PUBLISHER'S NOTE: Now that the ill-fated Motherisk program at the Hospital for Sick Children in Toronto has been totally shuttered up, I find it fascinating to look at how Cansford Labs, a drug and alcohol testing laboratory located in the U.K., analyzed the Motherisk debacle, as set out in a Blog published on the company's web site which offers, '5 reasons why the Motherisk scandal shouldn’t happen again."
Harold Levy: Publisher; The Charles Smith Blog.
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PASSAGE OF THE DAY: "
When things go as wrong as they did at Motherisk, it’s important not
to stick our heads in the sand. Especially when it involves vulnerable
individuals.
But Motherisk was an aberration. A tragic and disastrous aberration. The
science of hair sample testing remains a powerful tool when the
analysis is done correctly, appropriately, with quality control and
assurances and interpreted by qualified experts. Indeed, it’s only right that for vulnerable individuals, that nothing
but the best will do. A fact that Motherisk seemingly forgot."
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POST: "5 reasons why the Motherisk scandal shouldn’t happen again," by Lolita Tsanaclis, published on The Cansford Labs Blog m- The drug and alcohol testing blog - on December 6, 2017.
GIST: In the interconnected scientific
community, the reverberations of what happens in one corner of the globe
can be felt all across it, especially when these reverberations have
profound implications on people's lives. A recent example is the Motherisk scandal in Canada. We were shocked
and saddened, when we first heard of the case last year, and now that
more information has come to light we decided to study it to understand
how and why it happened. For a comprehensive look at the scandal, CBC has an excellent investigative report (below). In
short, Motherisk was a clinic operating within Toronto’s Hospital for
Sick Children which became a renowned centre for hair sample testing.
Between the late 1990s and early 2015, the clinic conducted hair-strand
drug and alcohol tests in a lab under the direction of Dr. Gideon Koren. The results of Motherisk’s hair tests were often used in custody and
child protection cases in part to decide whether a parent was fit to
care for a child. So what exactly is the controversy? As it turns out, for more than two decades Motherisk performed flawed
drug and alcohol testing on thousands of vulnerable families across
Canada, skewing decisions in over 35,000 child protection cases. Families were torn apart. As Susan Lang, the independent reviewer who
investigated the scandal, said: “losing your child is the capital
punishment of child protection law.” What went wrong? Lang’s report
exposed a litany of flaws in how Motherisk conducted its tests. The
picture that emerges, very clearly, is a case of flawed process, not
flawed science. 1. The tests were preliminary: The tests performed by Motherisk relied on the unconfirmed results of its enzyme-linked immuno-sorbent assay (ELISA) tests. ELISA is often used as a screening tool before more in-depth tests
are undertaken. It can be used in toxicology as a rapid presumptive
screen for certain classes of drugs. It’s useful if you need to screen a
large number of samples when the presumption that only a small
percentage will test positive. But it’s not definitive and the results
can be erroneously interpreted. The Motherisk Lab did not follow-up its presumed positive ELISA results with follow-on in-depth tests. Therefore, the results simply could not be relied upon to provide the absolute certainty needed. As Craig Chatterton, a forensic toxicologist and a proponent of hair
sample testing, correctly explains in the CBC report on Motherisk, a
preliminary test like ELISA can be spot on - but, tragically for the
families implicated, it can be 100% incorrect, too. Susan Lang’s report went on to say "No forensic toxicology laboratory
in the world uses ELISA testing the way MTDL [Motherisk] did. 2. Motherisk had no written standard operating procedures: Having standard, professional operating procedures in place is one of
the central pillars of any testing environment, not just hair sample
testing. In this regard, Motherisk failed egregiously. The Lang report found no evidence of any written
standard operating procedures at Motherisk. This raises serious doubts
about the reliability and, crucially, the standardisation of its testing
procedures. Both forensic and clinical laboratories should have standard
operating procedures in place for each of the tests they perform.
Motherisk had no clear, documented procedures which means the processes
could have varied substantially in each individual case, calling into
question, rightly, the integrity of the lab’s results. 3. No transparency: Motherisk’s next misstep was the lack of formal process and
documentation meant that it was almost impossible for any third party to
robustly assess its results. When the entire process isn’t adequately captured, it becomes easy for the lab to skirt over anomalies and simplify conclusions. At Cansford Labs, for instance, we share the evidence in full. This
is an absolutely vital component when the test will be involved in a
highly sensitive matter like child custody. The fact that Motherisk offered no insight into how its results were arrived at beggars belief.
4: Inadequate training and oversight: The inadequacy and transparency issues within Motherisk seeped all the way into the employees at the lab. From reading the Lang report, Motherisk scientists were operating
without any forensic training or oversight. The ELISA tests were
inadequate, but even if they weren’t, the individuals interpreting the
results weren’t properly trained. Nobody at Motherisk, including, rather incredibly, Dr. Koren himself, had the proper training. The lack of training manifested in all manner of amateurish mistakes.
Staff routinely failed to wash hair samples before analysis, for
example. One mother tested positive for alcohol because her
alcohol-laced hairspray had not been washed off the sample. With the
right training and process, these issues could easily have been avoided. 5. A compromised chain of custody" In the CBC report into Motherisk, one mother recalls how her second
test was conducted after she disputed the first test’s results: “With my
second test, the hair was done in the social worker’s office with the
scissors out of her desk, tape off her desk and cardboard from the
trash.” Her sample tested positive for crystal meth, but laughably when she
next saw her “hair sample”, the hair that allegedly belonged to her was
longer and a different colour.
It should go without saying, but any robust testing process
requires professionalism throughout. It’s not just about testing the
sample, but also about how the sample is collected and treated. The chain of custody is of paramount importance. Trusted professionals need to be present at every stage of the process, guided by the lab that will do the testing, and the procedures need to be the same for every single case. Motherisk was an aberration: When things go as wrong as they did at Motherisk, it’s important not
to stick our heads in the sand. Especially when it involves vulnerable
individuals.
But Motherisk was an aberration. A tragic and disastrous aberration. The science of hair sample testing remains a powerful tool when the
analysis is done correctly, appropriately, with quality control and
assurances and interpreted by qualified experts. Indeed, it’s only right that for vulnerable individuals, that nothing
but the best will do. A fact that Motherisk seemingly forgot."
https://blog.cansfordlabs.co.uk/the-drug-and-alcohol-testing-blog/5-reasons-why-the-motherisk-scandal-shouldnt-happen-again
PUBLISHER'S
NOTE: I am monitoring this case/issue. Keep your eye on the
Charles Smith Blog for reports on developments. 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 Please send any comments or information on other cases and issues of interest to the readers of this blog to: hlevy15@gmail.com. Harold Levy: Publisher; The Charles Smith Blog.
