Thursday, November 6, 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 Valin's case prepared by Inquiry staff reads, in part, as follows;

Valin died in June 1993, at the age of four, in Sault Ste. Marie,Ontario;

On the evening of June 26, 1993, Valin's parents left Valin and her brother in the care of their uncle, William Mullins-Johnson.

They did not check on her overnight.

The next morning, at approximately 7.00 a.m. Valin's mother found Valin in bed, face down and on her knees.

She called 911.

Ambualance attendants arrived at the scene and determined that Valin was already dead.

Following an autopsy conducted later that say, he police arrested and charger William Mullins-Johnson with first-degree murder and aggravated assault.

On September 21, 1994 a jury convicted Mr.Mullins-Johnson of first-degree murder.

He was sentenced to life in prison with no eligibility for parole for 25 years.

Mr. Mullins-Johnson appealed to the Court of Appeal for Ontario.

On Dec. 19, 1996, the Court dismissed the appeal.

Justice Stephen Borins dissented, which gave Mr.Mullins-Johnson the right to appeal to the Supreme Court of Canada;

The Supreme Court heard and dismissed Mr. Mullins-Johnson's appeal on May 26, 1998.

(On) September 7, 2005, Mr. Mullins-Johnson filed an application for ministerial review...

On September 21, 2005, 11 years after his conviction, Mr. Mullins-Johnson was granted bail pending his application;

On July 17, 2007, the federal minister of justice granted Mr. Mullins-Johnspn's application for ministerial review and referred the case to the Court of Appeal for Ontario.

On October 19, 2007, that Court allowed the appeal, quashed Mr. Mullins-Johnson's conviction for first-degree murder, and entered an acquittal;


Justice Goudge describes the events in Valin's Case as being most relevant to the story of growing concerns which took place in 2003, and later, after Dr. Smith's removal from the roster for coroner's autopsies.

One of the most alarming issues in the case relates to Dr. Smith's inability, or refusal - whichever theory you might explain this best - to produce the tissue blocks and microscopic slides from Valin's autopsy. (Without them Mullins-Johnson would never be able to establish his innocence);

"Dr. Smith first denied any knowledge of the case, and then he was adamant that he did not have the materials," wrote Goudge..."Contrary to what Dr. Smith had told the Deputy Chief Coroner (DR. Cairns), it was clear that he had never returned the materials to Dr. Rasaiah."

Justice Goudge described the sequence of events relating to the quest for the missing materials as "disturbing."

"Dr. Smith received and ignored request after request for the autopsy materials from a case he had reviewed and in which a man was in prison for first-degree murder," he explained.

"The materials were found in his own office almost 18 months after the first unanswered request.

The case raises serious questions about the storage and retention of autopsy materials and, more important, about Dr. Smith's disregard for the needs of the criminal justice system."

Goudge makes clear that the subsequent retesting of the exhibits established that "there was nothing in the histological material to support the infliction of any anal trauma (which only Smith claimed to see and would ultimately convict Mullins-Johnson of first-degree murder) - and the panel of independent international experts agreed unanimously, as did Chief Pathologist Dr. Michael Pollanen, that:

0: Dr. Smith had misinterpreted post-mortem changes for injury;

0: the cause of Valin's death was undetermined (she probably choked on her vomit while sleeping), and

0: there was no evidence of sexual abuse;

Interaction between forensic pathology and the criminal justice system;

Justice Goudge sees Valin's case as an example of flawed pathology which can all too often lead to tragic outcomes in pediatric death cases - such as a parent, family member, or caregiver being wrongly entangled in the criminal justice system, and wrongfully convicted and incarcerated..."as happened to William Mullins-Johnson in Valin's case."

He adds that whether the flawed pathology plays a part in a wrongful conviction (Valin's case) or in a lowing a criminal to escape detection (Jenna's case) "justice is not served and public confidence in the legal system is diminished."

Dr. Smith's lack of experience - and its consequences in Valin's case;

Justice Goudge observes that Smith's lack of training and experience, and his failure to recognize his lack of experience, led to William Mullins-Johnson's wrongful conviction for first-degree murder and the more than twelve years he had to spend behind bars before he was finally exonerated;

I wouldn't let Dr. Smith off the hook so easily...

It's not a question of Dr. Smith's failure to recognize his lack of experience.

Dr. Smith used his position as head of the Ontario Forensic Pediatric Pathology Unit to take as many of the forensic cases as possible - especially the ones that would attract lots of publicity.

As Justice Goudge put it:

"It is true that few pathologists were trained in forensic pathology, and that, in several of these cases, other doctors made the same mistakes he did.

It is clear, however, that many pathologists without proper forensic training shied away altogether from criminally suspicious cases or were careful to obtain the assistance of those few who had the requisite knowledge in forensic pathology.

No other pathologists threw themselves into the challenging area of pediatric forensic pathology, untrained, Quite the way Dr. Smith did.

Moreover, Dr. Smith tended to work in isolation.

He did not readily seek advice from or consult with colleagues about his difficult cases.

Over the course of time, as we have seen, this behaviour exacted an unacceptable price in a sequence of cases."

This was a matter of ego, control and arrogance - in which he selfishly put himself before those he was expected to serve in the criminal justice system in order to enhance his own undeserved reputation.

Worse, his superiors in the Chief Coroner's Office never stood in the way - as long as it would enhance their reputation too.

For shame;

Use of default analysis;

Justice Goudge points out that Dr. Smith improperly proceeded by way of default analysis in Valin's case - as he had in Nicholas' case - by concluding that his post-mortem findings were the result of non-accidental injury that he regarded as credible,

More particularly, in Valin's case:

"Dr. Smith and a SCAN physician reviewed the autopsy photographs and wrote a joint consultation report, dated August 6, 1993.

In their report, they noted that Valin's anus was gaping with a large opening and that there appeared to be fissures inside.

They wrote: "In the absence of a history of severe constipation, these findings would be suggestive of anal penetration, likely forceful, by a round blunt object."

The SickKids doctors also noticed bruising to Valin's face and upper chest and concluded: In the absence of a reasonable explanation by history (the findings) indicate non-accidental trauma, including sexual abuse."

Cooperating with other experts;

Justice Goudge rejects Smith's explanation that he did not cooperate with attempts to locate the forensic materials in Valin's case so they could be reviewed by another pathologist "because he did not understand the importance of his cooperation because of naivety about the justice system."

Not so, says Goudge.

"He repeatedly portrayed himself publicly as a knowledgeable and experienced participant in that forum."

"Dr. Smith's actions in (Valin's) case represent one of the starkest examples of his complete disregard for reasonable requests made by Crown counsel and another pathologist," Goudge concluded.

"Given that I describe this unfortunate incident earlier, I will not repeat what I said there.

Suffice it to say that there was absolutely no justification for Dr. Smith's callous disregard fir the requests made by Dr. Rasaiah and Crown counsel."