Part Five: Closing Submissions: Affected Families; Anatomy of Complaints That Fell On Deaf Ears;

IN CONCLUSION, DURING THE PERIOD UNDER REVIEW, THE VERY PERSON WHO HAD RESPONSIBILITY FOR OVERSIGHT WITH RESPECT TO THE ACTIVITIES OF THE ONTARIO PEDIATRIC FORENSIC PATHOLOGY UNIT, AND DR. SMITH IN PARTICULAR, WAS THE PERSON RESPONSIBLE FOR DEALING WITH COMPLAINTS FROM THE PUBLIC ABOUT BOTH CORONERS AND PATHOLOGISTS.

DR. YOUNG LACKED THE TOOLS BOTH TO EXERCISE EFFECTIVE OVERSIGHT AND TO RESPOND APPROPRIATELY TO COMPLAINTS.

FROM CLOSING SUBMISSIONS: THE AFFECTED FAMILIES GROUP;
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Some extremely interesting written closing submissions have been filed with the Goudge Inquiry by lawyers representing "The Affected Families Group."

This is a group of families who were directly affected by the systemic failings which occurred in pediatric forensic pathology in Ontario between 1991 and 2001; The lawyers are Peter Wardle (Wardle, Daley, Bernstein) and Julie M. Kirkpatrick.

The group argues that complaints made by parents or caregivers who felt they had been unfairly treated during the death investigation process fell on deaf ears because there was no independent complaints process;

"The Coroners Act itself does not contain any process by which complaints about the conduct of a coroner or pathologist acting under the Coroners Act are to be dealt with," this portion of the Group's submissions begins.

"Following the abolishment of the Coroner’s Council in 1998, any complaint about the conduct of a coroner or pathologist appears to have been dealt with by Dr. Young, in his capacity as Chief Coroner of Ontario," it continues.

"According to (Former Chief Coroner) Dr. (James) Young’s letter to the College of Physicians and Surgeons of Ontario dated April 10, 2002:

"I am responsible for bringing the policies and procedures to the attention of all those engaged in coroners’ work and, when there has been a breach of these policies and procedures, I communicate directly to the coroners and their agents."

There does not appear to have been any formal complaints process ever set up during Dr. Young’s tenure as Chief Coroner.

Instead, he appears to have assumed that he had an overriding supervisory authority under the Act to personally review complaints, investigate and respond.

The inadequacy of this process is amply demonstrated by the Nicholas case.

Mr. Gagnon initially complained to the Coroner’s Council on February 17, 1999 regarding Dr. Smith.

The complaint outlined a number of areas of concern regarding Dr. Smith’s conduct in extensive detail, including very specific criticisms about his pathologic findings;

Dr. Young’s reply dated May 6, 1999 acknowledged that many of the issues raised by Mr. Gagnon were “essential to the practice of forensic pathology.”

In addition, it provided Mr. Gagnon with a copy of the Forensic Pathology Pitfalls Memorandum which had recently been prepared by The Ontario Chief Coroner's Office;

However, on the critical allegations made by Mr. Gagnon regarding Dr. Smith (relating to competence, lack of expertise and bias), Dr. Young’s response was as follows: Experts must be allowed their individual opinions as this is what makes them experts. Their opinion is based on training and experiences. The question, is therefore, whether or not their opinion falls within a reasonable range given the facts of the case.

On March 6, 2000, Mr. Gagnon filed a complaint with the Solicitor General regarding Dr. Cairns’ conduct in the investigation into Nicholas’ death.

This complaint is particularly important in that it raised a number of questions about systemic issues.

In particular, Mr. Gagnon alleged that Dr. Cairns’ “quest to eradicate child abuse in Ontario had clouded his judgment and impaired the objectivity and credibility of the Ontario Chief Coroner's Office;"

The Solicitor General’s reply to Mr. Gagnon’s letter dated April 13, 2000 was prepared by Dr. Young.

That letter also repeated that “the opinion Dr. Smith came to was within a reasonable range given the facts of the case”.

The Ombudsman of Ontario, in its response to Mr. Gagnon dated September 24, 2001, recommended that the Solicitor General considered establishing an independent complaint handing body with special expertise to review complaints and ensure the accountability of the coroner system.

No such mechanism has ever been established.

In conclusion, during the period under review, the very person who had responsibility for oversight with respect to the activities of the Ontario Pediatric Forensic Pathology Unit, and Dr. Smith in particular, was the person responsible for dealing with complaints from the public about both coroners and pathologists.

Dr. Young lacked the tools both to exercise effective oversight and to respond appropriately to complaints.

In addition, as will be dealt with below, Dr. Young and the Ontario Chief Coroner's Office became closely identified with Dr. Smith and his work and had a built-in disincentive to provide objective and effective responses to complaints from the public.

Harold Levy...hlevy15@gmail.com;