"THE HISTORY STATES THAT HE (GAUROV'S BROTHER SAUROB)WAS PLAYING WHEN HE SUDDENLY FELL ON THE GROUND - APPARENTLY THE FATHER GAVE HIM SOMETHING, AND COMPRESSIONS AND MOUTH TO MOUTH. AND THEN THERE'S A SUGGESTION THERE MAY HAVE BEEN A SIMILAR EPISODE LAST YEAR;"
LAWYER JAMES LOCKYER TO COMMISSIONER STEPHEN GOUDGE DURING CROSS-EXAMINATION OF PROFESSOR HELEN WHITWELL;
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"BUT IF WE ASSUME FOR A MOMENT THAT JUST DAYS BEFORE GAUROV DIED HIS ONE (1) YEAR OLD BROTHER, SAUROB HAD BEEN THROUGH, WHAT COULD BE DESCRIBED AS A SIMILAR EXPERIENCE TO GAUROV, WOULD THAT SUGGEST THAT THERE MIGHT BE ANY KIND OF -- OF HEREDITARY PROBLEM WITHIN FAMILY?
DR. HELEN WHITWELL: "I DON'T THINK I CAN REALLY ANSWER THAT. IT MAY OR MAY NOT. I MEAN, WE -- WE JUST DON'T KNOW."
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LAWYER JAMES LOCKYER AND PROFESSOR HELEN WHITWELL;
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In an earlier posting I referred to the shocking disclosure from the Goudge Inquiry that Dinesh Kumar's lawyer's testified that he had not been informed by prosecutors about a disturbing decision from Ontario Court Justice Patrick Dunn in the Amber case.
That decision was was highly critical of the opinions of Dr. Charles Smith and the Hospital for Sick Children SCAN (Suspected Child Abuse And Neglect) team.
Two other shocking disclosures relating to Gaurov's case also emanated from the Inquiry;
The second - the subject of this post - was that Dr. Charles Smith had informed homicide investigators that both he, and Dr. Dirk Huyer, the head of the SCAN team at the Hospital for Sick Children In Toronto were both "struggling" to find criminality in the case - a far cry from the language in their official reports;
Now the third: It has been disclosed during the Goudge Inquiry that in March 1992, just a few days before Gaurov's death his brother Saurob, was seen at a walk-in clinic at the Hospital for Children for spells.
Lawyer James Lockyer told the Inquiry that he had "just obtained" Saurob's medical records through a request.
Lockyer said the the history states that he was playing when he suddenly fell on the ground - - and we don't quite know what -- and was cyanosed. Apparently the father gave him something, andC compressions and mouth to mouth. And then there's a suggestion there may have been a similar episode last year.
Lockyer began this portion of his cross-examination of Professor Helen Whitwell - the independent reviewer of Gaurov's case - by informing Commissioner Steven Goudge that, "Another document that we just obtained through a request is the medical records, or -- the medical records of Dinash's (phonetic) brother, Saurob.
And if we go to PFP302210 -- now it's -- it's the best we have so far, and we're trying to get a better copy of this document -- but if you look at this document, it's addressed to Dr. Rana, who was Saurob's -- and indeed still is -- Saurob's physician.
Saurob is now -- I think I'm right in saying -- seventeen (17) years old and, Mr. Commissioner, he -- he is with his parents, I'm glad to say.
Any event, it's a report from the Hospital for Sick Children.
If we go to the second page, you'll see this document.
I'm afraid you -- we don't know who it's from because you can't quite read it.
But if you look at this document on page 1 -- if you could show us page 1 again? There might a Dr. Bard, if there is such a doctor at the Hospital for Sick Children.
And you'll see -- and this is a matter of days before Gaurov's death.
If you could raise the page, give us the bottom of the page.
COMMISSIONER STEPHEN GOUDGE: Is there a date on it somewhere?
JAMES LOCKYER: Well, it's -- I think it's mark -- I'm right in saying we've worked it out as being March 1st, 1992. It might be March 11th or 21st.
it's -- it's -- there's a one (1) and we have reason to think it's March. And I think that becomes apparent.
CONTINUED BY MR. JAMES LOCKYER:
MR. JAMES LOCKYER: If you could give us the -- the -- to the bottom of this page, please.
Thank you. You'll see here that Saurob, in what's really just a matter of days before Gaurov's death, was seen in the walk-in clinic at the Hospital for Sick Children for these spells.
you see where I'm looking?
DR. HELEN WHITWELL: Yes.
MR. JAMES LOCKYER: The history states -- and -- and we can probably invent some of the lines -- some of the words that are missing -- the history states that he was playing when he suddenly fell on the ground - - and we don't quite know what -- and was cyanosed.
Apparently the father gave him something, and compressions and mouth to mouth.
And then there's a suggestion there may have been a similar episode last year.
And then if we go to the -- over the page, and there's -- you'll see in the last paragraph: "Difficult to elicit exactly what the problem is. In a consideration of the description of this spell, we feel it's worthwhile to do..." And I'm -- I'm sort of translating, Mr. Commissioner, to some extent. "...a reassessment of the patient after an EEG has been done."
We also -- I can also tell you that Gaurov's father used to be an ambulance attendant back in his home country.
DR. HELEN WHITWELL: Right.
MR. JAMES LOCKYER: And so had familiarity with resuscitation and mouth-to-mouth techniques.
DR. HELEN WHITWELL: Yes.
MR. JAMES LOCKYER: So if we -- and I appreciate this is a dreadful document, but it's all we've got at the moment, and as I say, we're trying to get a better copy of it.
But if we assume for a moment that just days before Gaurov died his one (1) year old brother, Saurob had been through, what could be described as a similar experience to Gaurov, would that suggest that there might be any kind of -- of hereditary problem within family?
DR. HELEN WHITWELL: I don't think I can really answer that. It may or may not. I mean, we -- we just don't know.
This Blogster has no doubt that there is no way - at this point of time - that Professor Whitwell, or anyone else could give a definitive answer to this question.
I am however troubled by the fact that the shocking disclosure appears to have merged for the first time almost two decades after Mr. Kumar pleaded guilty to criminal negligence in connection with Gaurov's death.
This is an important investigative fact which should have been discovered by both the corner and police investigators, relayed to the police, and then disclosed to defence counsel - if at that point of time the prosecution was determined to expose Mr. Kumar to criminal proceedings.
It is crucial to recollect that Mr. Kumar felt pressured to enter a plea to criminal negligence causing Gaurov's death shortly after it was offered by prosecutors in order to avoid the oppressive murder charge - while the family was still deeply in mourning.
His lawyers therefore never got down to the type of investigation which would have revealed this kind of information which may have offered a medical defence which indicated that Gaurov, like so many other infants in Dr. Charles Smith's cases, had died a tragic, but natural death.
Harold Levy...hlevy15@gmail.com;
Showing posts with label HSC. Show all posts
Showing posts with label HSC. Show all posts
Sunday, June 8, 2008
Saturday, June 7, 2008
Part Eight: Gaurov's Father: A Second Shocking Revelation From Goudge Inquiry; Both Smith And Huyer Were "Struggling" With Criminality In the Case;
"SPEAK TO PATHOLOGIST, DR. CHARLES SMITH, OF SICK KIDS HOSPITAL RE. UPDATE. STILL IS OF THE OPINION THAT DEATH WAS FROM EITHER TWO (2) SOURCES: SHAKEN BABY, BLUNT TRAUMA. HE HAS CONSULTED WITH DR. HUYER, SCAN PROGRAM. THEY BOTH HAVE MISGIVINGS ABOUT CRIMINAL ELEMENT. QUOTE, 'HAS STRUGGLED WITH THIS BEING CRIMINAL. AGREES TO MEET WITH MARY HALL ANY TIME.'"
NOTE WRITTEN BY TORONTO HOMICIDE OFFICER DETECTIVE JOHN LINE IN RELATION TO KUMAR INVESTIGATION. DETECTIVE LINE WAS REFERRING TO MARY HALL WHO WAS DESCRIBED BY LAWYER JAMES LOCKYER AS HEAD CROWN ATTORNEY IN THE SCARBOROUGH OFFICE OUT OF WHICH KUMAR WAS PROSECUTED;
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In an earlier posting I referred to the shocking disclosure from the Goudge Inquiry that Dinesh Kumar's lawyer's testified that he had not been informed by prosecutors about a disturbing decision from Ontario Court Justice Patrick Dunn in the Amber case.
That decision was was highly critical of the opinions of Dr. Charles Smith and the Hospital for Sick Children SCAN (Suspected Child Abuse And Neglect) team.
Two other shocking disclosures relating to Gaurov's case also emanated from the Inquiry;
The second - the subject of this post - was that Dr. Charles Smith had informed homicide investigators that both he, and Dr. Dirk Huyer, the head of the SCAN team at the Hospital for Sick Children In Toronto were both "struggling" to find criminality in the case - a far cry from the language in their official reports;
The section of transcript relating to this disclosure is found in lawyer James Lockyer's cross-examination of Dr. Helen Whitwell, the independent examiner who reviewed Gaurov's case at the request of former Chief Coroner, Dr. Barry McLellan;
It reads as follows:
MR. JAMES LOCKYER: And so in Gaurov's case, whilst we have -- the preexisting condition may have been responsible for what ultimately caused Gaurov's death, beyond that, potentially, as Dr. Pollanen has pointed out, we don't even seem to have the triad in the first place.
DR. HELEN WHITWELL: No, you don't.
MR. JAMES LOCKYER: I don't know quite why Dr. Smith said this, but he seems to have had a lot of trouble with the case himself, and we got some notes just a -- a few days ago in this regard. If we could go to PFP302155; And what we're looking at here is the notes of one (1) of the officers in charge of the case, Detective Lines (sic). And if you go -- could you -- I'm sorry, I don't have a page number here. Could you just keep -- keep moving and I'll tell you when to stop through these notes. We're looking for March 23rd, which you'll see at the top of one (1) of the pages. And if you look at the entry for 2:55 on March 23rd -- and if you could raise the page a little so we can go to the bottom of it -- what it says there, and this is Detective Lines, one (1) of the officers in charge, and what he's noted March 23rd of 1992, which is post-autopsy, he's noted: "Speak to pathologist, Dr. Charles Smith, of Sick Kids Hospital re.
update. Still is of the opinion that death was from either two (2) sources: shaken baby, blunt trauma. He has consulted with Dr. Huyer, SCAN program. They both have misgivings about criminal element. Quote, 'Has struggled with this being criminal. Agrees to meet with Mary Hall any time.' And I can just tell you, Dr. Whitwell, that Mary Hall was then a -- the head Crown attorney in the Scarborough office where --
DR. HELEN WHITWELL: Right.
MR. JAMES LOCKYER: -- out of which Mr. Kumar was prosecuted.
So it would seem, at least in the early days -- and this is before Gaurov's father is charged with the second degree murder of his son Gaurov -- that even after the autopsy, Dr. Smith, and indeed Dr. Huyer of the SCAN unit, to use the -- to use the quote, "struggling" with the question of whether any crime had
been committed in Gaurov's death in the first place. I don't think you would have known that. We only got this document about a week ago --
DR. HELEN WHITWELL: Right.
MR. JAMES LOCKYER: -- through -- through the officer himself providing it.
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We are told that this note was written before Dinesh Kumar was encouraged by prosecutors to plead guilty to criminal negligence causing his son Gaurov's death in order to avoid being prosecuted for murder.
The existence of such a note - in which both Dr. Smith and the Head of the SCAN team are struggling to find any scientific evidence of criminality in the case - clearly raises the prospect that there was no reasonable possibility of obtaining a conviction.
The last time I looked at a Criminal Code - Criminal Negligence Causing Death was just what it sounded like: a very serious criminal offence.
So we have to wonder why the prosecutors who, as crown attorneys, also hold the function of being officers of the Court, proceeded to take Mr. Kumar to Court on any criminal charge at all - whether they were bound by the law to withdraw all charges against him or not.
A very shocking revelation indeed, which, it seems, only raised its ugly head publicly more than 16-years after Mr. Kumar pleaded guilty to an offence he did not commit, to avoid life in prison for murder on the evidence of the celebrated Dr. Smith's evidence supported by the world famous Hospital for Sick Children, to regain custody of his son, and to avoid deportation from Canada;
How could our Canadian Justice system fall so low?
Next Posting: Part Nine; Gaurov's Father; A Third Shocking Revelation From The Goudge Inquiry;
Harold Levy...hlevy15@gmail.com;
NOTE WRITTEN BY TORONTO HOMICIDE OFFICER DETECTIVE JOHN LINE IN RELATION TO KUMAR INVESTIGATION. DETECTIVE LINE WAS REFERRING TO MARY HALL WHO WAS DESCRIBED BY LAWYER JAMES LOCKYER AS HEAD CROWN ATTORNEY IN THE SCARBOROUGH OFFICE OUT OF WHICH KUMAR WAS PROSECUTED;
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In an earlier posting I referred to the shocking disclosure from the Goudge Inquiry that Dinesh Kumar's lawyer's testified that he had not been informed by prosecutors about a disturbing decision from Ontario Court Justice Patrick Dunn in the Amber case.
That decision was was highly critical of the opinions of Dr. Charles Smith and the Hospital for Sick Children SCAN (Suspected Child Abuse And Neglect) team.
Two other shocking disclosures relating to Gaurov's case also emanated from the Inquiry;
The second - the subject of this post - was that Dr. Charles Smith had informed homicide investigators that both he, and Dr. Dirk Huyer, the head of the SCAN team at the Hospital for Sick Children In Toronto were both "struggling" to find criminality in the case - a far cry from the language in their official reports;
The section of transcript relating to this disclosure is found in lawyer James Lockyer's cross-examination of Dr. Helen Whitwell, the independent examiner who reviewed Gaurov's case at the request of former Chief Coroner, Dr. Barry McLellan;
It reads as follows:
MR. JAMES LOCKYER: And so in Gaurov's case, whilst we have -- the preexisting condition may have been responsible for what ultimately caused Gaurov's death, beyond that, potentially, as Dr. Pollanen has pointed out, we don't even seem to have the triad in the first place.
DR. HELEN WHITWELL: No, you don't.
MR. JAMES LOCKYER: I don't know quite why Dr. Smith said this, but he seems to have had a lot of trouble with the case himself, and we got some notes just a -- a few days ago in this regard. If we could go to PFP302155; And what we're looking at here is the notes of one (1) of the officers in charge of the case, Detective Lines (sic). And if you go -- could you -- I'm sorry, I don't have a page number here. Could you just keep -- keep moving and I'll tell you when to stop through these notes. We're looking for March 23rd, which you'll see at the top of one (1) of the pages. And if you look at the entry for 2:55 on March 23rd -- and if you could raise the page a little so we can go to the bottom of it -- what it says there, and this is Detective Lines, one (1) of the officers in charge, and what he's noted March 23rd of 1992, which is post-autopsy, he's noted: "Speak to pathologist, Dr. Charles Smith, of Sick Kids Hospital re.
update. Still is of the opinion that death was from either two (2) sources: shaken baby, blunt trauma. He has consulted with Dr. Huyer, SCAN program. They both have misgivings about criminal element. Quote, 'Has struggled with this being criminal. Agrees to meet with Mary Hall any time.' And I can just tell you, Dr. Whitwell, that Mary Hall was then a -- the head Crown attorney in the Scarborough office where --
DR. HELEN WHITWELL: Right.
MR. JAMES LOCKYER: -- out of which Mr. Kumar was prosecuted.
So it would seem, at least in the early days -- and this is before Gaurov's father is charged with the second degree murder of his son Gaurov -- that even after the autopsy, Dr. Smith, and indeed Dr. Huyer of the SCAN unit, to use the -- to use the quote, "struggling" with the question of whether any crime had
been committed in Gaurov's death in the first place. I don't think you would have known that. We only got this document about a week ago --
DR. HELEN WHITWELL: Right.
MR. JAMES LOCKYER: -- through -- through the officer himself providing it.
-------------------------------------------------------------------------------
We are told that this note was written before Dinesh Kumar was encouraged by prosecutors to plead guilty to criminal negligence causing his son Gaurov's death in order to avoid being prosecuted for murder.
The existence of such a note - in which both Dr. Smith and the Head of the SCAN team are struggling to find any scientific evidence of criminality in the case - clearly raises the prospect that there was no reasonable possibility of obtaining a conviction.
The last time I looked at a Criminal Code - Criminal Negligence Causing Death was just what it sounded like: a very serious criminal offence.
So we have to wonder why the prosecutors who, as crown attorneys, also hold the function of being officers of the Court, proceeded to take Mr. Kumar to Court on any criminal charge at all - whether they were bound by the law to withdraw all charges against him or not.
A very shocking revelation indeed, which, it seems, only raised its ugly head publicly more than 16-years after Mr. Kumar pleaded guilty to an offence he did not commit, to avoid life in prison for murder on the evidence of the celebrated Dr. Smith's evidence supported by the world famous Hospital for Sick Children, to regain custody of his son, and to avoid deportation from Canada;
How could our Canadian Justice system fall so low?
Next Posting: Part Nine; Gaurov's Father; A Third Shocking Revelation From The Goudge Inquiry;
Harold Levy...hlevy15@gmail.com;
Friday, June 6, 2008
Part Seven: Gaurov's Father; Shocking Disclosure At Inquiry: Kumar Not Told By Crowns About Recent Decision Blasting Smith And Sick Kids SCAN Team;
"THIS WAS A MAN WITH NO RECORD -- A NEW IMMIGRANT TO THIS COUNTRY, A WIFE WITH A BRAIN TUMOUR, A JOB. HE WAS A CONTRIBUTING MEMBER OF SOCIETY, AND ALL OF THE SUDDEN AN ATOMIC BOMB GOES OFF IN HIS LIFE -- MURDER 2. YOU HAVE TO TELL HIM BECAUSE THEY ALWAYS ASK, WHAT'S THE PENALTY, AND YOU SAY, LIFE WITH A MINIMUM PENALTY OF TEN (10) YEARS -- TEN (10) YEARS. HE WOULD HAVE GOTTEN OUT OF JAIL HAD HE
GOTTEN TEN (10) YEARS, AND IF THE TRIAL HAD TAKEN TWO (2) YEARS, HE'S JUST BE OUT NOW FOR FOUR (4) YEARS, AND HIS WHOLE LIFE WOULD BE SHATTERED. NOW, I -- I SEE IN THESE NOTES THAT I'VE BEEN GIVEN FOR THE FIRST TIME TODAY, THE MEETING JANUARY 30TH OF 1992, THE WORDS "DAMAGE CONTROL" APPEAR DEALING WITH THE CASE FROM MR. JUSTICE DUNN. I CAN'T MAKE A CONNECTION BETWEEN THAT MEETING AND WHAT HAPPENED IN MY CASE, EXCEPT THAT IT HAPPENED JUST A FEW WEEKS LATER OUT OF THE SAME OFFICE. I'M STILL SHOCKED."
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LAWYER DAVID GORRELL IN RESPONSE TO QUESTIONS POSED IN CROSS-EXAMINATION BY JAMES LOCKYER;
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One of the most shocking revelations from the Goudge Inquiry is Dinesh Kumar's lawyer's evidence that he was not been informed by prosecutors about a disturbing decision from Ontario Court Justice Patrick Dunn in the Amber case.
As we have seen in many previous posts, this decision was was highly critical of the opinions of Dr. Charles Smith and the Hospital for Sick Children SCAN team.
As will be seen towards the end of this post, a lack of access to this decision had dire consequences for Mr. Kumar which he bears to this day.
By was of background information, here is a post I ran on Thursday, January 10, 2008, under the heading "Damage Control And Lost Opportunity: The Hospital For Sick Children Suspected Child Abuse and Neglect (SCAN) Unit;"
It describes how the Hospital for Sick Children resorted to "damage control" rather than to dissecting Dunn's decision in order to see what they could learn from it in order to avoid future debacles.
I did not realize the additional significance of the damage control meeting - the presence of a prosecutor - until I was later exposed to Gaurov's case at the inquiry.
Here is the earlier post as published:
""C.S. FEELS HE WAS MISUNDERSTOOD."
FROM HOSPITAL FOR SICK CHILDREN DAMAGE CONTROL DOCUMENT;
One would like to think of the Hospital For Sick Children as an institution that wants to learn from its mistakes.
This would especially apply to the serious medical errors made by Dr. Charles Smith and the hospital's Suspected Child Abuse and Neglect (SCAN) Unit that led to a 12-year old girl Timmins, Ontario girl being wrongfully charged with manslaughter.
However, a document has emerged at the Goudge inquiry which shows that the SCAN team reacted to Ontario Court Judge Judge Patrick Dunn's scathing criticisms of its work by holding a "damage control" meeting at which Smith defended his work, and Dunn was branded as "strange" and "from the bottom of the heap"
The handwritten document does not evidence any concern on the part of Smith or the members of the SCAN team that Judge Dunn's rejection of the hospital's opinion that baby Amber was a victim of "shaken-baby syndrome," as opposed to a fall down the stairs, may have been well-founded.
Nor does it evidence any desire to figure out what went wrong so that the risk of future wrongful prosecutions can be minimized.
Instead, after noting that the meeting was attended by the members of the SCAN team and several prosecutors, it goes on to describe Dunn as "strange" a member of the "family court" and "not used to criminal standards."
It goes on to express a concern that, "the judgment is likely to be passed around and (symbol for "therefore") damage control)";
(In retrospect, this prediction was right on the mark as Dunn's carefully structured judgement is resonating today at the core of the Goudge inquiry as one of the first alarm bells to sound over Smith's competence.)
But is is evident that the "damage control" ultimately failed as the hospital's failure to accept its responsibility and do something to remedy its mistakes is now available on the public record for all to see.
One of the most disturbing suggestions in the document is the comment that there is "no precedential value re medical evidence. Family court judge at bottom of heap. Error may be brought up in another case."
The reality is that if Dunn's criticisms - as set out in a beautifully structured decision - had been heeded back in 1991, so many other individuals would have been spared the torment of being wrongfully accused of killing their beloved children.
Instead, the consensus of the meeting appears to be that it is, "acceptable to say we disagree with judge's judgment."
The notes indicated that Smith defended his opinion in the case on the basis that "our standard is higher than theirs" - (an apparent reference to the large number of U.S. experts called by the defence) - "but still has to be held up to a higher standard."
He also attempts to deflect criticism from himself by saying that the case involved an "outside opinion" and that he "relied on police photos."
"C.S. feels he was misunderstood," the anonymous minute-taker wrote.
This is typical of Dr. Charles Randal Smith.
Evidence called at the Inquiry indicates that even his defenders at the highest levels of the Chief Coroner's Office observed toward the end of his career at the hospital that he was incapable of accepting responsibility for his actions and tended to blame others for his own mistakes.
During his questioning yesterday of Dr. Dirk Huyer, former head of the SCAN team and Dr. Katy Driver, who played a prominent role for that team in Amber's case, lawyer Louis Sokolov, who represents the Association in Defence of the Wrongly Convicted, (AIDWYC) suggested that the Hospital's damage control meeting represented, "a lost opportunity."
He sure got that right.
(See previous posting: "A glimmer of understanding: Part Three; A dangerous mix; Dr. Charles Smith and the Hospital For Sick Children SCAN team.)
Posted by Harold levy at Thursday, January 10, 2008;"
Goudge Inquiry Counsel Mark Sandler twigged to the fact that the prosecutor who was present at the damage control meeting played an active role in the Kumar investigation - just several weeks later;
Here is Sandler's examination of David Gorrell, Kumar's lawyer, on this connection:
(Bear with me: I prefer to give full stretched of evidence rather than to risk inadvertently distorting the substance through editing);
CONTINUED BY MR. MARK SANDLER:
MR. MARK SANDLER: Thank you. Mr. Gorrell, we know from the materials that have been filed here that -- that Gaurov died in Toronto on March the 20th, 1992, at the age of five (5) weeks. Due to suspicions about his death, his older brother was apprehended by CAS on that same date. We also know that on June the 16th of 1992, the report of post-mortem examination prepared by Dr. Smith was issued. I'm going to take you to the overview report if I may, which is at Tab 1 of your materials. And if you'd go to PFP143828, at paragraph 59, and you'll
see paragraph 59 is at page 32 of the overview report.
MR. DAVID GORRELL: Thank you.
MR. MARK SANDLER: And you'll see that on June the 26th of 1992, there was a meeting involving Dr. Smith, Constable Line, Detective Rolf Prisor, and -- Prisor, and Crown counsel, Mary Hall and Sandra Kingston. Just stopping there for a -- for a moment. First of all, what was Ms. Hall's position back in June
of 1992, as you understand it?
MR. DAVID GORRELL: I believe she was the -- either a Bureau Chief, or a Crown attorney, an independent Crown attorney. I'm not sure if Scarborough had been hived off yet, and made into a -- a jurisdiction for a separate Crown. But she was the head person. (Blogster's Note: Prosecutor Hall did not testify at the Inquiry. Her side of the story is not represented in this post.)
MR. MARK SANDLER: And were you aware of what, if any, role she played in the Gaurov case?
MR. DAVID GORRELL: Well, she would obviously supervise. She did participate in the -- in a judicial pretrial that we had on October 22nd of 1992, but that was simply because the assigned Crown, I believe, was not available.
MR. MARK SANDLER: And that was Ms. Koehl?
MR. DAVID GORRELL: Ms. Koehl, yes.
MR. MARK SANDLER: And you see from the overview report that that meeting involving the police and Crown counsel and Dr. Smith took place on June the 26th, and the overview report reflects that, according to a police report, Dr. Smith confirmed his diagnosis of Shaken Baby Syndrome, and added that the injuries probably resulted from continuous shaking as opposed to a single violent shake. We also know, Mr. Gorrell, that on June the 29th of 1992, Gaurov's father was arrested for second degree murder, some three (3) days later.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: And the bail hearing took place on July the 10th -
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: -- and were you involved in the bail hearing?
MR. DAVID GORRELL: I became involved on July 2nd. The case first went to Dhamen Kissoon -- K-I- S-S-O-O-N, who had gone to the bar in 1989, and he retained me to lead on the defence. And I became involved on June 30th. And we worked on preparing the necessary affidavits and so on for the bail hearing from June 30th on.
MR. MARK SANDLER: All right.
MR. DAVID GORRELL: Until July 10th.
MR. MARK SANDLER: And we know from the materials that have been filed that the Crown consented to the release of your client on bail, pending trial. Am I right?
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: And I want to ask you about a conversation that your dockets reflect took place with Rita Koehl on the same date of the bail hearing, June -- July the 10th.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: Tell us what transpired.
MR. DAVID GORRELL: This is a -- a case that's sixteen (16) years ago, and therefore, I'm relying heavily on the notes that were found in Mr. Kissoon's file. My own file isn't -- is no longer available. According to the dockets and the notes that I have here, on the day of the bail hearing, Ms.
Koehl, with Sergeant Prisor, I think, present, discussed with me the possibility of a resolution by way of plea to something possibly for no time.
MR. MARK SANDLER: All right. And how did you react to the fact that on a murder case, the Crown had initiated a discussion with you that involved a
potential plea for -- for no time?
MR. DAVID GORRELL: I was surprised.
MR. MARK SANDLER: And did you have any explana -- or was any explanation given to you as to why the Crown was taking that position as -- that early and at that stage in the proceedings?
MR. DAVID GORRELL: Not that I recall, and I would not have asked. You don't look a gift horse in the mouth.
MR. MARK SANDLER: All right. And similarly, I see that, as you've indicated, there was a consent to your client's release on bail, pending trial.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: Was that in your experience usual for a murder case?
MR. DAVID GORRELL: John would be better to ask. I haven't done nearly as many as he has, but you can get consent releases on murders, and I think this would have been a case where you could have.
MR. MARK SANDLER: All right. Now, just seeing what, if anything, we can figure out about -- about why the Crown was motivated to proceed in the way it did. I want to ask you about something that you may or may not know about, and that is, we've heard some evidence here, Mr. Gorrell, that on January -- in January of 1992, that same year -- a conference -- a case conference was conducted at the Hospital for Sick Children in connection with the Amber case, and it arose out of the comments that Justice Dunn had made about the Hospital for Sick Children witnesses, including Dr. Smith, at -- at that trial, and we also know that in January of 1992, Ms. Hall and Ms. Kingston participated in that conference.
Two (2) questions arising out of that. Did either Ms. Hall or Ms. Kingston, or anyone else from the Crown's office have any discussions with you about the Amber case and its impact upon the Gaurov case?
MR. DAVID GORRELL: No.
MR. MARK SANDLER: Were you aware that -- that the Crowns, including Ms. Hall, had participated in a case conference in connection with the Amber case before the Gaurov case had taken place?
MR. DAVID GORRELL: No.
MR. MARK SANDLER: All right.
MR. DAVID GORRELL: All right, let me rephrase that. I know that they met again, I think, on June the 26th about this case, about the -- the Gaurov case, but I was unaware of this meeting. I have the notes in front of me here. I've seen them today for the first time. I was unaware of this meeting on January 30th, 1992.
MR. MARK SANDLER: All right. And you've made reference to -- to the meeting that took place here and -- and I've made reference to the Crown, so just taking you to page 32, paragraph 59, that's the reference that I took you to a little bit earlier of the meeting that took place involving Dr. Smith, the police, Ms. Hall, and Ms. Kingston. Am I right?
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: And were you aware that -- that that conference had taken place prior to the laying of the charges?
MR. DAVID GORRELL: I don't think so. It's been a long time ago, but I don't think I was aware of that meeting, and I don't think I had the police notes of it. I do have the original disclosure here from 1992, and the summary that is -- is available in these materials is not in that disclosure.
MR. MARK SANDLER: Okay, and leaving aside your awareness of the June 26th, 1992 meeting, you earlier indicated that you were the one that actually
gave Mr. Struthers a copy of the Amber decision, and this would be sometime later on.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: Were you even aware of the Amber decision back in June of 1992 or during the currency of your involvement in the Gaurov file?
MR. DAVID GORRELL: No, I was not.
MR. MARK SANDLER: Was it something that you would have been like -- that you would have liked to have been aware of?
MR. DAVID GORRELL: Oh, yes;"
As the following transcript indicates, lawyer James Lockyer, who represents William Mullins-Johnson, Sherry Sherret-Robinson and at least seven unnamed persons at the Inquiry, was quick to zoom into this connection in his cross-examination of Gorrell;
MR. DAVID GORRELL: This was a man with no record -- a new immigrant to this country, a wife with a brain tumour, a job," Gorrell told Lockyer;
"He was a contributing member of society, and all of the sudden an atomic bomb goes off in his life -- murder 2. You have to tell him because they always ask, What's the penalty, and you say, Life with a minimum penalty of ten (10) years -- ten (10) years. He would have gotten out of jail had he gotten ten (10) years, and if the trial had taken two (2) years, he's just be out now for four (4) years, and his
whole life would be shattered. Now, I -- I see in these notes that I've been given for the first time today, the meeting January 30th of 1992, the words "damage control" appear dealing with the case from Mr. Justice Dunn. I can't make a connection between that meeting and what happened in my case, except that it
happened just a few weeks later out of the same office. I'm still shocked.
MR. JAMES LOCKYER: The same Crown, as a matter of fact --
MR. DAVID GORRELL: Well, no, -- well, no, Ms. Koehl wasn't on this case, but Mary --
MR. JAMES LOCKYER: Mary Hall --
MR. DAVID GORRELL: Mary Hall, the same Crown attorney.
MR. JAMES LOCKYER: -- was the common denominator to your case and their case, is that right?
MR. DAVID GORRELL: Yes, and the Scarborough courthouse --
MR. JAMES LOCKYER: Mm-hm.
MR. DAVID GORRELL: -- and Charles Smith, Of course. But --
MR. JAMES LOCKYER: I think Mary Hall was actually the Crown when you did the pretrial in October--
MR. DAVID GORRELL: Yes, she did.
MR. JAMES LOCKYER: -- on the Gaurov case, is that right?
MR. DAVID GORRELL: She was there. I think Ms. Koehl was unavailable for some reason, but...
MR. JAMES LOCKYER: Yes. And I -- as I recall, Mr. Koehl also said that any plea arrangement would be subject to the approval of Ms. Hall.
MR. DAVID GORRELL: That I don't remember, but I -- I wouldn't be surprised in any case.
MR. JAMES LOCKYER: It's in one (1) of the documents in the file you arrived with today.
MR. DAVID GORRELL: Really?
MR. JAMES LOCKYER: Yes.
MR. DAVID GORRELL: Fine, then I accept
that.
MR. JOHN STRUTHERS: It was the practice
at the time.
MR. JAMES LOCKYER: Yes.
MR. DAVID GORRELL: But the -- just -- just to continue with this, what -- I said, my heart went out to Gaurov's father. I don't know how I'd -- I'd act in this situation if I had someone like Mr. Struthers saying, Well, you can get ninety (90) days on weekends. After emission, that's sixty (60) days. That's a maximum of fifteen (15) weekends. The Mimico is jammed, so you'll wind up doing only three (3), or four (4), or five (5). You can do that, or you can sit in the courtroom and be judged by everybody with a risk, with Charles Smith up there with a mantle of Sick Kids on his shoulder. You can go to jail. You can go to jail on a
manslaughter. I really didn't think a murder was in the cards, but you can go to jail on a manslaughter. What decision would I make? I'm pretty sure I'd make the
decision he made even if I were not guilty. But as his lawyer, I'm the only person in the whole scenario that Doesn't judge him. The police judge him when they charge him. The Crown judges him when they prosecute him. The Judge judges him, the jury judges him, the press judges him. When he says, I want to plead guilty, and
I will sign on the dotted line, and I did it, I'm not going to tell him, No, sir, you're going to face the trial and if you get eight (8) years, that's for the
greater good of the justice. I took his instructions and I -- I would not be at all surprised, with the stress that man was under at the time, if he was doing it out of expediency.
MR. JAMES LOCKYER: And the instructions that you received from him by way of the form that you prepared, obviously the way it's typed up, it was -- the words were your words in that document, is that fair?
MR. DAVID GORRELL: Yes, they were my words.
MR. JAMES LOCKYER: And they were words designed to fit the notion of criminal negligence. Reckless is hardly a word an east Indian that doesn't
speak English is going to come up with.
MR. DAVID GORRELL: No, the -- this -- these were my words.
MR. JAMES LOCKYER: Yes. And, as Mr. Struthers was just saying, it was more a document for your protection than a document to assist Gaurov's
father, is that fair?
MR. DAVID GORRELL: I think that's probably fair. It's also a document that you would use to fix his mind as to what he's doing, so that he can't
come back and -- I guess to protect counsel, that's right. I(t) was thirteen (13) pages;"
Dear readers:
Imagine how the prosecutors must have felt to learn about Justice Dunn's troubling criticisms of the work performed by Dr. Charles Smith and the Hospital for Sick Children SCAN-TEAM in the then recent Amber case;
Would that not have raised serious questions as to whether or not there was a reasonable possibility of obtaining a conviction in the case?
At the very least, shouldn't the existence of the decision - which was not likely publicly available at that time - have been made to the defence lawyers?
At least, that way they could assess the strength of the Crown's case before putting the plea to criminal negligence causing his son Gaurov's death to his client whether or not the law relating to disclosure at the time required them to do so?
As a criminal lawyer, I suspect that after reading the Dunn decision I would have been in a position to more confidently advise the client to contest the murder charge - instead of having to go through the contortions involved in a criminal negligence plea where I would have so much doubt about my client's guilt?
Just imagine how much pain this mourning family would have been spared - let alone the need to bear the load of sixteen years of stigma in their tiny community - and having to fight for ultimate exoneration after sixteen years in the Ontario Court of Appeal;
Next: Part Seven; Gaurov's father: Another shocking revelation;
Harold Levy: hlevy15@gmail.com;
GOTTEN TEN (10) YEARS, AND IF THE TRIAL HAD TAKEN TWO (2) YEARS, HE'S JUST BE OUT NOW FOR FOUR (4) YEARS, AND HIS WHOLE LIFE WOULD BE SHATTERED. NOW, I -- I SEE IN THESE NOTES THAT I'VE BEEN GIVEN FOR THE FIRST TIME TODAY, THE MEETING JANUARY 30TH OF 1992, THE WORDS "DAMAGE CONTROL" APPEAR DEALING WITH THE CASE FROM MR. JUSTICE DUNN. I CAN'T MAKE A CONNECTION BETWEEN THAT MEETING AND WHAT HAPPENED IN MY CASE, EXCEPT THAT IT HAPPENED JUST A FEW WEEKS LATER OUT OF THE SAME OFFICE. I'M STILL SHOCKED."
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LAWYER DAVID GORRELL IN RESPONSE TO QUESTIONS POSED IN CROSS-EXAMINATION BY JAMES LOCKYER;
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One of the most shocking revelations from the Goudge Inquiry is Dinesh Kumar's lawyer's evidence that he was not been informed by prosecutors about a disturbing decision from Ontario Court Justice Patrick Dunn in the Amber case.
As we have seen in many previous posts, this decision was was highly critical of the opinions of Dr. Charles Smith and the Hospital for Sick Children SCAN team.
As will be seen towards the end of this post, a lack of access to this decision had dire consequences for Mr. Kumar which he bears to this day.
By was of background information, here is a post I ran on Thursday, January 10, 2008, under the heading "Damage Control And Lost Opportunity: The Hospital For Sick Children Suspected Child Abuse and Neglect (SCAN) Unit;"
It describes how the Hospital for Sick Children resorted to "damage control" rather than to dissecting Dunn's decision in order to see what they could learn from it in order to avoid future debacles.
I did not realize the additional significance of the damage control meeting - the presence of a prosecutor - until I was later exposed to Gaurov's case at the inquiry.
Here is the earlier post as published:
""C.S. FEELS HE WAS MISUNDERSTOOD."
FROM HOSPITAL FOR SICK CHILDREN DAMAGE CONTROL DOCUMENT;
One would like to think of the Hospital For Sick Children as an institution that wants to learn from its mistakes.
This would especially apply to the serious medical errors made by Dr. Charles Smith and the hospital's Suspected Child Abuse and Neglect (SCAN) Unit that led to a 12-year old girl Timmins, Ontario girl being wrongfully charged with manslaughter.
However, a document has emerged at the Goudge inquiry which shows that the SCAN team reacted to Ontario Court Judge Judge Patrick Dunn's scathing criticisms of its work by holding a "damage control" meeting at which Smith defended his work, and Dunn was branded as "strange" and "from the bottom of the heap"
The handwritten document does not evidence any concern on the part of Smith or the members of the SCAN team that Judge Dunn's rejection of the hospital's opinion that baby Amber was a victim of "shaken-baby syndrome," as opposed to a fall down the stairs, may have been well-founded.
Nor does it evidence any desire to figure out what went wrong so that the risk of future wrongful prosecutions can be minimized.
Instead, after noting that the meeting was attended by the members of the SCAN team and several prosecutors, it goes on to describe Dunn as "strange" a member of the "family court" and "not used to criminal standards."
It goes on to express a concern that, "the judgment is likely to be passed around and (symbol for "therefore") damage control)";
(In retrospect, this prediction was right on the mark as Dunn's carefully structured judgement is resonating today at the core of the Goudge inquiry as one of the first alarm bells to sound over Smith's competence.)
But is is evident that the "damage control" ultimately failed as the hospital's failure to accept its responsibility and do something to remedy its mistakes is now available on the public record for all to see.
One of the most disturbing suggestions in the document is the comment that there is "no precedential value re medical evidence. Family court judge at bottom of heap. Error may be brought up in another case."
The reality is that if Dunn's criticisms - as set out in a beautifully structured decision - had been heeded back in 1991, so many other individuals would have been spared the torment of being wrongfully accused of killing their beloved children.
Instead, the consensus of the meeting appears to be that it is, "acceptable to say we disagree with judge's judgment."
The notes indicated that Smith defended his opinion in the case on the basis that "our standard is higher than theirs" - (an apparent reference to the large number of U.S. experts called by the defence) - "but still has to be held up to a higher standard."
He also attempts to deflect criticism from himself by saying that the case involved an "outside opinion" and that he "relied on police photos."
"C.S. feels he was misunderstood," the anonymous minute-taker wrote.
This is typical of Dr. Charles Randal Smith.
Evidence called at the Inquiry indicates that even his defenders at the highest levels of the Chief Coroner's Office observed toward the end of his career at the hospital that he was incapable of accepting responsibility for his actions and tended to blame others for his own mistakes.
During his questioning yesterday of Dr. Dirk Huyer, former head of the SCAN team and Dr. Katy Driver, who played a prominent role for that team in Amber's case, lawyer Louis Sokolov, who represents the Association in Defence of the Wrongly Convicted, (AIDWYC) suggested that the Hospital's damage control meeting represented, "a lost opportunity."
He sure got that right.
(See previous posting: "A glimmer of understanding: Part Three; A dangerous mix; Dr. Charles Smith and the Hospital For Sick Children SCAN team.)
Posted by Harold levy at Thursday, January 10, 2008;"
Goudge Inquiry Counsel Mark Sandler twigged to the fact that the prosecutor who was present at the damage control meeting played an active role in the Kumar investigation - just several weeks later;
Here is Sandler's examination of David Gorrell, Kumar's lawyer, on this connection:
(Bear with me: I prefer to give full stretched of evidence rather than to risk inadvertently distorting the substance through editing);
CONTINUED BY MR. MARK SANDLER:
MR. MARK SANDLER: Thank you. Mr. Gorrell, we know from the materials that have been filed here that -- that Gaurov died in Toronto on March the 20th, 1992, at the age of five (5) weeks. Due to suspicions about his death, his older brother was apprehended by CAS on that same date. We also know that on June the 16th of 1992, the report of post-mortem examination prepared by Dr. Smith was issued. I'm going to take you to the overview report if I may, which is at Tab 1 of your materials. And if you'd go to PFP143828, at paragraph 59, and you'll
see paragraph 59 is at page 32 of the overview report.
MR. DAVID GORRELL: Thank you.
MR. MARK SANDLER: And you'll see that on June the 26th of 1992, there was a meeting involving Dr. Smith, Constable Line, Detective Rolf Prisor, and -- Prisor, and Crown counsel, Mary Hall and Sandra Kingston. Just stopping there for a -- for a moment. First of all, what was Ms. Hall's position back in June
of 1992, as you understand it?
MR. DAVID GORRELL: I believe she was the -- either a Bureau Chief, or a Crown attorney, an independent Crown attorney. I'm not sure if Scarborough had been hived off yet, and made into a -- a jurisdiction for a separate Crown. But she was the head person. (Blogster's Note: Prosecutor Hall did not testify at the Inquiry. Her side of the story is not represented in this post.)
MR. MARK SANDLER: And were you aware of what, if any, role she played in the Gaurov case?
MR. DAVID GORRELL: Well, she would obviously supervise. She did participate in the -- in a judicial pretrial that we had on October 22nd of 1992, but that was simply because the assigned Crown, I believe, was not available.
MR. MARK SANDLER: And that was Ms. Koehl?
MR. DAVID GORRELL: Ms. Koehl, yes.
MR. MARK SANDLER: And you see from the overview report that that meeting involving the police and Crown counsel and Dr. Smith took place on June the 26th, and the overview report reflects that, according to a police report, Dr. Smith confirmed his diagnosis of Shaken Baby Syndrome, and added that the injuries probably resulted from continuous shaking as opposed to a single violent shake. We also know, Mr. Gorrell, that on June the 29th of 1992, Gaurov's father was arrested for second degree murder, some three (3) days later.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: And the bail hearing took place on July the 10th -
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: -- and were you involved in the bail hearing?
MR. DAVID GORRELL: I became involved on July 2nd. The case first went to Dhamen Kissoon -- K-I- S-S-O-O-N, who had gone to the bar in 1989, and he retained me to lead on the defence. And I became involved on June 30th. And we worked on preparing the necessary affidavits and so on for the bail hearing from June 30th on.
MR. MARK SANDLER: All right.
MR. DAVID GORRELL: Until July 10th.
MR. MARK SANDLER: And we know from the materials that have been filed that the Crown consented to the release of your client on bail, pending trial. Am I right?
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: And I want to ask you about a conversation that your dockets reflect took place with Rita Koehl on the same date of the bail hearing, June -- July the 10th.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: Tell us what transpired.
MR. DAVID GORRELL: This is a -- a case that's sixteen (16) years ago, and therefore, I'm relying heavily on the notes that were found in Mr. Kissoon's file. My own file isn't -- is no longer available. According to the dockets and the notes that I have here, on the day of the bail hearing, Ms.
Koehl, with Sergeant Prisor, I think, present, discussed with me the possibility of a resolution by way of plea to something possibly for no time.
MR. MARK SANDLER: All right. And how did you react to the fact that on a murder case, the Crown had initiated a discussion with you that involved a
potential plea for -- for no time?
MR. DAVID GORRELL: I was surprised.
MR. MARK SANDLER: And did you have any explana -- or was any explanation given to you as to why the Crown was taking that position as -- that early and at that stage in the proceedings?
MR. DAVID GORRELL: Not that I recall, and I would not have asked. You don't look a gift horse in the mouth.
MR. MARK SANDLER: All right. And similarly, I see that, as you've indicated, there was a consent to your client's release on bail, pending trial.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: Was that in your experience usual for a murder case?
MR. DAVID GORRELL: John would be better to ask. I haven't done nearly as many as he has, but you can get consent releases on murders, and I think this would have been a case where you could have.
MR. MARK SANDLER: All right. Now, just seeing what, if anything, we can figure out about -- about why the Crown was motivated to proceed in the way it did. I want to ask you about something that you may or may not know about, and that is, we've heard some evidence here, Mr. Gorrell, that on January -- in January of 1992, that same year -- a conference -- a case conference was conducted at the Hospital for Sick Children in connection with the Amber case, and it arose out of the comments that Justice Dunn had made about the Hospital for Sick Children witnesses, including Dr. Smith, at -- at that trial, and we also know that in January of 1992, Ms. Hall and Ms. Kingston participated in that conference.
Two (2) questions arising out of that. Did either Ms. Hall or Ms. Kingston, or anyone else from the Crown's office have any discussions with you about the Amber case and its impact upon the Gaurov case?
MR. DAVID GORRELL: No.
MR. MARK SANDLER: Were you aware that -- that the Crowns, including Ms. Hall, had participated in a case conference in connection with the Amber case before the Gaurov case had taken place?
MR. DAVID GORRELL: No.
MR. MARK SANDLER: All right.
MR. DAVID GORRELL: All right, let me rephrase that. I know that they met again, I think, on June the 26th about this case, about the -- the Gaurov case, but I was unaware of this meeting. I have the notes in front of me here. I've seen them today for the first time. I was unaware of this meeting on January 30th, 1992.
MR. MARK SANDLER: All right. And you've made reference to -- to the meeting that took place here and -- and I've made reference to the Crown, so just taking you to page 32, paragraph 59, that's the reference that I took you to a little bit earlier of the meeting that took place involving Dr. Smith, the police, Ms. Hall, and Ms. Kingston. Am I right?
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: And were you aware that -- that that conference had taken place prior to the laying of the charges?
MR. DAVID GORRELL: I don't think so. It's been a long time ago, but I don't think I was aware of that meeting, and I don't think I had the police notes of it. I do have the original disclosure here from 1992, and the summary that is -- is available in these materials is not in that disclosure.
MR. MARK SANDLER: Okay, and leaving aside your awareness of the June 26th, 1992 meeting, you earlier indicated that you were the one that actually
gave Mr. Struthers a copy of the Amber decision, and this would be sometime later on.
MR. DAVID GORRELL: Yes.
MR. MARK SANDLER: Were you even aware of the Amber decision back in June of 1992 or during the currency of your involvement in the Gaurov file?
MR. DAVID GORRELL: No, I was not.
MR. MARK SANDLER: Was it something that you would have been like -- that you would have liked to have been aware of?
MR. DAVID GORRELL: Oh, yes;"
As the following transcript indicates, lawyer James Lockyer, who represents William Mullins-Johnson, Sherry Sherret-Robinson and at least seven unnamed persons at the Inquiry, was quick to zoom into this connection in his cross-examination of Gorrell;
MR. DAVID GORRELL: This was a man with no record -- a new immigrant to this country, a wife with a brain tumour, a job," Gorrell told Lockyer;
"He was a contributing member of society, and all of the sudden an atomic bomb goes off in his life -- murder 2. You have to tell him because they always ask, What's the penalty, and you say, Life with a minimum penalty of ten (10) years -- ten (10) years. He would have gotten out of jail had he gotten ten (10) years, and if the trial had taken two (2) years, he's just be out now for four (4) years, and his
whole life would be shattered. Now, I -- I see in these notes that I've been given for the first time today, the meeting January 30th of 1992, the words "damage control" appear dealing with the case from Mr. Justice Dunn. I can't make a connection between that meeting and what happened in my case, except that it
happened just a few weeks later out of the same office. I'm still shocked.
MR. JAMES LOCKYER: The same Crown, as a matter of fact --
MR. DAVID GORRELL: Well, no, -- well, no, Ms. Koehl wasn't on this case, but Mary --
MR. JAMES LOCKYER: Mary Hall --
MR. DAVID GORRELL: Mary Hall, the same Crown attorney.
MR. JAMES LOCKYER: -- was the common denominator to your case and their case, is that right?
MR. DAVID GORRELL: Yes, and the Scarborough courthouse --
MR. JAMES LOCKYER: Mm-hm.
MR. DAVID GORRELL: -- and Charles Smith, Of course. But --
MR. JAMES LOCKYER: I think Mary Hall was actually the Crown when you did the pretrial in October--
MR. DAVID GORRELL: Yes, she did.
MR. JAMES LOCKYER: -- on the Gaurov case, is that right?
MR. DAVID GORRELL: She was there. I think Ms. Koehl was unavailable for some reason, but...
MR. JAMES LOCKYER: Yes. And I -- as I recall, Mr. Koehl also said that any plea arrangement would be subject to the approval of Ms. Hall.
MR. DAVID GORRELL: That I don't remember, but I -- I wouldn't be surprised in any case.
MR. JAMES LOCKYER: It's in one (1) of the documents in the file you arrived with today.
MR. DAVID GORRELL: Really?
MR. JAMES LOCKYER: Yes.
MR. DAVID GORRELL: Fine, then I accept
that.
MR. JOHN STRUTHERS: It was the practice
at the time.
MR. JAMES LOCKYER: Yes.
MR. DAVID GORRELL: But the -- just -- just to continue with this, what -- I said, my heart went out to Gaurov's father. I don't know how I'd -- I'd act in this situation if I had someone like Mr. Struthers saying, Well, you can get ninety (90) days on weekends. After emission, that's sixty (60) days. That's a maximum of fifteen (15) weekends. The Mimico is jammed, so you'll wind up doing only three (3), or four (4), or five (5). You can do that, or you can sit in the courtroom and be judged by everybody with a risk, with Charles Smith up there with a mantle of Sick Kids on his shoulder. You can go to jail. You can go to jail on a
manslaughter. I really didn't think a murder was in the cards, but you can go to jail on a manslaughter. What decision would I make? I'm pretty sure I'd make the
decision he made even if I were not guilty. But as his lawyer, I'm the only person in the whole scenario that Doesn't judge him. The police judge him when they charge him. The Crown judges him when they prosecute him. The Judge judges him, the jury judges him, the press judges him. When he says, I want to plead guilty, and
I will sign on the dotted line, and I did it, I'm not going to tell him, No, sir, you're going to face the trial and if you get eight (8) years, that's for the
greater good of the justice. I took his instructions and I -- I would not be at all surprised, with the stress that man was under at the time, if he was doing it out of expediency.
MR. JAMES LOCKYER: And the instructions that you received from him by way of the form that you prepared, obviously the way it's typed up, it was -- the words were your words in that document, is that fair?
MR. DAVID GORRELL: Yes, they were my words.
MR. JAMES LOCKYER: And they were words designed to fit the notion of criminal negligence. Reckless is hardly a word an east Indian that doesn't
speak English is going to come up with.
MR. DAVID GORRELL: No, the -- this -- these were my words.
MR. JAMES LOCKYER: Yes. And, as Mr. Struthers was just saying, it was more a document for your protection than a document to assist Gaurov's
father, is that fair?
MR. DAVID GORRELL: I think that's probably fair. It's also a document that you would use to fix his mind as to what he's doing, so that he can't
come back and -- I guess to protect counsel, that's right. I(t) was thirteen (13) pages;"
Dear readers:
Imagine how the prosecutors must have felt to learn about Justice Dunn's troubling criticisms of the work performed by Dr. Charles Smith and the Hospital for Sick Children SCAN-TEAM in the then recent Amber case;
Would that not have raised serious questions as to whether or not there was a reasonable possibility of obtaining a conviction in the case?
At the very least, shouldn't the existence of the decision - which was not likely publicly available at that time - have been made to the defence lawyers?
At least, that way they could assess the strength of the Crown's case before putting the plea to criminal negligence causing his son Gaurov's death to his client whether or not the law relating to disclosure at the time required them to do so?
As a criminal lawyer, I suspect that after reading the Dunn decision I would have been in a position to more confidently advise the client to contest the murder charge - instead of having to go through the contortions involved in a criminal negligence plea where I would have so much doubt about my client's guilt?
Just imagine how much pain this mourning family would have been spared - let alone the need to bear the load of sixteen years of stigma in their tiny community - and having to fight for ultimate exoneration after sixteen years in the Ontario Court of Appeal;
Next: Part Seven; Gaurov's father: Another shocking revelation;
Harold Levy: hlevy15@gmail.com;
Wednesday, May 7, 2008
Part One: Dr. Cutz's Recommendations To Goudge Inquiry; Remove Ontario Forensic Pediatric Pathology Unit From Sick Kids;
"IN SUMMARY, IT IS MY VIEW THAT THE DIVISION OF PATHOLOGY AT THE HOSPITAL, AND OTHER PEDIATRIC PATHOLOGY SERVICES AT OTHER LARGE ACADEMIC CENTERS, ARE BEST SUITED TO PROVIDE HIGH QUALITY PEDIATRIC PATHOLOGY SERVICES FOCUSING ON ACADEMIC ASPECTS THAT INCLUDE THE DIAGNOSIS AND INVESTIGATION OF PEDIATRIC DISEASES.
HOWEVER, TO ENSURE THAT INFANTS AND CHILDREN ARE PROTECTED FROM HARM AND ABUSE, THE REMAINING TEN PER CENT OF CASES THAT INCLUDE CLEAR HOMICIDES OR CRIMINALLY SUSPICIOUS DEATHS ARE BEST HANDLED BY QUALIFIED FORENSIC PATHOLOGISTS WHOSE TRAINING AND EXPERIENCE LIES PRIMARILY IN THE EXAMINATION OF VIOLENT DEATH, HOMICIDES AND SUCH.
THE BEST SETTING TO PERFORM THESE AUTOPSIES (WHICH TOTAL APPROXIMATELY 10-15 CASES PER YEAR) IS AT THE CHIEF CORONER'S OFFICE WHICH HAS THE QUALIFIED STAFF AND REQUIRED FACILITIES TO CONDUCT THE NECESSARY INVESTIGATIONS."
DR. ERNEST CUTZ: RECOMMENDATIONS TO GOUDGE INQUIRY;
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Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog is therefore publishing Dr. Cutz's submissions - beginning with his recommendation that the hospital should cease performing forensic autopsies - and focus, rather, on what he calls, "medical/natural death cases."
"I have reviewed the “List of Systemic Issues” currently available on the website of the Inquiry into Pediatric Forensic Pathology in Ontario," this portion of Dr. Cutz's submissions begins.
"The following document reflects my own personal views and comments on select questions posed in that list" it continues;
"My comments reflect over 35 years of experience in Pediatric Pathology, including pediatric forensic pathology.
I. Institutional Considerations: Should Ontario have an institutional setting dedicated to pediatric forensic pathology, or should pediatric services be delivered within a forensic pathology institutional setting?
In essence, it is my view that the pediatric pathology work performed in Ontario should not be all be performed by the same institution.
Rather, pediatric autopsy work should be divided between the Hospital for Sick Children (the Hospital) and the Office of the Chief Coroner of Ontario. (The Chief Coroner's Office);
I say this for the following reasons:
a) Approximately 90 per cent of pediatric cases investigated under the Coroner’s Warrant result from death due to natural causes or pediatric disease.
These cases are thus not “forensic” by nature.
It is appropriate that pediatric pathologists from the Hospital for Sick Children perform the autopsies in these cases.
It is my view, however, that the Hospital should only perform autopsies on these “medical/natural death cases”.
Therefore, there would no longer be a need for a Pediatric Forensic Pathology Unit (the Unit) at the Hospital;
Furthermore, it is my view that there is an incompatibility between the principal mission of the Hospital as being dedicated to academic pursuits and research and the Chief Coroner's Office which excludes research;
I believe that the institutional link between the Hospital and the Chief Coroner's Office should be discontinued.
b) In summary, it is my view that the Division of Pathology at the Hospital, and other Pediatric Pathology services at other large academic centers, are best suited to provide high quality pediatric pathology services focusing on academic aspects that include the diagnosis and investigation of pediatric diseases.
c) However, to ensure that infants and children are protected from harm and abuse, the remaining ten per cent of cases that include clear homicides or criminally suspicious deaths are best handled by qualified forensic pathologists whose training and experience lies primarily in the examination of violent death, homicides and such.
The best setting to perform these autopsies (which total approximately 10-15 cases per year) is at the Chief Coroner's Office which has the qualified staff and required facilities to conduct the necessary investigations.
d) In terms of the pediatric disease cases, the best protection against wrongful accusations in pediatric cases is the provision of a correct diagnosis of natural disease based on a solid scientific foundation.
The diagnosis of pediatric disease in the 21st century is based on sophisticated methods of cellular and molecular biology (i.e. testing for genetic or metabolic disorders).
This testing requires special expertise and facilities, all of which are available at the Hospital, but are not available at the Chief Coroner's Office;
e) Since research and education into pediatric disease is outside the mandate of the Chief Coroner's Office, the responsibility and the provision of resources for this essentially patient-related activity should be assumed by the Ministry of Health and Long term Care.
10. What is the most cost efficient way of delivering quality pediatric forensic pathology services? For example, what are the advantages and disadvantages of using staff doctors or fee-for-service doctors?
a) Staff Pathologists based at leading Pediatric Academic Institutions, such as the Hospital for Sick Children can deliver the most cost-efficient and highest quality pediatric pathology services.
All staff are qualified and experienced Pediatric Pathologists who are also cross-appointed to the University of Toronto and thus participate fully in research and educational activities.
b) The combination of high-level diagnostic skills in diagnosing pediatric disease, research into disease pathogenesis, and education ensures that the work of these pathologists is high quality and also serves to educate the next generation of pediatric pathologists, thereby addressing the shortage of professionals in this specialty."
This Blogster has addressed the issue as to whether the Ontario Forensic Pediatric Pathology Unit should remain at the Hospital for Sick Children in an earlier post entitled, "Up-Date: Expert Evidence; Part Three: Research Questions Whether Forensic Unit Once Headed By Smith Should Remain At Sick Kids," published on March 8, 2008;
For the benefit of those readers who have not read it, that post ran as follows:
"IN ADDITION TO AN ABSENCE OF MEANINGFUL OVERSIGHT, THE INTEGRATION OF THE (UNIT) WITHIN THE PEDIATRIC PATHOLOGY UNIT AT THE HOSPITAL FOR SICK CHILDREN(INCLUDING INTERACTION WITH THE SUSPECTED CHILD ABUSE AND NEGLECT (SCAN) TEAM) MAY HAVE CREATED A PARTICULAR KIND OF INSTITUTIONAL CULTURE THAT CONTRIBUTED TO THE “THINK DIRTY” ETHOS, DISCUSSED IN OTHER RESEARCH CONDUCTED FOR THIS INQUIRY,"
PROFESSOR LORNE SOSSIN IN RESEARCH PAPER PREPARED FOR THE GOUDGE INQUIRY;
Ontario's Pediatric Forensic Pathology Unit, once headed by Dr. Charles Smith, risks being tainted by its proximity to the Hospital for Sick Children's Sick Children's Suspected Child Abuse and Neglect (SCAN) team, a researcher suggests.
University of Toronto law professor Lorne Sossin, recommends that Ontario should rethink retention of the Unit at the (Hospital) in a paper commissioned by the Goudge Inquiry entitled, "oversight and accountability." (The paper is posted on the Inquiry's Web-site;)
"In addition to an absence of meaningful oversight, the integration of the (Unit) within the pediatric pathology unit at the Hospital for Sick Children(including interaction with the Suspected Child Abuse and Neglect (SCAN) team) may have created a particular kind of institutional culture that contributed to the “think dirty” ethos, discussed in other research conducted for this Inquiry," writes Sossin;
"While there may have been good reasons to establish the (Unit) and locate it in (the Hospital) the viability and desirability of this arrangement continuing should be the subject of further study."
This Bloggist focused this issue in a previous posting entitled "A glimpse of understanding: Part Three; A dangerous mix: Dr Charles Smith and the Hospital for Sick Children SCAN team." (Jan, 2, 2008;"
"In two recent recent postings I have linked Dr. Charles Smith's ability to have such a disastrous effect on Ontario's criminal justice system directly to the decision to appoint him to head the new Ontario Forensic Pediatric Pathology Unit which would be located at the Hospital for Sick Children in Ontario. (A glimmer of understanding; Parts One and Two);" the Blog began.
"One of the unfortunate by-products of this decision is that Smith would have increased influence with the Hospital for Sick Children's Suspected Child Abuse and Neglect (SCAN) Program," it continued.
"Smith, as director of the new prestigious new unit, and the hospital's SCAN unit would prove to be a dangerous mix.
Hospital literature described the SCAN Program as "a hospital-based, multidisciplinary team that offers care, support, and assessment to children and adolescents who may have been abused."
However, as a criminal lawyer, and Editor of the Criminal Lawyers Association Newsletter, In the 1980's I began hearing stories which indicated that the team had a propensity for turning tragic but innocent situations into criminal assaults.
In 1985, I learned about a case which confirmed my worse fears about the program - and wrote bout the case in the Toronto Star, under a headline that read: "They were caring parents, not child abusers"
"Sometimes, people acting with the best of intentions end up achieving the worst possible result," the story began.
"Such was the case in a recent dispute involving a northern Ontario couple and the Catholic Children's Aid Society of Metro Toronto.
The couple were plunged into a nightmare in which they were branded as child abusers of their then one-year-old son and had both of their children taken from them.
In fact, as later became clear when the case landed in court, their son, Tyler,
suffered from a rare bone disease and hadn't been abused at all.
After it became evident that Tyler wasn't developing properly and x-rays had revealed some bone lesions, his parents, whose identity cannot be published, asked their family physician in Elliot Lake to refer the child to Toronto's Hospital for Sick Children for examination by specialists.
But they returned home disappointed, early in January, 1985, as the hospital was unable to pinpoint the disease.
They were unaware that the head of the radiology department had concluded
that the x-rays "were suggestive of child abuse."
They were also unaware that a hospital child abuse team had met in their absence and had asked the medical staff to have the couple return to the hospital with both of their children.
On their arrival, officials of the Metro Children's Aid Society were waiting to "apprehend" both children under a law that permits children at "substantial risk" to be taken from their parents, pending a court hearing.
Bewildered, they returned alone to Elliot Lake to discover that their nightmare had only just begun.
The radiologist's diagnosis that the x-rays were "suggestive" of child abuse had mushroomed into the conclusion by a member of the abuse team that there was "a clear possibility of child abuse."
And the Metro Catholic Children's Aid Society, which had taken over the case, was planning to place Tyler in a foster home and the other child with his natural father.
This move was blocked following the intervention of a lawyer and a private social worker retained by the parents. That led to the children's placement with grandparents.
But the parents couldn't persuade the society to take further steps to find out what was wrong with Tyler, even though a renowned bone disease expert in California had concluded, after viewing the x-rays from the Hospital for Sick Children, that the
lesions were more consistent with bone disease than with fracture.
The expert had suggested to the hospital that certain tests should be carried out, but the hospital declined to perform these particular tests.
The parents were then forced to go to court on April, 22, 1986, to free Tyler so that he could be taken to California, partially at their own expense, and with the help of OHIP, for testing and diagnosis.
After a four-day hearing contested by the society, Family Court Judge Peter Nasmith granted the parents' application and made the decision that led to the proof that Tyler was a sick child, not an abused one, and that the parents were caring human
beings and not child abusers.
The California doctor confirmed his original diagnosis, and after doctors at an Ottawa hospital provided additional confirmation, the society finally withdrew the application to make the boy a crown ward.
What went wrong?
The key is provided by Judge Nasmith's comments at the hearing, where he took the unusual step of telling the society to pay costs to the parents for the legal proceedings.
Having concluded that, "the medical evidence was inconclusive and any evidence of possible abuse was of a very unreliable nature," and noting the difficulties the society faced because of the number of agencies involved and the fact that it was
"obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children," the judge said: "The fact remains that there was embarrassingly little effort to follow up on what had become a devastating allegation . . . I
think the position (the society) took was unreasonable and even arbitrary."
As to the heart of the problem, Judge Nasmith said: "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."
One can sympathize with children's aid societies because of the heavy pressures they face and their dilemma when confronted by complex medical information provided by experts.
But Nasmith's ruling spells out the high standards to be expected of them, and of the experts involved in the medical and social investigation of child abuse, because of the awesome legal and persuasive powers that they possess.
If Tyler's parents hadn't had sufficient commitment and ability - and the support of OHIP, the Ontario Legal Aid Plan, and a dedicated lawyer - what would the situation be now? Sound familiar?
The dangerous mix between Dr. Charles Smith and the Hospital for Sick Children SCAN team was all too apparent in a case before the Inquiry which I have been referring to as "the Timmin's case" in previous postings.
The case is the subject of a court decision released by Provincial Court Judge Patrick Dunn on July 25, 1991, the year the Ontario Forensic Pediatric Pathology Unit was formed and several years after the Nasmith decision. (Dr. Smith had been at the hospital since 1981);
As Dunn noted: "I am not the only person who believed (the babysitter). The Community believed her too until the Crown's shaking theory surfaced. When first presented, the Crown's case appeared quite plausible. But after the evidence of the defence experts (Dr. Smith and the Hospital for Sick Children SCAN team) it is riddled with reasonable doubts."Why would the babysitter shake Amber to death?
"Dr. Smith suggested by way of provocation that perhaps Amber was a "bear", like his son, when she woke up," Dunn wrote in his powerful 24-page judgment which resonates to this very day.
"In other words, that the child would be provocative by her irritable manner. This is not true on the facts and it was unfair to suggest the possibility because there was no basis for it."
(Dunn also ruled that, "I cannot find that (The Hospital for Sick Children) properly considered the relationship between the Babysitter and Amber or Amber's gentle and non-provocative disposition," as he blasted both Smith and the SCAN team for failing to obtain "a complete and accurate psycho-social history" - even though they new "the importance" of having it.")
I don't propose to dwell on the details case as I have previously addressed it in several postings on this Blog.
Suffice it to point out for now that Dunn expressed, "serious concerns about the manner in which certain physicians at the Hospital for Sick Children ... formulated their diagnosis." (Dunn stressed that wherever the evidence of the SCAN team members clashed with the defence witnesses, "I prefer to accept the evidence of the defence experts."
Dunn stressed that there were flaws in the Hospital for Sick Children 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," he explained."
"I mean that the fact gathering process, the communication procedures, and the documentation of the Hospital for Sick Children doctors, involved in this case are such that I am led to question the conclusion they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
Similar comments were made about Dr. Charles Smith's work by the independent reviewers who studied so many of his cases.
A very dangerous mix indeed."
Sossin makes a compelling argument for removing the Unit from the Hospital - which in this Blogster's view has not demonstrated over many years that it deserves the public trust.
This is yet another tough bullet for Commissioner Goudge to bite."
Harold Levy...hlevy15@gmail.com;
HOWEVER, TO ENSURE THAT INFANTS AND CHILDREN ARE PROTECTED FROM HARM AND ABUSE, THE REMAINING TEN PER CENT OF CASES THAT INCLUDE CLEAR HOMICIDES OR CRIMINALLY SUSPICIOUS DEATHS ARE BEST HANDLED BY QUALIFIED FORENSIC PATHOLOGISTS WHOSE TRAINING AND EXPERIENCE LIES PRIMARILY IN THE EXAMINATION OF VIOLENT DEATH, HOMICIDES AND SUCH.
THE BEST SETTING TO PERFORM THESE AUTOPSIES (WHICH TOTAL APPROXIMATELY 10-15 CASES PER YEAR) IS AT THE CHIEF CORONER'S OFFICE WHICH HAS THE QUALIFIED STAFF AND REQUIRED FACILITIES TO CONDUCT THE NECESSARY INVESTIGATIONS."
DR. ERNEST CUTZ: RECOMMENDATIONS TO GOUDGE INQUIRY;
-------------------------------------------------------------------------------
Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog is therefore publishing Dr. Cutz's submissions - beginning with his recommendation that the hospital should cease performing forensic autopsies - and focus, rather, on what he calls, "medical/natural death cases."
"I have reviewed the “List of Systemic Issues” currently available on the website of the Inquiry into Pediatric Forensic Pathology in Ontario," this portion of Dr. Cutz's submissions begins.
"The following document reflects my own personal views and comments on select questions posed in that list" it continues;
"My comments reflect over 35 years of experience in Pediatric Pathology, including pediatric forensic pathology.
I. Institutional Considerations: Should Ontario have an institutional setting dedicated to pediatric forensic pathology, or should pediatric services be delivered within a forensic pathology institutional setting?
In essence, it is my view that the pediatric pathology work performed in Ontario should not be all be performed by the same institution.
Rather, pediatric autopsy work should be divided between the Hospital for Sick Children (the Hospital) and the Office of the Chief Coroner of Ontario. (The Chief Coroner's Office);
I say this for the following reasons:
a) Approximately 90 per cent of pediatric cases investigated under the Coroner’s Warrant result from death due to natural causes or pediatric disease.
These cases are thus not “forensic” by nature.
It is appropriate that pediatric pathologists from the Hospital for Sick Children perform the autopsies in these cases.
It is my view, however, that the Hospital should only perform autopsies on these “medical/natural death cases”.
Therefore, there would no longer be a need for a Pediatric Forensic Pathology Unit (the Unit) at the Hospital;
Furthermore, it is my view that there is an incompatibility between the principal mission of the Hospital as being dedicated to academic pursuits and research and the Chief Coroner's Office which excludes research;
I believe that the institutional link between the Hospital and the Chief Coroner's Office should be discontinued.
b) In summary, it is my view that the Division of Pathology at the Hospital, and other Pediatric Pathology services at other large academic centers, are best suited to provide high quality pediatric pathology services focusing on academic aspects that include the diagnosis and investigation of pediatric diseases.
c) However, to ensure that infants and children are protected from harm and abuse, the remaining ten per cent of cases that include clear homicides or criminally suspicious deaths are best handled by qualified forensic pathologists whose training and experience lies primarily in the examination of violent death, homicides and such.
The best setting to perform these autopsies (which total approximately 10-15 cases per year) is at the Chief Coroner's Office which has the qualified staff and required facilities to conduct the necessary investigations.
d) In terms of the pediatric disease cases, the best protection against wrongful accusations in pediatric cases is the provision of a correct diagnosis of natural disease based on a solid scientific foundation.
The diagnosis of pediatric disease in the 21st century is based on sophisticated methods of cellular and molecular biology (i.e. testing for genetic or metabolic disorders).
This testing requires special expertise and facilities, all of which are available at the Hospital, but are not available at the Chief Coroner's Office;
e) Since research and education into pediatric disease is outside the mandate of the Chief Coroner's Office, the responsibility and the provision of resources for this essentially patient-related activity should be assumed by the Ministry of Health and Long term Care.
10. What is the most cost efficient way of delivering quality pediatric forensic pathology services? For example, what are the advantages and disadvantages of using staff doctors or fee-for-service doctors?
a) Staff Pathologists based at leading Pediatric Academic Institutions, such as the Hospital for Sick Children can deliver the most cost-efficient and highest quality pediatric pathology services.
All staff are qualified and experienced Pediatric Pathologists who are also cross-appointed to the University of Toronto and thus participate fully in research and educational activities.
b) The combination of high-level diagnostic skills in diagnosing pediatric disease, research into disease pathogenesis, and education ensures that the work of these pathologists is high quality and also serves to educate the next generation of pediatric pathologists, thereby addressing the shortage of professionals in this specialty."
This Blogster has addressed the issue as to whether the Ontario Forensic Pediatric Pathology Unit should remain at the Hospital for Sick Children in an earlier post entitled, "Up-Date: Expert Evidence; Part Three: Research Questions Whether Forensic Unit Once Headed By Smith Should Remain At Sick Kids," published on March 8, 2008;
For the benefit of those readers who have not read it, that post ran as follows:
"IN ADDITION TO AN ABSENCE OF MEANINGFUL OVERSIGHT, THE INTEGRATION OF THE (UNIT) WITHIN THE PEDIATRIC PATHOLOGY UNIT AT THE HOSPITAL FOR SICK CHILDREN(INCLUDING INTERACTION WITH THE SUSPECTED CHILD ABUSE AND NEGLECT (SCAN) TEAM) MAY HAVE CREATED A PARTICULAR KIND OF INSTITUTIONAL CULTURE THAT CONTRIBUTED TO THE “THINK DIRTY” ETHOS, DISCUSSED IN OTHER RESEARCH CONDUCTED FOR THIS INQUIRY,"
PROFESSOR LORNE SOSSIN IN RESEARCH PAPER PREPARED FOR THE GOUDGE INQUIRY;
Ontario's Pediatric Forensic Pathology Unit, once headed by Dr. Charles Smith, risks being tainted by its proximity to the Hospital for Sick Children's Sick Children's Suspected Child Abuse and Neglect (SCAN) team, a researcher suggests.
University of Toronto law professor Lorne Sossin, recommends that Ontario should rethink retention of the Unit at the (Hospital) in a paper commissioned by the Goudge Inquiry entitled, "oversight and accountability." (The paper is posted on the Inquiry's Web-site;)
"In addition to an absence of meaningful oversight, the integration of the (Unit) within the pediatric pathology unit at the Hospital for Sick Children(including interaction with the Suspected Child Abuse and Neglect (SCAN) team) may have created a particular kind of institutional culture that contributed to the “think dirty” ethos, discussed in other research conducted for this Inquiry," writes Sossin;
"While there may have been good reasons to establish the (Unit) and locate it in (the Hospital) the viability and desirability of this arrangement continuing should be the subject of further study."
This Bloggist focused this issue in a previous posting entitled "A glimpse of understanding: Part Three; A dangerous mix: Dr Charles Smith and the Hospital for Sick Children SCAN team." (Jan, 2, 2008;"
"In two recent recent postings I have linked Dr. Charles Smith's ability to have such a disastrous effect on Ontario's criminal justice system directly to the decision to appoint him to head the new Ontario Forensic Pediatric Pathology Unit which would be located at the Hospital for Sick Children in Ontario. (A glimmer of understanding; Parts One and Two);" the Blog began.
"One of the unfortunate by-products of this decision is that Smith would have increased influence with the Hospital for Sick Children's Suspected Child Abuse and Neglect (SCAN) Program," it continued.
"Smith, as director of the new prestigious new unit, and the hospital's SCAN unit would prove to be a dangerous mix.
Hospital literature described the SCAN Program as "a hospital-based, multidisciplinary team that offers care, support, and assessment to children and adolescents who may have been abused."
However, as a criminal lawyer, and Editor of the Criminal Lawyers Association Newsletter, In the 1980's I began hearing stories which indicated that the team had a propensity for turning tragic but innocent situations into criminal assaults.
In 1985, I learned about a case which confirmed my worse fears about the program - and wrote bout the case in the Toronto Star, under a headline that read: "They were caring parents, not child abusers"
"Sometimes, people acting with the best of intentions end up achieving the worst possible result," the story began.
"Such was the case in a recent dispute involving a northern Ontario couple and the Catholic Children's Aid Society of Metro Toronto.
The couple were plunged into a nightmare in which they were branded as child abusers of their then one-year-old son and had both of their children taken from them.
In fact, as later became clear when the case landed in court, their son, Tyler,
suffered from a rare bone disease and hadn't been abused at all.
After it became evident that Tyler wasn't developing properly and x-rays had revealed some bone lesions, his parents, whose identity cannot be published, asked their family physician in Elliot Lake to refer the child to Toronto's Hospital for Sick Children for examination by specialists.
But they returned home disappointed, early in January, 1985, as the hospital was unable to pinpoint the disease.
They were unaware that the head of the radiology department had concluded
that the x-rays "were suggestive of child abuse."
They were also unaware that a hospital child abuse team had met in their absence and had asked the medical staff to have the couple return to the hospital with both of their children.
On their arrival, officials of the Metro Children's Aid Society were waiting to "apprehend" both children under a law that permits children at "substantial risk" to be taken from their parents, pending a court hearing.
Bewildered, they returned alone to Elliot Lake to discover that their nightmare had only just begun.
The radiologist's diagnosis that the x-rays were "suggestive" of child abuse had mushroomed into the conclusion by a member of the abuse team that there was "a clear possibility of child abuse."
And the Metro Catholic Children's Aid Society, which had taken over the case, was planning to place Tyler in a foster home and the other child with his natural father.
This move was blocked following the intervention of a lawyer and a private social worker retained by the parents. That led to the children's placement with grandparents.
But the parents couldn't persuade the society to take further steps to find out what was wrong with Tyler, even though a renowned bone disease expert in California had concluded, after viewing the x-rays from the Hospital for Sick Children, that the
lesions were more consistent with bone disease than with fracture.
The expert had suggested to the hospital that certain tests should be carried out, but the hospital declined to perform these particular tests.
The parents were then forced to go to court on April, 22, 1986, to free Tyler so that he could be taken to California, partially at their own expense, and with the help of OHIP, for testing and diagnosis.
After a four-day hearing contested by the society, Family Court Judge Peter Nasmith granted the parents' application and made the decision that led to the proof that Tyler was a sick child, not an abused one, and that the parents were caring human
beings and not child abusers.
The California doctor confirmed his original diagnosis, and after doctors at an Ottawa hospital provided additional confirmation, the society finally withdrew the application to make the boy a crown ward.
What went wrong?
The key is provided by Judge Nasmith's comments at the hearing, where he took the unusual step of telling the society to pay costs to the parents for the legal proceedings.
Having concluded that, "the medical evidence was inconclusive and any evidence of possible abuse was of a very unreliable nature," and noting the difficulties the society faced because of the number of agencies involved and the fact that it was
"obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children," the judge said: "The fact remains that there was embarrassingly little effort to follow up on what had become a devastating allegation . . . I
think the position (the society) took was unreasonable and even arbitrary."
As to the heart of the problem, Judge Nasmith said: "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."
One can sympathize with children's aid societies because of the heavy pressures they face and their dilemma when confronted by complex medical information provided by experts.
But Nasmith's ruling spells out the high standards to be expected of them, and of the experts involved in the medical and social investigation of child abuse, because of the awesome legal and persuasive powers that they possess.
If Tyler's parents hadn't had sufficient commitment and ability - and the support of OHIP, the Ontario Legal Aid Plan, and a dedicated lawyer - what would the situation be now? Sound familiar?
The dangerous mix between Dr. Charles Smith and the Hospital for Sick Children SCAN team was all too apparent in a case before the Inquiry which I have been referring to as "the Timmin's case" in previous postings.
The case is the subject of a court decision released by Provincial Court Judge Patrick Dunn on July 25, 1991, the year the Ontario Forensic Pediatric Pathology Unit was formed and several years after the Nasmith decision. (Dr. Smith had been at the hospital since 1981);
As Dunn noted: "I am not the only person who believed (the babysitter). The Community believed her too until the Crown's shaking theory surfaced. When first presented, the Crown's case appeared quite plausible. But after the evidence of the defence experts (Dr. Smith and the Hospital for Sick Children SCAN team) it is riddled with reasonable doubts."Why would the babysitter shake Amber to death?
"Dr. Smith suggested by way of provocation that perhaps Amber was a "bear", like his son, when she woke up," Dunn wrote in his powerful 24-page judgment which resonates to this very day.
"In other words, that the child would be provocative by her irritable manner. This is not true on the facts and it was unfair to suggest the possibility because there was no basis for it."
(Dunn also ruled that, "I cannot find that (The Hospital for Sick Children) properly considered the relationship between the Babysitter and Amber or Amber's gentle and non-provocative disposition," as he blasted both Smith and the SCAN team for failing to obtain "a complete and accurate psycho-social history" - even though they new "the importance" of having it.")
I don't propose to dwell on the details case as I have previously addressed it in several postings on this Blog.
Suffice it to point out for now that Dunn expressed, "serious concerns about the manner in which certain physicians at the Hospital for Sick Children ... formulated their diagnosis." (Dunn stressed that wherever the evidence of the SCAN team members clashed with the defence witnesses, "I prefer to accept the evidence of the defence experts."
Dunn stressed that there were flaws in the Hospital for Sick Children 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," he explained."
"I mean that the fact gathering process, the communication procedures, and the documentation of the Hospital for Sick Children doctors, involved in this case are such that I am led to question the conclusion they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
Similar comments were made about Dr. Charles Smith's work by the independent reviewers who studied so many of his cases.
A very dangerous mix indeed."
Sossin makes a compelling argument for removing the Unit from the Hospital - which in this Blogster's view has not demonstrated over many years that it deserves the public trust.
This is yet another tough bullet for Commissioner Goudge to bite."
Harold Levy...hlevy15@gmail.com;
Sunday, April 20, 2008
Part Five: Case Studies; Systemic Factors; The "Tyrell" Case; As presented by the Affected Families Group;
Among the most insightful reads that have come out of the Goudge Inquiry are studies of several of the cases studied by the Inquiry - with a view to identifying the systemic issues that they raise.
These case studies have been filed by lawyers Peter Wardle and Julie Kirkpatrick who represent the Affected Families Group;
The third case has been identified by the Inquiry as the "Tyrell" case;
-----------------------------------------------------------------------------
By way of brief background:
Tyrell was born in Toronto on February the 1st of 1994.
Tyrell died on on January the 23rd, 1998 in Toronto.
He was almost four (4) years old at the time of his death.
Criminal proceedings were initiated against his caregiver.
The criminal proceedings concluded on January the 22nd of 2001 when the Crown
withdrew a charge of second degree murder that had been laid against the caregiver.
-------------------------------------------------------------------------------------
"Tyrell’s case is a striking example of the deficiencies with written post-mortem reports in Dr. Smith’s era," the case study begins;
"Other systemic issues arising from the case include confirmation bias, misleading testimony, inappropriate reference to controversy in the literature and communications between Crown and defence," it continues;
"The post-mortem report of Dr. Smith describes the cause of death as “CNS trauma”. It contains no history.
It contains no information explaining how the cause of death was determined. It says nothing one way or another about Maureen’s explanation about Tyrell's fall.
Although Dr. Becker obviously was consulted regarding the neuropathology issues raised by the post-mortem and authored a report on the central nervous system which was incorporated into the report, this is not apparent from the report itself.
The Hospital for Sick Children Final Autopsy Report, a document not released to the police, Crown or defence, contains a history which accurately describes Maureen’s summary of Tyrell’s fall (“he was jumping on couch and jumped backward off the couch, lost his footing, and fell backward, hitting his head on a marble table or a tile floor.
He immediately got up and tried to run forward but fell and struck his forehead”).
However, this report contains highly prejudicial information about Tyrell’s father.
It is impossible to say whether this information might have played a role in Dr. Smith’s thinking about the case.
In conclusion, there are a number of problems with the report itself – with what it contains and what is left out.
Dr. Smith’s reasoning and opinions are not contained in the report but in verbal sidebars with the police at various stages of the investigation.
No attempt appears to have been given to serious consideration of the explanation in light of the pathological findings of bruising in two different areas of the skull.
As outlined in the Overview Report, and in Dr. Crane’s evidence before the Inquiry, Dr. Smith’s evidence at the preliminary Inquiry was inflammatory and misleading.
He was drawn into testifying outside his expertise.
He repeated his opinions on whether short falls could kill in words that could have been taken from a transcript in Amber, even using the same article.
Instead of acknowledging any continuing debate in the literature, he attempted to suggest that Dr. Duhaime now supported his position.
According to Dr. Smith, “...with the newer studies, the literature is on my side”.
One can usefully contrast Dr. Smith’s approach to that of Dr. Robin Humphrey, Neurosurgeon in Chief at the Hospital for Sick Children, who was retained by the Crown shortly before trial.
Dr. Humphreys took the explanation provided by the caregiver as something to be considered seriously (“If the description of what happened to Tyrell...is in any way accurate...”).
He reviewed the pathology findings with the explanation in mind (“Those scalp contusions...could thus be in keeping with the two separate blows to the head created first by striking it on the table and floor, and then secondly after again falling to the floor”).
He concluded that the pathology could provide confirmation for this history (“There is pathological confirmation of these blows”).
He ended his report by concluding that there is considerable uncertainty as to the mechanism of the head injury.
Contrast this to Dr. Smith’s verbal advice to the police: “children do not die from accidental falls of this nature.”
It is clear in retrospect that in this case defence counsel laid traps for Dr. Smith, encouraging him to talk at the preliminary to get his evidence tied down, and preparing to demolish him at trial.
There was sharing of defence opinions just before trial, presumably to ensure that the Crown would not be in a position to seek further opinions.
The Chief Coroner's Office appears to have been unaware of any issues raised by this case until the time when the charges were stayed, when the media reported that the Crown had done so to avoid a miscarriage of justice.
At that time Dr. Cairns spoke to the Crown, Frank Armstrong, and was advised that there were no concerns about Dr. Smith’s conduct in the case.
Arguably, given the controversy swirling about Dr. Smith at the time, Dr. Cairns should have gone further.
Had he spoken to defence counsel, for instance, he may have learned of the misleading evidence given by Dr. Smith earlier in the case.
Harold Levy...hlevy15@gmail.com;
These case studies have been filed by lawyers Peter Wardle and Julie Kirkpatrick who represent the Affected Families Group;
The third case has been identified by the Inquiry as the "Tyrell" case;
-----------------------------------------------------------------------------
By way of brief background:
Tyrell was born in Toronto on February the 1st of 1994.
Tyrell died on on January the 23rd, 1998 in Toronto.
He was almost four (4) years old at the time of his death.
Criminal proceedings were initiated against his caregiver.
The criminal proceedings concluded on January the 22nd of 2001 when the Crown
withdrew a charge of second degree murder that had been laid against the caregiver.
-------------------------------------------------------------------------------------
"Tyrell’s case is a striking example of the deficiencies with written post-mortem reports in Dr. Smith’s era," the case study begins;
"Other systemic issues arising from the case include confirmation bias, misleading testimony, inappropriate reference to controversy in the literature and communications between Crown and defence," it continues;
"The post-mortem report of Dr. Smith describes the cause of death as “CNS trauma”. It contains no history.
It contains no information explaining how the cause of death was determined. It says nothing one way or another about Maureen’s explanation about Tyrell's fall.
Although Dr. Becker obviously was consulted regarding the neuropathology issues raised by the post-mortem and authored a report on the central nervous system which was incorporated into the report, this is not apparent from the report itself.
The Hospital for Sick Children Final Autopsy Report, a document not released to the police, Crown or defence, contains a history which accurately describes Maureen’s summary of Tyrell’s fall (“he was jumping on couch and jumped backward off the couch, lost his footing, and fell backward, hitting his head on a marble table or a tile floor.
He immediately got up and tried to run forward but fell and struck his forehead”).
However, this report contains highly prejudicial information about Tyrell’s father.
It is impossible to say whether this information might have played a role in Dr. Smith’s thinking about the case.
In conclusion, there are a number of problems with the report itself – with what it contains and what is left out.
Dr. Smith’s reasoning and opinions are not contained in the report but in verbal sidebars with the police at various stages of the investigation.
No attempt appears to have been given to serious consideration of the explanation in light of the pathological findings of bruising in two different areas of the skull.
As outlined in the Overview Report, and in Dr. Crane’s evidence before the Inquiry, Dr. Smith’s evidence at the preliminary Inquiry was inflammatory and misleading.
He was drawn into testifying outside his expertise.
He repeated his opinions on whether short falls could kill in words that could have been taken from a transcript in Amber, even using the same article.
Instead of acknowledging any continuing debate in the literature, he attempted to suggest that Dr. Duhaime now supported his position.
According to Dr. Smith, “...with the newer studies, the literature is on my side”.
One can usefully contrast Dr. Smith’s approach to that of Dr. Robin Humphrey, Neurosurgeon in Chief at the Hospital for Sick Children, who was retained by the Crown shortly before trial.
Dr. Humphreys took the explanation provided by the caregiver as something to be considered seriously (“If the description of what happened to Tyrell...is in any way accurate...”).
He reviewed the pathology findings with the explanation in mind (“Those scalp contusions...could thus be in keeping with the two separate blows to the head created first by striking it on the table and floor, and then secondly after again falling to the floor”).
He concluded that the pathology could provide confirmation for this history (“There is pathological confirmation of these blows”).
He ended his report by concluding that there is considerable uncertainty as to the mechanism of the head injury.
Contrast this to Dr. Smith’s verbal advice to the police: “children do not die from accidental falls of this nature.”
It is clear in retrospect that in this case defence counsel laid traps for Dr. Smith, encouraging him to talk at the preliminary to get his evidence tied down, and preparing to demolish him at trial.
There was sharing of defence opinions just before trial, presumably to ensure that the Crown would not be in a position to seek further opinions.
The Chief Coroner's Office appears to have been unaware of any issues raised by this case until the time when the charges were stayed, when the media reported that the Crown had done so to avoid a miscarriage of justice.
At that time Dr. Cairns spoke to the Crown, Frank Armstrong, and was advised that there were no concerns about Dr. Smith’s conduct in the case.
Arguably, given the controversy swirling about Dr. Smith at the time, Dr. Cairns should have gone further.
Had he spoken to defence counsel, for instance, he may have learned of the misleading evidence given by Dr. Smith earlier in the case.
Harold Levy...hlevy15@gmail.com;
Friday, April 18, 2008
Part Five: Case Studies: The "Tyrell" Case; Presented by the Affected Families Group;
Among the most insightful reads that have come out of the Goudge Inquiry are studies of several of the cases studied by the Inquiry - with a view to identifying the systemic issues that they raise.
These case studies have been filed by lawyers Peter Wardle and Julie Kirkpatrick who represent the Affected Families Group;
The third case has been identified by the Inquiry as the "Tyrell" case;
------------------------------------------------------------------------------------
By way of brief background:
Tyrell was born in Toronto on February the 1st of 1994.
Tyrell died on on January the 23rd, 1998 in Toronto.
He was almost four (4) years old at the time of his death.
Criminal proceedings were initiated against his caregiver.
The criminal proceedings concluded on January the 22nd of 2001 when the Crown
withdrew a charge of second degree murder that had been laid against the caregiver.
-------------------------------------------------------------------------------------
"Tyrell’s case is a striking example of the deficiencies with written post-mortem reports in Dr. Smith’s era," the case study begins;
"Other systemic issues arising from the case include confirmation bias, misleading testimony, inappropriate reference to controversy in the literature and communications between Crown and defence," it continues;
"The post-mortem report of Dr. Smith describes the cause of death as “CNS trauma”. It contains no history.
It contains no information explaining how the cause of death was determined. It says nothing one way or another about Maureen’s explanation about Tyrell's fall.
Although Dr. Becker obviously was consulted regarding the neuropathology issues raised by the post-mortem and authored a report on the central nervous system which was incorporated into the report, this is not apparent from the report itself.
The Hospital for Sick Children Final Autopsy Report, a document not released to the police, Crown or defence, contains a history which accurately describes Maureen’s summary of Tyrell’s fall (“he was jumping on couch and jumped backward off the couch, lost his footing, and fell backward, hitting his head on a marble table or a tile floor.
He immediately got up and tried to run forward but fell and struck his forehead”).
However, this report contains highly prejudicial information about Tyrell’s father.
It is impossible to say whether this information might have played a role in Dr. Smith’s thinking about the case.
In conclusion, there are a number of problems with the report itself – with what it contains and what is left out.
Dr. Smith’s reasoning and opinions are not contained in the report but in verbal sidebars with the police at various stages of the investigation.
No attempt appears to have been given to serious consideration of the explanation in light of the pathological findings of bruising in two different areas of the skull.
As outlined in the Overview Report, and in Dr. Crane’s evidence before the Inquiry, Dr. Smith’s evidence at the preliminary Inquiry was inflammatory and misleading.
He was drawn into testifying outside his expertise.
He repeated his opinions on whether short falls could kill in words that could have been taken from a transcript in Amber, even using the same article.
Instead of acknowledging any continuing debate in the literature, he attempted to suggest that Dr. Duhaime now supported his position.
According to Dr. Smith, “...with the newer studies, the literature is on my side”.
One can usefully contrast Dr. Smith’s approach to that of Dr. Robin Humphrey, Neurosurgeon in Chief at the Hospital for Sick Children, who was retained by the Crown shortly before trial.
Dr. Humphreys took the explanation provided by the caregiver as something to be considered seriously (“If the description of what happened to Tyrell...is in any way accurate...”).
He reviewed the pathology findings with the explanation in mind (“Those scalp contusions...could thus be in keeping with the two separate blows to the head created first by striking it on the table and floor, and then secondly after again falling to the floor”).
He concluded that the pathology could provide confirmation for this history (“There is pathological confirmation of these blows”).
He ended his report by concluding that there is considerable uncertainty as to the mechanism of the head injury.
Contrast this to Dr. Smith’s verbal advice to the police: “children do not die from accidental falls of this nature.”
It is clear in retrospect that in this case defence counsel laid traps for Dr. Smith, encouraging him to talk at the preliminary to get his evidence tied down, and preparing to demolish him at trial.
There was sharing of defence opinions just before trial, presumably to ensure that the Crown would not be in a position to seek further opinions.
The Chief Coroner's Office appears to have been unaware of any issues raised by this case until the time when the charges were stayed, when the media reported that the Crown had done so to avoid a miscarriage of justice.
At that time Dr. Cairns spoke to the Crown, Frank Armstrong, and was advised that there were no concerns about Dr. Smith’s conduct in the case.
Arguably, given the controversy swirling about Dr. Smith at the time, Dr. Cairns should have gone further.
Had he spoken to defence counsel, for instance, he may have learned of the misleading evidence given by Dr. Smith earlier in the case.
Harold Levy...hlevy15@gmail.com;
These case studies have been filed by lawyers Peter Wardle and Julie Kirkpatrick who represent the Affected Families Group;
The third case has been identified by the Inquiry as the "Tyrell" case;
------------------------------------------------------------------------------------
By way of brief background:
Tyrell was born in Toronto on February the 1st of 1994.
Tyrell died on on January the 23rd, 1998 in Toronto.
He was almost four (4) years old at the time of his death.
Criminal proceedings were initiated against his caregiver.
The criminal proceedings concluded on January the 22nd of 2001 when the Crown
withdrew a charge of second degree murder that had been laid against the caregiver.
-------------------------------------------------------------------------------------
"Tyrell’s case is a striking example of the deficiencies with written post-mortem reports in Dr. Smith’s era," the case study begins;
"Other systemic issues arising from the case include confirmation bias, misleading testimony, inappropriate reference to controversy in the literature and communications between Crown and defence," it continues;
"The post-mortem report of Dr. Smith describes the cause of death as “CNS trauma”. It contains no history.
It contains no information explaining how the cause of death was determined. It says nothing one way or another about Maureen’s explanation about Tyrell's fall.
Although Dr. Becker obviously was consulted regarding the neuropathology issues raised by the post-mortem and authored a report on the central nervous system which was incorporated into the report, this is not apparent from the report itself.
The Hospital for Sick Children Final Autopsy Report, a document not released to the police, Crown or defence, contains a history which accurately describes Maureen’s summary of Tyrell’s fall (“he was jumping on couch and jumped backward off the couch, lost his footing, and fell backward, hitting his head on a marble table or a tile floor.
He immediately got up and tried to run forward but fell and struck his forehead”).
However, this report contains highly prejudicial information about Tyrell’s father.
It is impossible to say whether this information might have played a role in Dr. Smith’s thinking about the case.
In conclusion, there are a number of problems with the report itself – with what it contains and what is left out.
Dr. Smith’s reasoning and opinions are not contained in the report but in verbal sidebars with the police at various stages of the investigation.
No attempt appears to have been given to serious consideration of the explanation in light of the pathological findings of bruising in two different areas of the skull.
As outlined in the Overview Report, and in Dr. Crane’s evidence before the Inquiry, Dr. Smith’s evidence at the preliminary Inquiry was inflammatory and misleading.
He was drawn into testifying outside his expertise.
He repeated his opinions on whether short falls could kill in words that could have been taken from a transcript in Amber, even using the same article.
Instead of acknowledging any continuing debate in the literature, he attempted to suggest that Dr. Duhaime now supported his position.
According to Dr. Smith, “...with the newer studies, the literature is on my side”.
One can usefully contrast Dr. Smith’s approach to that of Dr. Robin Humphrey, Neurosurgeon in Chief at the Hospital for Sick Children, who was retained by the Crown shortly before trial.
Dr. Humphreys took the explanation provided by the caregiver as something to be considered seriously (“If the description of what happened to Tyrell...is in any way accurate...”).
He reviewed the pathology findings with the explanation in mind (“Those scalp contusions...could thus be in keeping with the two separate blows to the head created first by striking it on the table and floor, and then secondly after again falling to the floor”).
He concluded that the pathology could provide confirmation for this history (“There is pathological confirmation of these blows”).
He ended his report by concluding that there is considerable uncertainty as to the mechanism of the head injury.
Contrast this to Dr. Smith’s verbal advice to the police: “children do not die from accidental falls of this nature.”
It is clear in retrospect that in this case defence counsel laid traps for Dr. Smith, encouraging him to talk at the preliminary to get his evidence tied down, and preparing to demolish him at trial.
There was sharing of defence opinions just before trial, presumably to ensure that the Crown would not be in a position to seek further opinions.
The Chief Coroner's Office appears to have been unaware of any issues raised by this case until the time when the charges were stayed, when the media reported that the Crown had done so to avoid a miscarriage of justice.
At that time Dr. Cairns spoke to the Crown, Frank Armstrong, and was advised that there were no concerns about Dr. Smith’s conduct in the case.
Arguably, given the controversy swirling about Dr. Smith at the time, Dr. Cairns should have gone further.
Had he spoken to defence counsel, for instance, he may have learned of the misleading evidence given by Dr. Smith earlier in the case.
Harold Levy...hlevy15@gmail.com;
Saturday, March 8, 2008
Up-Date: Expert Evidence; Part Three: Research Questions Whether Forensic Unit Once Headed By Smith Should Remain At Sick Kids;
"IN ADDITION TO AN ABSENCE OF MEANINGFUL OVERSIGHT, THE INTEGRATION OF THE (UNIT) WITHIN THE PEDIATRIC PATHOLOGY UNIT AT THE HOSPITAL FOR SICK CHILDREN(INCLUDING INTERACTION WITH THE SUSPECTED CHILD ABUSE AND NEGLECT (SCAN) TEAM) MAY HAVE CREATED A PARTICULAR KIND OF INSTITUTIONAL CULTURE THAT CONTRIBUTED TO THE “THINK DIRTY” ETHOS, DISCUSSED IN OTHER RESEARCH CONDUCTED FOR THIS INQUIRY,"
PROFESSOR LORNE SOSSIN IN RESEARCH PAPER PREPARED FOR THE GOUDGE INQUIRY;
Ontario's Pediatric Forensic Pathology Unit, once headed by Dr. Charles Smith, risks being tainted by its proximity to the Hospital for Sick Children's Sick Children's Suspected Child Abuse and Neglect (SCAN) team, a researcher suggests.
University of Toronto law professor Lorne Sossin, recommends that Ontario should rethink retention of the Unit at the (Hospital) in a paper commissioned by the Goudge Inquiry entitled, "oversight and accountability." (The paper is posted on the Inquiry's Web-site;)
"In addition to an absence of meaningful oversight, the integration of the (Unit) within the pediatric pathology unit at the Hospital for Sick Children(including interaction with the Suspected Child Abuse and Neglect (SCAN) team) may have created a particular kind of institutional culture that contributed to the “think dirty” ethos, discussed in other research conducted for this Inquiry," writes Sossin;
"While there may have been good reasons to establish the (Unit) and locate it in (the Hospital) the viability and desirability of this arrangement continuing should be the subject of further study."
This Bloggist focused this issue in a previous posting entitled "A glimpse of understanding: Part Three; A dangerous mix: Dr Charles Smith and the Hospital for Sick Children SCAN team." (Jan, 2, 2008;"
"In two recent recent postings I have linked Dr. Charles Smith's ability to have such a disastrous effect on Ontario's criminal justice system directly to the decision to appoint him to head the new Ontario Forensic Pediatric Pathology Unit which would be located at the Hospital for Sick Children in Ontario. (A glimmer of understanding; Parts One and Two);" the Blog began.
"One of the unfortunate by-products of this decision is that Smith would have increased influence with the Hospital for Sick Children's Suspected Child Abuse and Neglect (SCAN) Program," it continued.
"Smith, as director of the new prestigious new unit, and the hospital's SCAN unit would prove to be a dangerous mix.
Hospital literature described the SCAN Program as "a hospital-based, multidisciplinary team that offers care, support, and assessment to children and adolescents who may have been abused."
However, as a criminal lawyer, and Editor of the Criminal Lawyers Association Newsletter, In the 1980's I began hearing stories which indicated that the team had a propensity for turning tragic but innocent situations into criminal assaults.
In 1985, I learned about a case which confirmed my worse fears about the program - and wrote bout the case in the Toronto Star, under a headline that read: "They were caring parents, not child abusers"
"Sometimes, people acting with the best of intentions end up achieving the worst possible result," the story began.
"Such was the case in a recent dispute involving a northern Ontario couple and the Catholic Children's Aid Society of Metro Toronto.
The couple were plunged into a nightmare in which they were branded as child abusers of their then one-year-old son and had both of their children taken from them.
In fact, as later became clear when the case landed in court, their son, Tyler,
suffered from a rare bone disease and hadn't been abused at all.
After it became evident that Tyler wasn't developing properly and x-rays had revealed some bone lesions, his parents, whose identity cannot be published, asked their family physician in Elliot Lake to refer the child to Toronto's Hospital for Sick Children for examination by specialists.
But they returned home disappointed, early in January, 1985, as the hospital was unable to pinpoint the disease.
They were unaware that the head of the radiology department had concluded
that the x-rays "were suggestive of child abuse."
They were also unaware that a hospital child abuse team had met in their absence and had asked the medical staff to have the couple return to the hospital with both of their children.
On their arrival, officials of the Metro Children's Aid Society were waiting to "apprehend" both children under a law that permits children at "substantial risk" to be taken from their parents, pending a court hearing.
Bewildered, they returned alone to Elliot Lake to discover that their nightmare had only just begun.
The radiologist's diagnosis that the x-rays were "suggestive" of child abuse had mushroomed into the conclusion by a member of the abuse team that there was "a clear possibility of child abuse."
And the Metro Catholic Children's Aid Society, which had taken over the case, was planning to place Tyler in a foster home and the other child with his natural father.
This move was blocked following the intervention of a lawyer and a private social worker retained by the parents. That led to the children's placement with grandparents.
But the parents couldn't persuade the society to take further steps to find out what was wrong with Tyler, even though a renowned bone disease expert in California had concluded, after viewing the x-rays from the Hospital for Sick Children, that the
lesions were more consistent with bone disease than with fracture.
The expert had suggested to the hospital that certain tests should be carried out, but the hospital declined to perform these particular tests.
The parents were then forced to go to court on April, 22, 1986, to free Tyler so that he could be taken to California, partially at their own expense, and with the help of OHIP, for testing and diagnosis.
After a four-day hearing contested by the society, Family Court Judge Peter Nasmith granted the parents' application and made the decision that led to the proof that Tyler was a sick child, not an abused one, and that the parents were caring human
beings and not child abusers.
The California doctor confirmed his original diagnosis, and after doctors at an Ottawa hospital provided additional confirmation, the society finally withdrew the application to make the boy a crown ward.
What went wrong?
The key is provided by Judge Nasmith's comments at the hearing, where he took the unusual step of telling the society to pay costs to the parents for the legal proceedings.
Having concluded that, "the medical evidence was inconclusive and any evidence of possible abuse was of a very unreliable nature," and noting the difficulties the society faced because of the number of agencies involved and the fact that it was
"obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children," the judge said: "The fact remains that there was embarrassingly little effort to follow up on what had become a devastating allegation . . . I
think the position (the society) took was unreasonable and even arbitrary."
As to the heart of the problem, Judge Nasmith said: "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."
One can sympathize with children's aid societies because of the heavy pressures they face and their dilemma when confronted by complex medical information provided by experts.
But Nasmith's ruling spells out the high standards to be expected of them, and of the experts involved in the medical and social investigation of child abuse, because of the awesome legal and persuasive powers that they possess.
If Tyler's parents hadn't had sufficient commitment and ability - and the support of OHIP, the Ontario Legal Aid Plan, and a dedicated lawyer - what would the situation be now? Sound familiar?
The dangerous mix between Dr. Charles Smith and the Hospital for Sick Children SCAN team was all too apparent in a case before the Inquiry which I have been referring to as "the Timmin's case" in previous postings.
The case is the subject of a court decision released by Provincial Court Judge Patrick Dunn on July 25, 1991, the year the Ontario Forensic Pediatric Pathology Unit was formed and several years after the Nasmith decision. (Dr. Smith had been at the hospital since 1981);
As Dunn noted: "I am not the only person who believed (the babysitter). The Community believed her too until the Crown's shaking theory surfaced. When first presented, the Crown's case appeared quite plausible. But after the evidence of the defence experts (Dr. Smith and the Hospital for Sick Children SCAN team) it is riddled with reasonable doubts."Why would the babysitter shake Amber to death?
"Dr. Smith suggested by way of provocation that perhaps Amber was a "bear", like his son, when she woke up," Dunn wrote in his powerful 24-page judgment which resonates to this very day.
"In other words, that the child would be provocative by her irritable manner. This is not true on the facts and it was unfair to suggest the possibility because there was no basis for it."
(Dunn also ruled that, "I cannot find that (The Hospital for Sick Children) properly considered the relationship between the Babysitter and Amber or Amber's gentle and non-provocative disposition," as he blasted both Smith and the SCAN team for failing to obtain "a complete and accurate psycho-social history" - even though they new "the importance" of having it.")
I don't propose to dwell on the details case as I have previously addressed it in several postings on this Blog.
Suffice it to point out for now that Dunn expressed, "serious concerns about the manner in which certain physicians at the Hospital for Sick Children ... formulated their diagnosis." (Dunn stressed that wherever the evidence of the SCAN team members clashed with the defence witnesses, "I prefer to accept the evidence of the defence experts."
Dunn stressed that there were flaws in the Hospital for Sick Children 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," he explained."
"I mean that the fact gathering process, the communication procedures, and the documentation of the Hospital for Sick Children doctors, involved in this case are such that I am led to question the conclusion they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
Similar comments were made about Dr. Charles Smith's work by the independent reviewers who studied so many of his cases.
A very dangerous mix indeed."
Sossin makes a compelling argument for removing the Unit from the Hospital - which in this Blogster's view has not demonstrated over many years that it deserves the public trust.
This is yet another tough bullet for Commissioner Goudge to bite.
Harold Levy; hlevy15@gmail.com;
PROFESSOR LORNE SOSSIN IN RESEARCH PAPER PREPARED FOR THE GOUDGE INQUIRY;
Ontario's Pediatric Forensic Pathology Unit, once headed by Dr. Charles Smith, risks being tainted by its proximity to the Hospital for Sick Children's Sick Children's Suspected Child Abuse and Neglect (SCAN) team, a researcher suggests.
University of Toronto law professor Lorne Sossin, recommends that Ontario should rethink retention of the Unit at the (Hospital) in a paper commissioned by the Goudge Inquiry entitled, "oversight and accountability." (The paper is posted on the Inquiry's Web-site;)
"In addition to an absence of meaningful oversight, the integration of the (Unit) within the pediatric pathology unit at the Hospital for Sick Children(including interaction with the Suspected Child Abuse and Neglect (SCAN) team) may have created a particular kind of institutional culture that contributed to the “think dirty” ethos, discussed in other research conducted for this Inquiry," writes Sossin;
"While there may have been good reasons to establish the (Unit) and locate it in (the Hospital) the viability and desirability of this arrangement continuing should be the subject of further study."
This Bloggist focused this issue in a previous posting entitled "A glimpse of understanding: Part Three; A dangerous mix: Dr Charles Smith and the Hospital for Sick Children SCAN team." (Jan, 2, 2008;"
"In two recent recent postings I have linked Dr. Charles Smith's ability to have such a disastrous effect on Ontario's criminal justice system directly to the decision to appoint him to head the new Ontario Forensic Pediatric Pathology Unit which would be located at the Hospital for Sick Children in Ontario. (A glimmer of understanding; Parts One and Two);" the Blog began.
"One of the unfortunate by-products of this decision is that Smith would have increased influence with the Hospital for Sick Children's Suspected Child Abuse and Neglect (SCAN) Program," it continued.
"Smith, as director of the new prestigious new unit, and the hospital's SCAN unit would prove to be a dangerous mix.
Hospital literature described the SCAN Program as "a hospital-based, multidisciplinary team that offers care, support, and assessment to children and adolescents who may have been abused."
However, as a criminal lawyer, and Editor of the Criminal Lawyers Association Newsletter, In the 1980's I began hearing stories which indicated that the team had a propensity for turning tragic but innocent situations into criminal assaults.
In 1985, I learned about a case which confirmed my worse fears about the program - and wrote bout the case in the Toronto Star, under a headline that read: "They were caring parents, not child abusers"
"Sometimes, people acting with the best of intentions end up achieving the worst possible result," the story began.
"Such was the case in a recent dispute involving a northern Ontario couple and the Catholic Children's Aid Society of Metro Toronto.
The couple were plunged into a nightmare in which they were branded as child abusers of their then one-year-old son and had both of their children taken from them.
In fact, as later became clear when the case landed in court, their son, Tyler,
suffered from a rare bone disease and hadn't been abused at all.
After it became evident that Tyler wasn't developing properly and x-rays had revealed some bone lesions, his parents, whose identity cannot be published, asked their family physician in Elliot Lake to refer the child to Toronto's Hospital for Sick Children for examination by specialists.
But they returned home disappointed, early in January, 1985, as the hospital was unable to pinpoint the disease.
They were unaware that the head of the radiology department had concluded
that the x-rays "were suggestive of child abuse."
They were also unaware that a hospital child abuse team had met in their absence and had asked the medical staff to have the couple return to the hospital with both of their children.
On their arrival, officials of the Metro Children's Aid Society were waiting to "apprehend" both children under a law that permits children at "substantial risk" to be taken from their parents, pending a court hearing.
Bewildered, they returned alone to Elliot Lake to discover that their nightmare had only just begun.
The radiologist's diagnosis that the x-rays were "suggestive" of child abuse had mushroomed into the conclusion by a member of the abuse team that there was "a clear possibility of child abuse."
And the Metro Catholic Children's Aid Society, which had taken over the case, was planning to place Tyler in a foster home and the other child with his natural father.
This move was blocked following the intervention of a lawyer and a private social worker retained by the parents. That led to the children's placement with grandparents.
But the parents couldn't persuade the society to take further steps to find out what was wrong with Tyler, even though a renowned bone disease expert in California had concluded, after viewing the x-rays from the Hospital for Sick Children, that the
lesions were more consistent with bone disease than with fracture.
The expert had suggested to the hospital that certain tests should be carried out, but the hospital declined to perform these particular tests.
The parents were then forced to go to court on April, 22, 1986, to free Tyler so that he could be taken to California, partially at their own expense, and with the help of OHIP, for testing and diagnosis.
After a four-day hearing contested by the society, Family Court Judge Peter Nasmith granted the parents' application and made the decision that led to the proof that Tyler was a sick child, not an abused one, and that the parents were caring human
beings and not child abusers.
The California doctor confirmed his original diagnosis, and after doctors at an Ottawa hospital provided additional confirmation, the society finally withdrew the application to make the boy a crown ward.
What went wrong?
The key is provided by Judge Nasmith's comments at the hearing, where he took the unusual step of telling the society to pay costs to the parents for the legal proceedings.
Having concluded that, "the medical evidence was inconclusive and any evidence of possible abuse was of a very unreliable nature," and noting the difficulties the society faced because of the number of agencies involved and the fact that it was
"obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children," the judge said: "The fact remains that there was embarrassingly little effort to follow up on what had become a devastating allegation . . . I
think the position (the society) took was unreasonable and even arbitrary."
As to the heart of the problem, Judge Nasmith said: "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."
One can sympathize with children's aid societies because of the heavy pressures they face and their dilemma when confronted by complex medical information provided by experts.
But Nasmith's ruling spells out the high standards to be expected of them, and of the experts involved in the medical and social investigation of child abuse, because of the awesome legal and persuasive powers that they possess.
If Tyler's parents hadn't had sufficient commitment and ability - and the support of OHIP, the Ontario Legal Aid Plan, and a dedicated lawyer - what would the situation be now? Sound familiar?
The dangerous mix between Dr. Charles Smith and the Hospital for Sick Children SCAN team was all too apparent in a case before the Inquiry which I have been referring to as "the Timmin's case" in previous postings.
The case is the subject of a court decision released by Provincial Court Judge Patrick Dunn on July 25, 1991, the year the Ontario Forensic Pediatric Pathology Unit was formed and several years after the Nasmith decision. (Dr. Smith had been at the hospital since 1981);
As Dunn noted: "I am not the only person who believed (the babysitter). The Community believed her too until the Crown's shaking theory surfaced. When first presented, the Crown's case appeared quite plausible. But after the evidence of the defence experts (Dr. Smith and the Hospital for Sick Children SCAN team) it is riddled with reasonable doubts."Why would the babysitter shake Amber to death?
"Dr. Smith suggested by way of provocation that perhaps Amber was a "bear", like his son, when she woke up," Dunn wrote in his powerful 24-page judgment which resonates to this very day.
"In other words, that the child would be provocative by her irritable manner. This is not true on the facts and it was unfair to suggest the possibility because there was no basis for it."
(Dunn also ruled that, "I cannot find that (The Hospital for Sick Children) properly considered the relationship between the Babysitter and Amber or Amber's gentle and non-provocative disposition," as he blasted both Smith and the SCAN team for failing to obtain "a complete and accurate psycho-social history" - even though they new "the importance" of having it.")
I don't propose to dwell on the details case as I have previously addressed it in several postings on this Blog.
Suffice it to point out for now that Dunn expressed, "serious concerns about the manner in which certain physicians at the Hospital for Sick Children ... formulated their diagnosis." (Dunn stressed that wherever the evidence of the SCAN team members clashed with the defence witnesses, "I prefer to accept the evidence of the defence experts."
Dunn stressed that there were flaws in the Hospital for Sick Children 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," he explained."
"I mean that the fact gathering process, the communication procedures, and the documentation of the Hospital for Sick Children doctors, involved in this case are such that I am led to question the conclusion they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
Similar comments were made about Dr. Charles Smith's work by the independent reviewers who studied so many of his cases.
A very dangerous mix indeed."
Sossin makes a compelling argument for removing the Unit from the Hospital - which in this Blogster's view has not demonstrated over many years that it deserves the public trust.
This is yet another tough bullet for Commissioner Goudge to bite.
Harold Levy; hlevy15@gmail.com;
Friday, February 22, 2008
Smith Sues Health Board That Fired Him: Part One;
"IN HIS SUIT, SMITH IS ASKING THE HEALTH REGION FOR DAMAGES, INCLUDING LOSS OF SALARY, EMPLOYMENT BENEFITS, STIPENDS, PROFESSIONAL STATURE AND EMOTIONAL STRESS. HE'S ALSO CLAIMING DAMAGES "EXCEEDING $50,000.""
JANET FRENCH: SASKATOON STARPHOENIX;
-------------------------------------------------------------------------------------
The Saskatoon StarPhoenix reports that Dr. Charles Smith has sued the Saskatoon Regional Health Authority for wrongful dismissal.
As Janet French reports, the lawsuit follows a 2006 ruling by a tribunal that Smith had been treated unfairly when a one-year contract had been cut short.
The tribunal's decision will be reported in the next posting of the Blog:
For now, here is the StarPhoenix story - dated February 21, 2008;
SASKATOON -- Disgraced forensic pathologist Dr. Charles Smith -- whose faulty testimony landed many innocent people in jail in Ontario, and at least one person on death row in the U.S. -- is suing the Saskatoon Regional Health Authority for wrongful dismissal.
The suit comes in the wake of a 2006 tribunal that ruled the regional health authority was "unfair, unreasonable, and wrong" when it denied Dr. Smith hospital privileges in Saskatoon, cutting short a one-year contract to work as a surgical pathologist at Saskatoon City Hospital.
"There was no just cause for the dismissal of the plaintiff, nor has reasonable notice been provided, nor has the plaintiff been paid in lieu of reasonable notice," says Dr. Smith's statement of claim, filed in Saskatchewan's Court of Queen's Bench on Dec. 20.
Saskatoon lawyer Gary Bainbridge filed the suit while a public inquiry in Ontario was investigating Dr. Smith's questionable conclusions during his 20-year career as Ontario's top pediatric forensic pathologist .
Last month at the inquiry, Dr. Smith apologized repeatedly for his conduct over the years, saying he had "woefully inadequate" training in child forensic pathology when he began doing autopsies on children who had died suspiciously.
He admitted he had sloppy work habits and procrastinated, that he contributed to a miscarriage of justice, that he fabricated a tale about a judge who disagreed with his conclusions, and that when he testified as an expert witness, he thought he was supposed to be on the Crown's side, not an independent scientist.
A review of Dr. Smith's work, which prompted the inquiry, found Dr. Smith made significant errors in 20 of 45 suspicious child deaths he helped investigate between 1991 and 2001. In 12 of those cases, people were criminally convicted.
Dr. Smith also testified at a U.S. child-murder trial that ended with the conviction of the victim's father and a recommendation the man be put to death.
Dr. Smith suggested at the Ohio trial of Christopher Fuller that two-year-old Randi Fuller had been suffocated, most likely by someone putting pressure on her neck or chest. Though the jury urged in 2000 that Mr. Fuller be executed, the judge cited mitigating factors and imposed a sentence of life in prison.
When scrutiny of Dr, Smith's work intensified in 2005, he left Toronto's Hospital for Sick Children and began a one-year contract in Saskatoon as a surgical pathologist in September of that year. However, when it came time for the Saskatoon Health Region's board to approve his hospital privileges -- a process that's usually a rubber stamp -- the board said no.
With no hospital privileges, the health region terminated his contract in December 2005.
Dr. Smith appealed the board's decision to a rarely-used provincial tribunal, and in November 2006 the tribunal ruled the regional health authority made a mistake by denying Smith privileges.
The tribunal said it would have ordered the health region to reinstate Dr. Smith's hospital privileges, but his licence had expired and he couldn't then legally practise medicine in Saskatchewan.
Bryan Salte, associate registrar with the College of Physicians and Surgeons of Saskatchewan, said Dr. Smith re-applied for his Saskatchewan licence, which was granted from February to December 2007. The licence included a condition that he not practise forensic pathology, Mr. Salte said.
Right now, Dr. Smith is paying $300 a year for an "inactive" licence in Saskatchewan, meaning he can apply to have his licence reinstated with less paperwork than starting from scratch.
James Winkel, a spokesman with the Saskatoon Health Region, says Dr. Smith has since applied for two job postings for anatomic pathologists in Saskatoon. He did not get either job, and the positions were filled by other candidates, Mr. Winkel said.
"He's a pediatric pathologist, so the qualifications didn't fit the positions," he said.
Evert van Olst, legal counsel for the health region, said he could not comment on Dr. Smith's suit because the region has not yet been served with a statement of claim.
"This is the first I've heard about it," Mr. van Olst said. "I'm assuming that he issued it out of some kind of abundance of caution, and maybe doesn't have an intention of serving it."
The tribunal never gave the health region a solution to deal with Dr. Smith's "unfair" treatment, Mr. van Olst added.
"Obviously, Dr. Smith has been very much otherwise engaged, so he could not be able to provide services in any event," he added.
Dr. Smith could not be reached for comment, nor could his lawyer, Mr. Bainbridge.
Saskatoon StarPhoenix
Harold Levy: hlevy15@gmail.com;
JANET FRENCH: SASKATOON STARPHOENIX;
-------------------------------------------------------------------------------------
The Saskatoon StarPhoenix reports that Dr. Charles Smith has sued the Saskatoon Regional Health Authority for wrongful dismissal.
As Janet French reports, the lawsuit follows a 2006 ruling by a tribunal that Smith had been treated unfairly when a one-year contract had been cut short.
The tribunal's decision will be reported in the next posting of the Blog:
For now, here is the StarPhoenix story - dated February 21, 2008;
SASKATOON -- Disgraced forensic pathologist Dr. Charles Smith -- whose faulty testimony landed many innocent people in jail in Ontario, and at least one person on death row in the U.S. -- is suing the Saskatoon Regional Health Authority for wrongful dismissal.
The suit comes in the wake of a 2006 tribunal that ruled the regional health authority was "unfair, unreasonable, and wrong" when it denied Dr. Smith hospital privileges in Saskatoon, cutting short a one-year contract to work as a surgical pathologist at Saskatoon City Hospital.
"There was no just cause for the dismissal of the plaintiff, nor has reasonable notice been provided, nor has the plaintiff been paid in lieu of reasonable notice," says Dr. Smith's statement of claim, filed in Saskatchewan's Court of Queen's Bench on Dec. 20.
Saskatoon lawyer Gary Bainbridge filed the suit while a public inquiry in Ontario was investigating Dr. Smith's questionable conclusions during his 20-year career as Ontario's top pediatric forensic pathologist .
Last month at the inquiry, Dr. Smith apologized repeatedly for his conduct over the years, saying he had "woefully inadequate" training in child forensic pathology when he began doing autopsies on children who had died suspiciously.
He admitted he had sloppy work habits and procrastinated, that he contributed to a miscarriage of justice, that he fabricated a tale about a judge who disagreed with his conclusions, and that when he testified as an expert witness, he thought he was supposed to be on the Crown's side, not an independent scientist.
A review of Dr. Smith's work, which prompted the inquiry, found Dr. Smith made significant errors in 20 of 45 suspicious child deaths he helped investigate between 1991 and 2001. In 12 of those cases, people were criminally convicted.
Dr. Smith also testified at a U.S. child-murder trial that ended with the conviction of the victim's father and a recommendation the man be put to death.
Dr. Smith suggested at the Ohio trial of Christopher Fuller that two-year-old Randi Fuller had been suffocated, most likely by someone putting pressure on her neck or chest. Though the jury urged in 2000 that Mr. Fuller be executed, the judge cited mitigating factors and imposed a sentence of life in prison.
When scrutiny of Dr, Smith's work intensified in 2005, he left Toronto's Hospital for Sick Children and began a one-year contract in Saskatoon as a surgical pathologist in September of that year. However, when it came time for the Saskatoon Health Region's board to approve his hospital privileges -- a process that's usually a rubber stamp -- the board said no.
With no hospital privileges, the health region terminated his contract in December 2005.
Dr. Smith appealed the board's decision to a rarely-used provincial tribunal, and in November 2006 the tribunal ruled the regional health authority made a mistake by denying Smith privileges.
The tribunal said it would have ordered the health region to reinstate Dr. Smith's hospital privileges, but his licence had expired and he couldn't then legally practise medicine in Saskatchewan.
Bryan Salte, associate registrar with the College of Physicians and Surgeons of Saskatchewan, said Dr. Smith re-applied for his Saskatchewan licence, which was granted from February to December 2007. The licence included a condition that he not practise forensic pathology, Mr. Salte said.
Right now, Dr. Smith is paying $300 a year for an "inactive" licence in Saskatchewan, meaning he can apply to have his licence reinstated with less paperwork than starting from scratch.
James Winkel, a spokesman with the Saskatoon Health Region, says Dr. Smith has since applied for two job postings for anatomic pathologists in Saskatoon. He did not get either job, and the positions were filled by other candidates, Mr. Winkel said.
"He's a pediatric pathologist, so the qualifications didn't fit the positions," he said.
Evert van Olst, legal counsel for the health region, said he could not comment on Dr. Smith's suit because the region has not yet been served with a statement of claim.
"This is the first I've heard about it," Mr. van Olst said. "I'm assuming that he issued it out of some kind of abundance of caution, and maybe doesn't have an intention of serving it."
The tribunal never gave the health region a solution to deal with Dr. Smith's "unfair" treatment, Mr. van Olst added.
"Obviously, Dr. Smith has been very much otherwise engaged, so he could not be able to provide services in any event," he added.
Dr. Smith could not be reached for comment, nor could his lawyer, Mr. Bainbridge.
Saskatoon StarPhoenix
Harold Levy: hlevy15@gmail.com;
Sunday, February 10, 2008
More Insights On Search Of Dr. Charles Smith's Office For The Missing Mullins-Johnson Slides; Witness Statements;
"MS. ZWOLAKOWSKI FOUND SEVERAL UNUSUAL ITEMS IN DR. SMITH'S OFFICE," HER WITNESS STATEMENT SAYS;
I have devoted many postings to the search for the missing Mullins-Johnson slides - the only evidence that could possibly show that William Mullins-Johnson was innocent.
Dorothy Zwolakowski, an official in the Chief Coroner's Office, describes the search in detail - as well as an audit of all forensic exhibits at the Ontario Pediatric Forensic Pathology Unit - in a witness statement that has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of interviews of potential witnesses conducted by Goudge Inquiry staff);
Our readers are invited to read her entire statement on the Goudge Inquiry Web-page at www.goudgeinquiry.ca; (Go into transcripts and then click "witness statements";
For now, I just want to highlight a few of her observations which intrigue me.
First, Zwolakowski’s comments on the events of Nov. 26, 2004, when she and Dr. Cairns visited Dr. Smith at the Unit to ask him about and for the missing materials from the Mullins-Johnson case;
"They met with Dr. Smith in the pathology boardroom," the statement says.
"Dr. Cairns asked Dr. Smith about the material, but Dr. Smith did not appear recall that he had been involved in such a file.
Ms. Zwolakowski recalls being surprised that Dr. Smith did not go and look for the material, given the urgency of the situation."
This is pretty shocking.
Police, prosecutors, and Mullins=Johnson’s lawyer’s, had been trying desperately to get their hands on these microscopic slides and tissue blocks which were of life and death importance to Mullins-Johnson - and Dr. Smith did not see the urgency.
Something is hugely wrong with that picture;
The least Dr. Smith could have done - if he had any human feelings as to how his intransigence was affecting Mullins-Johnson - would have been to throw himself into the search and stick with it until the missing items were found.
(Unless, of course, he knew that the missing slides were somewhere else);
Secondly, Zwolakowski told the Inquiry that that it was clear to her when she was attempting to locate the materials that, "there were numerous slides in Dr. Smith’s office at the Unit”;
"Ms. Zwolakowski believes that this would have been obvious to anyone in his
office," her witness statement says.
"Ms. Zwolakowski was concerned that the slides were not stored in the storage room where they would normally be filed."
The message I get here is that the Hospital For Sick Children had utterly abdicated its responsibility to protect the public by supervising its employee, Dr. Smith - and that the hospital had failed to put the most basic systems for storing forensic materials in place;
The blame for that appalling lack of supervision cannot be placed entirely on the Chief Coroner's Office;
Lastly, Zwolakowski describes a grizzly find she made after the audit had been conducted and it was finally possible to get a grip on the contents of Dr. Smith's office:
"Ms. Zwolakowski found several unusual items in Dr. Smith’s office," her witness statement says.
For example, she discovered containers that once contained human wet tissue, but whose contents were now dried out because the formalin had evaporated.
"In addition, Ms. Zwolakowski located a Tupperware container that appeared to contain the rib cage of an infant".
Ms. Zwolakowski found this to be unusual."
Unusual?
It goes without saying that wet tissue has to be carefully protected in controlled temperatures so that it will not became degraded;
But it is the apparent anonymous rib-cage of an infant that tears my heart out.
No tags;
No protection - other than a tupperware container;
No recognition that this was once a child - somebody's child.
I don't like what this tells me about Dr. Smith;
Harold Levy...hlevy15@gmail.com;
I have devoted many postings to the search for the missing Mullins-Johnson slides - the only evidence that could possibly show that William Mullins-Johnson was innocent.
Dorothy Zwolakowski, an official in the Chief Coroner's Office, describes the search in detail - as well as an audit of all forensic exhibits at the Ontario Pediatric Forensic Pathology Unit - in a witness statement that has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of interviews of potential witnesses conducted by Goudge Inquiry staff);
Our readers are invited to read her entire statement on the Goudge Inquiry Web-page at www.goudgeinquiry.ca; (Go into transcripts and then click "witness statements";
For now, I just want to highlight a few of her observations which intrigue me.
First, Zwolakowski’s comments on the events of Nov. 26, 2004, when she and Dr. Cairns visited Dr. Smith at the Unit to ask him about and for the missing materials from the Mullins-Johnson case;
"They met with Dr. Smith in the pathology boardroom," the statement says.
"Dr. Cairns asked Dr. Smith about the material, but Dr. Smith did not appear recall that he had been involved in such a file.
Ms. Zwolakowski recalls being surprised that Dr. Smith did not go and look for the material, given the urgency of the situation."
This is pretty shocking.
Police, prosecutors, and Mullins=Johnson’s lawyer’s, had been trying desperately to get their hands on these microscopic slides and tissue blocks which were of life and death importance to Mullins-Johnson - and Dr. Smith did not see the urgency.
Something is hugely wrong with that picture;
The least Dr. Smith could have done - if he had any human feelings as to how his intransigence was affecting Mullins-Johnson - would have been to throw himself into the search and stick with it until the missing items were found.
(Unless, of course, he knew that the missing slides were somewhere else);
Secondly, Zwolakowski told the Inquiry that that it was clear to her when she was attempting to locate the materials that, "there were numerous slides in Dr. Smith’s office at the Unit”;
"Ms. Zwolakowski believes that this would have been obvious to anyone in his
office," her witness statement says.
"Ms. Zwolakowski was concerned that the slides were not stored in the storage room where they would normally be filed."
The message I get here is that the Hospital For Sick Children had utterly abdicated its responsibility to protect the public by supervising its employee, Dr. Smith - and that the hospital had failed to put the most basic systems for storing forensic materials in place;
The blame for that appalling lack of supervision cannot be placed entirely on the Chief Coroner's Office;
Lastly, Zwolakowski describes a grizzly find she made after the audit had been conducted and it was finally possible to get a grip on the contents of Dr. Smith's office:
"Ms. Zwolakowski found several unusual items in Dr. Smith’s office," her witness statement says.
For example, she discovered containers that once contained human wet tissue, but whose contents were now dried out because the formalin had evaporated.
"In addition, Ms. Zwolakowski located a Tupperware container that appeared to contain the rib cage of an infant".
Ms. Zwolakowski found this to be unusual."
Unusual?
It goes without saying that wet tissue has to be carefully protected in controlled temperatures so that it will not became degraded;
But it is the apparent anonymous rib-cage of an infant that tears my heart out.
No tags;
No protection - other than a tupperware container;
No recognition that this was once a child - somebody's child.
I don't like what this tells me about Dr. Smith;
Harold Levy...hlevy15@gmail.com;
Unopened Envelopes Containing Potential Evidence From Criminal Cases Found In Dr. Smith's Office At Hospital For Sick Children; Witness Statements;
"SHE OBSERVED THAT THE BOXES CONTAINED A VARIETY OF POTENTIALLY IMPORTANT MATERIAL, AND INCLUDED UNOPENED ENVELOPES THAT APPEARED TO CONTAIN EVIDENCE FROM CRIMINAL PROCEEDINGS IN OTHER JURISDICTIONS."
"FROM WITNESS STATEMENT OF DOROTHY ZWOLAKOWSKI FILED INTO EVIDENCE AT THE GOUDGE INQUIRY';
An official from the Ontario Chief Coroner's Office says she discovered potentially important evidence relating to criminal cases in unopened envelopes in boxes in Dr. Charles Smith's office at the Hospital For Sick Children.
This revelation comes from a "witness statement" made by Dorothy Zwolakowski, an official of the Ontario Chief Coroner's office, which has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of statements of potential witnesses provided to Inquiry staff);
According to this statement:
"Ms. Zwolakowski reported that at the end of the audit (in the spring of 2005 H.L.), Dr. Smith’s office was much more orderly than before.
Ms. Zwolakowski recalls that (Hospital For Sick Children) needed the office and the pathology department was moving.
Hospital For Sick Children) staff placed the contents of Dr. Smith’s office into 59 boxes.
Ms. Zwolakowski was concerned that the (Ontario Chief Coroner's Office) might need future access to the contents of the boxes, and that (the Hospital For Sick Children) might at some point send the boxes to Dr. Smith.
She observed that the boxes contained a variety of potentially important material, and included unopened envelopes that appeared to contain evidence from criminal proceedings in other jurisdictions."
The witness statement dies not indicate what steps the Chief Coroner's office criminal cases were involved - and what steps, if any, were taken to ensure that they were brought to the respective police officers, crown attorneys, and defence lawyers.
Nor is there any indication as to whether these criminal cases where still before the courts - or had been concluded.
It would seem to this Blogster that the public has a strong interest in learning the number of these envelopes, their contents, the criminal cases involved, how long they had been sitting in unopened envelopes in Dr. Smith's office, and the steps taken in the aftermath of their discovery.
Harold Levy...hlevy15@gmail.com;
"FROM WITNESS STATEMENT OF DOROTHY ZWOLAKOWSKI FILED INTO EVIDENCE AT THE GOUDGE INQUIRY';
An official from the Ontario Chief Coroner's Office says she discovered potentially important evidence relating to criminal cases in unopened envelopes in boxes in Dr. Charles Smith's office at the Hospital For Sick Children.
This revelation comes from a "witness statement" made by Dorothy Zwolakowski, an official of the Ontario Chief Coroner's office, which has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of statements of potential witnesses provided to Inquiry staff);
According to this statement:
"Ms. Zwolakowski reported that at the end of the audit (in the spring of 2005 H.L.), Dr. Smith’s office was much more orderly than before.
Ms. Zwolakowski recalls that (Hospital For Sick Children) needed the office and the pathology department was moving.
Hospital For Sick Children) staff placed the contents of Dr. Smith’s office into 59 boxes.
Ms. Zwolakowski was concerned that the (Ontario Chief Coroner's Office) might need future access to the contents of the boxes, and that (the Hospital For Sick Children) might at some point send the boxes to Dr. Smith.
She observed that the boxes contained a variety of potentially important material, and included unopened envelopes that appeared to contain evidence from criminal proceedings in other jurisdictions."
The witness statement dies not indicate what steps the Chief Coroner's office criminal cases were involved - and what steps, if any, were taken to ensure that they were brought to the respective police officers, crown attorneys, and defence lawyers.
Nor is there any indication as to whether these criminal cases where still before the courts - or had been concluded.
It would seem to this Blogster that the public has a strong interest in learning the number of these envelopes, their contents, the criminal cases involved, how long they had been sitting in unopened envelopes in Dr. Smith's office, and the steps taken in the aftermath of their discovery.
Harold Levy...hlevy15@gmail.com;
Saturday, February 9, 2008
Smith The Avenger: Witness Statements ;
"DR. SMITH TOOK A PERSONAL INTEREST IN ENSURING THAT PEOPLE WERE PUNISHED FOR HARMING CHILDREN;"
DR. MARTIN QUEEN IN WITNESS STATEMENT PROVIDED TO GOUDGE INQUIRY;
A medical resident who had "limited exposure" to Dr. Charles Smith when he did a three-month rotation at the Hospital For Sick Children in basic anatomical pathology from October to December, 1990, had the impression that "Dr. Smith took a personal interest in ensuring that people were punished for harming children."
Dr. Martin Queen's impression of Smith is set out in a witness statement provided to Goudge Inquiry staff which was entered into evidence and has been posted on the Goudge Inquiry's Web-site. (www.goudgeinquiry.ca);
(The "witness statement" is actually the summary of an interview with Dr. Queen which was conducted by Inquiry staff);
Queen's statement is of limited evidentiary value because it has not been subjected to the courtroom tools of examination and cross-examination.
However, it corresponds with the impressions of a Hamilton Spectator reporter who interviewed Smith in connection with a series of articles a trip Smith made to India in 1997.
He had been retained to help Hamilton, Ontario Police Service homicide officers locate and exhume the bodies of two infant twins children believed to have been murdered by their father.
“Cops and forensic pathologists agree that autopsies may not be pleasant but they are part of the job," reporter Jon Wells wrote.
"Yet for both, child autopsies are a different matter, often too hard for the heart and the soul.
But child autopsies were what Charles Smith did for a living.
As a pediatric forensic pathologist he specialized in the deaths of those who get to barely experience life.
On the emotional level, he felt the pain, the loss.
If the child had a favorite teddy bear, Smith would place it gently next to the corpse as he performed the autopsy.
In a field where clinical. Scientific detachment is required, Smith was a believing, practicing Christian.
When it comes to death almost everyone returns to their religious roots for comfort.
Smith did so all the time."
God, he believed, is a god of justice, and every wrong will be righted. As he opened the bodies of children, that thought helped."
My former Toronto Star colleague Catherine Porter raised the issue as to whether Dr. Smith was more interested in punishing abusers than in finding the truth, or the victim of a complicated field, in a story published on November 13, 1995;
Catherine began her story with a quote by Dr. Paul C.H. Brouardel, Chair of Forensic Medicine at the Sorbonne, who wrote in 1897:
"If the law has made you a witness, remain a man of science. You have no victim to avenge, no guilty or innocent person to convict or save - you must bear testimony within the limits of science."
She juxtaposed this quote with the following one:
"I've got a thing against people who hurt children.
Dr. Charles Smith, forensic pathologist, expert witness,
(2005) (To Toronto Star reporter Dale Brazao);
Porter also included Smith's quote to Brazao that, "I am passionate about my work...
"There is nothing more heart-wrenching than a mother with empty arms seeking answers as to why her baby died."
Smith stunned the inquiry with his admission that he believed for many years that his role was to help the prosecution win its case.
Dr. Queen's impressions, backed up by Dr. Smith's comments to journalists, go one step further;
They suggest that he also saw his role as reaping vengeance against those who harm children - and that he was more crusader than scientist.
Harold Levy...hlevy15@gmail.com;
DR. MARTIN QUEEN IN WITNESS STATEMENT PROVIDED TO GOUDGE INQUIRY;
A medical resident who had "limited exposure" to Dr. Charles Smith when he did a three-month rotation at the Hospital For Sick Children in basic anatomical pathology from October to December, 1990, had the impression that "Dr. Smith took a personal interest in ensuring that people were punished for harming children."
Dr. Martin Queen's impression of Smith is set out in a witness statement provided to Goudge Inquiry staff which was entered into evidence and has been posted on the Goudge Inquiry's Web-site. (www.goudgeinquiry.ca);
(The "witness statement" is actually the summary of an interview with Dr. Queen which was conducted by Inquiry staff);
Queen's statement is of limited evidentiary value because it has not been subjected to the courtroom tools of examination and cross-examination.
However, it corresponds with the impressions of a Hamilton Spectator reporter who interviewed Smith in connection with a series of articles a trip Smith made to India in 1997.
He had been retained to help Hamilton, Ontario Police Service homicide officers locate and exhume the bodies of two infant twins children believed to have been murdered by their father.
“Cops and forensic pathologists agree that autopsies may not be pleasant but they are part of the job," reporter Jon Wells wrote.
"Yet for both, child autopsies are a different matter, often too hard for the heart and the soul.
But child autopsies were what Charles Smith did for a living.
As a pediatric forensic pathologist he specialized in the deaths of those who get to barely experience life.
On the emotional level, he felt the pain, the loss.
If the child had a favorite teddy bear, Smith would place it gently next to the corpse as he performed the autopsy.
In a field where clinical. Scientific detachment is required, Smith was a believing, practicing Christian.
When it comes to death almost everyone returns to their religious roots for comfort.
Smith did so all the time."
God, he believed, is a god of justice, and every wrong will be righted. As he opened the bodies of children, that thought helped."
My former Toronto Star colleague Catherine Porter raised the issue as to whether Dr. Smith was more interested in punishing abusers than in finding the truth, or the victim of a complicated field, in a story published on November 13, 1995;
Catherine began her story with a quote by Dr. Paul C.H. Brouardel, Chair of Forensic Medicine at the Sorbonne, who wrote in 1897:
"If the law has made you a witness, remain a man of science. You have no victim to avenge, no guilty or innocent person to convict or save - you must bear testimony within the limits of science."
She juxtaposed this quote with the following one:
"I've got a thing against people who hurt children.
Dr. Charles Smith, forensic pathologist, expert witness,
(2005) (To Toronto Star reporter Dale Brazao);
Porter also included Smith's quote to Brazao that, "I am passionate about my work...
"There is nothing more heart-wrenching than a mother with empty arms seeking answers as to why her baby died."
Smith stunned the inquiry with his admission that he believed for many years that his role was to help the prosecution win its case.
Dr. Queen's impressions, backed up by Dr. Smith's comments to journalists, go one step further;
They suggest that he also saw his role as reaping vengeance against those who harm children - and that he was more crusader than scientist.
Harold Levy...hlevy15@gmail.com;
Saturday, September 22, 2007
Sick Kids Denied Funding by Goudge Inquiry
Commissioner Stephen Goudge's decision to deny the Hospital for Sick Children's request for funding appears to have gone quite unnoticed.
In a decision released on August 17, 2007, Goudge granted the hospital standing at the Inquiry on the basis that, "Many of the post mortem examinations that gave rise to the establishment of the Commission were performed at the OPFPU (Ontario Pediatric Forensic Pathology Unit).
In light of the direct involvement of (the hospital) and its personnel in pediatric forensic pathology in Ontario, there is no doubt that it should be accorded standing."
The hospital argued that it should receive funding for its expenses at the Inquiry as its involvement in the Commission had come about because of its cooperation with the Chief Coroner's Office over the years to serve the public interest and the needs of Ontario.
But Goudge denied funding after noting that the Chief Coroner's Office had given hospital an annual grant for its services, "so that (the hospital) has not had to expense significant health care dollars to assist (the coroners office);"
Goudge also rejected the hospital's argument that unless it received funding it would have to spend significant health care dollars to assist the Chief Coroner's Office.
"On the record before me, (the hospital) has not established that it cannot participate in the Inquiry without funding," he said.
However, Goudge added that, "it seems to me that (the hospital) may well have a moral claim on the province, both because of the genesis of its need to participate in the Commission and because it would be unfortunate if its delivery of health care suffered as a result."
Harold Levy; hlevy15@gmail.com;
In a decision released on August 17, 2007, Goudge granted the hospital standing at the Inquiry on the basis that, "Many of the post mortem examinations that gave rise to the establishment of the Commission were performed at the OPFPU (Ontario Pediatric Forensic Pathology Unit).
In light of the direct involvement of (the hospital) and its personnel in pediatric forensic pathology in Ontario, there is no doubt that it should be accorded standing."
The hospital argued that it should receive funding for its expenses at the Inquiry as its involvement in the Commission had come about because of its cooperation with the Chief Coroner's Office over the years to serve the public interest and the needs of Ontario.
But Goudge denied funding after noting that the Chief Coroner's Office had given hospital an annual grant for its services, "so that (the hospital) has not had to expense significant health care dollars to assist (the coroners office);"
Goudge also rejected the hospital's argument that unless it received funding it would have to spend significant health care dollars to assist the Chief Coroner's Office.
"On the record before me, (the hospital) has not established that it cannot participate in the Inquiry without funding," he said.
However, Goudge added that, "it seems to me that (the hospital) may well have a moral claim on the province, both because of the genesis of its need to participate in the Commission and because it would be unfortunate if its delivery of health care suffered as a result."
Harold Levy; hlevy15@gmail.com;
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