"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;
-------------------------------------------------------------------------------
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;
Showing posts with label barry mclellan. Show all posts
Showing posts with label barry mclellan. Show all posts
Saturday, June 7, 2008
Wednesday, May 14, 2008
Part Three: Think Dirty: The Paul Bernardo Connection; A perspective;
DEXTER, WHO SERVES AS DIRECTOR OF THE REGIONAL FORENSIC UNIT IN KINGSTON, SAID THE WORDING OF THE PROTOCOL IS "ABSOLUTELY" PROBLEMATIC.
HE TOLD THE INQUIRY INTO PEDIATRIC FORENSIC PATHOLOGY THIS MORNING THAT HE THOUGHT THE PROTOCOL WAS INAPPROPRIATE BECAUSE IT COULD LEAD HIM DOWN THE WRONG PATH WHEN TRYING TO DETERMINE HOW A CHILD DIED.
"IT INFERS A BIAS, A BIAS THAT SOMETHING BAD HAS HAPPENED. YOU'VE GOT TO BE OPEN TO A VARIETY OF POSSIBILITIES. SO OBJECTIVE THINKING IS THE APPROACH," HE SAID.
DR. DAVID DEXTER: THERESA BOYLE, TORONTO STAR;
-------------------------------------------------------------------------------
"I THINK -- MY UNDERSTANDING OF "THINK DIRTY" IS THAT IT WAS INTENDED TO TELL THE MEMBERS OF THE DEATH INVESTIGATION TEAM AND THE PATHOLOGIST TO CONSIDER CHILD ABUSE, AND IN OTHER CIRCUMSTANCES, HOMICIDE. I THINK IT HAS GROWN TO MEAN SOMETHING MORE THAN IT WAS EVER INTENDED TO MEAN."
DR. MICHAEL POLLANEN; IN RESPONSE TO QUESTION POSED BY COMMISSIONER STEPHEN GOUDGE;
-------------------------------------------------------------------------------
In recent postings I have focused on the "think dirty" policy introduced by Dr. James Young, former Chief Coroner of Ontario, which has come under considerable scrutiny at the Goudge Inquiry.
I have three principle problems with this misguided policy - which fortunately was discarded by Dr. Barry McLellan when he headed the Chief Coroner's Office;
First - It was utterly unnecessary;
Second: It should never have been foisted on coroners throughout Ontario - with their minimum training in forensic science, and:
Third, it was developed for use in the context of so-called "femicides" - and then applied to infant deaths without any consideration given to the complexity of infant deaths and the consequences to innocent parents and caregivers.
Dr. Young's policy was not supported by all coroners and pathologists.
As my former Toronto Star colleague Theresa Boyle reported on Jan 17, 2008, under the heading, "pathologists directed to "think dirty," Dr. David Dexter chose to ignore it;
"A Kingston pathologist said he ignored a provincial directive to "think dirty" when conducting autopsies on children because doing so could have led him to conclude they'd died of abuse when they hadn't," Boyles's story began.
"When you're starting from that point of view, the sort of inference is that you've got to create a trail of evidence or logic ... that reflects back on something bad having happened," Dr David Dexter explained to a public inquiry this morning," it continued;
"So it's an issue of bias, it's an issue of tunnel vision.... It's the wrong approach," he added.
In 1995, former chief coroner Jim Young issued a new protocol for pathologists, coroners and chiefs of police to use in death investigations involving children. It stated:
"Unfortunately in this day and age child abuse is a real issue and it is extremely important that all members of the investigative team 'think dirty';
"They must actively investigate each case as potential child abuse and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished and all members of the team are satisfied with the conclusion."
Dexter, who serves as director of the regional forensic unit in Kingston, said the wording of the protocol is "absolutely" problematic.
He told the Inquiry into Pediatric Forensic Pathology this morning that he thought the protocol was inappropriate because it could lead him down the wrong path when trying to determine how a child died.
"It infers a bias, a bias that something bad has happened. You've got to be open to a variety of possibilities. So objective thinking is the approach," he said.
The inquiry is looking at errors Dr. Charles Smith made in 20 cases in which people were charged, convicted or otherwise implicated in the deaths of children.
The difference between coroners and pathologists is that coroners oversee entire death investigations while pathologists conduct autopsies."
Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, clearly understood the danger posed by the "think dirty" policy.
Here is his testimony at the Goudge Inquiry in response to questions posed by Justice Stephen Goudge;
COMMISSIONER STEPHEN GOUDGE: Thanks. Before we leave this, there is a question that I have been meaning to ask you. It is a general question, Dr. Pollanen.
The evidence-based approach that you have eloquently put forward really has, as its goal, think truth, if I can put it that way, as opposed to "think dirty". Is that a fair juxtaposition?
DR. MICHAEL POLLANEN: Yes.
COMMISSIONER STEPHEN GOUDGE: Where does a heightened index of suspicion fit into that, if at all? Do you equate that with "think dirty", or is it somewhere in between, or --
(BRIEF PAUSE)
DR. MICHAEL POLLANEN: "Think dirty" is an unfortunate turn of phrase.
COMMISSIONER STEPHEN GOUDGE: Yeah. Yeah.
DR. MICHAEL POLLANEN: I think -- my understanding of "think dirty" is that it was intended to tell the members of the Death Investigation Team and the pathologist to consider child abuse, and in other circumstances, homicide.
I think it has grown to mean something more than it was ever intended to mean.
And I think the best way to say this in -- now -- where we -- where we sit now relative to "think dirty", is that if we think truth, if we think objectively, then there is no need to give specific advice about "thinking dirty", for example, or having high -- a high index of suspicion.
Because if -- if you're -- if you're allowing the facts to guide your thinking, they will guide you in the correct direction.
There needs to be no a priori set up for it.
Because if you are engaging the issues in a evidenced-based manner, you will get there.
But if it were so simple.
The -- the other competing variable is that we have, purely on an operation basis, and out of necessity, have identified a group of cases which are criminally suspicious and homicidal.
For the -- for the nature -- because we need to do -- to develop protocols and procedures to deal with those cases.
Because it's a -- it's an epidemiological situation that when you have undifferentiated cases -- this large number of undifferentiated cases, at some point in time before the pathologist gets involved, there has to be some type of streaming.
So the streaming happens essentially by the police, with some input by the coroner into this criminal -- this sort of amorphous category of criminally suspicious.
And that to some extent is "think dirty", unless you are making that decision, or those decisions are purely being made on the basis of evidence and fact.
So there's a lot of -- there's a lot of corollaries that come out of this discussion, but I think the best -- the best framework, or the best model to use to understand the methodology or the desirable process is the framework of an evidence based approach using as an a priori principle: think truth, think objectively, search for the truth.
I think that's the best platform because if you do that you don't need to think benign or malignant, the evidence will guide you.
COMMISSIONER STEPHEN GOUDGE: Okay. A couple of implications, I am sure more than a couple, have been read into the heightened index of suspicion notion.
One is the implication of presumption which you've spoken about; the other is an implication of more thorough investigation than one would have in a simple case.
Is that a fair kind of assertion of two (2) implications that might flow out of the notion of heightened index of suspicion?
DR. MICHAEL POLLANEN: You could think of it that way and I'll -- I'll give a concrete example. In the -- if you look at the protocol that -- the analysis that led to the '95 memo, six thirty-one (631) I think it was --
COMMISSIONER STEPHEN GOUDGE: Yes.
DR. MICHAEL POLLANEN: -- you'll notice that there was an analysis of how frequently x-rays were being done --
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: -- on infants. And what this -- what they found when they did that analysis, which was a very good analysis, was that x-rays were not
being done frequently, or as frequently as would be desirable.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: And the reason that's significant is that we -- we know that one of the patterns of child abuse are, for example, multiple fractures.
COMMISSIONER STEPHEN GOUDGE: Fractures, yes.
DR. MICHAEL POLLANEN: So the -- the evidence base, to use that term, the -- the conclusion that came from the analysis in the document was "do x- rays".
It did not support the conclusion "think dirty".
COMMISSIONER STEPHEN GOUDGE: So if heightened index of suspicion means gather all the evidence you possibly can and follow it wherever it leads, you would say that's fine?
DR. MICHAEL POLLANEN: Correct. It -- it can include -- it necessarily includes that.
COMMISSIONER STEPHEN GOUDGE: Okay. If it was to mean start with an a priori presumption, you would say that's not fine?
DR. MICHAEL POLLANEN: Correct. And let me enlarge that one (1) other way and say, we've talked about petechia; well, if we see petechia in someone's eyes at autopsy then that is an indication that the neck will need to be dissected in a special way to determine if they have been strangled.
Well, are the petechia telling us to "think dirty"?
No.
The petechia have within their differential diagnosis, manual strangulation, and because of that we need to apply a technique to detect it if it's there.
So in a way both are achieving the same outcome, except one (1) has as its value a search for the truth platform.
COMMISSIONER STEPHEN GOUDGE: Right. Okay, that is a helpful exchange. Thank you.
Harold Levy...hlevy@15gmail.com;
HE TOLD THE INQUIRY INTO PEDIATRIC FORENSIC PATHOLOGY THIS MORNING THAT HE THOUGHT THE PROTOCOL WAS INAPPROPRIATE BECAUSE IT COULD LEAD HIM DOWN THE WRONG PATH WHEN TRYING TO DETERMINE HOW A CHILD DIED.
"IT INFERS A BIAS, A BIAS THAT SOMETHING BAD HAS HAPPENED. YOU'VE GOT TO BE OPEN TO A VARIETY OF POSSIBILITIES. SO OBJECTIVE THINKING IS THE APPROACH," HE SAID.
DR. DAVID DEXTER: THERESA BOYLE, TORONTO STAR;
-------------------------------------------------------------------------------
"I THINK -- MY UNDERSTANDING OF "THINK DIRTY" IS THAT IT WAS INTENDED TO TELL THE MEMBERS OF THE DEATH INVESTIGATION TEAM AND THE PATHOLOGIST TO CONSIDER CHILD ABUSE, AND IN OTHER CIRCUMSTANCES, HOMICIDE. I THINK IT HAS GROWN TO MEAN SOMETHING MORE THAN IT WAS EVER INTENDED TO MEAN."
DR. MICHAEL POLLANEN; IN RESPONSE TO QUESTION POSED BY COMMISSIONER STEPHEN GOUDGE;
-------------------------------------------------------------------------------
In recent postings I have focused on the "think dirty" policy introduced by Dr. James Young, former Chief Coroner of Ontario, which has come under considerable scrutiny at the Goudge Inquiry.
I have three principle problems with this misguided policy - which fortunately was discarded by Dr. Barry McLellan when he headed the Chief Coroner's Office;
First - It was utterly unnecessary;
Second: It should never have been foisted on coroners throughout Ontario - with their minimum training in forensic science, and:
Third, it was developed for use in the context of so-called "femicides" - and then applied to infant deaths without any consideration given to the complexity of infant deaths and the consequences to innocent parents and caregivers.
Dr. Young's policy was not supported by all coroners and pathologists.
As my former Toronto Star colleague Theresa Boyle reported on Jan 17, 2008, under the heading, "pathologists directed to "think dirty," Dr. David Dexter chose to ignore it;
"A Kingston pathologist said he ignored a provincial directive to "think dirty" when conducting autopsies on children because doing so could have led him to conclude they'd died of abuse when they hadn't," Boyles's story began.
"When you're starting from that point of view, the sort of inference is that you've got to create a trail of evidence or logic ... that reflects back on something bad having happened," Dr David Dexter explained to a public inquiry this morning," it continued;
"So it's an issue of bias, it's an issue of tunnel vision.... It's the wrong approach," he added.
In 1995, former chief coroner Jim Young issued a new protocol for pathologists, coroners and chiefs of police to use in death investigations involving children. It stated:
"Unfortunately in this day and age child abuse is a real issue and it is extremely important that all members of the investigative team 'think dirty';
"They must actively investigate each case as potential child abuse and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished and all members of the team are satisfied with the conclusion."
Dexter, who serves as director of the regional forensic unit in Kingston, said the wording of the protocol is "absolutely" problematic.
He told the Inquiry into Pediatric Forensic Pathology this morning that he thought the protocol was inappropriate because it could lead him down the wrong path when trying to determine how a child died.
"It infers a bias, a bias that something bad has happened. You've got to be open to a variety of possibilities. So objective thinking is the approach," he said.
The inquiry is looking at errors Dr. Charles Smith made in 20 cases in which people were charged, convicted or otherwise implicated in the deaths of children.
The difference between coroners and pathologists is that coroners oversee entire death investigations while pathologists conduct autopsies."
Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, clearly understood the danger posed by the "think dirty" policy.
Here is his testimony at the Goudge Inquiry in response to questions posed by Justice Stephen Goudge;
COMMISSIONER STEPHEN GOUDGE: Thanks. Before we leave this, there is a question that I have been meaning to ask you. It is a general question, Dr. Pollanen.
The evidence-based approach that you have eloquently put forward really has, as its goal, think truth, if I can put it that way, as opposed to "think dirty". Is that a fair juxtaposition?
DR. MICHAEL POLLANEN: Yes.
COMMISSIONER STEPHEN GOUDGE: Where does a heightened index of suspicion fit into that, if at all? Do you equate that with "think dirty", or is it somewhere in between, or --
(BRIEF PAUSE)
DR. MICHAEL POLLANEN: "Think dirty" is an unfortunate turn of phrase.
COMMISSIONER STEPHEN GOUDGE: Yeah. Yeah.
DR. MICHAEL POLLANEN: I think -- my understanding of "think dirty" is that it was intended to tell the members of the Death Investigation Team and the pathologist to consider child abuse, and in other circumstances, homicide.
I think it has grown to mean something more than it was ever intended to mean.
And I think the best way to say this in -- now -- where we -- where we sit now relative to "think dirty", is that if we think truth, if we think objectively, then there is no need to give specific advice about "thinking dirty", for example, or having high -- a high index of suspicion.
Because if -- if you're -- if you're allowing the facts to guide your thinking, they will guide you in the correct direction.
There needs to be no a priori set up for it.
Because if you are engaging the issues in a evidenced-based manner, you will get there.
But if it were so simple.
The -- the other competing variable is that we have, purely on an operation basis, and out of necessity, have identified a group of cases which are criminally suspicious and homicidal.
For the -- for the nature -- because we need to do -- to develop protocols and procedures to deal with those cases.
Because it's a -- it's an epidemiological situation that when you have undifferentiated cases -- this large number of undifferentiated cases, at some point in time before the pathologist gets involved, there has to be some type of streaming.
So the streaming happens essentially by the police, with some input by the coroner into this criminal -- this sort of amorphous category of criminally suspicious.
And that to some extent is "think dirty", unless you are making that decision, or those decisions are purely being made on the basis of evidence and fact.
So there's a lot of -- there's a lot of corollaries that come out of this discussion, but I think the best -- the best framework, or the best model to use to understand the methodology or the desirable process is the framework of an evidence based approach using as an a priori principle: think truth, think objectively, search for the truth.
I think that's the best platform because if you do that you don't need to think benign or malignant, the evidence will guide you.
COMMISSIONER STEPHEN GOUDGE: Okay. A couple of implications, I am sure more than a couple, have been read into the heightened index of suspicion notion.
One is the implication of presumption which you've spoken about; the other is an implication of more thorough investigation than one would have in a simple case.
Is that a fair kind of assertion of two (2) implications that might flow out of the notion of heightened index of suspicion?
DR. MICHAEL POLLANEN: You could think of it that way and I'll -- I'll give a concrete example. In the -- if you look at the protocol that -- the analysis that led to the '95 memo, six thirty-one (631) I think it was --
COMMISSIONER STEPHEN GOUDGE: Yes.
DR. MICHAEL POLLANEN: -- you'll notice that there was an analysis of how frequently x-rays were being done --
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: -- on infants. And what this -- what they found when they did that analysis, which was a very good analysis, was that x-rays were not
being done frequently, or as frequently as would be desirable.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: And the reason that's significant is that we -- we know that one of the patterns of child abuse are, for example, multiple fractures.
COMMISSIONER STEPHEN GOUDGE: Fractures, yes.
DR. MICHAEL POLLANEN: So the -- the evidence base, to use that term, the -- the conclusion that came from the analysis in the document was "do x- rays".
It did not support the conclusion "think dirty".
COMMISSIONER STEPHEN GOUDGE: So if heightened index of suspicion means gather all the evidence you possibly can and follow it wherever it leads, you would say that's fine?
DR. MICHAEL POLLANEN: Correct. It -- it can include -- it necessarily includes that.
COMMISSIONER STEPHEN GOUDGE: Okay. If it was to mean start with an a priori presumption, you would say that's not fine?
DR. MICHAEL POLLANEN: Correct. And let me enlarge that one (1) other way and say, we've talked about petechia; well, if we see petechia in someone's eyes at autopsy then that is an indication that the neck will need to be dissected in a special way to determine if they have been strangled.
Well, are the petechia telling us to "think dirty"?
No.
The petechia have within their differential diagnosis, manual strangulation, and because of that we need to apply a technique to detect it if it's there.
So in a way both are achieving the same outcome, except one (1) has as its value a search for the truth platform.
COMMISSIONER STEPHEN GOUDGE: Right. Okay, that is a helpful exchange. Thank you.
Harold Levy...hlevy@15gmail.com;
Part Three: Think Dirty: The Paul Bernardo Connection; Some Perspectives;
"I THINK -- MY UNDERSTANDING OF "THINK DIRTY" IS THAT IT WAS INTENDED TO TELL THE MEMBERS OF THE DEATH INVESTIGATION TEAM AND THE PATHOLOGIST TO CONSIDER CHILD ABUSE, AND IN OTHER CIRCUMSTANCES, HOMICIDE. I THINK IT HAS GROWN TO MEAN SOMETHING MORE THAN IT WAS EVER INTENDED TO MEAN."
DR. MICHAEL POLLANEN; IN RESPONSE TO QUESTION POSED BY COMMISSIONER STEPHEN GOUDGE;
-------------------------------------------------------------------------------
In recent postings I have focused on the "think dirty" policy introduced by Dr. James Young, former Chief Coroner of Ontario, which has come under considerable scrutiny at the Goudge Inquiry.
I have three principle problems with this misguided policy - which fortunately was discarded by Dr. Barry McLellan when he headed the Chief Coroner's Office;
First - It was utterly unnecessary;
Second: It should never have been foisted on coroners throughout Ontario - with their minimum training in forensic science, and:
Third, it was developed for use in the context of so-called "femicides" - and then applied to infant deaths without any consideration given to the complexity of infant deaths and the consequences to innocent parents and caregivers.
Not all pathologists and coroners agreed with the "think dirty" policy.
As Theresa Boyle, my former colleague at the Toronto Star, wrote in a story published on Jan 17, 2008 under the heading "Pathologists directed to "think dirty, probe told," Dr. David Dexter, a Kingston, Ontario pathologist decided to ignore it;
"A Kingston pathologist said he ignored a provincial directive to "think dirty" when conducting autopsies on children because doing so could have led him to conclude they'd died of abuse when they hadn't," Boyle's story began.
"When you're starting from that point of view, the sort of inference is that you've got to create a trail of evidence or logic ... that reflects back on something bad having happened," Dr David Dexter explained to a public inquiry this morning," the story continued;
""So it's an issue of bias, it's an issue of tunnel vision.... It's the wrong approach," he added.
In 1995, former chief coroner Jim Young issued a new protocol for pathologists, coroners and chiefs of police to use in death investigations involving children. It stated:
"Unfortunately in this day and age child abuse is a real issue and it is extremely important that all members of the investigative team 'think dirty.'
"They must actively investigate each case as potential child abuse and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished and all members of the team are satisfied with the conclusion."
Dexter, who serves as director of the regional forensic unit in Kingston, said the wording of the protocol is "absolutely" problematic.
He told the Inquiry into Pediatric Forensic Pathology this morning that he thought the protocol was inappropriate because it could lead him down the wrong path when trying to determine how a child died.
"It infers a bias, a bias that something bad has happened. You've got to be open to a variety of possibilities. So objective thinking is the approach," he said.
The inquiry is looking at errors Dr. Charles Smith made in 20 cases in which people were charged, convicted or otherwise implicated in the deaths of children.
The difference between coroners and pathologists is that coroners oversee entire death investigations while pathologists conduct autopsies."
Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, clearly understood the danger posed by the "think dirty" policy.
Here is his testimony at the Goudge Inquiry in response to questions posed by Justice Stephen Goudge;
COMMISSIONER STEPHEN GOUDGE: Thanks. Before we leave this, there is a question that I have been meaning to ask you. It is a general question, Dr. Pollanen.
The evidence-based approach that you have eloquently put forward really has, as its goal, think truth, if I can put it that way, as opposed to "think dirty". Is that a fair juxtaposition?
DR. MICHAEL POLLANEN: Yes.
COMMISSIONER STEPHEN GOUDGE: Where does a heightened index of suspicion fit into that, if at all? Do you equate that with "think dirty", or is it somewhere in between, or --
(BRIEF PAUSE)
DR. MICHAEL POLLANEN: "Think dirty" is an unfortunate turn of phrase.
COMMISSIONER STEPHEN GOUDGE: Yeah. Yeah.
DR. MICHAEL POLLANEN: I think -- my understanding of "think dirty" is that it was intended to tell the members of the Death Investigation Team and the pathologist to consider child abuse, and in other circumstances, homicide.
I think it has grown to mean something more than it was ever intended to mean.
And I think the best way to say this in -- now -- where we -- where we sit now relative to "think dirty", is that if we think truth, if we think objectively, then there is no need to give specific advice about "thinking dirty", for example, or having high -- a high index of suspicion.
Because if -- if you're -- if you're allowing the facts to guide your thinking, they will guide you in the correct direction.
There needs to be no a priori set up for it.
Because if you are engaging the issues in a evidenced-based manner, you will get there.
But if it were so simple.
The -- the other competing variable is that we have, purely on an operation basis, and out of necessity, have identified a group of cases which are criminally suspicious and homicidal.
For the -- for the nature -- because we need to do -- to develop protocols and procedures to deal with those cases.
Because it's a -- it's an epidemiological situation that when you have undifferentiated cases -- this large number of undifferentiated cases, at some point in time before the pathologist gets involved, there has to be some type of streaming.
So the streaming happens essentially by the police, with some input by the coroner into this criminal -- this sort of amorphous category of criminally suspicious.
And that to some extent is "think dirty", unless you are making that decision, or those decisions are purely being made on the basis of evidence and fact.
So there's a lot of -- there's a lot of corollaries that come out of this discussion, but I think the best -- the best framework, or the best model to use to understand the methodology or the desirable process is the framework of an evidence based approach using as an a priori principle: think truth, think objectively, search for the truth.
I think that's the best platform because if you do that you don't need to think benign or malignant, the evidence will guide you.
COMMISSIONER STEPHEN GOUDGE: Okay. A couple of implications, I am sure more than a couple, have been read into the heightened index of suspicion notion.
One is the implication of presumption which you've spoken about; the other is an implication of more thorough investigation than one would have in a simple case.
Is that a fair kind of assertion of two (2) implications that might flow out of the notion of heightened index of suspicion?
DR. MICHAEL POLLANEN: You could think of it that way and I'll -- I'll give a concrete example. In the -- if you look at the protocol that -- the analysis that led to the '95 memo, six thirty-one (631) I think it was --
COMMISSIONER STEPHEN GOUDGE: Yes.
DR. MICHAEL POLLANEN: -- you'll notice that there was an analysis of how frequently x-rays were being done --
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: -- on infants. And what this -- what they found when they did that analysis, which was a very good analysis, was that x-rays were not
being done frequently, or as frequently as would be desirable.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: And the reason that's significant is that we -- we know that one of the patterns of child abuse are, for example, multiple fractures.
COMMISSIONER STEPHEN GOUDGE: Fractures, yes.
DR. MICHAEL POLLANEN: So the -- the evidence base, to use that term, the -- the conclusion that came from the analysis in the document was "do x- rays".
It did not support the conclusion "think dirty".
COMMISSIONER STEPHEN GOUDGE: So if heightened index of suspicion means gather all the evidence you possibly can and follow it wherever it leads, you would say that's fine?
DR. MICHAEL POLLANEN: Correct. It -- it can include -- it necessarily includes that.
COMMISSIONER STEPHEN GOUDGE: Okay. If it was to mean start with an a priori presumption, you would say that's not fine?
DR. MICHAEL POLLANEN: Correct. And let me enlarge that one (1) other way and say, we've talked about petechia; well, if we see petechia in someone's eyes at autopsy then that is an indication that the neck will need to be dissected in a special way to determine if they have been strangled.
Well, are the petechia telling us to "think dirty"?
No.
The petechia have within their differential diagnosis, manual strangulation, and because of that we need to apply a technique to detect it if it's there.
So in a way both are achieving the same outcome, except one (1) has as its value a search for the truth platform.
COMMISSIONER STEPHEN GOUDGE: Right. Okay, that is a helpful exchange. Thank you.
Harold Levy...hlevy@15gmail.com;
DR. MICHAEL POLLANEN; IN RESPONSE TO QUESTION POSED BY COMMISSIONER STEPHEN GOUDGE;
-------------------------------------------------------------------------------
In recent postings I have focused on the "think dirty" policy introduced by Dr. James Young, former Chief Coroner of Ontario, which has come under considerable scrutiny at the Goudge Inquiry.
I have three principle problems with this misguided policy - which fortunately was discarded by Dr. Barry McLellan when he headed the Chief Coroner's Office;
First - It was utterly unnecessary;
Second: It should never have been foisted on coroners throughout Ontario - with their minimum training in forensic science, and:
Third, it was developed for use in the context of so-called "femicides" - and then applied to infant deaths without any consideration given to the complexity of infant deaths and the consequences to innocent parents and caregivers.
Not all pathologists and coroners agreed with the "think dirty" policy.
As Theresa Boyle, my former colleague at the Toronto Star, wrote in a story published on Jan 17, 2008 under the heading "Pathologists directed to "think dirty, probe told," Dr. David Dexter, a Kingston, Ontario pathologist decided to ignore it;
"A Kingston pathologist said he ignored a provincial directive to "think dirty" when conducting autopsies on children because doing so could have led him to conclude they'd died of abuse when they hadn't," Boyle's story began.
"When you're starting from that point of view, the sort of inference is that you've got to create a trail of evidence or logic ... that reflects back on something bad having happened," Dr David Dexter explained to a public inquiry this morning," the story continued;
""So it's an issue of bias, it's an issue of tunnel vision.... It's the wrong approach," he added.
In 1995, former chief coroner Jim Young issued a new protocol for pathologists, coroners and chiefs of police to use in death investigations involving children. It stated:
"Unfortunately in this day and age child abuse is a real issue and it is extremely important that all members of the investigative team 'think dirty.'
"They must actively investigate each case as potential child abuse and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished and all members of the team are satisfied with the conclusion."
Dexter, who serves as director of the regional forensic unit in Kingston, said the wording of the protocol is "absolutely" problematic.
He told the Inquiry into Pediatric Forensic Pathology this morning that he thought the protocol was inappropriate because it could lead him down the wrong path when trying to determine how a child died.
"It infers a bias, a bias that something bad has happened. You've got to be open to a variety of possibilities. So objective thinking is the approach," he said.
The inquiry is looking at errors Dr. Charles Smith made in 20 cases in which people were charged, convicted or otherwise implicated in the deaths of children.
The difference between coroners and pathologists is that coroners oversee entire death investigations while pathologists conduct autopsies."
Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, clearly understood the danger posed by the "think dirty" policy.
Here is his testimony at the Goudge Inquiry in response to questions posed by Justice Stephen Goudge;
COMMISSIONER STEPHEN GOUDGE: Thanks. Before we leave this, there is a question that I have been meaning to ask you. It is a general question, Dr. Pollanen.
The evidence-based approach that you have eloquently put forward really has, as its goal, think truth, if I can put it that way, as opposed to "think dirty". Is that a fair juxtaposition?
DR. MICHAEL POLLANEN: Yes.
COMMISSIONER STEPHEN GOUDGE: Where does a heightened index of suspicion fit into that, if at all? Do you equate that with "think dirty", or is it somewhere in between, or --
(BRIEF PAUSE)
DR. MICHAEL POLLANEN: "Think dirty" is an unfortunate turn of phrase.
COMMISSIONER STEPHEN GOUDGE: Yeah. Yeah.
DR. MICHAEL POLLANEN: I think -- my understanding of "think dirty" is that it was intended to tell the members of the Death Investigation Team and the pathologist to consider child abuse, and in other circumstances, homicide.
I think it has grown to mean something more than it was ever intended to mean.
And I think the best way to say this in -- now -- where we -- where we sit now relative to "think dirty", is that if we think truth, if we think objectively, then there is no need to give specific advice about "thinking dirty", for example, or having high -- a high index of suspicion.
Because if -- if you're -- if you're allowing the facts to guide your thinking, they will guide you in the correct direction.
There needs to be no a priori set up for it.
Because if you are engaging the issues in a evidenced-based manner, you will get there.
But if it were so simple.
The -- the other competing variable is that we have, purely on an operation basis, and out of necessity, have identified a group of cases which are criminally suspicious and homicidal.
For the -- for the nature -- because we need to do -- to develop protocols and procedures to deal with those cases.
Because it's a -- it's an epidemiological situation that when you have undifferentiated cases -- this large number of undifferentiated cases, at some point in time before the pathologist gets involved, there has to be some type of streaming.
So the streaming happens essentially by the police, with some input by the coroner into this criminal -- this sort of amorphous category of criminally suspicious.
And that to some extent is "think dirty", unless you are making that decision, or those decisions are purely being made on the basis of evidence and fact.
So there's a lot of -- there's a lot of corollaries that come out of this discussion, but I think the best -- the best framework, or the best model to use to understand the methodology or the desirable process is the framework of an evidence based approach using as an a priori principle: think truth, think objectively, search for the truth.
I think that's the best platform because if you do that you don't need to think benign or malignant, the evidence will guide you.
COMMISSIONER STEPHEN GOUDGE: Okay. A couple of implications, I am sure more than a couple, have been read into the heightened index of suspicion notion.
One is the implication of presumption which you've spoken about; the other is an implication of more thorough investigation than one would have in a simple case.
Is that a fair kind of assertion of two (2) implications that might flow out of the notion of heightened index of suspicion?
DR. MICHAEL POLLANEN: You could think of it that way and I'll -- I'll give a concrete example. In the -- if you look at the protocol that -- the analysis that led to the '95 memo, six thirty-one (631) I think it was --
COMMISSIONER STEPHEN GOUDGE: Yes.
DR. MICHAEL POLLANEN: -- you'll notice that there was an analysis of how frequently x-rays were being done --
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: -- on infants. And what this -- what they found when they did that analysis, which was a very good analysis, was that x-rays were not
being done frequently, or as frequently as would be desirable.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. MICHAEL POLLANEN: And the reason that's significant is that we -- we know that one of the patterns of child abuse are, for example, multiple fractures.
COMMISSIONER STEPHEN GOUDGE: Fractures, yes.
DR. MICHAEL POLLANEN: So the -- the evidence base, to use that term, the -- the conclusion that came from the analysis in the document was "do x- rays".
It did not support the conclusion "think dirty".
COMMISSIONER STEPHEN GOUDGE: So if heightened index of suspicion means gather all the evidence you possibly can and follow it wherever it leads, you would say that's fine?
DR. MICHAEL POLLANEN: Correct. It -- it can include -- it necessarily includes that.
COMMISSIONER STEPHEN GOUDGE: Okay. If it was to mean start with an a priori presumption, you would say that's not fine?
DR. MICHAEL POLLANEN: Correct. And let me enlarge that one (1) other way and say, we've talked about petechia; well, if we see petechia in someone's eyes at autopsy then that is an indication that the neck will need to be dissected in a special way to determine if they have been strangled.
Well, are the petechia telling us to "think dirty"?
No.
The petechia have within their differential diagnosis, manual strangulation, and because of that we need to apply a technique to detect it if it's there.
So in a way both are achieving the same outcome, except one (1) has as its value a search for the truth platform.
COMMISSIONER STEPHEN GOUDGE: Right. Okay, that is a helpful exchange. Thank you.
Harold Levy...hlevy@15gmail.com;
Saturday, December 29, 2007
"Think Dirty"; Part One: Two Words At The Heart Of The Inquiry;
"UNFORTUNATELY, IN THIS DAY AND AGE, CHILD ABUSE IS A REAL ISSUE, AND IT IS EXTREMELY IMPORTANT THAT ALL MEMBERS OF THE INVESTIGATIVE TEAM THINK DIRTY."
FROM PROTOCOL ISSUED BY DR. JAMES YOUNG TO ALL CORONERS, PATHOLOGISTS, AND CHIEFS OF POLICE IN ONTARIO ON APRIL 10, 1995.
Two words, containing only three syllables lie at the heart of the Goudge Inquiry: "Think Dirty."
They are contained in a protocol issued by former chief coroner Dr. James Young to all coroners, pathologists, and chiefs of police in Ontario on April 10, 1995.
The policy was ultimately dropped by Dr. Barry McLellan, Dr. Young's successor, after he became Chief Coroner in April, 2004;
The protocol read:
"Unfortunately, in this day and age, child abuse is a real issue, and it is extremely important that all members of the investigative team "Think Dirty."
They must actively investigate each case as potential child abuse, and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished, and all members of the team are satisfied with the conclusion."
During the nine years the protocol remained in effect, these words communicated through "think dirty" slides that were used in presentations to coroners throughout the province and other members of the death investigation teams.
The obvious danger of the new policy was that it could be interpreted as requiring local coroners and pathologists to act like police officers instead of as impartial doctors and scientists.
There was also a risk that it could encourage pathologists and prosecutors to feel that they were required to search for criminality behind every death of a child.
A risk that it could turn most innocent death of a child into a murder with all of the horrific consequences, to loving parents, families and caregivers that we have seen thus far at the Goudge Inquiry - especially since Dr. Young's new policy was introduced at a time of heightened public fear over child abuse and pressure on the authorities to do something about it.
At the very least, this Bloggist wonders if the new policy may have validated Dr. Charles Smith's suspicious approach to his work in his own mind - when he still had years of work to accomplish.
In fact, Dr. Young testified that he got the idea from a cop, adopted it, and used it in his own presentations.
Dr. Young told the Inquiry that the "Think Dirty" approach was formulated during a period of world-wide concern "that pediatric deaths weren't being properly investigated."
"(We) were very aware and there were discussions, again, at any forensic meeting about the difficulties in investigating pediatric deaths, and the fact that they -- children died of different things than adults did; and the very difficult job of sorting out metabolic disorders, SIDS, cases of Shaken Baby, cases of
subtle -- suffocation, of subtle child abuse, and dating of injuries, you know, to make sure that what was attributed to the death was -- was relevant," he told Commissioner Goudge.
Young testified that the new protocol was simply intended to remind people to look out for signs of criminality during the course of their investigations.-
Young stressed that, " It was not -- absolutely not, and it was never contemplated or discussed at any meeting I ever attended where the phrase was used, to mean that make cases -- make cases criminal matters when they aren't.
But he agreed with Commission Counsel Mark Sandler that, "with the benefit of -- of what we've learned since, it might be advisable for the Chief Coroner's Office to -- to develop another phrase to communicate the same sentiment."
The new policy troubled Dr. Ernest Cutz, a distinguished pathologist and researcher at the Hospital for Sick Children.
Dr. Cutz is one of the world's leading authorities on the Sudden Infant Death Syndrome (SIDS);
Cutz told the Inquiry he found the concept of "thinking dirty" inappropriate because he interpreted as saying, "you are implying guilt up front, and, you know, until proven otherwise."
"I use the balanced approach," he said. "Looking at the facts and evidence, you know, regardless of what the motto is."
Cutz said that it made sense to be alert to the possibility of criminality in those relatively few cases where there had been a history with law enforcement or involvement with a Children's Aid Society.
However, he objected to the protocol because, "too heavy on the side of the forensic" as contrasted with the function of "Looking (at) what is the cause of death and...what what are the diseases and mechanism underlying it."
Doctor Cutz noted that he had voiced his objections to the protocol to the late Dr. Larry Becker, Head of the Pathology Department, but was not aware if Dr. Becker passed his objections on to the Chief Coroner's Office.
He said, however, that he had seen reference in correspondence to a meeting at ended by senior officials of the Chief Coroners Office, including Dr. Bernard Chiasson, at which Dr. Becker raised his own concerns about the policy.
On January 21, 1997, Dr. Cutz wrote a letter to Dr. Chiasson at the Chief Coroner's Office requesting a meeting to discuss information he had received from Dr. Becker that the Coroner's office was considering removing himself and a colleague from the rotation for performing medico-legal autopsies at the hospital.
The transcript of Dr. Cutz's testimony on this subject reads as follows:
MS. JENNIFER MCALEER: (Commission Counsel); And what -- what else did Dr. Becker tell you?
DR. ERNEST CUTZ: Well, you know, he said that, you know, if -- if I want any -- any sort of explanation as to the reasons and/or, you know, what -- what -- how can one mediate the situation, I have to -- to see Dr. Chiasson.
MS. JENNIFER MCALEER: And did you, in fact, meet with Dr. Chiasson --
DR. ERNEST CUTZ: Yes, I did.
MS. JENNIFER MCALEER: -- to discuss this issue?
DR. ERNEST CUTZ: Yeah.
MS. JENNIFER MCALEER: And what -- what was your recollection of those discussions?
DR. ERNEST CUTZ: Well, I sort of outline in my letter here that, you know, the -- my experience at doing these cases at the Hospital for Sick Children and
outlining my, you know, experience in the different kinds of conditions which include, you know, natural deaths as well as -- as well as cases of child maltreatment or suspected homicide. And I bring to his attention one (1)
particular illustrated case to show that I have the same level of concern and erudition in carrying out pathology investigations, and I give -- give him example of it.
MS. JENNIFER MCALEER: Well, did Dr. Chiasson explain to you why -- well, first of all, did he verify what Dr. Becker had told you, that there was a
prospect that you and Dr. Wilson would be removed from the roster doing medicolegal work? Did he tell you that was something they were considering?
DR. ERNEST CUTZ: Well, when I asked for the meeting I said, This is what I'd like to discuss with him. So he didn't sort of say, you know, You're going to
be removed. But, you know, we were discussing the -- the situation.
MS. JENNIFER MCALEER: And what was your understanding as a result of your letter and your meeting with Dr. Chiasson? Did you continue to perform
medicolegal autopsies?
DR. ERNEST CUTZ: Yes, I did.
MS. JENNIFER MCALEER: And was your performance of those medicolegal autopsies restricted in any way?
DR. ERNEST CUTZ: No, it wasn't restricted. I continued, as before, doing the non- homicide cases. You know, when I asked as to what the reasons were for removing me, it was sort of very vague. Something saying I was soft on crime, and I didn't collab-- or cooperate with the police which came to me as a 1 total surprise.
MS. JENNIFER MCALEER: Okay. So who said you were soft on crime?
DR. ERNEST CUTZ: Dr. Chiasson. Or there was a perception of.
MS. JENNIFER MCALEER: And do you know what the basis of that perception was?
DR. ERNEST CUTZ: He didn't explain, didn't give examples.
MS. JENNIFER MCALEER: And -- and the second reason was because you had difficulty communicating with the police?
DR. ERNEST CUTZ: No, that I did not cooperate with the police, which came as a total surprise, as I don't recall any incident. I was most cooperative at all instances with the police. I had no reason to -- so it came as a total surprise to me.
MS. JENNIFER MCALEER: And did Dr. Chiasson explain to you what the basis of that concern was --
DR. ERNEST CUTZ: He said he has -- he has no specific examples.
MS. JENNIFER MCALEER: Okay. Did you discuss this issue with Dr. Smith?
DR. ERNEST CUTZ: No.
MS. JENNIFER MCALEER: And after -- after this point in time, Dr. Cutz, you did continue to do medicolegal autopsies?
DR. ERNEST CUTZ: That's right. I thought the meeting with Dr. Chiasson was useful because we cleared the air, you know, this -- this -- to see what
the problems were. And, you know, actually I -- I -- part of the letter was -- you know, I gave him the breakdown of all the cases I did in the past five (5)
years, which was two hundred, twenty-five (225) cases, and -- and show him that, you know, it -- major portion were pediatric disease, which is no way anybody would have diagnosis outside of a pediatric centre. Okay. So -- so we -- we rendered a very valuable service to -- to making the right diagnosis for
the families. Okay. And then I show him the percentage of cases which went to inquests, which went to -- okay, which -- in every instance I was involved, a correct diagnosis was made, the crime was pursued, the crime was prosecuted and the person was jailed for -- for the crime.
For his part, Dr. Chaisson testified at the Inquiry that he had concerns about Dr. Cutz's and his colleague's "attitude over forensics."
Pressed by Commissioner Goudge over what he meant by their "attitude over forensics" Dr. Chiasson replied:
"From a pediatric pathology perspective, they were not insignificant, and -- and it wasn't simply the number of -- of cases as -- as much as my perception that when it came to cases they -- they weren't really as apprised at looking at injuries and the potential significance of -- of injuries as, was my view of, Dr. Smith, who was clearly interested in pediatric forensic pathology and -- and, you know, whose focus was in that - - that area."
The good news is that Dr. Barry McLellan put the "think dirty" protocol to rest when he became chief Coroner.
"(My) own teaching in recent years has been that it's important to keep an open mind. But, I can tell you that "think dirty" slides and the phrase "think dirty" was removed from many of the standard presentations that we were giving to members of the death investigation team".
"When I redid the presentation that the coroner's office gives as part of the major case management course, that was taken out of the course," McLellan explained.
"So, I can't say that there has been a specific effort to send out a communication saying, Don't think dirty, but the approach has been different through our educational courses, through our new courses for coroners, and the emphasis is to keep an open mind. And, as such, you know, we'll end up with the best quality of death investigation."
I will give the last word for this posting to Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, who told the Ontario Court of Appeal in the Mullins-Johnson case that new guidelines effectively tell Ontario's pathologists and coroners: "Don't think dirty; Think objectively. Think truth."
Harold Levy...hlevy15@gmail.com...
FROM PROTOCOL ISSUED BY DR. JAMES YOUNG TO ALL CORONERS, PATHOLOGISTS, AND CHIEFS OF POLICE IN ONTARIO ON APRIL 10, 1995.
Two words, containing only three syllables lie at the heart of the Goudge Inquiry: "Think Dirty."
They are contained in a protocol issued by former chief coroner Dr. James Young to all coroners, pathologists, and chiefs of police in Ontario on April 10, 1995.
The policy was ultimately dropped by Dr. Barry McLellan, Dr. Young's successor, after he became Chief Coroner in April, 2004;
The protocol read:
"Unfortunately, in this day and age, child abuse is a real issue, and it is extremely important that all members of the investigative team "Think Dirty."
They must actively investigate each case as potential child abuse, and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished, and all members of the team are satisfied with the conclusion."
During the nine years the protocol remained in effect, these words communicated through "think dirty" slides that were used in presentations to coroners throughout the province and other members of the death investigation teams.
The obvious danger of the new policy was that it could be interpreted as requiring local coroners and pathologists to act like police officers instead of as impartial doctors and scientists.
There was also a risk that it could encourage pathologists and prosecutors to feel that they were required to search for criminality behind every death of a child.
A risk that it could turn most innocent death of a child into a murder with all of the horrific consequences, to loving parents, families and caregivers that we have seen thus far at the Goudge Inquiry - especially since Dr. Young's new policy was introduced at a time of heightened public fear over child abuse and pressure on the authorities to do something about it.
At the very least, this Bloggist wonders if the new policy may have validated Dr. Charles Smith's suspicious approach to his work in his own mind - when he still had years of work to accomplish.
In fact, Dr. Young testified that he got the idea from a cop, adopted it, and used it in his own presentations.
Dr. Young told the Inquiry that the "Think Dirty" approach was formulated during a period of world-wide concern "that pediatric deaths weren't being properly investigated."
"(We) were very aware and there were discussions, again, at any forensic meeting about the difficulties in investigating pediatric deaths, and the fact that they -- children died of different things than adults did; and the very difficult job of sorting out metabolic disorders, SIDS, cases of Shaken Baby, cases of
subtle -- suffocation, of subtle child abuse, and dating of injuries, you know, to make sure that what was attributed to the death was -- was relevant," he told Commissioner Goudge.
Young testified that the new protocol was simply intended to remind people to look out for signs of criminality during the course of their investigations.-
Young stressed that, " It was not -- absolutely not, and it was never contemplated or discussed at any meeting I ever attended where the phrase was used, to mean that make cases -- make cases criminal matters when they aren't.
But he agreed with Commission Counsel Mark Sandler that, "with the benefit of -- of what we've learned since, it might be advisable for the Chief Coroner's Office to -- to develop another phrase to communicate the same sentiment."
The new policy troubled Dr. Ernest Cutz, a distinguished pathologist and researcher at the Hospital for Sick Children.
Dr. Cutz is one of the world's leading authorities on the Sudden Infant Death Syndrome (SIDS);
Cutz told the Inquiry he found the concept of "thinking dirty" inappropriate because he interpreted as saying, "you are implying guilt up front, and, you know, until proven otherwise."
"I use the balanced approach," he said. "Looking at the facts and evidence, you know, regardless of what the motto is."
Cutz said that it made sense to be alert to the possibility of criminality in those relatively few cases where there had been a history with law enforcement or involvement with a Children's Aid Society.
However, he objected to the protocol because, "too heavy on the side of the forensic" as contrasted with the function of "Looking (at) what is the cause of death and...what what are the diseases and mechanism underlying it."
Doctor Cutz noted that he had voiced his objections to the protocol to the late Dr. Larry Becker, Head of the Pathology Department, but was not aware if Dr. Becker passed his objections on to the Chief Coroner's Office.
He said, however, that he had seen reference in correspondence to a meeting at ended by senior officials of the Chief Coroners Office, including Dr. Bernard Chiasson, at which Dr. Becker raised his own concerns about the policy.
On January 21, 1997, Dr. Cutz wrote a letter to Dr. Chiasson at the Chief Coroner's Office requesting a meeting to discuss information he had received from Dr. Becker that the Coroner's office was considering removing himself and a colleague from the rotation for performing medico-legal autopsies at the hospital.
The transcript of Dr. Cutz's testimony on this subject reads as follows:
MS. JENNIFER MCALEER: (Commission Counsel); And what -- what else did Dr. Becker tell you?
DR. ERNEST CUTZ: Well, you know, he said that, you know, if -- if I want any -- any sort of explanation as to the reasons and/or, you know, what -- what -- how can one mediate the situation, I have to -- to see Dr. Chiasson.
MS. JENNIFER MCALEER: And did you, in fact, meet with Dr. Chiasson --
DR. ERNEST CUTZ: Yes, I did.
MS. JENNIFER MCALEER: -- to discuss this issue?
DR. ERNEST CUTZ: Yeah.
MS. JENNIFER MCALEER: And what -- what was your recollection of those discussions?
DR. ERNEST CUTZ: Well, I sort of outline in my letter here that, you know, the -- my experience at doing these cases at the Hospital for Sick Children and
outlining my, you know, experience in the different kinds of conditions which include, you know, natural deaths as well as -- as well as cases of child maltreatment or suspected homicide. And I bring to his attention one (1)
particular illustrated case to show that I have the same level of concern and erudition in carrying out pathology investigations, and I give -- give him example of it.
MS. JENNIFER MCALEER: Well, did Dr. Chiasson explain to you why -- well, first of all, did he verify what Dr. Becker had told you, that there was a
prospect that you and Dr. Wilson would be removed from the roster doing medicolegal work? Did he tell you that was something they were considering?
DR. ERNEST CUTZ: Well, when I asked for the meeting I said, This is what I'd like to discuss with him. So he didn't sort of say, you know, You're going to
be removed. But, you know, we were discussing the -- the situation.
MS. JENNIFER MCALEER: And what was your understanding as a result of your letter and your meeting with Dr. Chiasson? Did you continue to perform
medicolegal autopsies?
DR. ERNEST CUTZ: Yes, I did.
MS. JENNIFER MCALEER: And was your performance of those medicolegal autopsies restricted in any way?
DR. ERNEST CUTZ: No, it wasn't restricted. I continued, as before, doing the non- homicide cases. You know, when I asked as to what the reasons were for removing me, it was sort of very vague. Something saying I was soft on crime, and I didn't collab-- or cooperate with the police which came to me as a 1 total surprise.
MS. JENNIFER MCALEER: Okay. So who said you were soft on crime?
DR. ERNEST CUTZ: Dr. Chiasson. Or there was a perception of.
MS. JENNIFER MCALEER: And do you know what the basis of that perception was?
DR. ERNEST CUTZ: He didn't explain, didn't give examples.
MS. JENNIFER MCALEER: And -- and the second reason was because you had difficulty communicating with the police?
DR. ERNEST CUTZ: No, that I did not cooperate with the police, which came as a total surprise, as I don't recall any incident. I was most cooperative at all instances with the police. I had no reason to -- so it came as a total surprise to me.
MS. JENNIFER MCALEER: And did Dr. Chiasson explain to you what the basis of that concern was --
DR. ERNEST CUTZ: He said he has -- he has no specific examples.
MS. JENNIFER MCALEER: Okay. Did you discuss this issue with Dr. Smith?
DR. ERNEST CUTZ: No.
MS. JENNIFER MCALEER: And after -- after this point in time, Dr. Cutz, you did continue to do medicolegal autopsies?
DR. ERNEST CUTZ: That's right. I thought the meeting with Dr. Chiasson was useful because we cleared the air, you know, this -- this -- to see what
the problems were. And, you know, actually I -- I -- part of the letter was -- you know, I gave him the breakdown of all the cases I did in the past five (5)
years, which was two hundred, twenty-five (225) cases, and -- and show him that, you know, it -- major portion were pediatric disease, which is no way anybody would have diagnosis outside of a pediatric centre. Okay. So -- so we -- we rendered a very valuable service to -- to making the right diagnosis for
the families. Okay. And then I show him the percentage of cases which went to inquests, which went to -- okay, which -- in every instance I was involved, a correct diagnosis was made, the crime was pursued, the crime was prosecuted and the person was jailed for -- for the crime.
For his part, Dr. Chaisson testified at the Inquiry that he had concerns about Dr. Cutz's and his colleague's "attitude over forensics."
Pressed by Commissioner Goudge over what he meant by their "attitude over forensics" Dr. Chiasson replied:
"From a pediatric pathology perspective, they were not insignificant, and -- and it wasn't simply the number of -- of cases as -- as much as my perception that when it came to cases they -- they weren't really as apprised at looking at injuries and the potential significance of -- of injuries as, was my view of, Dr. Smith, who was clearly interested in pediatric forensic pathology and -- and, you know, whose focus was in that - - that area."
The good news is that Dr. Barry McLellan put the "think dirty" protocol to rest when he became chief Coroner.
"(My) own teaching in recent years has been that it's important to keep an open mind. But, I can tell you that "think dirty" slides and the phrase "think dirty" was removed from many of the standard presentations that we were giving to members of the death investigation team".
"When I redid the presentation that the coroner's office gives as part of the major case management course, that was taken out of the course," McLellan explained.
"So, I can't say that there has been a specific effort to send out a communication saying, Don't think dirty, but the approach has been different through our educational courses, through our new courses for coroners, and the emphasis is to keep an open mind. And, as such, you know, we'll end up with the best quality of death investigation."
I will give the last word for this posting to Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist, who told the Ontario Court of Appeal in the Mullins-Johnson case that new guidelines effectively tell Ontario's pathologists and coroners: "Don't think dirty; Think objectively. Think truth."
Harold Levy...hlevy15@gmail.com...
Tuesday, November 27, 2007
Goudge Inquiry: "Thinking Dirty: Dr. Cairns Defends "The Indefensible;"
This blogster was surprised to hear Dr. James Cairns, Deputy Chief Coroner attempt to defend the idea of "thinking dirty" which became an official policy in 1994 when it was circulated to Coroners, pathologists and polices services across Ontario.
"The police and the coroner are both at a scene as independent parties," said the memo which was circulated by then Chief Coroner, Dr. James Young.
"While working together they should also be prepared to vigorously, but fairly, question each other's conclusions about the death.
Everyone should be "thinking dirty" and not get lulled into accepting the most obvious conclusions at the beginning of an investigation."
This was not a few lines spouted from the podium of a coroner's conference.
It was an official document containing instructions from head office.
It was the party line.
I was surprised to hear Dr. Cairns defend this policy - using an example that all car accidents may not be innocent - because the policy, which was discontinued ten years later when Dr. Barry McLellan became chief coroner, is indefensible.
The evidence that it is indefensible lies in Dr. McLellan's stated reason for ordering a review into forty-five suspicious death of children cases in which Dr. Smith was involved, in order to restore public confidence in the coroner's office.
The evidence also lies before our very eyes in the twenty cases before the Goudge inquiries in which dirty thinking turned the most innocent but unfortunate falls, bumps of a child's head on a table, or the mere fact that a child's death could not be explained into homicides - and invariably into criminal charges.
Worse, the evidence lies in the all too many individuals who went through so much agony because of a policy based on suspicion rather than the dictates of science - a policy that turned doctors into police officers- and made heroes out of those who could boast that they, in true CSI fashion, had detected crimes.
But to Dr. Cairns, "thinking dirty" was just another slogan - as he put it, "like the Nike Swoosh."
Nike Swoosh?
When Commissioner Goudge pressed Dr. Cairns as to whether "thinking dirty" was akin to a presumption of guilt, Cairns replied: "No, it was not a presumption of guilt. It was to ensure that you haven't missed a homicide."
In this Blogster's humble opinion the coroner or pathologist should never be burdened with considerations of guilt or innocence.
His or her job is to independently, thoroughly and impartially gather the evidence - no matter where it may lead - and to ground all findings on the of science as opposed to suspicion or ideology.
We have all seen - through the evidence called thus far the inquiry - what happens when this isn't isn't the case.
Leave the policing to the cops.
Harold Levy; hlevy15@gmail.com;
"The police and the coroner are both at a scene as independent parties," said the memo which was circulated by then Chief Coroner, Dr. James Young.
"While working together they should also be prepared to vigorously, but fairly, question each other's conclusions about the death.
Everyone should be "thinking dirty" and not get lulled into accepting the most obvious conclusions at the beginning of an investigation."
This was not a few lines spouted from the podium of a coroner's conference.
It was an official document containing instructions from head office.
It was the party line.
I was surprised to hear Dr. Cairns defend this policy - using an example that all car accidents may not be innocent - because the policy, which was discontinued ten years later when Dr. Barry McLellan became chief coroner, is indefensible.
The evidence that it is indefensible lies in Dr. McLellan's stated reason for ordering a review into forty-five suspicious death of children cases in which Dr. Smith was involved, in order to restore public confidence in the coroner's office.
The evidence also lies before our very eyes in the twenty cases before the Goudge inquiries in which dirty thinking turned the most innocent but unfortunate falls, bumps of a child's head on a table, or the mere fact that a child's death could not be explained into homicides - and invariably into criminal charges.
Worse, the evidence lies in the all too many individuals who went through so much agony because of a policy based on suspicion rather than the dictates of science - a policy that turned doctors into police officers- and made heroes out of those who could boast that they, in true CSI fashion, had detected crimes.
But to Dr. Cairns, "thinking dirty" was just another slogan - as he put it, "like the Nike Swoosh."
Nike Swoosh?
When Commissioner Goudge pressed Dr. Cairns as to whether "thinking dirty" was akin to a presumption of guilt, Cairns replied: "No, it was not a presumption of guilt. It was to ensure that you haven't missed a homicide."
In this Blogster's humble opinion the coroner or pathologist should never be burdened with considerations of guilt or innocence.
His or her job is to independently, thoroughly and impartially gather the evidence - no matter where it may lead - and to ground all findings on the of science as opposed to suspicion or ideology.
We have all seen - through the evidence called thus far the inquiry - what happens when this isn't isn't the case.
Leave the policing to the cops.
Harold Levy; hlevy15@gmail.com;
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