dr. Smith's colleagues at the Hospital for Sick Children had identified errors in his surgical pathology diagnostic skills.

Rothstein also read to Cairns a second letter to Smith from Becker, dated April 18, 1997, which read in part:

"Dear Charles:

As you are aware, the surgical reports for which you've been responsible have not been completed according to the established standards agreed upon in 1994. You have received regular reminders over the past two (2) years about the delays in completion of reports.

An example of such a letter covering the last several months is enclosed.

In addition, during the limited number of weeks per year that you have been
responsible for completion of the surgical reports, there have been a disproportion in the number of complaints about diagnostic 1 inconsistencies from pediatricians and surgeons."

And, then, continued in the second paragraph:

"Neither Paul nor I can see any improvement in the reporting time or the accuracy of the reports over the past two (2) years.

Therefore, I regret to inform you that I must curtail your responsibilities in
surgical pathology until you prove to me evidence of successful completion of continuing education courses that will improve your skills in surgical pathology.

You must also demonstrate that all records in the division are completed in a timely fashion, consistent with standards established by the hospital.

You will not be doing surgical pathology on a regular rotation and, accordingly, the salary from the Division of Pathology will be reduced by twenty thousand
(20,000) for 1997."

Asked by Rothstein if it had ever come to his attention that the Hospital had taken that measure, Dr. Cairns tersely replied, "No, it did not."

Rothstein's examination of Dr. Cairns continued as follows:

MS. LINDA ROTHSTEIN: Did it ever come to your attention that the hospital was taking the position that Dr. Smith needed more education in the area of surgical pathology?

DR. CAIRNS: No, it did not.

MS. LINDA ROTHSTEIN: And what, if any, influence would that have had on your confidence in Dr. Smith?

DR. CAIRNS: Well, part of the role and -- of-- the pathologist, particularly in children's autopsy, would be the histological examination; what he was seeing down the microscope.

It was our belief that Dr. Smith was a pathologist at the Hospital for Sick Kids with an excellent reputation and be diagnostically accurate in histological samples.

The histological samples that he'd be doing in his hospital work may well be very similar to the type of histological samples he'd be looking for us.

So this -- this would indicate a serious concern about his diagnostic abilities.

MS. LINDA ROTHSTEIN: And looked at systemically, Dr. Cairns, is this evidence of a disconnect between the Hospital for Sick Children, on the one hand, and the (Chief Coroner's office) on the other?

DR. CAIRNS: Yes, it -- it is my feeling that it would have been very helpful if, when Dr. Chiasson and myself were having meetings with Dr. Becker and sharing our concerns -- and our concerns were primarily with his delay, but that it would have been extremely helpful for there had been some sharing of this information with us.

It obviously would have made a significant difference. What the legalities of that are, I can't answer.

But, certainly, it would have been of great assistance to us.

Because we were never in the position where we felt his histology was -- was questionable.

COMMISSIONER STEPHEN GOUDGE: Did Dr. Becker ever say, We had the same problems about delay that you're complaining to us about?

DR. CAIRNS: No. No, he didn't...;

This humble Bloggist cannot deny that the unpleasant words "cover up" entered his mind as he listened to Dr. Cairn's testimony.

But the more balanced part of me says let's withhold our judgment until Hospital For Sick Children officials take the witness stand in the coming months.

They certainly have a great deal to explain.

Subsequent evidence called at the Inquiry has raised a question as to whether the letter from the late Dr. Becker was ever sent to Dr. Smith.

But is relatively clear from testimony given by Dr. Glenn Taylor, the current head of the Hospital's pathology department, and Dr.Ernest Cutz, that Dr. Smith never interrupted his surgical pathology work, that his salary was never reduced, and that he never took any remedial courses.

It is also clear from cross-examination of Dr. Taylor by Carolyn Silver, Counsel for the Chief Coroner's Office, that the Hospital covered up Dr. Smith's sub-standard work in the identified case from both the Chief Coroner's Office and the College.

Silver was hovering close to the truth when she asked the following questions of Dr. Taylor and got the following terse answers.

MS. CAROLYN SILVER: Both of you have given evidence about the concerns you had or the concerns that you were aware of with respect to Dr. Smith's work
as a pathologist while he worked at Sick Kids, fair enough?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And I'll -- I'll just ask one (1) of you to answer and if there's any disagreement from the other, perhaps you could indicate so? And there were concerns with respect to Dr. Smith's surgical pathology, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And concerns with respect to his opinions regarding cause of death in certain forensic cases, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And there were certainly concerns about the timeliness of his reports, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And that's all been gone over in some detail, fair enough?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And in terms of addressing those concerns, some of those concerns were brought up with Dr. Smith in correspondence by the hospital, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And certain concerns were brought up at rounds by people, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And you've heard evidence from the Coroner's Office that they thought some of those concerns were significant, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And you're aware that -- at least, Dr. Cairns gave evidence that some of that information -- it might have been helpful to share that with the Coroner's Office, fair enough?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And that much of that information was not shared with the Coroner's Office, fair enough?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And we've also heard evidence about information that the Coroner's Office had with respect to Dr. Smith that was not shared with Sick Kids, correct?

DR. GLENN TAYLOR: Yes.

MS. CAROLYN SILVER: And the concerns about Dr. Smith's work as a pathologist at the Hospital for Sick Kids was present from, at least, let's say, 1995 through to, at least, the early 2000s, correct?

DR. GLENN TAYLOR: Yes.Commissioner Goudge did not permit Silver to directly ask Taylor and Cutz, in her words, "whether they would agree that the Hospital for Sick Kids should have shared their concerns with the regulatory body of the College?"

I, however, am under no such restraints and am disturbed that the Hospital, through its lawyer William Carter, suggested that the law did not oblige the hospital to report these matters involving Dr. Smith to the College.

That the hospital should try and shield itself by the law sends me the message that it is lacking a moral compass - and that it still doesn't understand that by taking on the Forensic Pediatric Unit for the province it was taking on an important public trust.

Why didn't the hospital exercise its moral, if not legal obligations?

I have several theories - and the readers of this Blog likely have some of their own.

At the most innocent level, the Hospital For Sick Children is a complex institution composed of many elements of which the Pediatric Forensic Pathology Unit was only a tiny component which was not likely on the radar of senior administrators.

To be utterly fair, the Hospital had not had much experience with forensic autopsies before the unit was established, and there is no evidence that the Chief Coroner's office had gone out of its way to ensure the hospital understood its role and was fully equipped to do its important job.

Also to be fair, it was the Chief Coroner's Office - not the hospital - that allowed Dr. Smith to be propelled to super-star status - and the more important Dr. Smith became the harder it would have been for the hospital to take him to task without serious public relation's ramifications.

That said, the Hospital's failure to reign in Dr. Smith in spite of mounting evidence that his incompetence was harming patients - and its admitted failure to share this information with the Chief Coroner's Office and the College of Physicians and Surgeons of Ontario is unforgivable.

Also unforgivable, is for the Hospital For Sick Children to have allowed Dr. Smith to maintain for years a sorely cluttered office which has become a disturbing symbol of the Inquiry.

As a former secretary testified at the Inquiry: "There were some tissues, you know, that were dried out in plastic containers. There was some sort of of just skeletal bones in another little dish. There was a little, sort of, wrist bead. Those kids, the children who were usually sick; They make beads for their wrists. So each time they have a procedure you have a bead. There was one of those." (See earlier Blog: Dr. Smith's office: Part Three);

This disgusting office was also a symbol of the numerous forensic exhibits lost or misplaced by Dr. Smith over the years which would have made a critical difference for wrongly accused persons protesting their innocence.

Hospital officials have allowed this ugly blot to remain in front of their eyes day after day, year after year.

In this Bloggist's view, the hospital violated its public trust to such an irreparable degree that the Unit should be shut down and placed elsewhere under the direct control of the Chief Coroner's office.

That can't happen soon enough.

Harold Levy...hlevy15@gmail.com;