Monday, November 3, 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 of Sharon's case prepared by Commission staff indicates that:

"Sharon was born in Kingston, Ontario, on December 28, 1989. She was the child of Louise Reynolds and David, Sharon died on June 12, 1997, at the age of seven and a half years.

On June 26, 1997, Ms. Reynolds was charged with second degree murder in the death of Sharon. The preliminary inquiry was conducted from April to November 1998. On November 19,1998, the Honourable Mr. Justice Megginson committed Ms. Reynolds to trial on the charge. She was remanded without bail from June 26, 1997, until April 26, 1999 when she was released with the consent of the Crown, on certain terms and conditions.

The Crown withdrew the charge against Ms. Reynolds on January 2, 201, indicating that it did not have a reasonable prospect of conviction."


One of Justice Goudge's first criticisms of Charles Smith in Sharon's case is that "he performed the autopsy anyway" - even though, "at the time, he had very little experience with penetrating wounds, having seen only one or two cases involving stab wounds and one or two other cases involving dog bites."

This is the case where prosecutors had to make repeated requests to Dr.Smith for his report - and even had to issue a subpoena requiring him to attend court and produce it.

He finally produced the report to the Crown on March 8, 1998, nine months after completing the post-mortem examination;

Justice Goudge also criticizes Smith's categorical denial of suggestions by defence counsel that a dog had attacked Sharon,saying dismissively: "As absurd as it is to think that a polar bear attacked Sharon, so it is equally absurd that it's a dog wound," which, of course,it was.

As Justice Goudge put it:

"Dr. Smith's errors in Sharon's case were basic. He lacked the forensic pathology training and experience required to assess properly Sharon's penetrating wounds. Yet he took the case on anyway. The results were catastrophic. He turned what forensically qualified experts say are clearly dog bites into something much more sinister, Dr. Smith's misdiagnosis in Sharon's case might have been prevented had he had the appropriate training and expertise in forensic pathology,or if he had consulted with someone with such a background.

Justice Goudge did not buy Smith's argument in closing submissions that other experts, including a forensic ondontologist, had also misinterpreted Sharon's wounds, saying: "This is true, but does not excuse Dr. Smith's errors in the case."

Autopsy practice:

It was only on reading the Goudge report that I realized that Dr. Smith's conduct of the autopsy in Sharon's case was as deficient - as replete with "serious errors" - as his post-mortem on Baby Jenna which has been referred to earlier in this series.

Goudge points out that Dr. Smith:

0: Did not shave the hair to conduct a detailed assessment of the wound margins when examining Sharon's scalp injury; (standard procedure - like the swab in Jenna's case);

0: Did not take swabs of the wounds to test for saliva;

0: Did not dissect the spinal canal and cord as he should have , given that the injuries went down to the spine;

0: Failed to measure the depth of key injuries, such as a penetrating wound in the neck. (An important measurement to determine if a dog could have caused Sharon's injuries);

0: Did not examine the scalp adequately under the microscope during the ancillary testing phase of the autopsy;

Reporting in a timely fashion;

In addition to an "inexcusable" nine and a half month delay in in providing his report, Goudge blasts Smith for failing to respond to defence lawyers and prosecutors who were seeking it, as he tells us: "Two days before his scheduled court date, Dr. Smith completed his report of post-mortem examination and faxed it to the Crown;

Justice Goudge also refers to Smith's failure to understand "that his role as an expert witness is not to support the Crown."

In this respectful Bloggist's view, this interpretation of Smith's performance is far too kind. Dr. Smith stressed the importance of being a neutral witness in his lectures to medical students.

He knew damn well what he was doing - helping the Crown win the case - through himself into the task and did it very well.

The overstated expertise of the expert:

Justice Goudge points out that, "rather than acknowledging the limits to his expertise, Dr. Smith sometimes mislead the court by overstating his knowledge in a particular area.

In Sharon's case this was typified by the impression he left at Louise Reynold's preliminary hearing that he had a significant expertise with both stab and dog wounds, by saying: "I've seen dog wounds. I've seen coyote wounds,I've seen wolf wounds. I recently went to an archipelago of islands owned by another country near the North Pole and had the occasion to study osteology and look at patterns of wounding from Polar Bears."

"His attempt to so exaggerate his abilities disguised his lack of relevant expertise," said Goudge.

Loss of forensic materials from the case that should have been safeguarded;

Justice Smith points out that Smith lost forensic materials in Sharon's case that he had a professional responsibility to protect: a cast of Sharon's skull and a set of x-rays.

The loss of the cast was significant: Louise Reynold's lawyers believed that it was important for their defences and had it not been lost it may not have been necessary to exhume Sharon's body with all of the emotional pain and suffering this would mean for her family.

Although the loss of the X-Rays was less consequential, Goudge reported that the loss of these materials was a sign of Smith's "disorganization, carelessness and sloppiness."

In this Blogster's view something far more insidious is involved: Smith tended to "lose" exhibits which would may have assisted the defence or proven that in the Waudby case his opinion was wrong such as the skull cast, the hair found in Baby Jenna's genital area, and the microscopic slides in the Mullins-Johnson case.

Forces much darker than "disorganization,carelessness and sloppiness" were at play.