COUNTDOWN: 24 DAYS TO GO; WILL DR. CHARLES SMITH'S PERSONAL RESPONSIBILITY BE OVERSHADOWED IN GOUDGE REPORT BY MOUNTAINS OF SYSTEMIC FACTORS?

"SYSTEMIC CAUSES: ALWAYS AN AMORPHOUS UNDERTAKING SINCE VIGILANT REVIEW, BY ITS VERY MINUTIAE, CAN TOTALLY MISS THE ONUS OF THE THING, BITING OFF SO MUCH UPON WHICH TO CHEW THAT THE CULPRITS ARE NEVER SPIT UP FOR PROPER CENSURE. DUCK THE BUCK BY SPREADING RESPONSIBILITY AROUND."

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"PATHOLOGY IS AN INEXACT SCIENCE, HE ADDED. WHICH IS TRUE. BUT SMITH WAS RARELY LESS THAN EXACTING ON THE STAND."

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ROSIE DIMANNO; TORONTO STAR;

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This question is posed by my former colleague at the Toronto Star - and one of my favourite scribes - Rosie DiManno, in a column which ran on November 13, 2007, under the heading "Disgraced Pathologist Only The Start: Fallout from the inquiry into Smith's work likely to cast a shadow over chief coroner, among others."

This is a valid question: Ontario's forensic pathology system was under-funded and poorly managed during the Smith years, and Dr. Smith can hardley be blamed for everything that plagued the system;

"Disgraced: "To bring shame or discredit upon; to remove from favour or position." (Webster's definition)," Rosie's column, began;

"That is the adjective most commonly applied to Dr. Charles Smith these days, routinely so in media reports, and repeatedly by some of the same journalists who were reverential and lionizing of the famous pathologist not too long ago," it continued.

"There had developed a cult of awe around the man – not unlike the groupie obeisance that now surrounds James Lockyer, crusading defender of the unjustly convicted.

At some point during the public inquiry into pediatric forensic pathology that got underway yesterday, Lockyer – among those granted standing, representing the constituency of wrongfully convicted – will get his shot at Smith. So will a phalanx of other lawyers; the hearing room is jammed with legalists.

"Disgraced" is the dialectic currency, the anti-honorific, appended to Smith, certainly since the probe was ordered seven months ago by the province, after an investigation of 45 child deaths – in which Smith conducted autopsies or provided expert testimony – detonated what had been suspicions of forensic righteousness run amok and allegedly poor oversight by the coroner's office of their kids' knight-errant.

Coroner's inquests never affix blame, one reason why many doubt their usefulness although jury recommendations are widely adopted in the hope of preventing similar deaths. And this inquiry is essentially an inquest squared, scrutinizing the wherefores of a system that failed to corral Smith before so many lives were damaged.

Systemic causes: Always an amorphous undertaking since vigilant review, by its very minutiae, can totally miss the onus of the thing, biting off so much upon which to chew that the culprits are never spit up for proper censure. Duck the buck by spreading responsibility around.

Smith may have done wrong; indeed, he palpably did, since his damning conclusions, re-visited, have resulted in some convictions reversed. Twenty of his cases form the basis of this inquiry.

Senior management at the Coroner's Office of Ontario – the coroners who supervise the pathologists, especially – will predictably, maybe rightfully, get smacked around on the witness stand. It should be noted, however, that most coroners are administrators; they're not the laboratory rats looking down a microscope or examining wounds. They look at paper, more often than not.

If in thrall to Smith, they weren't alone. Crown attorneys, with no motivation for disparaging their own expert witness, were just as eagerly deceived. Even defence counsel failed to aggressively rebut because the professional bona fides, the body of work, was so daunting. As now seems apparent, many of those vindications on behalf of harmed children, dead children, were false indictments amounting to a hill of beans, bad forensics and a massively unwarranted reputation.

I suspect a house will be made to fall on the heads of former chief coroner Dr. James Young and soon-retiring deputy chief coroner Dr. Jim Cairns for lapses in "quality control" and failure to adequately investigate concerns about Smith's post-mortem reports when they first arose. I can't jump ahead of the evidence so will refrain from commenting now.

But Smith certainly made a pre-emptive manoeuvre yesterday, having his lawyer read an apology into the record as the inquiry began. Dr. Smith "regrets."

Dr. Smith acknowledges he made a number of mistakes "for which he is truly sorry."

Yet Smith pointedly emphasized he worked "at the direction of the Office of the Chief Coroner of Ontario." He explicitly criticized the "informational disconnect" and lack of "integration" in a criminal investigation.

Pathology is an inexact science, he added. Which is true. But Smith was rarely less than exacting on the stand."

Well said Rosie;

Harold Levy...hlevy15@gmail.com;