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CLICK HERE IF YOU MISSED PART ONE (December 12, 2021) OF THIS TWO-PART SERIES: Their baby died. But their nightmare was only beginning. How a flawed child death investigation tore a grieving family apart.
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PART TWO: (December 16, 2021);
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PUBLISHER'S NOTE: Dr. Jane Turner, the forensic pathologist who performed the autopsy on Baby Alexander who had died suddenly, concluded that "the working diagnosis is rickets with pathological fractures." That means Alexander died of a medical condition which displayed symptoms similar to those caused by an inflicted injury - and that the baby's grieving parents had not committed any crime. That should have been the end of it. Let them grieve. This Blog has published numerous cases where the parents or caregiver were ultimately exonerated when, through medical experts, they were cleared on appeal. (Often after spending years in prison). The difference here, is that Dr. Turner recognized the possibility of 'rickets' from the outset - and if as she had been listened to, that would have been the end of the matter. Sadly it didn't end there, solely because of the entrance of Dr. Burke Baird into the medical investigation - who according to The Toronto Star was a child maltreatment specialist who had assessed Alexander’s twin, who had similar fractures, and who said that the breaks were likely caused by abuse. Bairds opinion was backed up by Dr. Michael Pollanen, Ontario's Chief Pathologist and an "independent committee" within the Coroner's office. Reporter Rachel Mendleson, reports that: "Turner replied saying there was much she could say about the pediatrician and “his conduct in this case, but I will save it for another time. “I will just say that he is doing this family a grave disservice by refusing to accept the facts in this case and by trying to obfuscate the autopsy findings.” The pediatrician is Baird, who declined to comment for this story. In an unrelated child protection case earlier this year, a judge refused to qualify him as an expert witness in the field of child maltreatment. The judge questioned the reliability of “child maltreatment” theory, and was critical of Baird’s reliance on second-hand information." ..............."Nearly a year after Alexander died, Brooke and Ryan learned for the first time that Turner believed Alexander’s death was likely caused by a bone disease, as opposed to abuse – and that she had long held this opinion. She also outlined alleged shortcomings with Baird’s assessment of Alexander’s twin and his conclusion that Holden had been subjected to “inflicted trauma.” Baird failed to document the bruises he said he found on the baby, Turner’s letter alleged. She said there were significant omissions in Baird’s reports to Children’s Aid in March 2018, including that he failed to properly test Holden for bone disease or disclose the full opinion of the radiologist, who initially believed Alexander’s x-rays showed signs of abuse. She said the radiologist reviewed a second set of scans – taken two weeks after Holden’s assessment by Baird – that showed no change in the fractures, pointing to the possibility of an underlying bone condition." One of the positive elements of this story of a family put through hell by Ontario's death investigation system is that the police truly acted as they should by refusing to get caught in the squabble among the medical officials, and refusing to lay a criminal charges until they had a reasonable probability of conviction when the case came to court. Indeed, the senior homicide detective on the case, 30-year veteran Staff-Sgt. Dave Oleniuk, and his team probed the death, so far had found no evidence of criminality, and was troubled by the fact that the baby's death had been elevated from 'undetermined' to 'homicide'. As Mendleson reports: "Oleniuk remembered leaving the final case conference almost a year earlier with the distinct impression that everyone around the table had agreed that Alexander’s death should be classified as undetermined. “I’m never going to dispute a doctor with their medical opinions but when they don’t give me a definitive cause and then just rule it a homicide anyway — well, I don’t need to be a doctor to point out the inconsistency,” he told the Star. “I’m not arresting anybody based on that.” That was a stark contrast to the numerous Charles Smith cases (many reported in this Blog) where the police accepted the pathologist's opinion without question - thereby abdicating their responsibility to conduct their own full and fair investigation. I will be following developments closely.
Harold Levy: Publisher. The Charles Smith Blog.
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QUOTE OF THE DAY: "In a statement on her behalf, Turner’s lawyer said that changing the manner of death to homicide “lacks a credible basis in forensic science.”
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STORY: "Parents want a chance to grieve properly," by Reporter Rachel Mendleson, published by The Toronto Star, on December 17, 2021. (Part Two in a two-part investigation.)
SUB-HEADING: "Coroner ruled baby's death a homicide, despite police finding."
The sudden death of their brown-eyed baby boy had left Brooke and Ryan desperate for answers.
Alexander had been thriving after being born premature. Then he went limp, still dressed in a Santa onesie he’d worn for family Christmas photos.
Two months later, they still did not know what caused his death or how to get Children’s Aid to give their surviving children back. They knew little about the ongoing medical investigation, except that they felt treated as criminals.
The information the Hamilton parents were looking for was in a hospital lab downtown, just a few kilometres from their apartment.
On Feb. 2, 2018, the forensic pathologist who performed the baby’s autopsy solidified her opinion about the cause of the mysterious fractures found on Alexander and his surviving twin.
“The working diagnosis is rickets with pathologic fractures,” Dr. Jane Turner wrote in an email to the supervising coroner, explaining that she had reviewed the evidence with a bone pathologist. A natural cause, she believed, not homicide.
Turner called Children’s Aid. The investigative coroner, Dr. Richard Porter, followed up with the agency, too. He told the Star he wanted to make sure Children’s Aid “didn’t get heavy-handed” with the family, “because there might be a logical explanation that didn’t include something suspicious.”
The senior homicide detective on the case, 30-year veteran Staff-Sgt. Dave Oleniuk, and his team probed the death and so far had found no evidence of criminality.
But Dr. Burke Baird, the child maltreatment specialist who had assessed Alexander’s twin, who had similar fractures, said the breaks were likely caused by abuse.
The contradicting opinions left Children’s Aid and police with questions. The family remained in the dark. Their names have been changed to protect their identities as required under the law governing child protection cases.
Doctors met to discuss the case on Feb. 22. This was when Ontario’s chief pathologist, Dr. Michael Pollanen, first became involved, court records suggest. He joined by phone.
The next day, in an email to Turner, Pollanen said there was a “fundamental discrepancy about whether or not this child has been physically abused.”
“Because the child abuse paediatrician specifically has intervened strongly and early,” the Ontario Forensic Pathology Service needs to review the bone specimen, he said.
He told Turner that this “should not be interpreted as undermining your diagnosis, or indicating a lack of confidence in your determination.” Based on the description of the bone evidence provided in the case conference, it “sounds like rickets rather than fractures,” he added.
Turner replied saying there was much she could say about the pediatrician and “his conduct in this case, but I will save it for another time.
“I will just say that he is doing this family a grave disservice by refusing to accept the facts in this case and by trying to obfuscate the autopsy findings.”
The pediatrician is Baird, who declined to comment for this story. In an unrelated child protection case earlier this year, a judge refused to qualify him as an expert witness in the field of child maltreatment. The judge questioned the reliability of “child maltreatment” theory, and was critical of Baird’s reliance on second-hand information.
Pollanen came to Hamilton to review the bone slides. On Feb. 28, he told Turner in an email that in the sections of bone he examined, he did not detect signs of any bone disease.
The underlying cause of the fractures remained unexplained, he concluded. “However, traumatic fracture is a consideration.”
On March 4, nearly three months after they were taken and separated, the court placed Brooke and Ryan’s kids – Nicole and Holden – with their grandparents.
Brooke and Ryan were ecstatic, but the arrangement was far from perfect. Another adult had to have eyes on them whenever they were with their kids, and the parents weren’t allowed to sleep over.
“You’re still not sleeping comfortably, because you’re not listening to them breathe,” Ryan said. “You’re not listening to them babble and talk in their sleep at home.”
Pollanen had assigned the case to an independent committee within the Ontario Forensic Pathology Service for review.
Oleniuk, the veteran Hamilton detective investigating Alexander’s death, pressed for an update.
He thought Turner’s opinion made sense. Alexander had been in the hospital for the first 11 days of his life, then seen weekly by his doctor. There was no opportunity for someone to inflict the old fractures found during the autopsy.
Still, he told the Star, “we weren’t going to make any final decisions about it until we get the final questions from the (post-mortem) answered.”
In September 2018, Oleniuk said the coroner’s office told him that the review committee was now waiting on opinion from another group of experts at a clinic in Melbourne, Australia.
By then, Turner was back in Missouri.
She had resigned from her position as director of the now-shuttered Hamilton Regional Forensic Pathology Unit, claiming her integrity was being threatened.
She expressed concern repeatedly about the committee’s review, saying it was proceeding without transparency or expertise required to analyze the bone evidence.
She had recently received more information about Baird’s influential opinion that she believed raised further questions about its reliability. She wanted to make sure Children’s Aid knew what she’d found.
Ryan was at his grandmother’s house in October 2018 when he got an urgent call from his lawyer. There was something he needed to see.
Ryan rushed home. It was a letter from Turner, addressed to Children’s Aid, copying Oleniuk. Ryan and Brooke lay side-by-side on their bed, scrolling through the letter on their phones.
I wish to share some important information with you related to the death investigation, it began.
Nearly a year after Alexander died, Brooke and Ryan learned for the first time that Turner believed Alexander’s death was likely caused by a bone disease, as opposed to abuse – and that she had long held this opinion.
She also outlined alleged shortcomings with Baird’s assessment of Alexander’s twin and his conclusion that Holden had been subjected to “inflicted trauma.” Baird failed to document the bruises he said he found on the baby, Turner’s letter alleged. She said there were significant omissions in Baird’s reports to Children’s Aid in March 2018, including that he failed to properly test Holden for bone disease or disclose the full opinion of the radiologist, who initially believed Alexander’s x-rays showed signs of abuse.
She said the radiologist reviewed a second set of scans – taken two weeks after Holden’s assessment by Baird – that showed no change in the fractures, pointing to the possibility of an underlying bone condition.
Ryan and Brooke cried. For the first time since their baby died and their other children were taken, the parents finally had some information about what happened to Alexander. And after a year of being maligned and disbelieved, they felt as if there was finally someone on their side.
The review of the case ended where it began.
In a December 2018 letter to Turner, the deputy chief forensic pathologist heading the independent committee told her that the “consensus” opinion was that there was no evidence that Alexander’s fractures were due to metabolic bone disease and “inflicted trauma was not excluded.”
This view, they said, was supported by the “child abuse pediatrician” who assessed Holden, and by the view of the experts in Australia, who did a limited review of the case.
Turner refused to change her opinion and did not include the committee’s opinion in her post-mortem report.
Although she acknowledged she could not rule out abuse, the basic facts of the case, as well as the bone pathology evidence, had led her to conclude the baby likely died as a result of sepsis, due to a metabolic bone disease.
The case went back to Pollanen and he sided with the committee. Though the cause of death was undetermined, “inflicted injury has not been excluded in this case,” Pollanen said in his report to Dr. Dirk Huyer, Ontario’s chief coroner. (Pollanen and Huyer declined interview requests for this story; their spokesperson said she could not comment on the case.)
Oleniuk attended the final case conference that was held the next month,
in March 2019. In his police notes, he described the discussion as “heated at some points” between Turner and Pollanen, but that Pollanen conceded they hadn’t figured out how Alexander died.
In his report, Oleniuk said he raised the “practical point of how did these injuries occur?”
The detective was stunned when he received a letter written by Huyer, Ontario’s chief coroner, in January 2020. After receiving the opinion of another bone expert who reviewed parts of the case, Huyer had added his own conclusions to the coroner’s report, noting “the child suffered traumatic injury which is unexplained historically or medically.”
The cause of Alexander’s death remained unknown. But it was now classified as homicide.
Oleniuk remembered leaving the final case conference almost a year earlier with the distinct impression that everyone around the table had agreed that Alexander’s death should be classified as undetermined.
“I’m never going to dispute a doctor with their medical opinions but when they don’t give me a definitive cause and then just rule it a homicide anyway — well, I don’t need to be a doctor to point out the inconsistency,” he told the Star. “I’m not arresting anybody based on that.”
In a statement on her behalf, Turner’s lawyer said that changing the manner of death to homicide “lacks a credible basis in forensic science.”
Brooke and Ryan got their kids back in August 2019, 20 months after they were removed – and they kept them even after Huyer classified Alexander’s death a homicide.
They say they only learned of the determination when a Children’s Aid worker threatened to take their kids away again because of it, though the agency then backed off from that threat.
The battle between doctors rages on, as Turner has taken the Death Investigation Oversight Council to court. She alleges the council did not properly probe and respond to her 2019 complaint against Pollanen and Huyer, which focused, in large part, on their involvement in this case.
Before he retired last summer, Porter, the investigating coroner, told the council: “We aren’t protecting the living here … we are harassing the crap out of them (the parents),” the court records state.
Brooke and Ryan just want a chance to grieve. The allegations of abuse robbed them and their families of the opportunity to mourn Alexander when he died. They never had a funeral.
They are hopeful that Children’s Aid will close their file in the coming months and, when that happens, their families can come together and honour their son.
For now, they remember him in small ways. His parents keep a sleeper Alexander wore in a memory box. His siblings each have a necklace containing some of his ashes.
In his grandparents’ backyard, where Ryan grew up, his family planted a blue spruce sapling. They will watch it grow alongside his twin brother.
The entire story can be read at:
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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;
