"CALLS TO “THINK DIRTY” HAVE BEEN PART OF THE PROBLEM IN THE INVESTIGATION OF SUDDEN UNEXPECTED DEATHS OF INFANTS, LEADING TO INSENSITIVE TREATMENT OF BEREAVED PARENTS, INADEQUATE INVESTIGATIONS, INCORRECT DIAGNOSES, AND LOSS OF INFORMATION ABOUT THE CAUSES OF THE MAJORITY OF SUDDEN UNEXPECTED DEATHS OF INFANTS THAT ARE NATURAL."
JOYCE EPSTEIN: FOUNDATION FOR THE STUDY OF ENGLISH DEATHS:
-------------------------------------------------------------------------------
In earlier postings in the series we saw how Ontario's "think dirty" policy - originally aimed at detecting "femicides" - had an apparent link to serial rapists and killers Paul Bernardo and Karla Homolka in the early 1990's.
In that case, there was a public outcry after police and the pathologists had failed to detect the fact that Tammy Homolka had been drugged with Halcion, a hypnotic, and raped before dying a short time later.
It is therefore interesting to learn that a "think dirty" policy was advocated in England in the late 1990's in the aftermath of the convictions of Dr. Harold Shipman - who some regard as the world's most prolific serial killer.
In that case as well there was a public outcry after police and pathologists had failed to detect to detect the administration of a drug - overdoses of morphine - in some of his victims.
Wikipdedia tells us that:
"Harold Frederick "Fred" Shipman (January 14, 1946 – January 13, 2004) was an English general practitioner and serial killer.
On 31 January 2000, Shipman was found guilty of 15 murders and sentenced to life imprisonment with a recommendation from the trial judge that he should never be released.
Two years later, Home Secretary David Blunkett agreed with this recommendation.
After his trial, a public inquest chaired by Dame Janet Smith, decided that there was enough evidence to suggest that Shipman had killed a total of over 215 people, about 80 percent of them female.
His youngest victim was Peter Lewis, a 41-year-old man.
The official inquiry into his career concluded that there existed "real suspicion" that he had murdered a total of over 215 people.
Some reports have claimed that Shipman may have killed more than 215 people.
Much of Britain's legislation concerning health care and medicine was reviewed and modified as a direct and indirect result of Shipman's crimes, especially after the findings of the Shipman Inquiry, which began on September 1, 2000 and lasted almost two years.
Shipman is the only British doctor to have been found guilty of murdering his patients......
Six doctors who had signed cremation forms for Shipman's victims were charged with misconduct by the General Medical Council, which claimed that they should have noticed the pattern between Shipman's home visits and his patients' deaths.
All of these doctors were found not guilty.
Shipman's widow, Primrose Shipman, was called to give evidence about two of the deaths during the inquiry.
She maintained her husband's innocence both before and after the prosecution.
In October 2005, a similar hearing was held against two doctors who worked at Tameside General Hospital in 1994, and had failed to detect that Shipman had deliberately administered a "grossly excessive" dose of morphine.
Here is where "think dirty" comes in;
Dame Janet Smith's many recommendations including the creation of a team of coroners' investigators trained to “think dirty” about the causes of death.
Dame Janet had received testimony about Ontario's system from then Chief Coroner Dr. James Young, who travelled to England to testify.
This portion of her report, based on Dr. Young's evidence, indicates that in Ontario:
"Following a report of a death, investigating coroners are instructed to attend the scene of death, unless there's good reason for not doing so. Investigating coroners should complete a certificate confirming that he/she has legally seized the body. Investigating coroners are instructed considered -- to consider the worst possibility or 'think dirty' and to liaise with the family in investigating the death."
After the Shipman report was released - with its "think dirty" recommendation - a British organization called "the Foundation for the Study of Infant Deaths" was quick to point out that this particular recommendation could have serious adverse consequences in the case of investigations of infant deaths.
This was pointed out by Joyce Epstein, the Association's director, in a letter to a medical publication.
"Your legal correspondent reports that the Shipman inquiry calls for coroners’ investigators to “think dirty” about the causes of death (19 July)," the letter began.
"It is important to point out that Dame Janet Smith, who heads the inquiry, made clear in her Discussion Paper of October 2002 that the investigation of Sudden Unexpected Deaths of Infants (referred to by the British as SUDI) has to be handled differently," it continued;
"Calls to “think dirty” have been part of the problem in the investigation of Sudden Unexpected Deaths of Infants, leading to insensitive treatment of bereaved parents, inadequate investigations, incorrect diagnoses, and loss of information about the causes of the majority of Sudden Unexpected Deaths of Infants that are natural."
In Sudden Unexpected Deaths of Infants, suspicion should be the end point, not the starting point, of any coronial investigation.
The Foundation for the Study of Infant Deaths has been encouraging medical and forensic professionals to cooperate in undertaking comprehensive, standardised and thorough investigations of sudden unexpected deaths of infants.
The Foundation gave evidence to the Shipman inquiry to try to ensure that any changes recommended in the coronial investigation process in response to Shipman do not adversely affect handling of Sudden Unexpected Deaths of Infants and requesting the inquiry to take advantage of the opportunity to improve investigation of infant as well as adult deaths.
The Shipman Report’s overall recommendations are welcome, in particular the provision for medical expertise in coronial investigations.
Dame Janet said in the October 2002 paper that a new coroners’ service should develop protocols for special handling of Sudden Unexpected Deaths of Infants and we concur.
It would be extremely unfortunate if general reporting of the Shipman inquiry gave renewed life to the “think dirty” catchphrase which has caused so much harm in the investigation of infant deaths."
It appears from Ms. Epstein's comments that Dame Janet was aware that the investigation of the sudden unexpected deaths of infants had to be handled differently than those of adults.
I do not see any indication from the evidence called at the Goudge Inquiry that Ontario's Chief Coroner's Office directed its mind to the difference - and to potential consequences - before circulating its "think dirty" policy in 1995;
Harold Levy...hlevy15@gmail.com'
Showing posts with label bernardo. Show all posts
Showing posts with label bernardo. Show all posts
Thursday, May 15, 2008
Wednesday, May 14, 2008
Part Two: Think Dirty: The Paul Bernardo Connection;
MR. MARK SANDLER: FIRST OF ALL, WHO WAS RESPONSIBLE FOR THE USE OF THE PHRASE AND WHAT, IN YOUR VIEW, DID IT REFER TO?
DR. JAMES YOUNG: I DOUBT ANYONE WOULD WANT TO TAKE OWNERSHIP FOR IT NOW, BUT I CAN TELL YOU I WON'T TAKE OWNERSHIP. I DON'T KNOW WITH CERTAINTY. I MEAN, I SUPPOSE THE PERSON WHO USED IT THE MOST OFTEN WAS DR. CAIRNS, BUT I REALLY DON'T KNOW -- I DON'T KNOW WHERE IT CAME FROM WITH ANY CERTAINTY. WHAT WAS HAPPENING AT THAT POINT IN TIME --"
FORMER CHIEF CORONER DR. JAMES YOUNG TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
MS. LINDA ROTHSTEIN: DO YOU NOT ACCEPT, DR. CAIRNS, THAT AT THE VERY LEAST, THE LANGUAGE "THINKING DIRTY" MAY SUGGEST A LACK OF OBJECTIVITY, A MIND-SET THAT MAY CONCLUDE THAT THERE IS FOUL PLAY WHERE, INDEED, THERE ISN'T ANY?
DR. CAIRNS: I THINK THERE IS A VERY DISTINCT DIFFERENCE BETWEEN "THINKING DIRTY" AND "ACTING DIRTY" AND I THINK "THINKING DIRTY" MEANS DO NOT ACCEPT THINGS AT FACE VALUE; CONSIDER THAT THERE -- THAT THERE IS SOMETHING ELSE GOING ON...
FORMER DEPUTY CHIEF CORONER DR. JAMES CAIRNS TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
MS. LINDA ROTHSTEIN: NOW, THE NOTION OF HAVING A VERY HIGH INDEX OF SUSPICION AND, INDEED, THE NOTION OF THINKING DIRTY, WHAT, IF ANY, IMPACT DID THE EXPERIENCE THAT YOUR OFFICE HAVE WITH THIS CASE AND WITH FEMICIDE HAVE ON ITS APPROACH TO THE IN -- INVESTIGATION OF INFANT DEATHS?
DR. CAIRNS: I THINK ONE COULD SAY THAT IT WAS JUST TRANSPOSED FROM ONE TO THE OTHER. I FELT IT HAD A -- EXACTLY THE SAME TYPE OF -- OF IMPLICATION.
FORMER DEPUTY CHIEF CORONER DR. JAMES CAIRNS TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
In a previous post, we saw how former Chief Coroner Dr. James Young declined "to take ownership" when asked by Goudge Commission counsel Linda Rothstein who was responsible for use of the phrase "think dirty" - and referred to Dr.James Cairns as, "the person who used it the most often."
I am therefore presenting Dr. Cairn's interpretation of the phrase "think dirty" and its origins in his evidence to the Goudge Inquiry:
MS. LINDA ROTHSTEIN: All right. And if you would be good enough to turn to page 5 of that document, I want to take you to an excerpt of some interest, I think, to the Commissioner. Page 5, please. I'm reading, Dr. Cairns, the first full sentence on that page.
"The police and the coroner are both at a scene as independent parties. While
working together they should also be prepared to vigorously, but fairly,
question each other's conclusions about the death. Everyone should be [quote]
'thinking dirty' [close quote] and not get lulled into accepting the most
obvious conclusions at the beginning of an investigation."
Now, may I ask you, Dr. Cairns, is that the first time, to you knowledge, that the expression, "thinking dirty" found its way into a Chief Coroner's Office policy?
DR. CAIRNS: Yes.
MS. LINDA ROTHSTEIN: Where did you first hear that expression, Dr. Cairns?
DR. CAIRNS: I think I first heard that expression from Jack Press.
MS. LINDA ROTHSTEIN: Who was he?
DR. CAIRNS: Jack Press had been a Toronto homicide officer who had -- when he retired, had moved over to be the liaison officer for Dr. Hillsdon Smith with -- with police.
MS. LINDA ROTHSTEIN: And in what context did Dr. -- did -- sorry -- did Jack Press use that terminology?
DR. CAIRNS: I think probably as it's explained here, don't -- don't accept things as they are. Think of more sinister applications or there may be
a more sinister explanation.
MS. LINDA ROTHSTEIN: And if we can go over the page to the last page of that memo, 623, the last sentence reads:
"This tragic case serves as an excellent example of the complexities of investigating female deaths and reminds us that we must approach all such investigations with a suspicious mind."
DR. CAIRNS: Correct.
COMMISSIONER STEPHEN GOUDGE: Sorry, where is that?
Ms. LINDA ROTHSTEIN: The last page, at the bottom there, Commissioner. The last --
COMMISSIONER STEPHEN GOUDGE: Yes, I have it, thank you.
C0NTINUED BY MS. LINDA ROTHSTEIN:
MS. LINDA ROTHSTEIN: And again, Dr. Cairns, was that suggestion taken to heart by the coroner's office?
DR. CAIRNS: Yes, it was, and of interest, at that particular time, given budgetary restraints, the government thought they could do away with all reconstructions and that, sort of, the policeman could be a jack of all trades, and this highlighted the need for experts in reconstruction. It helps me when I'm tied up on the 410 or the 401 for twenty-four (24) hours because you're not
allowed to understand why they have to close down the roads. And in fact, that was impetus for ensuring that these specialized services were not disbanded. And following this, I can think of at least three (3) further, shall we say, car accidents where, in fact, because of this a -- a homicide did -- was not missed. And we educated both the police and the coroners to stop using the word, "a car accident;" that there has been a -- a motor fatality. And it may be
natural causes, it may be accident, it may be suicide, but if you're subliminally are saying I've been called to a car accident, you're probably subliminally accepting it -- it is an accident. So admittedly, a major issue in terms of both coroners and police keeping an open eye in terms of is this really consistent with an accident, particularly where there was a husband and wife, or a boyfriend and a girlfriend in the vehicle, at the time.
MS. LINDA ROTHSTEIN: Now, the notion of having a very high index of suspicion and, indeed, the notion of thinking dirty, what, if any, impact did the
experience that your office have with this case and with femicide have on its approach to the in -- investigation of infant deaths?
DR. CAIRNS: I think one could say that it was just transposed from one to the other. I felt it had a -- exactly the same type of -- of implication.
MS. LINDA ROTHSTEIN: And we know, Dr. Cairns, that, indeed, your office was responsible for creating one (1) of the first guidelines that anyone
knows of in coroners context dealing with the investigation of sudden and unexpected infant deaths, Memorandum 631 in 1995. But before we look at that again, give the Commissioner the appropriate context; what was the climate that the Coroner's Office was responding to at that time in terms of the level of community alarm about the potential for child abuse?
DR. CAIRNS: I think the issue of child abuse in the late '80s and early '90s was just starting to become on the horizon. I, certainly, at medical school, had never been taught anything about child abuse, and most of my Canadian colleagues who had graduated in the '70s and the very early '80s had no
education about child abuse. And this was something that was -- was starting to -- to be accepted as a sad but real issue in -- in the late '80s, early '90s.
MS. LINDA ROTHSTEIN: And had there been any inquests that had increased the level of concern that the OCCO had about that issue?
DR. CAIRNS: There had, and I had presided over -- over one (1) of those inquests, so that was also occurring.
MS. LINDA ROTHSTEIN: All right. Now, we've spent some time with the Commissioner going through the -- the various aspects of that memorandum. Accepting that, indeed, it was a leader in developing protocols around the investigation of sudden and unexpected child deaths at its time, do you now agree with Dr. Pollanen that in 2007, it is better for all members of the Death
Investigation Team to approach their work by thinking objectively or thinking about truth, rather than "thinking dirty"?
DR. CAIRNS: I -- I don't because I think we're playing on a semantic of words. In that directive in 1995, and if you could bring me to the tab because there is the word "think dirty", and then after that there is an explanation of what that means.
MS. LINDA ROTHSTEIN: Would you turn up 090594, please? I -- I --
COMMISSIONER STEPHEN GOUDGE: Is that in this binder?
MS. LINDA ROTHSTEIN: It's in the Coroner's Manual, sir.
COMMISSIONER STEPHEN GOUDGE: All right.
CONTINUED BY MS. LINDA ROTHSTEIN:
MS. LINDA ROTHSTEIN: Dr. Cairns, I don't think there's any doubt and I don't for a moment suggest that it doesn't -- it isn't explained by meaning that one
should have a high index of suspicion, so if that was the passage that you wanted to show me to, there's no doubt about that.
DR. CAIRNS: That -- that -- that is correct, yes.
MS. LINDA ROTHSTEIN: All right. So, do I understand you to say, Dr. Cairns, that in your view this is just a difference of language that doesn't have any actual difference in meaning?
DR. CAIRNS: That -- that is exactly my position.
MS. LINDA ROTHSTEIN: Do you not accept, Dr. Cairns, that at the very least, the language "thinking dirty" may suggest a lack of objectivity, a mind-set that may conclude that there is foul play where, indeed, there isn't any?
DR. CAIRNS: I think there is a very distinct difference between "thinking dirty" and "acting dirty" and I think "thinking dirty" means do not accept things at face value; consider that there -- that there is something else going on.
If -- if I could ask you to direct me to the memo put out by Dr. McLellan in 2004, once again dealing with femicide; it -- it's to try and make -- make a point on semantics of words.
COMMISSIONER STEPHEN GOUDGE: Just while you're looking at that, Dr. Cairns, can I just go back and ask a couple of questions about the origination of
the phrase? When the memo that you've been taken to of June 1994 was circulated by Dr. Young, was Ontario the first to put that kind of language out to its coroners, pathologists, and policing services, or was that something that was done elsewhere at that time, or do you know?
DR. CAIRNS: I'm sorry, Commissioner, I -- I couldn't give you a definitive
answer on that.
COMMISSIONER STEPHEN GOUDGE: Okay. And I took from what you said that what was being sought to be captured then was the recommendation of the coroner's counsel that one should assume all deaths are homicide until satisfied they're not, is that --
DR. CAIRNS: Absolutely.
COMMISSIONER STEPHEN GOUDGE: That's what you were trying to capture.
DR. CAIRNS: Yes. That -- that -- that was the intention, yes.
COMMISSIONER STEPHEN GOUDGE: Okay.
DR. CAIRNS: They were to "think dirty" was a catchy phrase which seemed at the time to bring people's attention to it.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. CAIRNS: It was like the Nike swoosh; it was just a way of saying the same thing and that's -- that's where it was coming from, yes.
COMMISSIONER STEPHEN GOUDGE: In lawyers' terms, would that be captured in the notion of a presumption of guilt?
DR. CAIRNS: No. It was not presumption of guilt, it was to ensure that you haven't missed a homicide. So it would ensure that you do all the appropriate things to -- to satisfy yourself that there hasn't been a homicide.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. CAIRNS: Just -- I think, speaking from -- from my own point of view, if you're investigating deaths, I think the one (1) thing we want to make sure we don't do is to let homicides go undetected. And this was: Do not accept at face value things you have to consider that there may be some other explanation.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. CAIRNS: But it certainly wasn't as a way of right to everybody, this is an -- automatically a homicide.
CONTINUED BY MS. LINDA ROTHSTEIN:
MS. LINDA ROTHSTEIN: Dr. Cairns, you had asked me to find you the May 12, 2004, memorandum, 0408, by Dr. McLellan with respect to the issue of females dying of apparent accidental or suicidal manner in the company of a male partner. Commissioner, it's at 032431. I'm going to read to you from that, Dr. Cairns, the language I think you were suggesting was important to us. --
MR. BRIAN GOVER: I wonder --
MS. LINDA ROTHSTEIN: -- .
MR. BRIAN GOVER: Thank you. I was going to ask that it be brought up for the witness to see.
MS. LINDA ROTHSTEIN: I think the language you were going to take me to starts at the bottom of that page, does it not?
"Whenever a female dies as a result of apparent suicide or accident where the
only witness is a male partner, past or present, the autopsy will be conducted
by a regional coroner's pathologist who currently performs homicide autopsies.
These autopsies will be conducted as if the death has taken place under
suspicious circumstances".
DR. CAIRNS: That's correct. This is a follow-up memo to the one (1) that you referred to earlier that was put out by Dr. Young. And what this is saying is at those times we were asking the coroner and the pathologist to pay note to the possibility. And here it's been added up a level in that now these autopsies will not be done locally, they will be done only at a forensic pathology centre of
excellence and will be done by a forensic pathologist. And that autopsy will be done with heightened concern that this may be a homicide and therefore the examination will be much more elaborate, including peeling back skin and doing a dry neck dissection. So this is going to a greater extent to rule out the possibility that -- that this is a homicide.
MS. LINDA ROTHSTEIN: And then turning to the next page, Dr. Cairns. Would you turn to the next page, please, Registrar.
"Although this policy deals with apparent accidental and suicidal deaths, coroners and police are reminded to remain vigilant for the
possibility of foul play in every circumstance where..."
And then it sets out the problematic circumstances. And, again, that's the language that you say, as I understand it, Dr. Cairns, was mean to be captured by the expression "thinking dirty"?
DR. CAIRNS: Correct. Commissioner, if -- if I could explain to you, and this
is not in any way a flippant comment. It's a serious comment, but different people use language in a different way. And I know what Dr. McLellan is saying and
I know what Dr. Young and myself were saying. I think they're the same but they're characterized differently. I don't mean this flippantly, but I think the best way I can describe it to you is I would called a shovel a shovel; Dr. McLellan might be inclined to call it an agriculture instrument.
MS. LINDA ROTHSTEIN: And that's how you explain the difference of language between this language which we've just examined which was authored by Dr.
McLellan and the third -- thinking dirty language which you and Dr. Young were accustomed to using?
DR. CAIRNS: That is correct.
MS. LINDA ROTHSTEIN: All right. Thank you.
Next posting: "Part Three; Think Dirty; The Paul Bernardo Connection; A perspective;"
Harold Levy...hlevy15@gmail.com;
DR. JAMES YOUNG: I DOUBT ANYONE WOULD WANT TO TAKE OWNERSHIP FOR IT NOW, BUT I CAN TELL YOU I WON'T TAKE OWNERSHIP. I DON'T KNOW WITH CERTAINTY. I MEAN, I SUPPOSE THE PERSON WHO USED IT THE MOST OFTEN WAS DR. CAIRNS, BUT I REALLY DON'T KNOW -- I DON'T KNOW WHERE IT CAME FROM WITH ANY CERTAINTY. WHAT WAS HAPPENING AT THAT POINT IN TIME --"
FORMER CHIEF CORONER DR. JAMES YOUNG TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
MS. LINDA ROTHSTEIN: DO YOU NOT ACCEPT, DR. CAIRNS, THAT AT THE VERY LEAST, THE LANGUAGE "THINKING DIRTY" MAY SUGGEST A LACK OF OBJECTIVITY, A MIND-SET THAT MAY CONCLUDE THAT THERE IS FOUL PLAY WHERE, INDEED, THERE ISN'T ANY?
DR. CAIRNS: I THINK THERE IS A VERY DISTINCT DIFFERENCE BETWEEN "THINKING DIRTY" AND "ACTING DIRTY" AND I THINK "THINKING DIRTY" MEANS DO NOT ACCEPT THINGS AT FACE VALUE; CONSIDER THAT THERE -- THAT THERE IS SOMETHING ELSE GOING ON...
FORMER DEPUTY CHIEF CORONER DR. JAMES CAIRNS TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
MS. LINDA ROTHSTEIN: NOW, THE NOTION OF HAVING A VERY HIGH INDEX OF SUSPICION AND, INDEED, THE NOTION OF THINKING DIRTY, WHAT, IF ANY, IMPACT DID THE EXPERIENCE THAT YOUR OFFICE HAVE WITH THIS CASE AND WITH FEMICIDE HAVE ON ITS APPROACH TO THE IN -- INVESTIGATION OF INFANT DEATHS?
DR. CAIRNS: I THINK ONE COULD SAY THAT IT WAS JUST TRANSPOSED FROM ONE TO THE OTHER. I FELT IT HAD A -- EXACTLY THE SAME TYPE OF -- OF IMPLICATION.
FORMER DEPUTY CHIEF CORONER DR. JAMES CAIRNS TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
In a previous post, we saw how former Chief Coroner Dr. James Young declined "to take ownership" when asked by Goudge Commission counsel Linda Rothstein who was responsible for use of the phrase "think dirty" - and referred to Dr.James Cairns as, "the person who used it the most often."
I am therefore presenting Dr. Cairn's interpretation of the phrase "think dirty" and its origins in his evidence to the Goudge Inquiry:
MS. LINDA ROTHSTEIN: All right. And if you would be good enough to turn to page 5 of that document, I want to take you to an excerpt of some interest, I think, to the Commissioner. Page 5, please. I'm reading, Dr. Cairns, the first full sentence on that page.
"The police and the coroner are both at a scene as independent parties. While
working together they should also be prepared to vigorously, but fairly,
question each other's conclusions about the death. Everyone should be [quote]
'thinking dirty' [close quote] and not get lulled into accepting the most
obvious conclusions at the beginning of an investigation."
Now, may I ask you, Dr. Cairns, is that the first time, to you knowledge, that the expression, "thinking dirty" found its way into a Chief Coroner's Office policy?
DR. CAIRNS: Yes.
MS. LINDA ROTHSTEIN: Where did you first hear that expression, Dr. Cairns?
DR. CAIRNS: I think I first heard that expression from Jack Press.
MS. LINDA ROTHSTEIN: Who was he?
DR. CAIRNS: Jack Press had been a Toronto homicide officer who had -- when he retired, had moved over to be the liaison officer for Dr. Hillsdon Smith with -- with police.
MS. LINDA ROTHSTEIN: And in what context did Dr. -- did -- sorry -- did Jack Press use that terminology?
DR. CAIRNS: I think probably as it's explained here, don't -- don't accept things as they are. Think of more sinister applications or there may be
a more sinister explanation.
MS. LINDA ROTHSTEIN: And if we can go over the page to the last page of that memo, 623, the last sentence reads:
"This tragic case serves as an excellent example of the complexities of investigating female deaths and reminds us that we must approach all such investigations with a suspicious mind."
DR. CAIRNS: Correct.
COMMISSIONER STEPHEN GOUDGE: Sorry, where is that?
Ms. LINDA ROTHSTEIN: The last page, at the bottom there, Commissioner. The last --
COMMISSIONER STEPHEN GOUDGE: Yes, I have it, thank you.
C0NTINUED BY MS. LINDA ROTHSTEIN:
MS. LINDA ROTHSTEIN: And again, Dr. Cairns, was that suggestion taken to heart by the coroner's office?
DR. CAIRNS: Yes, it was, and of interest, at that particular time, given budgetary restraints, the government thought they could do away with all reconstructions and that, sort of, the policeman could be a jack of all trades, and this highlighted the need for experts in reconstruction. It helps me when I'm tied up on the 410 or the 401 for twenty-four (24) hours because you're not
allowed to understand why they have to close down the roads. And in fact, that was impetus for ensuring that these specialized services were not disbanded. And following this, I can think of at least three (3) further, shall we say, car accidents where, in fact, because of this a -- a homicide did -- was not missed. And we educated both the police and the coroners to stop using the word, "a car accident;" that there has been a -- a motor fatality. And it may be
natural causes, it may be accident, it may be suicide, but if you're subliminally are saying I've been called to a car accident, you're probably subliminally accepting it -- it is an accident. So admittedly, a major issue in terms of both coroners and police keeping an open eye in terms of is this really consistent with an accident, particularly where there was a husband and wife, or a boyfriend and a girlfriend in the vehicle, at the time.
MS. LINDA ROTHSTEIN: Now, the notion of having a very high index of suspicion and, indeed, the notion of thinking dirty, what, if any, impact did the
experience that your office have with this case and with femicide have on its approach to the in -- investigation of infant deaths?
DR. CAIRNS: I think one could say that it was just transposed from one to the other. I felt it had a -- exactly the same type of -- of implication.
MS. LINDA ROTHSTEIN: And we know, Dr. Cairns, that, indeed, your office was responsible for creating one (1) of the first guidelines that anyone
knows of in coroners context dealing with the investigation of sudden and unexpected infant deaths, Memorandum 631 in 1995. But before we look at that again, give the Commissioner the appropriate context; what was the climate that the Coroner's Office was responding to at that time in terms of the level of community alarm about the potential for child abuse?
DR. CAIRNS: I think the issue of child abuse in the late '80s and early '90s was just starting to become on the horizon. I, certainly, at medical school, had never been taught anything about child abuse, and most of my Canadian colleagues who had graduated in the '70s and the very early '80s had no
education about child abuse. And this was something that was -- was starting to -- to be accepted as a sad but real issue in -- in the late '80s, early '90s.
MS. LINDA ROTHSTEIN: And had there been any inquests that had increased the level of concern that the OCCO had about that issue?
DR. CAIRNS: There had, and I had presided over -- over one (1) of those inquests, so that was also occurring.
MS. LINDA ROTHSTEIN: All right. Now, we've spent some time with the Commissioner going through the -- the various aspects of that memorandum. Accepting that, indeed, it was a leader in developing protocols around the investigation of sudden and unexpected child deaths at its time, do you now agree with Dr. Pollanen that in 2007, it is better for all members of the Death
Investigation Team to approach their work by thinking objectively or thinking about truth, rather than "thinking dirty"?
DR. CAIRNS: I -- I don't because I think we're playing on a semantic of words. In that directive in 1995, and if you could bring me to the tab because there is the word "think dirty", and then after that there is an explanation of what that means.
MS. LINDA ROTHSTEIN: Would you turn up 090594, please? I -- I --
COMMISSIONER STEPHEN GOUDGE: Is that in this binder?
MS. LINDA ROTHSTEIN: It's in the Coroner's Manual, sir.
COMMISSIONER STEPHEN GOUDGE: All right.
CONTINUED BY MS. LINDA ROTHSTEIN:
MS. LINDA ROTHSTEIN: Dr. Cairns, I don't think there's any doubt and I don't for a moment suggest that it doesn't -- it isn't explained by meaning that one
should have a high index of suspicion, so if that was the passage that you wanted to show me to, there's no doubt about that.
DR. CAIRNS: That -- that -- that is correct, yes.
MS. LINDA ROTHSTEIN: All right. So, do I understand you to say, Dr. Cairns, that in your view this is just a difference of language that doesn't have any actual difference in meaning?
DR. CAIRNS: That -- that is exactly my position.
MS. LINDA ROTHSTEIN: Do you not accept, Dr. Cairns, that at the very least, the language "thinking dirty" may suggest a lack of objectivity, a mind-set that may conclude that there is foul play where, indeed, there isn't any?
DR. CAIRNS: I think there is a very distinct difference between "thinking dirty" and "acting dirty" and I think "thinking dirty" means do not accept things at face value; consider that there -- that there is something else going on.
If -- if I could ask you to direct me to the memo put out by Dr. McLellan in 2004, once again dealing with femicide; it -- it's to try and make -- make a point on semantics of words.
COMMISSIONER STEPHEN GOUDGE: Just while you're looking at that, Dr. Cairns, can I just go back and ask a couple of questions about the origination of
the phrase? When the memo that you've been taken to of June 1994 was circulated by Dr. Young, was Ontario the first to put that kind of language out to its coroners, pathologists, and policing services, or was that something that was done elsewhere at that time, or do you know?
DR. CAIRNS: I'm sorry, Commissioner, I -- I couldn't give you a definitive
answer on that.
COMMISSIONER STEPHEN GOUDGE: Okay. And I took from what you said that what was being sought to be captured then was the recommendation of the coroner's counsel that one should assume all deaths are homicide until satisfied they're not, is that --
DR. CAIRNS: Absolutely.
COMMISSIONER STEPHEN GOUDGE: That's what you were trying to capture.
DR. CAIRNS: Yes. That -- that -- that was the intention, yes.
COMMISSIONER STEPHEN GOUDGE: Okay.
DR. CAIRNS: They were to "think dirty" was a catchy phrase which seemed at the time to bring people's attention to it.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. CAIRNS: It was like the Nike swoosh; it was just a way of saying the same thing and that's -- that's where it was coming from, yes.
COMMISSIONER STEPHEN GOUDGE: In lawyers' terms, would that be captured in the notion of a presumption of guilt?
DR. CAIRNS: No. It was not presumption of guilt, it was to ensure that you haven't missed a homicide. So it would ensure that you do all the appropriate things to -- to satisfy yourself that there hasn't been a homicide.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. CAIRNS: Just -- I think, speaking from -- from my own point of view, if you're investigating deaths, I think the one (1) thing we want to make sure we don't do is to let homicides go undetected. And this was: Do not accept at face value things you have to consider that there may be some other explanation.
COMMISSIONER STEPHEN GOUDGE: Right.
DR. CAIRNS: But it certainly wasn't as a way of right to everybody, this is an -- automatically a homicide.
CONTINUED BY MS. LINDA ROTHSTEIN:
MS. LINDA ROTHSTEIN: Dr. Cairns, you had asked me to find you the May 12, 2004, memorandum, 0408, by Dr. McLellan with respect to the issue of females dying of apparent accidental or suicidal manner in the company of a male partner. Commissioner, it's at 032431. I'm going to read to you from that, Dr. Cairns, the language I think you were suggesting was important to us. --
MR. BRIAN GOVER: I wonder --
MS. LINDA ROTHSTEIN: -- .
MR. BRIAN GOVER: Thank you. I was going to ask that it be brought up for the witness to see.
MS. LINDA ROTHSTEIN: I think the language you were going to take me to starts at the bottom of that page, does it not?
"Whenever a female dies as a result of apparent suicide or accident where the
only witness is a male partner, past or present, the autopsy will be conducted
by a regional coroner's pathologist who currently performs homicide autopsies.
These autopsies will be conducted as if the death has taken place under
suspicious circumstances".
DR. CAIRNS: That's correct. This is a follow-up memo to the one (1) that you referred to earlier that was put out by Dr. Young. And what this is saying is at those times we were asking the coroner and the pathologist to pay note to the possibility. And here it's been added up a level in that now these autopsies will not be done locally, they will be done only at a forensic pathology centre of
excellence and will be done by a forensic pathologist. And that autopsy will be done with heightened concern that this may be a homicide and therefore the examination will be much more elaborate, including peeling back skin and doing a dry neck dissection. So this is going to a greater extent to rule out the possibility that -- that this is a homicide.
MS. LINDA ROTHSTEIN: And then turning to the next page, Dr. Cairns. Would you turn to the next page, please, Registrar.
"Although this policy deals with apparent accidental and suicidal deaths, coroners and police are reminded to remain vigilant for the
possibility of foul play in every circumstance where..."
And then it sets out the problematic circumstances. And, again, that's the language that you say, as I understand it, Dr. Cairns, was mean to be captured by the expression "thinking dirty"?
DR. CAIRNS: Correct. Commissioner, if -- if I could explain to you, and this
is not in any way a flippant comment. It's a serious comment, but different people use language in a different way. And I know what Dr. McLellan is saying and
I know what Dr. Young and myself were saying. I think they're the same but they're characterized differently. I don't mean this flippantly, but I think the best way I can describe it to you is I would called a shovel a shovel; Dr. McLellan might be inclined to call it an agriculture instrument.
MS. LINDA ROTHSTEIN: And that's how you explain the difference of language between this language which we've just examined which was authored by Dr.
McLellan and the third -- thinking dirty language which you and Dr. Young were accustomed to using?
DR. CAIRNS: That is correct.
MS. LINDA ROTHSTEIN: All right. Thank you.
Next posting: "Part Three; Think Dirty; The Paul Bernardo Connection; A perspective;"
Harold Levy...hlevy15@gmail.com;
Monday, May 12, 2008
Part One: "Think Dirty": The Paul Bernardo Connection;
"DESPITE THE PAIR'S QUESTIONABLE BEHAVIOUR - VACUUMING AND WASHING LAUNDRY IN THE MIDDLE OF THE NIGHT, DESPITE THE PRESENCE OF A CHEMICAL BURN ON TAMMY'S FACE, NIAGARA REGIONAL POLICE AND THE HOMOLKA FAMILY ACCEPTED THE PAIR'S VERSION OF EVENTS;"
WIKIPEDIA ACCOUNT OF THE DRUG/RAPE RELATED KILLING OF TAMMY HOMOLKA BY HER SISTER KARLA AND PAUL BERNARDO;
-------------------------------------------------------------------------------
MR. MARK SANDLER: AND AS I'M SURE IT HAS NOT BEEN LOST ON YOU, ONE (1) OF THE ISSUES THAT -- THAT HAS BEEN DISCUSSED HERE IS -- IS THE EXPRESSION, THAT'S USED IN THE MANUAL, "THINKING DIRTY".
DR. JAMES YOUNG: MM-HM.
MR. MARK SANDLER: FIRST OF ALL, WHO WAS RESPONSIBLE FOR THE USE OF THE PHRASE AND WHAT, IN YOUR VIEW, DID IT REFER TO?
DR. JAMES YOUNG: I DOUBT ANYONE WOULD WANT TO TAKE OWNERSHIP FOR IT NOW, BUT I CAN TELL YOU I WON'T TAKE OWNERSHIP. I DON'T KNOW WITH CERTAINTY. I MEAN, I SUPPOSE THE PERSON WHO USED IT THE MOST OFTEN WAS DR. CAIRNS, BUT I REALLY DON'T KNOW -- I DON'T KNOW WHERE IT CAME FROM WITH ANY CERTAINTY. WHAT WAS HAPPENING AT THAT POINT IN TIME --"
FORMER CHIEF CORONER DR. JAMES YOUNG TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
During the course of the Goudge Inquiry I have been increasingly fascinated by the "think dirty" doctrine - and curious as to where it originated.
I was surprised to find that there was a "think dirty" link in Ontario with the notorious investigations of serial killers and rapists Paul Bernardo and Karla Homolka;
The "think dirty" connection relates directly to the drug/rape related death of Karla Homolka's sister Tammy, on December 24, 1990 - which was dismissed as "due to natural causes" by the local Coroner and the Niagara Regional Police Service;
Here is the Wikipedia account of the sordid Tammy Homolka story;
"By 1990, Bernardo was spending large amounts of time with the Homolka family, upon whom he had made a favourable impression," the account begins;
"He was engaged to the eldest daughter and flirting constantly with the youngest," it continues;
"He had not told them that he had lost his job at Price Waterhouse and instead was smuggling cigarettes across the nearby U.S.-Canadian border.
In time he had become obsessed with Tammy Homolka, peeping into her window and entering her room to masturbate while she slept.
Homolka had helped him by breaking the blinds in her sister's window to allow Bernardo access for his stalking.
In July Bernardo took Tammy across the border for more beer for a Homolka party; while there, Bernardo later told his fiancee, "they got drunk and began making out".
According to Bernardo's testimony at his trial, on July 25, 1990, Homolka laced spaghetti sauce with crushed valium she had stolen from her employer, Martindale Animal Clinic.
She served dinner to her sister, who soon lost consciousness.
Bernardo began to rape her while Homolka watched but after about a minute Tammy came to.
And over the summer, he plied Tammy and her friends with gifts, food, and sodas that had "a film and a few white flecks on the top".
Six months before their 1991 wedding, Homolka stole the anesthetic agent Halothane from the clinic.
On December 23, 1990, Homolka and Bernardo administered sleeping pills to the 15-year-old in a rum-and-eggnog drink.
After Tammy was unconscious Homolka and Bernardo undressed her and Homolka applied a Halothane-soaked cloth to her sister's nose and mouth.
Homolka wanted to "give Tammy's virginity to Bernardo for Christmas" as, according to Homolka, Bernardo had always been upset that she was not a virgin when they met.
With her parents sleeping upstairs, the pair filmed themselves as they raped her in the basement.
Tammy began to vomit. The pair tried unsuccessfully to revive her, then called 911, but not before they hid evidence, redressed Tammy, and moved her into her basement bedroom.
A few hours later Tammy Homolka was pronounced dead at St. Catharines General Hospital without having regained consciousness.
Despite the pair's questionable behaviour - vacuuming and washing laundry in the middle of the night[25], despite the presence of a chemical burn on Tammy's face, Niagara Regional Police and the Homolka family accepted the pair's version of events[26].
The official cause of Tammy Homolka's death was accidental - choking on her vomit after consumption of alcohol.
The pair subsequently filmed themselves with Karla wearing Tammy's clothing and pretending to be Tammy.
They also moved out of the Homolka house to a rented Port Dalhousie bungalow, to let her parents deal with their grief.
In response to public furor over the fact that police investigators had failed to arrest Bernardo in spite of blatant indications of foul play - and numerous promising leads that were not followed up over the years - the Ontario Government asked the Late Superior Court Justice Archie Campbell to review the investigation.
It is in Justice Campbell's 473-page report - published in June, 1996, I discovered that the then Chief Coroner, Dr. James Young, had initiated a "think dirty" policy -while the Bernardo fiasco was unfolding;
Justice Campbell found that the investigating Coroner, Dr. Joseph Rosloski, "faced with a puzzling and unexplained death, felt it his duty to come up with some kind of tidy answer and fell back on asthma as a cause of death without thinking it through as clearly as he might have and indeed without knowing how she died."
Campbell went on to conclude that:
"It was inappropriate for Dr. Rosloski to submit a final report sowing death by natural causes when there was a dramatic and unexplained second degree burn over much of Tammy's face, inappropriate to report that she died by means of natural causes when he did not know how she died, and inappropriate to list asthma as a cause of death when he had no evidence that asthma caused or contributed in any way to her death."
However, we are now aware that after Bernardo was arrested for "the Scarborough rapes" the Coroner's investigation into Tammy's death was re-opened by by Dr. Young and Deputy Chief Coroner Dr. Jim Cairns.
Tammy's remains were exhumed, a second post-mortem conducted, and the cause of death was re-classified as a homicide on the basis that Tammy died of aspiration of stomach contents while unconscious due to the administration of Halcion and Halothane.
Here is where "think dirty" comes in.
Justice Campbell notes in a section of his report called "The Coroner's system" that, "a number of changes have been made by the Chief Coroner's Office in the system of death investigation as it existed at the time of Tammy Homolka's death."
The first change that he enunciates in a list of eight changes is: "Training and reinforcement in the need for coroners to "think dirty" in the face of suspicious circumstances."
Campbell also zeroed in on the fact that a rape kit had not been administered in the post-mortem examination of Tammy Homolka "although the possibility of sexual activity was briefly considered");
"We know now that Tammy was sexually assaulted by both Bernardo and Homolka and Homolka. It is not certain that a rape kit would have revealed this fact had one been administered at the time of the post-mortem examination," Campbell wrote.
"Had a rape kit been administered and vaginal swabs and washings tested positive however it is clear that the investigation into the death of Tammy Homolka would have taken a different course."
"In encouraging coroners to 'think dirty,' Dr. Young's memorandum of June 6, 1994 concerning the investigation of potential female homicides committed by intimate partners emphasized the complexities of investigating female deaths and reminded coroners to approach all such investigations with a suspicious mind."
Dr. Young's June 6, 1994 memorandum - under the heading "Extracts From Chief Coroner's Report - is included as an Appendix in the Campbell report.
The very first paragraph refers to the importance of coroners "thinking dirty."
"In 1992, the Office of the Chief Coroner instituted a special three day course which is mandatory for all new coroners when they first embark on their Coroner work. This course stresses the importance of coroners "thinking dirty" and the necessity for the use of "team work" involving all the different agencies and disciplines responsible for a death investigation..."
Why 1992?
There is no indication in the memorandum as to why new Ontario Coroner's were first taught to "think dirty" in this particular year.
One possibility: There would have been considerable public anxiety in the province - and in the Chief Coroner's Office - around this time; As Campbell notes: "Between May of 1987 and December of 1992, Paul Bernardo raped or sexually assaulted at least eighteen women in Scarborough, Peel, and St. Catherines and killed three women in St. Catherines and Burlington."
Bernardo was not arrested until February 17, 1993;
Now we get to the crunch;
Justice Campbell notes that Dr. Young's "think dirty" policy - in place as far back as 1992 - was applied in relation to "potential female homicides committed by intimate partners."
How and when did the "think dirty" policy become extended to investigations into the deaths of babies?
Perhaps there are some answers to this interesting question in Dr. Young's evidence to the Goudge Inquiry;
Here is what he had to say about it - under examination by Commission Counsel Mark Sandler;
MR. MARK SANDLER: And if I can take you to PFP057584. And this is in your document that's called the Coroner's Investigative Manual.
COMMISSIONER STEPHEN GOUDGE: There should be a binder that is --
MR. MARK SANDLER: There should be a separate binder that has the manual in it.
COMMISSIONER STEPHEN GOUDGE: A black binder.
DR. JAMES YOUNG: Yes, okay. Yeah.
CONTINUED BY MR. MARK SANDLER:
MR. MARK SANDLER: And if you can go to page 349 of the document. And I'm going to ask you very briefly about this because it has been dealt with fairly extensively in the evidence. And -- and I'm going to ask, really, just one (1) -- one (1) or two (2) questions arising out of it. his is the memorandum Number 631 dated April 10, 1995, to all coroners, pathologists, and chiefs of police in Ontario, re: the new protocol to be used in the investigation of the sudden and unexpected death of any child under two (2) years of age. And as I'm sure it has not been lost on you, one (1) of the issues that -- that has been discussed here is -- is the expression, that's used in the manual, "thinking dirty".
DR. JAMES YOUNG: Mm-hm.
MR. MARK SANDLER: First of all, who was responsible for the use of the phrase and what, in your view, did it refer to?
DR. JAMES YOUNG: I doubt anyone would want to take ownership for it now, but I can tell you I won't take ownership. I don't know with certainty. I mean, I suppose the person who used it the most often was Dr. Cairns, but I really don't know -- I don't know where it came from with any certainty. What was happening at that point in time --
MR. MARK SANDLER: Just -- just stopping there for a moment, because -- because I know you wouldn't want to leave this mis-impression. It certainly was -- was a phrase that you adopted and used in presentations yourself --
DR. JAMES YOUNG: Occasionally. I had a 'think dirty' side, yes.
MR. MARK SANDLER: Okay. And so I just interrupted you. So you were going to provide the Commissioner with the context in which the -- the phrase was used I take it?
DR. JAMES YOUNG: Well this -- this was the period worldwide when there was concern that -- that pediatric deaths weren't being properly investigated. And 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. So they -- there was an awareness that the level of investigation of what the -- things that were important in a pediatric death are very different then the things that are important in a -- in a adult death and that the signs and symptoms are very different. But in order to do that, then you have to make the -- again, starting where do the problems mostly occur? The problems occur at the front end of an investigation. So the idea and the object was then that the investigating coroners and the police that are involved in these cases need to understand they can't walk into a situation, look at a scene -- first of all they need to go to the scene, which wasn't always being done, and they need to look at the scene with -- with a more careful observation then -- then just simply deciding that something -- well this looks like everything's fine, and it's a nice family, and therefore we'll -- we'll assume that everything's fine. Not that you're not going to end up back at that result, but what you have to do is go through the various possibilities in your mind and at the end of it you want to be able to conclude whether or not, in fact, this represents a suicide, an accident, a homicide, a natural or an undetermined death. But -- but don't fix on one (1), go through the list and try to in fact do it in an inquisitive na -- way. And that's really what it was meant to -- to do; is just simply awaken people to the fact that different and -- kinds of information and a different mind set needed to be addressed. 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. That was not the intention. It was meant to awaken the - - the need to think in broader terms.
MR. MARK SANDLER: All right. And --
DR. JAMES YOUNG: In retrospect it's probably not the greatest phrase, but absolute -- until this Inquiry, no one ever raised it with us and said, It's a bad phrase. You know, it's the passage of time and the events here have cast a different light on it then was ever thought of at the time.
MR. MARK SANDLER: All right. So I -- I take it as implicit if not explicit on what you've just said, is that you recognize that -- 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?
DR. JAMES YOUNG: Sure, sure. And that's how -- that's why we're always changing things and re -- you know, there's a lot of these memos that are reworked memos from the past, because as we get through and have experience, we take those experiences and change things.
Harold Levy...hlevy15@gmail.com;
WIKIPEDIA ACCOUNT OF THE DRUG/RAPE RELATED KILLING OF TAMMY HOMOLKA BY HER SISTER KARLA AND PAUL BERNARDO;
-------------------------------------------------------------------------------
MR. MARK SANDLER: AND AS I'M SURE IT HAS NOT BEEN LOST ON YOU, ONE (1) OF THE ISSUES THAT -- THAT HAS BEEN DISCUSSED HERE IS -- IS THE EXPRESSION, THAT'S USED IN THE MANUAL, "THINKING DIRTY".
DR. JAMES YOUNG: MM-HM.
MR. MARK SANDLER: FIRST OF ALL, WHO WAS RESPONSIBLE FOR THE USE OF THE PHRASE AND WHAT, IN YOUR VIEW, DID IT REFER TO?
DR. JAMES YOUNG: I DOUBT ANYONE WOULD WANT TO TAKE OWNERSHIP FOR IT NOW, BUT I CAN TELL YOU I WON'T TAKE OWNERSHIP. I DON'T KNOW WITH CERTAINTY. I MEAN, I SUPPOSE THE PERSON WHO USED IT THE MOST OFTEN WAS DR. CAIRNS, BUT I REALLY DON'T KNOW -- I DON'T KNOW WHERE IT CAME FROM WITH ANY CERTAINTY. WHAT WAS HAPPENING AT THAT POINT IN TIME --"
FORMER CHIEF CORONER DR. JAMES YOUNG TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
During the course of the Goudge Inquiry I have been increasingly fascinated by the "think dirty" doctrine - and curious as to where it originated.
I was surprised to find that there was a "think dirty" link in Ontario with the notorious investigations of serial killers and rapists Paul Bernardo and Karla Homolka;
The "think dirty" connection relates directly to the drug/rape related death of Karla Homolka's sister Tammy, on December 24, 1990 - which was dismissed as "due to natural causes" by the local Coroner and the Niagara Regional Police Service;
Here is the Wikipedia account of the sordid Tammy Homolka story;
"By 1990, Bernardo was spending large amounts of time with the Homolka family, upon whom he had made a favourable impression," the account begins;
"He was engaged to the eldest daughter and flirting constantly with the youngest," it continues;
"He had not told them that he had lost his job at Price Waterhouse and instead was smuggling cigarettes across the nearby U.S.-Canadian border.
In time he had become obsessed with Tammy Homolka, peeping into her window and entering her room to masturbate while she slept.
Homolka had helped him by breaking the blinds in her sister's window to allow Bernardo access for his stalking.
In July Bernardo took Tammy across the border for more beer for a Homolka party; while there, Bernardo later told his fiancee, "they got drunk and began making out".
According to Bernardo's testimony at his trial, on July 25, 1990, Homolka laced spaghetti sauce with crushed valium she had stolen from her employer, Martindale Animal Clinic.
She served dinner to her sister, who soon lost consciousness.
Bernardo began to rape her while Homolka watched but after about a minute Tammy came to.
And over the summer, he plied Tammy and her friends with gifts, food, and sodas that had "a film and a few white flecks on the top".
Six months before their 1991 wedding, Homolka stole the anesthetic agent Halothane from the clinic.
On December 23, 1990, Homolka and Bernardo administered sleeping pills to the 15-year-old in a rum-and-eggnog drink.
After Tammy was unconscious Homolka and Bernardo undressed her and Homolka applied a Halothane-soaked cloth to her sister's nose and mouth.
Homolka wanted to "give Tammy's virginity to Bernardo for Christmas" as, according to Homolka, Bernardo had always been upset that she was not a virgin when they met.
With her parents sleeping upstairs, the pair filmed themselves as they raped her in the basement.
Tammy began to vomit. The pair tried unsuccessfully to revive her, then called 911, but not before they hid evidence, redressed Tammy, and moved her into her basement bedroom.
A few hours later Tammy Homolka was pronounced dead at St. Catharines General Hospital without having regained consciousness.
Despite the pair's questionable behaviour - vacuuming and washing laundry in the middle of the night[25], despite the presence of a chemical burn on Tammy's face, Niagara Regional Police and the Homolka family accepted the pair's version of events[26].
The official cause of Tammy Homolka's death was accidental - choking on her vomit after consumption of alcohol.
The pair subsequently filmed themselves with Karla wearing Tammy's clothing and pretending to be Tammy.
They also moved out of the Homolka house to a rented Port Dalhousie bungalow, to let her parents deal with their grief.
In response to public furor over the fact that police investigators had failed to arrest Bernardo in spite of blatant indications of foul play - and numerous promising leads that were not followed up over the years - the Ontario Government asked the Late Superior Court Justice Archie Campbell to review the investigation.
It is in Justice Campbell's 473-page report - published in June, 1996, I discovered that the then Chief Coroner, Dr. James Young, had initiated a "think dirty" policy -while the Bernardo fiasco was unfolding;
Justice Campbell found that the investigating Coroner, Dr. Joseph Rosloski, "faced with a puzzling and unexplained death, felt it his duty to come up with some kind of tidy answer and fell back on asthma as a cause of death without thinking it through as clearly as he might have and indeed without knowing how she died."
Campbell went on to conclude that:
"It was inappropriate for Dr. Rosloski to submit a final report sowing death by natural causes when there was a dramatic and unexplained second degree burn over much of Tammy's face, inappropriate to report that she died by means of natural causes when he did not know how she died, and inappropriate to list asthma as a cause of death when he had no evidence that asthma caused or contributed in any way to her death."
However, we are now aware that after Bernardo was arrested for "the Scarborough rapes" the Coroner's investigation into Tammy's death was re-opened by by Dr. Young and Deputy Chief Coroner Dr. Jim Cairns.
Tammy's remains were exhumed, a second post-mortem conducted, and the cause of death was re-classified as a homicide on the basis that Tammy died of aspiration of stomach contents while unconscious due to the administration of Halcion and Halothane.
Here is where "think dirty" comes in.
Justice Campbell notes in a section of his report called "The Coroner's system" that, "a number of changes have been made by the Chief Coroner's Office in the system of death investigation as it existed at the time of Tammy Homolka's death."
The first change that he enunciates in a list of eight changes is: "Training and reinforcement in the need for coroners to "think dirty" in the face of suspicious circumstances."
Campbell also zeroed in on the fact that a rape kit had not been administered in the post-mortem examination of Tammy Homolka "although the possibility of sexual activity was briefly considered");
"We know now that Tammy was sexually assaulted by both Bernardo and Homolka and Homolka. It is not certain that a rape kit would have revealed this fact had one been administered at the time of the post-mortem examination," Campbell wrote.
"Had a rape kit been administered and vaginal swabs and washings tested positive however it is clear that the investigation into the death of Tammy Homolka would have taken a different course."
"In encouraging coroners to 'think dirty,' Dr. Young's memorandum of June 6, 1994 concerning the investigation of potential female homicides committed by intimate partners emphasized the complexities of investigating female deaths and reminded coroners to approach all such investigations with a suspicious mind."
Dr. Young's June 6, 1994 memorandum - under the heading "Extracts From Chief Coroner's Report - is included as an Appendix in the Campbell report.
The very first paragraph refers to the importance of coroners "thinking dirty."
"In 1992, the Office of the Chief Coroner instituted a special three day course which is mandatory for all new coroners when they first embark on their Coroner work. This course stresses the importance of coroners "thinking dirty" and the necessity for the use of "team work" involving all the different agencies and disciplines responsible for a death investigation..."
Why 1992?
There is no indication in the memorandum as to why new Ontario Coroner's were first taught to "think dirty" in this particular year.
One possibility: There would have been considerable public anxiety in the province - and in the Chief Coroner's Office - around this time; As Campbell notes: "Between May of 1987 and December of 1992, Paul Bernardo raped or sexually assaulted at least eighteen women in Scarborough, Peel, and St. Catherines and killed three women in St. Catherines and Burlington."
Bernardo was not arrested until February 17, 1993;
Now we get to the crunch;
Justice Campbell notes that Dr. Young's "think dirty" policy - in place as far back as 1992 - was applied in relation to "potential female homicides committed by intimate partners."
How and when did the "think dirty" policy become extended to investigations into the deaths of babies?
Perhaps there are some answers to this interesting question in Dr. Young's evidence to the Goudge Inquiry;
Here is what he had to say about it - under examination by Commission Counsel Mark Sandler;
MR. MARK SANDLER: And if I can take you to PFP057584. And this is in your document that's called the Coroner's Investigative Manual.
COMMISSIONER STEPHEN GOUDGE: There should be a binder that is --
MR. MARK SANDLER: There should be a separate binder that has the manual in it.
COMMISSIONER STEPHEN GOUDGE: A black binder.
DR. JAMES YOUNG: Yes, okay. Yeah.
CONTINUED BY MR. MARK SANDLER:
MR. MARK SANDLER: And if you can go to page 349 of the document. And I'm going to ask you very briefly about this because it has been dealt with fairly extensively in the evidence. And -- and I'm going to ask, really, just one (1) -- one (1) or two (2) questions arising out of it. his is the memorandum Number 631 dated April 10, 1995, to all coroners, pathologists, and chiefs of police in Ontario, re: the new protocol to be used in the investigation of the sudden and unexpected death of any child under two (2) years of age. And as I'm sure it has not been lost on you, one (1) of the issues that -- that has been discussed here is -- is the expression, that's used in the manual, "thinking dirty".
DR. JAMES YOUNG: Mm-hm.
MR. MARK SANDLER: First of all, who was responsible for the use of the phrase and what, in your view, did it refer to?
DR. JAMES YOUNG: I doubt anyone would want to take ownership for it now, but I can tell you I won't take ownership. I don't know with certainty. I mean, I suppose the person who used it the most often was Dr. Cairns, but I really don't know -- I don't know where it came from with any certainty. What was happening at that point in time --
MR. MARK SANDLER: Just -- just stopping there for a moment, because -- because I know you wouldn't want to leave this mis-impression. It certainly was -- was a phrase that you adopted and used in presentations yourself --
DR. JAMES YOUNG: Occasionally. I had a 'think dirty' side, yes.
MR. MARK SANDLER: Okay. And so I just interrupted you. So you were going to provide the Commissioner with the context in which the -- the phrase was used I take it?
DR. JAMES YOUNG: Well this -- this was the period worldwide when there was concern that -- that pediatric deaths weren't being properly investigated. And 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. So they -- there was an awareness that the level of investigation of what the -- things that were important in a pediatric death are very different then the things that are important in a -- in a adult death and that the signs and symptoms are very different. But in order to do that, then you have to make the -- again, starting where do the problems mostly occur? The problems occur at the front end of an investigation. So the idea and the object was then that the investigating coroners and the police that are involved in these cases need to understand they can't walk into a situation, look at a scene -- first of all they need to go to the scene, which wasn't always being done, and they need to look at the scene with -- with a more careful observation then -- then just simply deciding that something -- well this looks like everything's fine, and it's a nice family, and therefore we'll -- we'll assume that everything's fine. Not that you're not going to end up back at that result, but what you have to do is go through the various possibilities in your mind and at the end of it you want to be able to conclude whether or not, in fact, this represents a suicide, an accident, a homicide, a natural or an undetermined death. But -- but don't fix on one (1), go through the list and try to in fact do it in an inquisitive na -- way. And that's really what it was meant to -- to do; is just simply awaken people to the fact that different and -- kinds of information and a different mind set needed to be addressed. 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. That was not the intention. It was meant to awaken the - - the need to think in broader terms.
MR. MARK SANDLER: All right. And --
DR. JAMES YOUNG: In retrospect it's probably not the greatest phrase, but absolute -- until this Inquiry, no one ever raised it with us and said, It's a bad phrase. You know, it's the passage of time and the events here have cast a different light on it then was ever thought of at the time.
MR. MARK SANDLER: All right. So I -- I take it as implicit if not explicit on what you've just said, is that you recognize that -- 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?
DR. JAMES YOUNG: Sure, sure. And that's how -- that's why we're always changing things and re -- you know, there's a lot of these memos that are reworked memos from the past, because as we get through and have experience, we take those experiences and change things.
Harold Levy...hlevy15@gmail.com;
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