Saturday, November 1, 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 Jenna's case prepared by Goudge Inquiry staff tells us that:

Jenna was born in Peterborough, Ontario on April 21, 1995 to Randy and Brenda Waudby. Jenna died on January 22, 1997, at the age of 21-months in Peterborough; Mrs. Waudby was charged with second-degree murder on Sept. 18 1997. The criminal proceeding concluded on June 15, 1999, when the charge was withdrawn. The local Children's Aid Society apprehended Ms. Waudby's older child, Justine, on the day of Jenna's death and placed her in temporary foster care. She remained in foster care until January 27, 1997, when she moved in with Tom and Kim Waudby, her maternal aunt and uncle. She remained there until March 27, 1997, at which time she was again placed in foster care. She was ordered returned to Ms. Waudby's care on May 2, 1997, pursuant to an Order of Justice A.P.Ingram and remained in her care until Sept. 18, 1997, the day of Ms. Waudby's arrest. She was later re-apprehended on the date of Ms. Waudby's arrest. The Children's Aid Society also apprehended a second child, M.W. born after Jenna's death, and placed him with his father. On July 23, 1999, subsequent to the withdrawal of Ms. Waudby's murder charge, Justine was ordered returned to her mother's care. That same day, access was also granted to M.W. who would continue to reside with his father. The Children's Aid Society appealed the decision. On August 13, 1999, the appeal was dismissed. On Dec. 28, 2006, the youth who was babysitting Jenna the night she died was charged with second-degree murder. On December 14, 2006, J.D. pleaded guilty to manslaughter. The criminal proceeding concluded on March 1, 2007, when he was sentenced as a youth to 22 months incarceration followed by 11 months of community supervision;


Justice Goudge reaches the astonishing conclusion that even by the time the former chief coroner, Dr. James Young testified at the Inquiry, "he did not see any problems with the pathology evidence provided by Dr. Smith in Jenna's case."

In short, he stood up for Dr. Smith right to the very end - even though Dr. Benita Porter, his colleague in the Chief Coroner's Office, had provided her own opinion, based on her expertise and the opinion of several pathology experts, that the time between Jenna's injuries and her death was less than six hours (Which, of course, put her in the exclusive company of J.D. the teenage baby-sitter, when the fatal injuries were inflicted.

"Even by the time Dr. Young testified at the Inquiry, he did not see any problems with the pathology evidence provided by Dr. Smith in Jenna's case," wrote Goudge.

"He was not concerned that other experts disagreed with Dr. Smith about the timing of the fatal injuries.

He testified that he thought it was problematic when experts gave too narrow a window of time, but was not concerned if an expert provided a window that was too broad.

Dr. Young maintained that Dr. Smith was not wrong, given that the injuries were inflicted within 24 hours before death.

In his view, Dr. Smith just did not narrow the time period as far as he could have to six hours before death.

Dr. Michael Pollanen, the present Chief Forensic Pathologist, testified at the Inquiry that Dr. Young's analysis of Dr. Smith's pathology opinion was simply incorrect.

He said that, although it is often the counsel of caution to give a broader window for time of death or the time that injuries were inflicted, the principle does not apply where part of the broader time frame is excluded by the pathology evidence, as was the case here.

It is of fundamental importance to identify precisely when the injuries were inflicted wherever that is possible.

In this case, the pathology clearly indicated that the fatal injuries were inflicted within hours of death, and that they could not have been inflicted earlier;"

Justice Goudge reaches the pointed conclusion that coroners, like Smith and Cairns, should not have been supervising pathologists like Smith.

"Jenna's case illustrates the danger of having coroners provide oversight of of pathologists who do forensic work," Goudge ruled.

"This structural weakness contributed greatly to the failure of oversight with regard to Dr. Smith.

Without the training in forensic pathology necessary for meaningful oversight of pathologists, Dr. Young and Dr. Cairns simply could not see this red flag."

This humble Blogster respects the systemic point being made by Justice Goudge.

I have to add, however, that there appear to be curious personal ties of some significant nature between the three men - Smith, Cairns and Young - which had nothing to do with their training but strongly affected their decision making process;

Justice Goudge so points out that although Drs. Young and Cairns ultimately developed concerns about Dr. Smith's conduct in Jenna's case, Dr. Smith's status at the Chief Coroner's Office did not change after a confrontation with Dr. Cairns, he continued to sit on two influential committees (the Pediatric Death Review Committee and the Deaths Under Two Committee), and he continued to hold on to the position of director of the Ontario Pediatric Forensic Pathology Unit.

Goudge notes Dr. Cairn's explanation that the Chief Coroner's Office thought Smith's role was sufficiently limited because he could not perform post-mortem examinations in any more criminally suspicious cases - and the Office was concerned that, if it took further steps regarding Dr. Smith, it might harm the on-going criminal investigation in Jenna's case.

"However, looking back on the episode when he testified at the Inquiry, Dr. Young could not muster any explanation for his on-going support and trust in Dr. Smith as of April 2002, stating rather forlornly, "I don't know why we didn't stop him from doing anything at that time...I just don't know."