In the most recent posting - Can of Worms; Part Two - I focused on the call by Ottawa defence lawyers for a probe of the forensic examinations conducted by Dr. Brian Johnston, who headed a forensic unit in Eastern Ontario.
The posting referred to Dr. David Chaisson's testimony at the Goudge Inquiry that Johnston was permitted to hold on to his job for nine years even though senior officials of the Chief Coroner's Office were aware that he was error-prone.
(Chaisson is the former chief forensic pathologist of Ontario;)
Here is Dr. Chiasson's unedited testimony in response to questions posed by Goudge Commission Counsel Linda Rothstein:
MS. LINDA ROTHSTEIN: But before we turn to those, I -- I do want to touch on at least what you've just raised, which is the oversight issues that you confronted, apart from those that arose at Sick Kids. I'm quite right, am I, Dr. Chiasson, that the Hospital for Sick Children was not the only forensic unit that you viewed as needing some improvement?
DR. DAVID CHIASSON: That's correct.
MS. LINDA ROTHSTEIN: And in particular, am I right that you -- during this same period of time were confronting some fairly significant problems in the Eastern Ontario Regional Forensic Unit?
DR. DAVID CHIASSON: I was.
MS. LINDA ROTHSTEIN: All right. Am I right that that is a unit that started in January of 1994, again, just shortly before you assumed the position as the Chief Forensic Pathologist?
DR. DAVID CHIASSON: Yes. And so I had nothing to do with creation of the unit -- of that unit.
MS. LINDA ROTHSTEIN: And am I right that that was a unit that restricted its cases to adult cases?
DR. DAVID CHIASSON: Yes.
MS. LINDA ROTHSTEIN: And the children's cases had historically, I think you and I talked about this this morning, been routed to CHEO, the Children's Hospital in Eastern Ontario?
DR. DAVID CHIASSON: Yes.
MS. LINDA ROTHSTEIN: Who headed up the Eastern Ontario Regional Forensic Unit which in the documents is referred to, Commissioner, as the EORFPU?
DR. DAVID CHIASSON: Dr. Brian Johnston.
MS. LINDA ROTHSTEIN: Okay. What was his background, Dr. Chiasson?
DR. DAVID CHIASSON: As I understand around the time in the Unit, he was a hospital pathologist working, I think it was at the Riverside
Hospital. He was doing a -- a large number of forensic cases, coroner's cases, in the -- as part of his role although he was a hospital pathologist and doing other -- other things. His background, as I understood it was that he had done some form of training, I think in Winnipeg. This wouldn't have been, I don't think, a formal training program in the extent of that of -- as I'm unclear. I do not believe at that time that he had any formal certification in forensic pathology.
COMMISSIONER STEPHEN GOUDGE: But the training was forensic that he had in Winnipeg, or do you know?
DR. DAVID CHIASSON: Well, and I don't know when I learned this as opposed to what I knew at the time. I -- I think there was some indication of some additional training in Winnipeg doing -- doing forensic
cases, but I don't think it was a formal training program. I could be wrong about that.
MS. LINDA ROTHSTEIN: Now can you tell the Commissioner, very briefly, but by way of overview, Dr. Chiasson, whether you had some concerns about Dr. Johnston's unit, and indeed about his own forensic pathology work in this period; '95, '96, '97?
DR. DAVID CHIASSON: Yes. I -- I had significant concerns about the work that was coming out of this unit, and specifically the work of Dr. Johnston. I'd reviewed a number of his cases as part of the quality control review process that I had instigated and I was identifying, what I thought were significant forensic pathology issues. Most notably was a case where he
concluded that an individual had been strangled. In reviewing his pm report, it was clear that there were other potential explanations for the death including significant coronary artery disease, including a significant level of methadone in -- in the blood. I therefore carried out a formal review. And I -- I should say that Dr. Johnston had given a preliminary opinion at the time of autopsy that the cause of death was strangulation, which in itself was in my view, problematic.
COMMISSIONER STEPHEN GOUDGE: What? The preliminary part?
DR. DAVID CHIASSON: Yes, the preliminary part of the diagnosis of manual strangulation in the setting of other significant pathology findings and in the setting of -- you don't know what the toxicology
report is yet to -- to find. So an individual, as I understand, was
arrested, was in custody at the time. I performed a detailed review, including review of the histologic slides, reviewing of the hyoid bone which was an issue as to whether it was fractured or not, and all the photographs. I met with the Ottawa police investigator involved in the case and eventually issued my own report indicating that I did not think that the diagnosis of
strangulation could be substantiated as being certainly the most likely cause of death. I thought that there was significant -- or there were other very real possibilities. I think ultimately we concluded, I think was, most likely he died
of a combination of drug intoxication and a significant coronary heart disease.
MS. LINDA ROTHSTEIN: And indeed, the result down the line was that there were some civil litigation that arose out of that case. Am I right about that?
DR. DAVID CHIASSON: Well, the initial result was that the accused in this matter was released from custody and -- and charges were dropped.
Subsequently, a civil lawsuit against Dr. Johnston -- and I think the Ottawa police and some other parties was -- was instigated, yes.
MS. LINDA ROTHSTEIN: Indeed, Commissioner, we have a copy of that in your Volume III, the Decision from the Superior Court of Justice in that case at 141947, that's Tab 17. The name of the deceased in that case, am
I correct, Dr. Chiasson, was Marcel Vaness (phonetic)?
DR. DAVID CHIASSON: Yes.
MS. LINDA ROTHSTEIN: And you, somehow, escaped involvement in the civil litigation. You may want to postulate as to why that happened. But I don't see you mentioned. Were you a witness, Dr. Chiasson?
DR. DAVID CHIASSON: I was not a witness in the civil litigation. I don't know why. I mean, it's obviously, it's -- it's not my job to subpoena myself in such circumstances.
MS. LINDA ROTHSTEIN: You -- you may be interested to note though, Commissioner, that Dr. John Butt at paragraph 12 was the expert forensic pathologist testifying on behalf of the plaintiff and Dr. Peter Marcustein (phonetic) was the expert forensic pathologist testifying on behalf of Dr. Johnston. Let's look at one other example arising from that unit, by no means exhaustive of your concerns, but as a way of perhaps illustrating what kind of
comments you were occasionally -- or when necessary -- making on the post-mortem reports that you actually received. And that's the case that we now have on the screen involving, I understand, a deceased by the name of Dan Jones.
Is that right?
DR. DAVID CHIASSON: Yes. I don't see the name there but I think that's the -- the reference --
MS. LINDA ROTHSTEIN: So if we look at that and, Commissioner, with that, you may also want to turn up Tab 4 of Volume III which is 141753.
But, Registrar, if you could just leave this so Dr. Chiasson has both the two (2) page autopsy report prepared by Dr. Johnston and his notes of it. And, Dr. Chiasson, if you would take us through your note which you'll find at Tab 4 of Volume III and assist the Commissioner with the sorts of concerns that you were attempting to address as part of your review of -- of provincial post-mortem reports.
DR. DAVID CHIASSON: Well, there's a number of issues here that -- that caused me concern. As a pathologist working in a coroner's system, the
determination of manner is not part of his responsibility and there's clearly references to the manner of death here in -- in the -- in the report. I'm not arguing that that isn't the right manner of death in this case. I'm
saying that a pathologist working in a coroner's system should avoid references to the manner of death, and he's making clearly a reference to homicidal in -- in the title. The issue of close range which is made
there; in fact, if you look in the report, it's not really well-defined what he means by -- by close range firing. And certainly, that is a significant forensic pathology issue when one's dealing with a gunshot wound. And especially if one is opining that it's homicidal; if it's, in fact, it's close range there's, you know, the alternative that it is suicidal is always,
you know, needs to be considered. The reference to 12 gauge shotgun which is
not in the title -- the title you could argue is -- is kind of trying to describe the case in some kind of summary fashion. But, in fact, the reference in the summary of findings that this is a single 12 gauge shotgun blast
is clearly something that can't be established by a pathologist examining a body. You can't tell what kind of -- you can say it's a shotgun blast or -- but not 12 gauge or -- or whatever unless you're a firearms expert concurrently and have examined the weapon, in my view. And then in the summary part of this
report, there's reference to death occurring within three (3) to four (4) minutes. And this is a comment that -- it goes back to the opinions and how much opinion you should put into a report. It's an opinion in this case that, yes,
it's on page 2 and it's at the end there. It's an opinion that in all likelihood how long somebody survived is not -- is in all likelihood not -- not that critical one and is one that I don't think you can substantiate. The degree of accuracy with which you can determine how long somebody survives and injury is -- is not an exact science. It's a difficult thing, and -- and to opine such a thing in a report, to me is -- is misleading and suggests the degree of accuracy which I don't think can be supported. There's reference in the history to the decedent; possible cocaine dealer and being treated for
psychotic psychiatric illness. It's arguable as to how - - how relevant that is to the establishment that he's a homicide victim and whether that could be somehow deemed to be unnecessary prejudicial information. There's also reference to a history of hay fever and being treated would react -- and I mean there - - there's too much information here that is inconsequential as far as the forensic pathology side of things. So there are -- there is this issue about
history and what you put in. I think one tries to be concise and try to restrict your history to that part that is relevant to your forensic pathology work. And then when you're rendering forensic pathology opinions -- the thing here, he doesn't really expand on his close-range firing which is an important
forensic pathology issue, but yet, he gives a time of survival post-injury which I don't think is -- is forensically accurate and is really probably of limited
importance. So there's all sorts of, what I consider, forensic pathology issues in this report.
MS. LINDA ROTHSTEIN: So turning to the next tab if you would, Dr. Chiasson, Mr. Commissioner as well, Tab 5 of Volume III, 141787. There you've
documented in some reform some of the concerns as of February 13th; I'm not sure if it's '96, '97, '98.
DR. DAVID CHIASSON: I think it's '96.
MS. LINDA ROTHSTEIN: Okay. So you record: "Isolationist attitude. Has never requested assistance with any cases. Was offered opportunity to visit, came for a few days, no changes. Reports confusing; poorly organized, repetitious, makes unwarranted conclusions, administrative apparently not reviewing any cases from the unit..." And so on. Help us. How serious was that level of concern?
DR. DAVID CHIASSON: Well, it -- it was of concern, I mean, in -- we've already talked about the Vaness case. The Vaness case caused me extreme concern. This -- this is -- this case is of less concern, I think.
I don't think it had any criminal court proceeding impact issue, but it -- it suggests a background of forensic pathology approach that -- that I have difficulty reconciling. And then the administrative stuff is, you
know, again it's -- it's relatively minor considering what I thought to be the important -- the very important issue as to the actual nature of the reports that were being produced and the -- and the PMs that were being performed.
MS. LINDA ROTHSTEIN: Did you engage in discussions with the Regional Supervising Coroner and Dr. Johnston's superior, Dr. Micheau (phonetic) and indeed Dr. Young, in attempt to try and improve the situation in Ottawa?
DR. DAVID CHIASSON: Yes, I did.
MS. LINDA ROTHSTEIN: And what did you
try to do?
DR. DAVID CHIASSON: Well, I had a number of meetings over a time period with Dr. Bechard who -- we worked together as -- he was Regional Coroner situated in Kingston. We met with Dr. Johnston. We suggested
certain remedial activities. We invited them to come to Toronto for several months in order to work within the unit; get a sense of what we were doing, get a sense of what my expectations were, the way we approach things. So it was -- it was a remedial form of activity.
MS. LINDA ROTHSTEIN: And was Dr. Johnston amenable to those suggestions?
DR. DAVID CHIASSON: No.
MS. LINDA ROTHSTEIN: So what happened?
DR. DAVID CHIASSON: I wrote a member -- memo to Dr. Young indicating basically a summary of -- of the events and what was going on in -- in Ottawa. I suggested that he be removed as the Director of the Ottawa Unit. And he could continue to work as a forensic pathologist, but that we needed to seek out a new director and hopefully have him continue to work but under -- under somebody else's direction.
MS. LINDA ROTHSTEIN: And is that your memo that we find at Tab 13, dated February 3, 1998?
DR. DAVID CHIASSON: Yes, it is.
MS. LINDA ROTHSTEIN: And can -- Registrar, that's 141866. So the bottom line for you then was that a new director needed to be recruited?
DR. DAVID CHIASSON: Yes. And for the benefit of those present, this is the draft memorandum. There's actually, just before it --
MS. LINDA ROTHSTEIN: Oh, sorry. Thank
you.
DR. DAVID CHIASSON: -- in the book there
is the actual memorandum.
MS. LINDA ROTHSTEIN: 130640. Thank you
for that.
DR. DAVID CHIASSON: I think they're both very similar, but that's -- a formal memo was issued to Dr. Young.
MS. LINDA ROTHSTEIN: What was Dr. Young's view?
DR. DAVID CHIASSON: I -- I don't have a specific recall of -- of his view. I mean, what I'm proposing here is that we need to find somebody to try
and -- to find somebody to take over the Unit. And we did work towards doing that. We tried to recruit a Dr. Irvine who was just finishing up her training. And we saw that there were issues obviously with having a junior take over a unit where there's a fairly seriou -- sig -- sorry, senior person involved. But we needed somebody that we could work with who -- who sort of followed more standard
forensic pathology approaches, could oversee the work of Dr. Johnston. So Dr. Young -- I never did get a formal reply from Dr. Young to my memorandum. We talked about it, we're trying to do what we could in terms of recruiting. In the meantime, however, Dr. Johnston remained the director.
MS. LINDA ROTHSTEIN: And indeed remained the director until the time that you left your position as the Chief Forensic Pathologist, am I right?
DR. DAVID CHIASSON: That's correct, yes.
MS. LINDA ROTHSTEIN: And, Commissioner, you will find in the rest of that volume, some of the documents that chronicle the story after Dr. Chiasson's involvement, and indeed the issue again became of some concern, I think you'll see, for doctors Pollanen and McLellan. And you can read through the documents which will bring that to light. I take it, Dr. Chiasson, you can't really shed a lot of light from personal knowledge on what
happened after your resignation as the Chief Forensic Pathologist, or -- or do you know in fact?
DR. DAVID CHIASSON: Well, I -- I know that Dr. McLellan did contact me to find out, you know, what information that I had that could be helpful to him in terms of the past while I was there, and I provided a copy of this memo and some other documents related to that.
COMMISSIONER STEPHEN GOUDGE: Is Dr.
Johnston still there?
DR. DAVID CHIASSON: Dr. Johnston is still working at the Unit as -- as far as I know, yes.
COMMISSIONER STEPHEN GOUDGE: Is he the Director? Or do you know?
DR. DAVID CHIASSON: I don't know whether he's still the Director or not.
MS. LINDA ROTHSTEIN: He's about to retire, Commissioner. But it's -- when you read through the documents, Commissioner, you -- the story I think is more or less told in those documents that you have, in the rest of that binder.
COMMISSIONER STEPHEN GOUDGE: Okay.
Thanks.
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