Part Six: Closing Submissions; Affected Families Group: "Think Dirty";

UNFORTUNATELY, IN THIS DAY AND AGE, CHILD ABUSE IS A REAL ISSUE, AND IT IS EXTREMELY IMPORTANT THAT ALL MEMBERS OF THE INVESTIGATIVE TEAM “THINK DIRTY.”

THEY MUST ACTIVELY INVESTIGATE EACH CASE AS POTENTIAL CHILD ABUSE, AND NOT COME TO A PREMATURE CONCLUSION REGARDING THE CAUSE AND MANNER OF DEATH UNTIL THE COMPLETE INVESTIGATION IS FINISHED AND ALL MEMBERS OF THE TEAM ARE SATISFIED WITH THE CONCLUSION.

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EXCERPT FROM MEMO 631: "THE 'YOU SHALL USE IT MEMO'...

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This Blog is currently looking at the closing written submissions filed by various parties appearing at the Goudge Inquiry which is expected to report on September 30, 2008.

The current focus is on the submissions filed by the "Affected Families Group" - 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 Group is represented by lawyers Peter Wardle (Wardle, Daley, Bernstein) and Julie M. Kirkpatrick;

Today's focus is on the Group's assertion that "the real question for this Inquiry is what impact the “Think Dirty” mindset had on child death in investigations during the period under review."

The "thinking dirty" section of the submissions begins with the following excerpt from the infamous directive:

"Unfortunately, in this day and age, child abuse is a real issue, and it is extremely important that all members of the investigative team “Think Dirty.”

They must actively investigate each case as potential child abuse, and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished and all members of the team are satisfied with the conclusion."

"It was sent out as a directive: ‘You Shall Use It’," the section continues;

"According to Dr. McLellan, the genesis for Memo 631 was a shared concern by the coroners and police that in several cases of pediatric death around the province, autopsies, skeletal surveys, and toxicology were not being done.


According to Dr. Smith, the protocol was the culmination of a fifteen year effort on his part to change how pediatric forensic autopsies were done in Ontario.

It was specifically designed to respond to mistakes that had been made in investigations and to give guidance to “people who weren’t involved in these kinds of death investigations on a frequent basis.”

For Dr. Young, the protocol was a point of pride because the Memo was “leading edge in trying to document and get consistency in these areas”:

"The philosophy without calling it that, was being adopted worldwide…. If you went to forensic meetings that was the discussion that was going on. The formalization of a protocol and the institutionalizing of trying to get consistency in the approach to these cases, we were leading edge at that point in time."

For Cairns, the phrase “think dirty” was “like the Nike swoosh” – a brand.

In 2003, Dr. Young attended as a witness before the Shipman Inquiry and gave evidence about “the philosophy” that led to findings made by Dame Janet Smith as follows:

"…the coronial service in Ontario seeks and is successful in securing for itself a high public role. The profile ensures that the public is aware of both the existence of the service and mechanism of investigating deaths about which there is any concern or problem. This acts as a positive encouragement to report deaths about which any concern arises… the investigating coroners are instructed to consider the possibility of “think dirty” and to liaise with the family in investigating the death."

However, in his evidence before the Inquiry, Dr. Young took great pains to distance himself from his former “brand” by saying:

“I doubt anyone would want to take ownership for it now, but I can tell you I won’t take ownership…. I mean I suppose the person who used it the most often was Dr. Cairns, but I really don’t know.”

The real issue about “Think Dirty” is not the words themselves.

Several witnesses have testified that the words were intended only to connote that persons investigating unexpected child deaths should utilize a “high index of suspicion”.

The phrase “Think Dirty” has now been replaced in the 2007 Autopsy Guidelines with a mandate to “Think Objectively, Think Truth”, with an admonition to “keep an open mind to death by child abuse”, which we accept as appropriate.

The real question for this Inquiry is what impact the “Think Dirty” mindset had on child death in investigations during the period under review."

Harold Levy...hlevy15@gmail.com;