Tuesday, October 28, 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;


"Nicholas' case represents a particularly troubling example of how the organizational weaknesses of the Chief Coroner's Office, together with errors of judgment by Dr. Young and Dr. Cairns, combined to prevent meaningful oversight of Dr. Smith."

Justice Stephen Goudge.


It is crucial to understand that although Nicholas died on November 30, 1995, his death in no way came under suspicion until Dr. Smith produced a consultation report for the Pediatric Death Review Committee more than two years later - on January 24, 1997 - in which he concluded that: In the absence of an alternative explanation, the death of this young boy (was) attributed to blunt head injury."

As a result of Smith's intervention in the case, backed by Dr. Cairns, the Gagnon family had to endure the horror of having Nicholas' body exhumed several years after his death - later to learn that Dr. Smith brought his 11-year-old son to the exhumation;

Justice Goudge faults Cairns for his blind support of Smith in spite of the contents of an affidavit prepared on behalf of Nicholas' mother by a Winnipeg pathologist who concluded that Dr. Smith's conclusions "went far beyond the boundaries that can be supported by the presenting scientific and forensic facts."

Goudge also points out that even though the mother's lawyer sent excerpts from Judge Dun's decision criticizing Smith's work, "Despite Justice Dunn's pointed criticisms, Dr. Cairns neither obtained a full copy of the decision nor took any other steps to investigate Judge Dunn's findings."

One of the most severe criticisms relates to an affidavit Dr. Cairns swore in the Childrens Aid Society proceedings in which he "wholly agreed" with Smith's findings -
even though Cairns was utterly unqualified to give such an opinion "and had not reviewed any of the underlying medical evidence in the case."

"Dr. Cairns told the Inquiry that, in his affidavit, he intended to communicate only that the Chief Coroner's Office accepted Dr. Smith's opinion," wrote Goudge.

"But Dr. Cairns affidavit went much farther than that: it contained what purported to be an expert pathology opinion..."

"Had Dr. Cairns clearly restricted himself to matters within his area of expertise, it is likely that the Chief Coroner's Office or the Children's Aid Society would have obtained an independent pathology opinion much sooner than it did."

It gets worse;

Even when Cairns was finally ordered an independent opinion from an American expert - Dr. Mary Case - who concluded that there were no findings to support the conclusion that the death was caused by either a head injury or an asphyxial mechanism, as Smith had reported - "Dr. Cairns testified at the Inquiry that his confidence in Dr. Smith's judgment was not shaken that Dr. Smith's by the Chief Coroner's Office decision to accept Dr. Case's opinion in Nicholas' case."

Justice Goudge added that: "In light of expert opinions from Dr. Case and Dr. de Sa that Dr. Smith's opinion had no basis in the pathology evidence, this lack of concern is troubling."

Goudge says that although Young testified that he did not become concerned about Smith's work on the Nicholas' case until after his office received the Case opinion - and that he met with Smith and instructed him to be "more conservative in his views" - Young should have responded more forcefully.

"Other than Dr. Young's conversation as described, Dr. Smith was not reprimanded after the conclusion of Nicholas' case," Goudge wrote in his report. "Dr. Young did not put any of his concerns in writing."

"He took no measures to improve Dr. Smith's skills or knowledge, and he created no plan of action to improve the situation."

Harold Levy...hlevy15@gmail.com;