Thursday, October 30, 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;


After reviewing the College of Physicians and Surgeons of Ontario's handling of three complaints lodged against Dr. Charles Smith - including the Nicholas case - - Justice Goudge ruled with remarkable understatement,that: "while the College did play its role as one accountability mechanism for doctors, with hindsight a more vigorous response would have been preferable."

"There is no doubt that the misinformation it received from Dr. Smith, its acceptance of this information without testing it, and its failure to be informed of relevant facts by the Chief Coroner's Office contributed to what happened," Goudge continued.

"However, this review remains yet another lesson in the need for active vigilance if oversight and accountability mechanisms are to do their job properly;"

Remarkable understatement indeed!