PUBLISHER'S VIEW: I am pleased to have the opportunity to devote some space to a newly published book: "The Nurses Are Innocent: The Digoxin Poisoning Fallacy," by Gavin Hamilton M.D. The title refers to the investigation of the deaths of babies at the Hospital for Sick Children in 1980 and 1981 for which a nurse named Susan Nelles was charged with murder. (My first free-lance story for the Toronto Star described Ms. Nelle's discharge at her preliminary hearing). I later wrote in the Star about the public inquiry in which Justice Samuel Grange found that babies had been murdered in spite of testimony which shredded the validity of digoxin tests conducted by Ontario's Centre for Forensic Sciences and raised a significant doubt as to whether any babies had been murdered. Now Dr. Hamilton, a retired radiologist, has, at least in my mind, provided the real reason for the deaths of the unfortunate babies at the renowned hospital: A toxin found in natural rubber which is technically like digoxin, which was used in disposable plastic syringes and intravenous devices. As the late Dr. Peter Macklem, the above noted witness at the Grange Inquiry, says in his preface to this book: "What can be learned from this black stain on Canada's judicial system? One lesson certainly stands out: We cannot ever again allow a group of unqualified amateur diagnosticians to make life and death decisions about such important matters as potential serial murders." Dr. Macklem's comments have me thinking about the so-called arson experts in Texas who concluded with such compelling certainty that Cameron Todd Willingham had set the fire which killed his family - and were proven to have been so terribly, terribly wrong. (Willingham, an innocent man, was executed in Texas). Dr. Hamilton also has a tantalizing theory that a certain now-disgraced pathologist named Charles Smith may have been responsible for turning the tragic deaths into murders. He points out that "In 1980 - which was at the beginning of what was to become known as the digoxin baby poisoning epidemic period, he was hired by the Hospital for Sick Children as an anatomic pathologist - with an expressed keen interest in performing autopsies on children who had died suddenly." This book can be purchased through Amazon at:
http://www.amazon.ca/Nurses-Are-Innocent-Digoxin-Poisoning/dp/1459700570
Harold Levy: Publisher; The Charles Smith Blog
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Dr. Gavin Hamilton's suspicion that Charles Smith's propensity to find murder where babies die of natural causes led to the baby deaths at the Hospital for Sick Children being categorized as homicides - and the prosecution of nurse Susan Nelles for murder is the subject of a story by Brian Bethune published in Maclean's on December 22, 2011.
"Then there was the Charles Smith factor," wrote Bethune. "The persuasive, incompetent and now disgraced pathologist began his career at Sick Kids in 1980. It’s impossible to evaluate Smith’s exact role in a murder investigation that arose because of findings made in the hospital’s autopsy rooms, but Hamilton is sure it was significant: “I smell him,” he says in an interview, “I smell his presence.”
In "The Nurses are Innocent: The Digoxin Poisoning fallacy," Hamilton makes his case for Smith's possible involvement as follows:
O: The series of HSC cardiac ward baby deaths became defined as murder by intentional digoxin poisoning from interpretations of specimens taken in the HSC autopsy rooms by members of their Department of Pathology.
O: The natural causes for the findings and even evidence that surfaced that was obviously exonerating, were dismissed.
O: Although a panel of HSC attending physicians and nurses had concluded that the deaths were from natural causes, a murder theory rose out of the autopsy rooms - a theory promoted and defended by the Crown prosecutors and by those operating under the aegis of the office of the Chief Coroner of Ontario.
O: Charles Smith was a link between the Hospital for Sick Children and the Chief Coroner's Office. ( He had worked (for the Hospital) as a pathologist working in the Department of Pathology since 1980 - while also working as a pediatric forensic pathologist on a fee-for-service basis for the Chief Coroner of Ontario.)
More specifically, Hamilton argues that: "Dr. Smith was hired as a resident in pathology at the University of Toronto (which included the Hospital for Sick Children) from 1978 to 1980. In 1980 - which was at the beginning of what was to become known as the digoxin baby poisoning epidemic period, he was hired by the Hospital for Sick Children as an anatomic pathologist - with an expressed keen interest in performing autopsies on children who had died suddenly."
But Hamilton points out that, "To the dismay of the Toronto Hospital for Sick Children and the criminal justice system of Canada, Justice Goudge determined conclusively that Dr. Smith's interpretations had incorrectly assigned child autopsy findings to murder as the cause of death in twenty cases from 1981 to 2001."
The 1981 date is a significant link according to Hamilton because, "In 1980-1981 , during the apparent rise in the number of of Hospital for Sick Children cardiac ward deaths, all of these deaths had been studied carefully and discussed by the nursing staff and attending physicians , who attributed them to natural causes."
"However," he writes, " based on interpretations of specimens taken in the autopsy rooms by the pathology department, these "natural deaths" suddenly became the focus of an intensive murder investigation - murder by intentional digoxin, perpetrated by the attending nursing staff."
"Is it just a coincidence that, shortly after Dr. Smith was hired by the Hospital for Sick Children as an anatomical pathologist, a murder theory arose, based on interpretations of specimens taken in the autopsy rooms by a pathologist?"
Hamilton also seizes on several disturbing findings of the Goudge Inquiry to buttress his theory, including:
O: Smith's "quick" assumption of the role of a forensic pediatric pathologist always working out of the pathology department of the Hospital for Sick Children - even though he lacked formal pathology training;
O: Smith's overly intimate relationship with the Ontario Chief Coroner's Office which bolstered his reputation and tried to cover up his misdeeds.
O: "His willingness ability to craft his interpretation of autopsy findings to suit a preconceived and often erroneous opinion that child murders has been committed.
O: Smith's disregard of the neutrality and respect for science expected of a forensic expert as indicated by his admission to the inquiry that when his career began in the 1980's he believed his role was to act as an advocate for the Crown "and make a case look good " - an admission which Hamilton deems relevant "to the baby deaths that the crown prosecutors were alleging to be murder by digoxin poisoning."
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There is no question in my mind that Gavin Hamilton has made a strong case for the influence of Charles Smith in the police investigation that led to the sorely flawed decision to charge nurse Susan Nelles with murdering babies at the hospital.
Indeed there are two other factors which to my mind reinforce his conclusion: the "get tough against child abuse" prosecutorial attitude which was prevalent at the hospital at the time and a "think dirty" attitude deeply rooted in Ontario's Chief Coroner's Office.
We need to look no further than Justice Goudge's report to confirm the sick atmosphere at the hospital at the time where he concludes:
"Dr. Smith failed to understand that his role as an expert witness was not to support the Crown. At the Inquiry he was candid on this point. He had never received any instructions in giving expert evidence. He acknowledged that, when he first began his career in the 1980's, he believed that his role was to act as an advocate for the Crown and "to make a case look good." He explained that the perception originated, in some measure, from the culture of advocacy that he said prevailed at Sick Kids at the time. In the early 1980's, there was a legitimate concern at Sick Kids that child abuse was under-reported, under-detected, and under-prosecuted. Dr. Smith was part of that advocacy culture and perceived that his job, at least in part, was to reverse those trends."
The over-zealous anti-child abuse attitude had been the subject of an exhibit filed at the inquiry - the judgment given by the judge in the case of two parents from Northern Ontario charged with physically abusing their one-year-old son following an investigation in the mid-eighties by the hospital's SCAN (Suspected Child Abuse and Neglect) Team. (
A renowned bone disease expert in California later concluded after viewing the x-rays from the Hospital that the lesions were more consistent with bone disease than with fracture.)
Ontario Court Judge Judge Peter Nasmith criticized the arbitrary actions of a Children's Aid Society in the case, noting that, " it was "obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children." Nasmith went on to say that: "No doubt the real fly in the ointment here is the child abuse team at the Hospital for Sick Children
as they moved from a position of possible abuse to a diagnosis of abuse. This was a surprising stance for them to take, and I think it underlines the need for a protection agency receiving reports under (child) protection legislation and for courts in these cases to continue to scrutinize the zeal of the well-meaning people who are so understandably devoted to fighting the scourge that is child abuse. This zeal has created a subtle dynamic that can somehow convert a suspicion of child abuse into a presumption of child abuse."
Charles Smith worked closely with the Hospital for Sick Children SCAN Team which had been involved in several of the cases probed by the Goudge Inquiry.
In a case set in Timmins, Ontario where a 12-year-old girl was charged with manslaughter in connection with a death in 1988 as a result of Smith opinion (backed up by the SCAN Team) that she had shaken the 16-month-old girl she was baby-sitting for, Judge Patrick Dunn reject Smith's opinion in it's entirety, and accepted the evidence of the defence expert witnesses over the hospital's witnesses.
Judge Dunn took the extraordinary step of rejecting Smith's opinion ( even though he had conducted the autopsy and seen first-hand what he had reported on) - and then flailing the approach taken by the hospital staff.
"In a section called "Problems in the HSC Inquiry," Dunn rules: "For reasons I am about to discuss, there are flaws in the H.S.C. (sic) approach and hence their opinion about shaking should not be given great weight. I am not talking now about whether shaking exists or whether it or some other mechanism killed Amber. I mean that the fact gathering process, the communication procedures, and the documentation of the medical opinion of the H.S.C. doctors involved in this case are such that I am led to question the conclusion that they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
One would have expected that following a trial in which the work performed by Smith and the SCAN Team was assessed to determine what went wrong and how the hospital's work could be improved in the future. (After all, a 12-year-old babysitter had been wrongfully charged one of the most serious crimes in the Code as a result of their opinions and observations.)
Instead, as Justice Goudge notes in his report, the Hospital went into damage control at a special meeting called to review the case.
"In January 1992, SCAN physicians, Dr. Smith, and Crown counsel met to discuss Justice Dunn's reasons for judgment," Goudge wrote.
"No one present at that meeting appears to have taken to heart Justice Dunn's many criticisms of Dr. Smith and other hospital physicians. Rather, they concluded that the judge did not adequately understand the science of shaken baby syndrome."
Smith would later lie in Court under oath that after the trial Dunn told him, during the course of an airplane flight, that he believed the babysitter was guilty and that he believed the opinions provided by the Hospital for Sick Children's doctors.
In another murder case before the Goudge Inquiry an Ontario Superior Court Justice reject a "statement" taken by a member of the Sick Kids SCAN team on the basis that the team had violated her right to counsel, and not properly cautioned her that the "statement" could be used against her at her trial.
This case, which originated in 1999, is yet another example of the prosecutorial atmosphere that reigned at the Hospital for Sick Children for years. (The type of atmosphere in which innocent deaths of babies can be transformed into murders).
A senior prosecutor later "stayed" the charge on the basis that to continue the case would not be in the interests of justice because doing so could result in an injustice.
By this time, the statement of claim in a legal action against Smith alleged the woman was jailed for approximately three weeks until bail could be obtained, and following media coverage was stigmatized by members of the community as a "baby killer," with all of the physical and mental stress that that would entail.
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The other factor that to my mind reinforce Dr. Hamilton's conclusion that Charles Smith played a significant role in the sorely flawed decision to charge nurse Susan Nelles with murdering babies at the hospital is the "think dirty" attitude that was well rooted in the Chief Coroner's office when then Chief Coroner Dr. James Young formalized it on a protocol issued to all coroners, pathologists, and chiefs of police in Ontario on April 10, 1995.
"Unfortunately, in this day and age, child abuse is a real issue, and it is extremely important that all members of the investigative team "Think Dirty," The "think dirty" protocol, which was discontinued after Dr. Young stepped down in 2004, stipulated.
"They must actively investigate each case as potential child abuse, and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished, and all members of the team are satisfied with the conclusion."
During the nine years the protocol remained in effect, these words communicated through "think dirty" slides that were used in presentations to coroners throughout the province and other members of the death investigation teams.
During the course of the Goudge Inquiry, Commission Counsel Linda Rothstein tracked down the genesis of the "think dirty" approach through her questioning of former deputy chief coroner Dr. Jim Cairns in the following exchange.
"MS. LINDA ROTHSTEIN: Where did you first hear that expression, Dr. Cairns?
DR. CAIRNS: I think I first heard that expression from Jack Press.
MS. LINDA ROTHSTEIN: Who was he?
DR. CAIRNS: Jack Press had been a Toronto homicide officer who had -- when he retired, had moved over to be the liaison officer for Dr. Hillsdon Smith with -- with police.
MS. LINDA ROTHSTEIN: And in what context did Dr. -- did -- sorry -- did Jack Press use that terminology?
DR. CAIRNS: I think probably as it's explained here, don't -- don't accept things as they are. Think of more sinister applications or there may be a more sinister explanation."
We learn from the Goudge report that Hillsdon Smith was the Provincial Forensic Pathologist between 1975 and 1994.
To bring matters full circle, before retiring and joining the Chief Coroner's staff, Jack Press was one of the investigating officers in the investigation of Susan Nelles in connection with the deaths of babies at the hospital for Sick Children.
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In sum, this humble Blogger concludes that Dr. Hamilton has managed to place Charles Smith's fingerprints all over the transformation of the natural deaths of babies at the Hospital for Sick Children into murders.
I also smell Smith's presence.
To my mind, Susan Nelles, a loving, devoted nurse branded as a serial killer, was a victim of a perfect storm: A persuasive, unprincipled pathologist lacking training in forensic pathology, who set out to vindicate dead children as he tried to ingratiate himself with police and prosecutors, a hospital which had declared war on child abuse and saw it in the most innocent circumstances, and a Chief Coroner's office which operated under the principle of " think dirty" - rather than instructing the province's pathologists, coroners and police officers to be dispassionate and objective - and to think "truth."
POSTSCRIPT: It is important to stress that Justice Goudge endorsed major changes within the Chief Coroner's Office after Dr. Barry McLellan took over from Dr. James Young in April 2004 - and that he heard evidence from the director of the Hospital for Sick Children SCAN team that changes had already been made which would make it unlikely that there would be any future debacles of the sort that tainted the previous era.
PUBLISHER'S NOTE: The Toronto Star, my previous employer for more than twenty incredible years, has put considerable effort into exposing the harm caused by Dr. Charles Smith and his protectors - and into pushing for reform of Ontario's forensic pediatric pathology system. The Star has a "topic" section which focuses on recent stories related to Dr. Charles Smith. It can be found at:
http://www.thestar.com/topic/charlessmith
Information on "The Charles Smith Blog Award"- and its nomination process - can be found at:
http://smithforensic.blogspot.com/2011/05/charles-smith-blog-award-nominations.html
Harold Levy: Publisher; The Charles Smith Blog; hlevy15@gmail.com.
