AFTERMATH TO RELEASE OF GOUDGE REPORT: PART THREE; ANALYSIS; SICK KIDS "IMPEDED" CHIEF CORONER'S OFFICE, GOUDGE SAYS;

"NOTWITHSTANDING THEIR ONGOING CONCERNS ABOUT DELAYS AND DIAGNOSTIC DISCREPANCIES IN DR. SMITH'S WORK, IT APPEARS THAT NO ONE AT SICK KIDS TOOK ANY FORMAL DISCIPLINARY ACTION AGAINST DR. SMITH, NOR DID THEY TELL THE CHIEF CORONER'S OFFICE ABOUT THEIR MISGIVINGS."

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It is understandable that initial reaction to release of the Goudge report should focus on the utter lack of accountability exercised over Dr. Smith by his superiors in the Chief Coroner's Office, Dr. Young and Dr. Cairns.

However, we should not allow ourselves to overlook Justice Goudge's finding that the Hospital for Sick Children - Dr. Smith's employer - "impeded the Office of the Chief Coroner's ability to provide meaningful oversight."

Curiously, the censuring of the renowned hospital is buried almost at the very end of the Inquiry's 278 page volume labelled "Systemic Review"and only takes up four pages in the Commission's overall report.

Goudge explains that from at least 1995 to 1997, Dr. Becker and others at Sick Kids had concerns about the timing and the quality of Dr. Smith's pathology work for the hospital.

"Notwithstanding their ongoing concerns about delays and diagnostic discrepancies in Dr. Smith's work, it appears that no one at Sick Kids took any formal disciplinary action against Dr. Smith, nor did they tell the Chief Coroner's Office about their misgivings."

"Ultimately, I cannot determine what might have happened had Sick Kids informed the Chief Coroner's Office about its concerns, but there can be no doubt that, if they had been known, these concerns should have informed the actions of the Chief Coroner's Office from 1995 to 1997."

"By choosing not to provide this information Sick Kids impeded the (Chief Coroner's Office's) ability to provide meaningful insight."

After reviewing serious diagnostic errors made by Smith in his work for the hospital, Justice Goudge acknowledges that these cases were "a small minority of all of the surgical pathology work that Dr. Smith conducted during the course of his career,"

"However, at times, his colleagues were clearly frustrated with his diagnostic mistakes," he continues.

"This frustration was evidenced by an email written by Dr. Thorner to Dr. Becker in May 1997 in which he referred to two complaints regarding Dr. Smith as "another nail for the coffin."

"However, it must be said that the complaints regarding diagnostic issues did not rise to the level where the pathologist-in-chief formally restricted Dr. Smith's privileges."

In this Bloggist's humble view, it must also be said that the hospital's cover-up of Dr. Smith's mistakes was Justice Goudge should have taken the hospital much more firmly to task.

Instead, he recommends that the Ontario Forensic Pediatric Pathology Unit should remain at Sick Kids - a responsibility which it has not demonstrated that it deserves.

Harold Levy...hlevy15@gmail.com;