"YESTERDAY, AN OVERHAULED CORONERS ACT WAS GIVEN ROYAL ASSENT TO ENSURE SUCH TRAGEDIES NEVER HAPPEN AGAIN. THE LEGISLATION REQUIRES, FOR THE FIRST TIME, THAT THE PROVINCE’S CHIEF CORONER BE HELD ACCOUNTABLE TO AN OVERSIGHT COUNCIL. AND IT PAVES THE WAY FOR THE CREATION OF A COMPLAINTS COMMITTEE THAT WILL TRACK COMPLAINTS ABOUT CORONERS AND PATHOLOGISTS.
THE NEW LEGISLATION COINCIDES WITH YOUNG’S RESIGNATION AS A MEMBER OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO. EFFECTIVE THIS PAST MONDAY, IT MEANS HE CAN NO LONGER PRACTISE MEDICINE IN THE PROVINCE...
THE BAD NEWS FOR YOUNG DIDN’T END WITH THE INQUIRY. GOUDGE’S REPORT WAS FOLLOWED BY THE REVELATION THAT YOUNG IS BEING INVESTIGATED BY THE COLLEGE, THE REGULATORY BODY FOR DOCTORS. THE COLLEGE ONLY INVESTIGATES DOCTORS FOR ALLEGATIONS OF PROFESSIONAL MISCONDUCT AND INCOMPETENCE. SHOULD CASES GO BEFORE A DISCIPLINARY COMMITTEE, PENALTIES CAN RANGE FROM A REPRIMAND TO A LICENCE REVOCATION. THE INVESTIGATION IS ONGOING DESPITE YOUNG’S RESIGNATION FROM THE COLLEGE. INCREDIBLY, JUST SIX YEARS AGO, THE COLLEGE HAD HONOURED YOUNG WITH ITS PRESTIGIOUS PRESIDENT’S AWARD FOR HIS HANDLING OF THE SARS CRISIS. (THE COLLEGE IS ALSO INVESTIGATING SMITH AND CAIRNS, THE LATTER OF WHOM, LIKE YOUNG, RESIGNED THIS WEEK FROM PRACTICING MEDICINE.)"
STAFF REPORTER THERESA BOYLE: THE TORONTO STAR;" PHOTO: STEVE RUSSELL;
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The Toronto Star has become the first Canadian newspaper to examine the role played by former Chief Coroner Dr. James Young in the problems which plagued Ontario's forensic pediatric pathology system during the Charles Smith years and led to so many devastating miscarriages of justice.
The superb article, by Staff reporter Theresa Boyle, who reported the Goudge Inquiry for the Star, bears the following preface: "The Swissair Flight 111 crash. The Walkerton E. coli crisis. The SARS outbreak. Over the course of his illustrious career, Dr. James Young presided over all of them with deftness and aplomb. But then, just when his star was at its brightest, a cloud appeared – on his watch."
Toronto Star photographer Steve Russell's photograph of Dr. Young is accompanied by a cut-line which says: "James Young, former chief coroner of Ontario, is seen outside his home near Barrie. Young left the public service in 2007 after a stint in Ottawa, though he still does consulting work on pandemic preparedness."
The article, published on June 6. 2009, under the heading "In the face of disaster", can be found, with Links to other Smith-related videos and stories, at http://www.thestar.com/news/gta/article/646616.
It is accompanied by Dr. Young's resume, as follows;
"James Young is best known for being Ontario's chief coroner for 14 years. Other career highlights:
Leadership
• President of the American Academy of Forensic Sciences
• President of the International Association of Coroners and Medical Examiners, and associate professor of forensic science at the University of Toronto
• Led international teams investigating politically sensitive deaths in Nigeria, Colombia, Kazakhstan; gave expert advice on cases in Canada, the U.S., New Zealand, Bermuda, England, Israel, Japan and Thailand
Teaching
• Gave lectures to the Law Society of Upper Canada, the Ontario Crown Attorneys' School, the Ontario Provincial Police, the New York State Police Academy, the FBI National Executive Institute and Israeli police
Awards
• Received the President's Award from the College of Physicians and Surgeons for his role in the SARS outbreak response
• Was given the John R. Hunt Award from the American Academy of Forensic Sciences for outstanding contributions to the field;
"Wearing a bow tie and black tuxedo, Dr. James Young stood beaming at the foot of the grand staircase at Queen’s Park. It was the evening of Sept. 20, 2005, and Young was receiving the province’s highest honour - the Order of Ontario," Boyle's article begins;
"The night marked the pinnacle of an illustrious public service career that spanned 23 years and included a long list of impressive appointments," the article continues;
“Dr. James Young has had to do tasks over the years that others may find gruesome. But as Ontario’s former chief coroner and commissioner of emergency management, it goes with the job,” exclaimed Joan Andrew, secretary general of the Order.
She spoke of how Young had ably co-managed the SARS crisis, and how he had helped identify victims of the 9/11 terrorist attacks in New York, the Swissair plane crash in Nova Scotia, the Asian tsunami and the Bali terrorist bombings.
On this night, Young’s star was at its brightest. He was being lauded as Canada’s man at some of the worst disasters in modern history. And as incoming president of the American Academy of Forensic Sciences, he was a respected figure in the international forensic scene. He was also a leading authority in pandemic preparedness.
But life was about to change for this accomplished man. While Young had been busy travelling from crisis to crisis, one brewed in his own backyard - one partly of his own making. Young would be found to have contributed to major miscarriages of justice that shattered public confidence in pediatric forensic pathology and seriously compromised Ontario’s criminal justice system.
The scandal, which rocked the Office of the Chief Coroner of Ontario, saw family members and caregivers wrongly implicated in the deaths of children because of flawed pathology. The casualties included William Mullins Johnson, 38, who spent 12 years in jail after being wrongly convicted of first-degree murder of his 4-year-old niece. Other cases where mistakes had been made are now in various states of appeal.
The province is looking at compensation for the victims, which could leave taxpayers on the hook for millions.
Yesterday, an overhauled Coroners Act was given royal assent to ensure such tragedies never happen again. The legislation requires, for the first time, that the province’s chief coroner be held accountable to an oversight council. And it paves the way for the creation of a complaints committee that will track complaints about coroners and pathologists.
The new legislation coincides with Young’s resignation as a member of the College of Physicians and Surgeons of Ontario. Effective this past Monday, it means he can no longer practise medicine in the province.
Young’s downfall serves as a cautionary tale in failed accountability and the dangers of putting too much stock in a single individual.
In November 2005, a major review began into the work of a rogue pathologist, who, for years, had been under Young’s watch. Dr. Charles Smith, the probe would eventually reveal, had erred in investigations into the deaths of 20 children. In some cases, parents and caregivers were wrongfully prosecuted and siblings of dead children were put up for adoption.
The public inquiry that followed in 2007-08 would find that Smith lacked expertise in forensic pathology and that Young and his deputy, Dr. Jim Cairns, failed in their obligation to oversee him. The two de facto supervisors were blind to Smith’s inadequacies partly because they also lacked any specialized training in forensic pathology.
What’s worse, the pair played a major role in building Smith’s reputation as the most eminent pediatric forensic pathologist in Ontario. Young and Cairns had a “symbiotic” relationship with Smith whose stature reflected well on the coroner’s office, states the final report of the inquiry, released last October. They actively protected Smith from critics who had identified his shortcomings as many as 17 years earlier.
As Young accepted extra responsibilities in government, the office of the chief coroner suffered and an environment that fostered miscarriages of justice flourished. But instead of considering if the coroner’s office had played a role in wrongful convictions, Young was more concerned about the adverse publicity that Smith might attract, the inquiry found.
“Dr. Young was the last to see the writing on the wall,” wrote inquiry commissioner Justice Stephen Goudge. “With the additional burdens imposed by his new responsibilities, Dr. Young’s inattention to day-to-day administration was a recipe for a failure of oversight.”
Problems with oversight and accountability were compounded by misconceptions over Young’s expertise with even his political bosses assuming he had more credentials than he did.
Young, 60, declined to be interviewed, but in an email he wrote that he didn’t realize he had done anything wrong: “With the benefit of hindsight, I would have made some decisions differently, but at the time I believed I was doing what was right.”
He added: “The inquiry has provided valuable lessons for individuals and institutions. While I may not agree with some aspects of the Commission’s report, debating these differences will not in my view advance the cause of building a better system for the future.”
The bad news for Young didn’t end with the inquiry. Goudge’s report was followed by the revelation that Young is being investigated by the college, the regulatory body for doctors. The college only investigates doctors for allegations of professional misconduct and incompetence. Should cases go before a disciplinary committee, penalties can range from a reprimand to a licence revocation. The investigation is ongoing despite Young’s resignation from the college. Incredibly, just six years ago, the college had honoured Young with its prestigious President’s Award for his handling of the SARS crisis. (The college is also investigating Smith and Cairns, the latter of whom, like Young, resigned this week from practicing medicine.)
Young grew up in east-end Toronto and had ambitions in medicine as far back as high school. The notation beside his Grade 13 photo in the 1968 yearbook from Monarch Park Secondary School says he desired to become a “successful physician.” (It also states his nickname was “Cuddles,” that he liked girls and that an alternative to becoming a doctor was to become a “back-seat contortionist.”)
Young attended the University of Toronto for pre-med and medical school. While there, he wrote part-time on sports for the Globe and Mail.
After earning his medical degree in 1975, Young became chief intern at Scarborough General Hospital, responsible for a team of 12, the first of many leadership positions.
The following year, he moved to Elmvale - outside Barrie - to become a small-town doctor with a general practice. He married a nurse, Eileen, with whom he had four sons.
In 1977, Young became an investigative coroner for Simcoe County. He was appointed regional coroner in 1982 and returned to Toronto. This marked the start of a full-time career in public service.
Young eventually became deputy chief coroner and in 1990 he got the top job in the coroner’s office.
The Ontario coroner’s office on Grenville St. is just a couple of blocks from Queen’s Park. It’s a grey bunker of a building that receives as many as 2,000 bodies a year. While many have died of natural, but not readily apparent, causes, others are victims of accidents, suicides and homicides.
Young’s office was on the second floor; it was known to be cluttered with stacks of paper scattered about. Smith’s office, over at the Hospital for Sick Children, was also known to be chronically messy.
Young admitted that attending to details and paperwork wasn’t his strong point. He told the Hamilton Spectator in 2003 that he didn’t have a computer in his office and didn’t keep files.
“I like big challenges. I’m not big on routine. I actually get quite bored with routine. So I’m much better with a little bit of chaos and a little bit of tension.”
The falls of both Young and Smith are rooted in the confusion over roles and qualifications of players in Ontario’s nascent death investigation system.
Coroners, like Young, are medical doctors who lead death investigations, making the ultimate determination of how someone died, using information provided by police, families, medical records and forensic pathologists.
Pathologists, like Smith, are doctors with specialized training who work in labs and, for example, diagnose cancerous tumours. “Forensic” pathologists have further training, learning to conduct autopsies and testify in court.
Young was sometimes mistaken for a forensic pathologist. And Smith was hailed as Ontario’s top pediatric forensic pathologist, even though he had no formal forensic training.
Canada is decades behind Britain and the United States in formally training forensic pathologists. Pathologists doing forensic work here have traditionally been self-taught and informally trained, like Smith. In recent years, more of them have been educated abroad and the first homegrown forensic pathologists are expected to graduate later this year.
Smith began working as a pathologist at the Hospital for Sick Children in 1981 and by the end of the decade, he began doing work for the coroner’s office, conducting autopsies on children who had died under criminally suspicious circumstances.
In 1991, the Ontario pediatric forensic pathology unit was opened at Sick Kids, a creation of the coroner’s office and the hospital. The following year, Smith was appointed director.
“It does not appear that Dr. Young conducted a serious search for other, more qualified or experienced candidates, or that he attempted to improve Dr. Smith’s skills in forensic pathology after recommending his appointment. The need for forensic pathology expertise was simply not appreciated, and Dr. Smith’s appointment was convenient,” Goudge wrote.
Young was named assistant deputy minister of the public safety division of the Ministry of the Solicitor General in 1994. In this capacity, he oversaw the Centre of Forensic Sciences, the Ontario Fire Marshal’s office and Emergency Measures Ontario.
Young’s career began veering toward emergency and disaster response in 1998. That year, he assisted in recovery efforts after Swissair Flight 111 plunged into the sea off the coast of Peggy’s Cove, Nova Scotia. And he helped coordinate relief efforts after a brutal ice storm crippled eastern Ontario.
After 9/11, he was dispatched to New York to lead an Ontario forensic team assisting in the recovery.
Young’s reputation grew with each disaster.
In 2002, he became commissioner of public safety. In the post 9/11 world, the government wanted to ensure Ontario was prepared to respond to terrorist attacks and other emergencies. Young was the province’s front man in the war against terrorism.
During the 2003 SARS outbreak, Young participated in daily news conferences to update the public on measures to contain the virus. He liked the media and the media liked him; he was friendly, accessible and delivered good sound bites. “We got better ratings than the Edge of Night,” he said in a speech years later. “We became folk stars in our own area.”
On a sunny afternoon in August 2003, Young was snoozing on a chaise lounge in the backyard of his cottage, near Barrie, taking full advantage of his first full days off in months thanks to the SARS crisis.
Understandably, he was none too pleased when the office called about a power outage.
“It’s sunny up here and I really don’t care,” he told the caller.
“You do care.”
“No, I don’t.”
When told the whole province was out of power, he quickly changed his tune. He arranged for an OPP helicopter to pick him up near his cottage, stop in Caledon to fetch then-Premier Ernie Eves, and then head to Toronto.
A state of emergency was declared and stayed in effect for eight days. In playing a lead role in turning the lights back on in the province, Young was at his best: in the eye of the storm, and front and centre in the media.
Young was always ready and willing to take charge and the politicians loved him for it. The provincial Conservatives, who held government from 1995 to 2003, were among his biggest fans. Bob Runciman, currently the party’s interim leader, once referred to him as “the poster boy for public service in the province of Ontario.”
But that stellar reputation was partly built on misconceptions about his expertise.
For example, Liberal MPP Monte Kwinter, who served as community safety minister from 2003 to 2007, thought Young performed autopsies. He revealed this during an interview when explaining how, as a minister, he wasn’t in a position to technically evaluate Young’s work. “How am I supposed to know if he’s doing a good job or not. Am I supposed to go in and say, `Are you sure you dissected that guy properly?’ What do I know?”
Kwinter wasn’t the only political boss to think this. Former federal health minister Pierre Pettigrew said he chose to dispatch Young to the tsunami because, “He’s one of the top pathologists in Canada.” (Pettigrew later explained he didn’t have any records before him when he made the comment and his memory was a little hazy.)
Sometimes the media got it wrong, referring to Young as a pathologist and an expert in DNA analysis. So did government news releases. The one announcing his Order of Ontario award referred to him as “one of Canada’s foremost forensic scientists.”
Despite these misconceptions, Young’s reputation grew, as did his curriculum vitae.
At the inquiry, a section of his CV, titled Papers Presented, came under scrutiny. It lists research studies presented at U.S. conferences on which he is named as an author along with Smith and others. But under questioning, Young revealed he hadn’t, in fact, authored nor presented a number of these papers.
“My name is last because that’s where it deserves to be,” Young said. “I wasn’t writing the paper or generating the research or presenting the paper ..... It’s a way of sort of being able to say ..... this is the body of research that the office is doing right now.”
Dr. John Butt, a highly regarded forensic pathologist who testified about Smith’s errors at the inquiry, has since raised further questions about Young’s bio, in particular a portion that details his involvement in the Swissair recovery. Butt was Nova Scotia’s medical examiner at the time and his office had called Young for assistance.
Butt says he was surprised when he stumbled across Young’s bio on the Internet years later and saw how Ontario’s chief coroner had described his role. What caught Butt’s attention was this excerpt, also contained in Young’s CV: “Provided expert support and guidance to the Chief Medical Examiner of Nova Scotia in managing the entire process required to identify the victims of Swissair flight number 111 ..... Co-ordinated the collection of ante-mortem files, the forensic examination of the remains, and the cross referencing of the information collected so that positive identifications could be made and communicated to next of kin. September through October, 1998.”
Young “exaggerated” his role, particularly the claim that he “coordinated” these different tasks, Butt charges. “He had no unique sectors that he was in charge of,” argues Butt, now a Vancouver-based forensic consultant. He agrees that Young provided him with “expert support and guidance,” but says the “entire process” of identifying victims took more than a year and Young had been there for less than a month.
Butt says that “without question” Young was a big help. He was by Butt’s side much of the time and was a valuable sounding board and an able troubleshooter. “He wasn’t unproductive. I mean, I want to give the guy credit,” Butt says. “I’ll tell you what his forte is. He’s a good leader and he’s got a quick mind.”
Young was stripped of his coroner’s title in 2004 by the Liberal government. “The one issue that we had is that he was both the chief coroner and the commissioner of emergency management. That was sort of a conflict,” Kwinter told the Star in an interview.
It was later that year, after Dr. Barry McLellan moved from deputy to chief coroner, that the whistle was finally blown on Smith. McLellan forced Smith to resign as director of the Ontario pediatric forensic pathology unit, a step he had wanted to take earlier but was vetoed by Young.
McLellan subsequently initiated an internal review of Smith’s work, a move that led to the inquiry.
It struck a discordant note to see Young on the stand. The man, who for 14 years served at the helm of a tribunal that pointed out systemic shortcomings, was now being grilled about widespread deficiencies in his own.
Sitting in the witness box, Young fumbled as he apologized for his role in the debacle: “I ..... it ..... it distresses me tremendously to think that during my watch and during my time that these things happened ..... and it ..... it ..... I really do apologize for the miscarriages of justice.”
Young admitted he should have done more: “I don’t know why we didn’t stop (Smith) doing everything at that time ..... I just don’t know.”
Lawyer Julian Falconer struck a nerve, arguing that Young was not guided by the public’s interest when he took on more senior jobs in government: “I am going to suggest to you that the decision to occupy the position of assistant deputy minister while remaining chief coroner for the province of Ontario was borne out of a professional ambition and resulted in the erosion of the accountability of the office of the chief coroner and had nothing to do with enhancing the credibility or function of the office of the chief coroner.”
Young angrily denied the allegation. “I didn’t make that decision. The government chose ..... asked me to assume that role. I went along with it,” he said. “The government was well aware that I was reporting to myself, but also I was reporting in essence to the deputy minister at a higher level with more detail.”
Young indicated to the inquiry that historical worldly events call for strong leaders: “There are times for certain kinds of leaders in certain places in history. At the time that I was chief coroner and doing the other work, I made a conscious decision to agree with the government to do the other work.”
Perhaps the most damning evidence heard at the inquiry was that Young had ignored warning signals about Smith as early as 1991. At that time Justice Patrick Dunn had acquitted a Timmins girl who at the age of 12 had been charged with manslaughter in the death of a toddler she had been babysitting. Smith had been the Crown’s key witness and Dunn determined Smith lacked objectivity, failed to thoroughly investigate the case, neglected to keep proper records and lacked familiarity with relevant scientific literature.
Young testified he had only learned of the Dunn decision in 2007, shortly before the inquiry started, and was “dumbfounded” by it. But he acknowledged that he had numerous opportunities to learn of it earlier:
An investigator from the College of Physicians and Surgeons of Ontario told Young about it in 1997 while probing a complaint about Smith. But Goudge said Young had not fully appreciated the significance of the complaint because his objectivity was coloured by his belief that Smith was the leading pediatric forensic pathologist in Ontario, by Smith misleading him about the case and by his own misunderstandings about it.
The Dunn decision was cited in a 1999 complaint to the Coroner’s Council, a body that investigated complaints about coroners. But the council had been disbanded only months earlier and the complaint found its way to Young’s desk. Young personally responded to the complaint, saying he had read it “in detail and considered ..... very carefully.” But he told the inquiry he had no recollection of reading the part in question.
In 1999, the CBC’s Fifth Estate also mentioned the Dunn decision. Young said he was away when it aired and didn’t watch it on his return. Nevertheless, he urged the province to pay for part of the lawsuit launched against the CBC by Smith. (Smith eventually dropped the suit.)
In 2001, the Dunn decision was mentioned in a Maclean’s magazine feature about Smith, titled “Dead Wrong.” In a letter to a member of the public who had inquired about it, Young replied that the article itself was “dead wrong” and full of inaccuracies. But when asked about the article and letter at the inquiry, Young said: “I remember reading the article, but ..... it didn’t sink in, that’s all I know.”
Throughout the 1990s, complaints about Smith mounted as coroners, police, Crown counsel and individuals weighed in. Much of the criticism was similar to that raised by Dunn.
Young and his deputy, Cairns, not only failed to rein in Smith, they protected the pathologist from those who could. When the college wanted to investigate a complaint about Smith in 1997, they argued the regulatory body had no jurisdiction over the coroner’s office. In 2000, Young told the media and the attorney general’s ministry that his office would review Smith’s cases to assess his competence, but the idea was later quietly dropped. In 2001, Young asked Smith to stop doing coroner’s cases, not because of concerns about the pathologist’s competence, but because of the negative attention he might attract.
In April 2002, after it was determined the college did have jurisdiction to investigate Smith, Young sent a letter to the regulatory body, defending Smith in response to complaints filed against him. Young sent the letter even though he was aware that serious questions had been raised about Smith’s ethics and judgment. What’s more, the letter had been written by Smith’s lawyers and Young sent it, virtually unaltered.
In his report, Goudge slammed Young, saying the letter “misled” the college. “Dr. Young told the inquiry that he sent this letter in an attempt to be fair to Dr. Smith. He did so, however, at a cost to the public interest ..... The letter was not balanced or objective or candid. It was not a letter worthy of a senior public office holder in Ontario.”
Young made many valuable contributions to the province, but at the end of the day his biggest mistake was failing to mind the store.
“I think the moral coming out of this is that no matter what systems you have in place, personality and individual judgment are ultimately going to be what oversight rises or falls on,” says Lorne Sossin, a law professor at the University of Toronto, who conducted research for the inquiry, authoring a paper on oversight.
But he adds: “I’d hate to see there be a sense that all the ills that led to miscarriages of justice resting on his (Young’s) shoulders because I think that would be unfair.”
Many other factors contributed to the miscarriages, including: an outdated Coroners Act, a shortage of forensic pathologists, inadequate quality control measures, organizational weaknesses, insufficient action by Cairns (who also declined to be interviewed) and a “think dirty” culture that encouraged the consideration of abuse in cases where children had died.
In 2005, Young was squeezed out of the Ontario bureaucracy, according to government sources. Julian Fantino’s contract was not renewed as Toronto police chief and there was talk he was going to run in the next election for the provincial Tories. To thwart that, the Liberal government gave Young’s job as commissioner to Fantino. In turn, the government helped Young land a job in Ottawa as special adviser to the deputy minister of public safety and emergency preparedness. The province even paid Young’s salary - $299,000 in 2007 - while he worked for the federal government. Young wasn’t happy about the move, sources say.
He left Ottawa - and the public service - at the end of 2007.
Young, in his email, said he devoted much of his life to public service with the best of intentions:
“I entered public service more than 25 years ago because I believed that coroners’ work could improve the country and the province I love. My assignments were varied, often challenging and in some cases unprecedented. I am grateful to have been given these opportunities. I recognize all those that supported me and especially the sacrifices made by my family. Throughout my career I always acted in good faith and did what I thought was best for the people of Ontario and Canada.”
Young has moved from his Toronto condo to his cottage and is doing consulting work in the area of pandemic preparedness. Although he was once a leading Canadian authority in this area, he has been notably absent from the public arena during the swine flu outbreak, over which there is ongoing global concern about a pandemic.
Until his retirement about a month ago, he had been working occasional shifts at a Barrie after-hours clinic.
For the time being, Young says, he’s taking a break from public service.
“Whether this is temporary or permanent remains to be seen.”"
Harold Levy; hlevy15@gmail.com;
