Wednesday, October 29, 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.

Maurice Gagnon's efforts to get answers about his grandson Nicholas' death included a complaint he lodged in February, 1999 with the Coroner's Council - a body that had been created to deal with serious complaints about the work of Coroners which had unfortunately been repealed in December, 1998.

Justice Goudge tells us that although former Chief Coroner Dr. James Young personally responded to the complaint:

0: Young did not forward the complaint to, Dr. Chiasson, his Chief Forensic Pathologist (As he testified he normally would have done);

0: Young did not delegate any investigation of the complaint to any member of his staff;

0: And "Indeed, there is no evidence that Dr. Young took any measures to investigate the details of Gagnon's concerns about Dr. Smith's practices in the Nicholas case."

I remember trying to hide my cynicism at the Inquiry when Young testified that it was not possible for him to respond to every aspect of a detailed complaint - and that it was his practice to skip sections of complaints (without reading them) which he deemed to be irrelevant.

This didn't ring true to me because I was very familiar with this complaint - and all of the other complaints filed by Mr. Gagnon.

As Justice Goudge described it:

"Mr. Gagnon's complaint outlined several concerns about Dr. Smith's conduct in Nicholas' case, including the exaggeration of findings of "mild diastasis" into "widely split skull sutures," reliance on undocumented "corridor" consultations, contradictory findings regarding scalp injury, and identification of post-mortem facts as abnormal findings. He also referenced Justice Dunn's decision in Amber's case and included lengthy quotations from the judge's findings and criticism of Dr. Smith."

Although Dr. Young testified that he had no recollection of reading the section of Maurice Gagnon's complaint quoting Justice Dunn's decision, Young is on the record as stating in a draft of his response to the complaint sent to senior officials in his office that he had read Mr. Gagnon's complaint "in detail" and considered it very carefully.

Justice Goudge noted several "regrettable and significant inaccuracies" in Dr, Young's response to Maurice Gagnon, including:

0: His statement that as soon as his office became aware of Dr. Halliday's expert opinion, it requested an opinion from a third independent forensic pathologist; (Not so, said Goudge.The Chief Coroner's Office did not contemplate consulting with an independent expert until the Gagnon family's lawyers raised the issue six months after Dr., Halliday's first opinion.

0: Dr, Young's statement that he had read the Gagnon complaint "in detail" and considered it very carefully: "That was not true," Goudge ruled. "Dr. Young testified at the Inquiry that he probably skipped the portion of the complaint that quoted from Justice Dunn's decision."

(Our readers will recollect that had Dr. Young admitted reading this decision - described by Justice Goudge as a disturbing alarm bell - he would have to explain why he did not take immediate action to review Dr. Smith's cases and rein him in.)

In Justice Goudge's words:

"I found Dr. Young's testimony on this issue very troubling. He insisted that the College should defer to the Chief Coroner's Office to investigate these complaints. Yet his actions displayed a serious disregard for his responsibility to read, investigate, and respond fairly to complaints from the public. He did not give Mr. Gagnon's complaint the Attention it deserved."