Thursday, October 23, 2008


Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.

I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.

I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.

Justice Goudge's findings relating to the various cases have been scattered throughout the report.

My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;


An overview report prepared by Commission staff tells us that Nicholas was born in Sudbury, Ontario on January 2, 1995.

Nicholas was the child of Lianne Gagnon and Steven Tolin.

Nicholas died on November 30, 1995, in Sudbury.

Nicholas was 11 months old at the time of his death.

Criminal proceedings were not initiated.

The local children's aid society initiated proceedings in respect of Ms. Gagnon's second child, born in 1968.

The proceedings concluded on March 25, 1999 when the society withdrew the protection application;


Maurice Gagnon, Nicholas's grand-father, launched a barrage of complaints against Dr. Smith and Dr. Cairns to the Ontario government, the Chief Coroner's Office, the College of Physicians and Surgeons of Ontario (the College) and even the province's Ombudsman.

The common thread was that Smith was guilty of professional misconduct, that the Chief Coroner's Office lacked accountability, that former Deputy Chief Coroner, Dr. Jim Cairns, was unduly influenced by Smith's opinion, and that Cairn's judgment had been clouded by his quest to eradicate child abuse.

Justice Goudge agreed with many of Gagnon's complaints.

"Mr. Gagnon was persistent. His letters were well researched and well reasoned. Given what is now known, many of his concerns about Dr. Smith, Dr. Cairns and the (Chief Coroner's Office) were legitimate," he ruled. "Unfortunately, those in the senior positions at the Chief Coroner's Office did not listen."

Maurice Gagnon's complaints - laced with specific criticisms of Dr. Smith's work on the case - resonated with Justice Goudge, who faulted Smith as follows, for:

0: Continuing to insist that Nicholas had not died of natural causes but from cerebral edema, consistent with a blunt force injury to the head, in spite of key findings which underpinned his diagnosis.

0: Misrepresenting a radiologist's findings in an affidavit prepared for a family court hearing; The "mild diastasis" noted by the radiologist, became "marked widening of the skull sutures" as communicated by Charles Smith;

0: Providing a baseless opinion in the case - subsequently disproved by one independent expert who concluded that Smith's opinion was unsubstantiated and baseless - and another who testified that Smith's conclusion about Nicholas's death went "far beyond the boundaries that can be supported by the presenting scientific and forensic facts."

Justice Goudge was also disturbed by Dr. Smith's response to the complaints made against him, saying: "Dr. Smith's reaction to the complaints made against him was no better (than the complaint in Amber's case); As with the complaint in Amber's case, he responded by denying that he had done anything wrong."

"He responded not only by emphasizing the reasons for his opinion, but by telling the College that he had never received some of the relevant materials from the coroner or police (though he had), and by claiming that he was not involved in any way with the Children's Aid Society (although clearly he was);"

Other findings:

Misinterpreting artefact's:

At the second post-mortem examination, Smith found "some discolouration in the skull over the right parietal bone and along the soutures, which he suggested was consistent with blunt force injury; He concluded that the cause of death was cerebral edema, consistent with blunt force injury.

The expert reviewers who reviewed Nicholas case reported that: "The discolouration was post-mortem - a common finding visible whenever a body a body has been buried and subsequently exhumed. "It was an artifact of no significance and did not indicate the presence of injury";

Justuce Goudge says this misdiagnosis exemplifies "the risks if inadequate forensic pathology training."

Use of default diagnosis;

Goudge says that in Nicholas' case, Smith "concluded that his post-mortem findings were the result of non-accidental injury because there was no explanation of accidental injury that he regarded as credible...This is the default diagnosis approach..."It makes non-accidental injury the pathologist's default position and puts the onus on others to exclude it."

Specifically: Smith wrote a consultation report, "finding that Nicholas had cerebral edema, an increased head circumference, splitting skull sutures, a fracture to the left side of his mandible, and a scalp injury. He concluded: "In the absence of a reasonable explanation, the death of this boy is attributed to blunt head injury."...Goudge says he should have taken an evidence-based approach: begin from position of objectivity, have an open mind and consider all the possibilities before arriving at a conclusion."

Failure to record alleged consultations with other experts:

An issue arose whether in fact he had in fact obtained an opinion from Dr. Venita Jay, a neuropathologist, as he claimed.

Dr. Jay had no specific recollection of this alleged opinion - or of any opinion she offered.

Dr. Smith first mentioned that he had obtained this opinion after a pathologist retained by Nicholas's mother and grandfather alleged that Smith should have consulted with a neuropathologist but failed to do so!


Justice Goudge found that Smith made "false and misleading statements" to the College - which was investigating a complaint about his conduct in Nicholas's case---adding that his misrepresentations frustrated any meaningful over sight that the two institutions might have offered."

More specifically, Justice Goudge took issue with Smith's response to Maurice Gagnon's allegation that he had failed to investigate Nicholas's previous medical records, including his head circumference in life.

Smith replied to the College that he had not been provided with these measurements;

"The statement was wrong," said Goudge. "The lead investigating officer, Sergeant Keetch, gave Dr. Smith those very records during a meeting in May 1997";