"IN FACT, MANY FAMILIES FEEL ISOLATED AND BECOME CRIME SUSPECTS IN THE EYES OF THE PUBLIC EVEN THOUGH NO CRIME HAS BEEN COMMITTED.
CLEARLY A MORE BALANCED APPROACH IS NEEDED THAT RESTS MORE ON THE PRESUMPTION OF INNOCENCE THAN IMPLYING GUILT UP FRONT."
DR. ERNEST CUTZ: RECOMMENDATIONS TO GOUDGE INQUIRY;
Dr. Ernest Cutz has performed an important public service with his unique recommendations that families of deceased children be given support and treated with sympathy by pathologists conducting investigations into the deaths of their children.
Dr. Cutz is a distinguished pathologist at the Hospital for Sick Children in Toronto, who has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog is therefore publishing his submissions on the following systemic issues being considered by the Gouge Inquiry on "the role of the family.":
0:Should there be guidelines for communications between the pathologist or the coroner and the family?
0: How should an ongoing criminal or child protection investigation affect the communication?
0: How, if at all, can the family’s need to grieve be reconciled with the work of the pathologist in a pediatric forensic death?
"The death of a child has a profound effect on the family unit with lifelong consequences," this recommendation begins;
"At present, all such deaths become the subject of police investigation and the home where the child has died becomes a “crime scene” adding further shock to the already distraught family. There is no specific counseling, education or long term follow- up," it continues;
"In fact, many families feel isolated and become crime suspects in the eyes of the public even though no crime has been committed.
Clearly a more balanced approach is needed that rests more on the presumption of innocence than implying guilt up front.
One possible solution could be the involvement of a Public Health nurse or other health care professionals who are knowledgeable in infant care practices.
These individuals should have initial contact with the families and should be responsible for public education, emotional support and long-term follow-up with affected families.
Further, these individuals could be trained as death scene investigators in child deaths to identify potential risk factors and to insure best infant care practices.
This approach could help create a more compassionate and sensitive mechanism for investigating children’s deaths.
In the past, pediatric pathologists sometimes interacted with SIDS and SUD families prior to and/or following the autopsy.
The pathologist would explain his of her findings and help the family to cope with their grief.
Some Hospital for Sick Children staff pathologists have also interacted with SIDS parents organizations by providing information and lecturing on SIDS.
My suggestion is to encourage and re-establish these links since pediatric pathologists are best qualified to explain autopsy findings in these cases.
Interaction with families will have a positive effect in terms of regaining the trust of the public and also increase the profile of pediatric pathologists, helping with recruitment issue."
Harold Levy...hlevy15@gmail.com;
-------------------------------------------------------------------------------
Showing posts with label cutz. Show all posts
Showing posts with label cutz. Show all posts
Friday, May 9, 2008
Thursday, May 8, 2008
Part Two: Dr. Ernest Cutz's Recommendations: Thinking Dirty V. Scientific Objectivity When It Comes To Sudden Unexpected Death of Children;
"FURTHERMORE, IT IS MY VIEW THAT RESEARCH SCIENTISTS ARE DISCOURAGED FROM PURSUING BASIC RESEARCH INTO SUDDEN INFANT DEATH SYNDROME SINCE IT REMAINS UNDER A CLOUD OF SUSPICION AND SUBJECT OF CRIMINAL INVESTIGATION."
Dr. ERNEST CUTZ: SUBMISSIONS TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog continues our series on Dr. Cutz's submissions with his thoughts on the need to emphasize research aimed at preventing Sudden Infant Death Syndrome - rather then criminalizing parents and caregivers on the base of unsound sound.
Dr. Cutz addresses this recommendation to three of the systemic factors being explored by the Goudge Commission:
0: What is the approach that best balances the objective that no individual be wrongly accused of child abuse with the objective that children be protected from abuse?
0: What are the relative merits of “thinking dirty” or “thinking truth” or other alternatives? and,
0: How is scientific objectivity best maintained throughout the examination to avoid “tunnel vision” that merely seeks support for an a priori conclusion?
(In an earlier Blog, I recorded Dr. Cutz's disagreement with the controversial "think dirty" protocol released by then Chief Coroner Dr. James Young to all of Ontario's coroner's, pathologists and chiefs of police, on April 10, 1995. I have repeated this post below for the benefit of our readers who did not have the opportunity to peruse it; It ran under the heading: "Think Dirty"; Part One: Two Words At The Heart Of The Inquiry;")
"The (above) objectives can be achieved by the provision of correct pathologic diagnoses based on solid scientific foundations," recommendation begins;
"The acquisition of and advances in medical knowledge are dependent on robust scientific research that constantly evolves and progresses over time," it continues;
"The Inquiry has seen how this evolution in thinking occurs through exposure to the debate and recent changes in attitude with respect to the interpretation of findings relating to Shaken Baby Syndrome.
Similar changes in attitude and thinking have occurred in the areas of Sudden Unexpected Infant Death, Sudden Infant Death Syndrome, and related conditions.
For example, during the 1990s a prevalent, early view was that Sudden Unexpected Infant Death and Sudden Infant Death Syndrome occurred due to “positional asphyxia”, overlaying caused by co-sleeping, or homicide.
These views have not been substantiated by solid scientific evidence.
Now, the prone sleeping position and co-sleeping are recognized as risk factors but are not the actual cause of death in sudden Infant Death Syndrome;
Today we know that Sudden Infant Death Syndrome is a pediatric disease recognized by the World Health Organization as a distinct pediatric medical disease entity.
In addition, Sudden Infant Death Syndrome is not a uniform entity but rather a heterogeneous multifactorial disorder with variable triggering and potentiating factors.
This is as exemplified by the so-called “triple risk model”, i.e. Sudden Infant Death Syndrome occurs as a result of interactions involving (1) a vulnerable infant who possesses some underlining biological abnormality; (2) a critical period of development; and (3) an exogenous stressor such as maternal smoking, mild infection or an unsafe sleeping position.
Current thinking in this area, which reflects recent advances in molecular medicine, indicates that an underlining biological abnormality in large proportion of Sudden Unexpected Infant Deaths and Sudden Infant Death Syndrome cases may, in fact, be due to genetic or molecular disorders (i.e. defects in cardiac or neuronal ion channels, etc.) that are now detectable by modern techniques of molecular pathology.
Notwithstanding these changes, confusion between what are risk factors for Sudden Infant Death Syndrome and what is the actual cause of death in Sudden Infant Death Syndrome persists in certain forensic circles.
Individuals in these circles continue to identify the cause of death in Sudden Infant Death Syndrome cases as being, for example, co-sleeping, which is inaccurate and misleading.
If Sudden Infant Death Syndrome was due to this simple explanation, how could one explain the fact that babies have slept in these situations for many years, but only some die while many do not?
Identifying a baby’s sleep environment as the sole factor responsible for the infant’s death gives only part of the explanation and leads to feelings of guilt and, potentially, to wrongful accusations of parents and caregivers.
Given the importance of accurately identifying and describing cause of death, it is problematic that there is currently very limited or non-existent scientific research on Sudden Unexpected Infant Death and Sudden Infant Death Syndrome;
This is partly due to the fact that the mandate of the Chief Coroner's Office which oversees all pediatric forensic cases, does not include research into medical diseases and because the current legislation and all agreements between the Chief Coroner's Office and the Hospital for Sick Children (including the most recent Ontario Pediatric Forensic Unit agreement)... explicitly forbid the use of tissues for medical research.
Furthermore, it is my view that research scientists are discouraged from pursuing basic research into Sudden Infant Death Syndrome since it remains under a cloud of suspicion and subject of criminal investigation.
To overcome the obstacles surrounding the use of tissues for research individual parental consent can be obtained or a legislative change, similar to that of the State of California, which authorizes and mandates research into Sudden Unexpected Infant Death and Sudden Infant Death Syndrome could be made.
Consequently an “Ontario Center for the study of Sudden Infant Death Syndrome/Sudden Unexpected Infant Death, based on the San Diego Sudden Infant Death Syndrome/Sudden Unexpected Infant Death Research Project database model, should be established at HSC with collaboration projects that include other Ontario pediatric academic centers that perform autopsies on Sudden Infant Death Syndrome/ Sudden Unexpected Infant Death cases.
Funding for the Center should be provided by the Ministry of Long Term Health;
Further, to encourage research in Sudden Unexpected Infant Death and Sudden Infant Death Syndrome, targeted, competitive, peer-reviewed research grants into Sudden Unexpected Infant Death and Sudden Infant Death Syndrome in a form of “Request for Application” should be issued by the Government of Ontario and by the Federal Government through Canadian Institute of Health Research/Institute of Child Health.
The resulting research is important because it would define protocols and methods for molecular diagnoses of disorders underlying Sudden Unexpected Infant Death and Sudden Infant Death Syndrome (for example, the specific channelopaties affecting the cardiovascular or nervous systems).
These new diagnostic tests could provide objective scientific evidence that would be exculpatory in contentious cases of infant death.
The tests would be analogous to DNA tests used currently in the criminal justice system.
When, if at all, should the terms “Sudden Infant Death Sndrome" and "Sudden Unexpected Infant Death" be used in a post mortem report?
These terms are well established and widely accepted in Pediatric clinical and pathology practice.
There is no compelling reason to not to use them in a post-mortem report.
The definition and terminology related to Sudden Infant Death Syndrome and Sudden Unexpected Infant Death has been the subject of a recent review and update by an international panel of experts comprised of paediatric and forensic pathologists with extensive experience in Sudden Unexpected Infant Death Syndrome;
The panel also included pediatricians and an epidemiologist.
It is important to use the correct terminology with respect to Sudden Unexpected Infant Death and Sudden Infant Death Syndrome so that accurate statistics are generated to monitor the incidence and trends of Sudden Unexpected Infant Death and Sudden Infant Death Syndrome as well as to ensure that well-defined groups of cases are used in research studies.
My recommendation is to adopt the use the criteria and definitions outlined in the above publication in Ontario.
c) With advances in Sudden Infant Death Syndrome research it will be possible in the future to render specific pathological diagnoses which will have the effect of removing ambiguity as to the cause and manner of death.
This will reduce the number of cases that today are designated as “undetermined” or “unascertained”.
---------------------------------------------------------------------------------
Here is the earlier Blog on which articulates Dr. Cutz's disagreement with the controversial "think dirty" protocol released by then Chief Coroner Dr. James Young to all of Ontario's coroner's, pathologists and chiefs of police, on April 10, 1995:
"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;
Dr. ERNEST CUTZ: SUBMISSIONS TO THE GOUDGE INQUIRY;
-------------------------------------------------------------------------------
Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog continues our series on Dr. Cutz's submissions with his thoughts on the need to emphasize research aimed at preventing Sudden Infant Death Syndrome - rather then criminalizing parents and caregivers on the base of unsound sound.
Dr. Cutz addresses this recommendation to three of the systemic factors being explored by the Goudge Commission:
0: What is the approach that best balances the objective that no individual be wrongly accused of child abuse with the objective that children be protected from abuse?
0: What are the relative merits of “thinking dirty” or “thinking truth” or other alternatives? and,
0: How is scientific objectivity best maintained throughout the examination to avoid “tunnel vision” that merely seeks support for an a priori conclusion?
(In an earlier Blog, I recorded Dr. Cutz's disagreement with the controversial "think dirty" protocol released by then Chief Coroner Dr. James Young to all of Ontario's coroner's, pathologists and chiefs of police, on April 10, 1995. I have repeated this post below for the benefit of our readers who did not have the opportunity to peruse it; It ran under the heading: "Think Dirty"; Part One: Two Words At The Heart Of The Inquiry;")
"The (above) objectives can be achieved by the provision of correct pathologic diagnoses based on solid scientific foundations," recommendation begins;
"The acquisition of and advances in medical knowledge are dependent on robust scientific research that constantly evolves and progresses over time," it continues;
"The Inquiry has seen how this evolution in thinking occurs through exposure to the debate and recent changes in attitude with respect to the interpretation of findings relating to Shaken Baby Syndrome.
Similar changes in attitude and thinking have occurred in the areas of Sudden Unexpected Infant Death, Sudden Infant Death Syndrome, and related conditions.
For example, during the 1990s a prevalent, early view was that Sudden Unexpected Infant Death and Sudden Infant Death Syndrome occurred due to “positional asphyxia”, overlaying caused by co-sleeping, or homicide.
These views have not been substantiated by solid scientific evidence.
Now, the prone sleeping position and co-sleeping are recognized as risk factors but are not the actual cause of death in sudden Infant Death Syndrome;
Today we know that Sudden Infant Death Syndrome is a pediatric disease recognized by the World Health Organization as a distinct pediatric medical disease entity.
In addition, Sudden Infant Death Syndrome is not a uniform entity but rather a heterogeneous multifactorial disorder with variable triggering and potentiating factors.
This is as exemplified by the so-called “triple risk model”, i.e. Sudden Infant Death Syndrome occurs as a result of interactions involving (1) a vulnerable infant who possesses some underlining biological abnormality; (2) a critical period of development; and (3) an exogenous stressor such as maternal smoking, mild infection or an unsafe sleeping position.
Current thinking in this area, which reflects recent advances in molecular medicine, indicates that an underlining biological abnormality in large proportion of Sudden Unexpected Infant Deaths and Sudden Infant Death Syndrome cases may, in fact, be due to genetic or molecular disorders (i.e. defects in cardiac or neuronal ion channels, etc.) that are now detectable by modern techniques of molecular pathology.
Notwithstanding these changes, confusion between what are risk factors for Sudden Infant Death Syndrome and what is the actual cause of death in Sudden Infant Death Syndrome persists in certain forensic circles.
Individuals in these circles continue to identify the cause of death in Sudden Infant Death Syndrome cases as being, for example, co-sleeping, which is inaccurate and misleading.
If Sudden Infant Death Syndrome was due to this simple explanation, how could one explain the fact that babies have slept in these situations for many years, but only some die while many do not?
Identifying a baby’s sleep environment as the sole factor responsible for the infant’s death gives only part of the explanation and leads to feelings of guilt and, potentially, to wrongful accusations of parents and caregivers.
Given the importance of accurately identifying and describing cause of death, it is problematic that there is currently very limited or non-existent scientific research on Sudden Unexpected Infant Death and Sudden Infant Death Syndrome;
This is partly due to the fact that the mandate of the Chief Coroner's Office which oversees all pediatric forensic cases, does not include research into medical diseases and because the current legislation and all agreements between the Chief Coroner's Office and the Hospital for Sick Children (including the most recent Ontario Pediatric Forensic Unit agreement)... explicitly forbid the use of tissues for medical research.
Furthermore, it is my view that research scientists are discouraged from pursuing basic research into Sudden Infant Death Syndrome since it remains under a cloud of suspicion and subject of criminal investigation.
To overcome the obstacles surrounding the use of tissues for research individual parental consent can be obtained or a legislative change, similar to that of the State of California, which authorizes and mandates research into Sudden Unexpected Infant Death and Sudden Infant Death Syndrome could be made.
Consequently an “Ontario Center for the study of Sudden Infant Death Syndrome/Sudden Unexpected Infant Death, based on the San Diego Sudden Infant Death Syndrome/Sudden Unexpected Infant Death Research Project database model, should be established at HSC with collaboration projects that include other Ontario pediatric academic centers that perform autopsies on Sudden Infant Death Syndrome/ Sudden Unexpected Infant Death cases.
Funding for the Center should be provided by the Ministry of Long Term Health;
Further, to encourage research in Sudden Unexpected Infant Death and Sudden Infant Death Syndrome, targeted, competitive, peer-reviewed research grants into Sudden Unexpected Infant Death and Sudden Infant Death Syndrome in a form of “Request for Application” should be issued by the Government of Ontario and by the Federal Government through Canadian Institute of Health Research/Institute of Child Health.
The resulting research is important because it would define protocols and methods for molecular diagnoses of disorders underlying Sudden Unexpected Infant Death and Sudden Infant Death Syndrome (for example, the specific channelopaties affecting the cardiovascular or nervous systems).
These new diagnostic tests could provide objective scientific evidence that would be exculpatory in contentious cases of infant death.
The tests would be analogous to DNA tests used currently in the criminal justice system.
When, if at all, should the terms “Sudden Infant Death Sndrome" and "Sudden Unexpected Infant Death" be used in a post mortem report?
These terms are well established and widely accepted in Pediatric clinical and pathology practice.
There is no compelling reason to not to use them in a post-mortem report.
The definition and terminology related to Sudden Infant Death Syndrome and Sudden Unexpected Infant Death has been the subject of a recent review and update by an international panel of experts comprised of paediatric and forensic pathologists with extensive experience in Sudden Unexpected Infant Death Syndrome;
The panel also included pediatricians and an epidemiologist.
It is important to use the correct terminology with respect to Sudden Unexpected Infant Death and Sudden Infant Death Syndrome so that accurate statistics are generated to monitor the incidence and trends of Sudden Unexpected Infant Death and Sudden Infant Death Syndrome as well as to ensure that well-defined groups of cases are used in research studies.
My recommendation is to adopt the use the criteria and definitions outlined in the above publication in Ontario.
c) With advances in Sudden Infant Death Syndrome research it will be possible in the future to render specific pathological diagnoses which will have the effect of removing ambiguity as to the cause and manner of death.
This will reduce the number of cases that today are designated as “undetermined” or “unascertained”.
---------------------------------------------------------------------------------
Here is the earlier Blog on which articulates Dr. Cutz's disagreement with the controversial "think dirty" protocol released by then Chief Coroner Dr. James Young to all of Ontario's coroner's, pathologists and chiefs of police, on April 10, 1995:
"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;
Wednesday, May 7, 2008
Part One: Dr. Cutz's Recommendations To Goudge Inquiry; Remove Ontario Forensic Pediatric Pathology Unit From Sick Kids;
"IN SUMMARY, IT IS MY VIEW THAT THE DIVISION OF PATHOLOGY AT THE HOSPITAL, AND OTHER PEDIATRIC PATHOLOGY SERVICES AT OTHER LARGE ACADEMIC CENTERS, ARE BEST SUITED TO PROVIDE HIGH QUALITY PEDIATRIC PATHOLOGY SERVICES FOCUSING ON ACADEMIC ASPECTS THAT INCLUDE THE DIAGNOSIS AND INVESTIGATION OF PEDIATRIC DISEASES.
HOWEVER, TO ENSURE THAT INFANTS AND CHILDREN ARE PROTECTED FROM HARM AND ABUSE, THE REMAINING TEN PER CENT OF CASES THAT INCLUDE CLEAR HOMICIDES OR CRIMINALLY SUSPICIOUS DEATHS ARE BEST HANDLED BY QUALIFIED FORENSIC PATHOLOGISTS WHOSE TRAINING AND EXPERIENCE LIES PRIMARILY IN THE EXAMINATION OF VIOLENT DEATH, HOMICIDES AND SUCH.
THE BEST SETTING TO PERFORM THESE AUTOPSIES (WHICH TOTAL APPROXIMATELY 10-15 CASES PER YEAR) IS AT THE CHIEF CORONER'S OFFICE WHICH HAS THE QUALIFIED STAFF AND REQUIRED FACILITIES TO CONDUCT THE NECESSARY INVESTIGATIONS."
DR. ERNEST CUTZ: RECOMMENDATIONS TO GOUDGE INQUIRY;
-------------------------------------------------------------------------------
Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog is therefore publishing Dr. Cutz's submissions - beginning with his recommendation that the hospital should cease performing forensic autopsies - and focus, rather, on what he calls, "medical/natural death cases."
"I have reviewed the “List of Systemic Issues” currently available on the website of the Inquiry into Pediatric Forensic Pathology in Ontario," this portion of Dr. Cutz's submissions begins.
"The following document reflects my own personal views and comments on select questions posed in that list" it continues;
"My comments reflect over 35 years of experience in Pediatric Pathology, including pediatric forensic pathology.
I. Institutional Considerations: Should Ontario have an institutional setting dedicated to pediatric forensic pathology, or should pediatric services be delivered within a forensic pathology institutional setting?
In essence, it is my view that the pediatric pathology work performed in Ontario should not be all be performed by the same institution.
Rather, pediatric autopsy work should be divided between the Hospital for Sick Children (the Hospital) and the Office of the Chief Coroner of Ontario. (The Chief Coroner's Office);
I say this for the following reasons:
a) Approximately 90 per cent of pediatric cases investigated under the Coroner’s Warrant result from death due to natural causes or pediatric disease.
These cases are thus not “forensic” by nature.
It is appropriate that pediatric pathologists from the Hospital for Sick Children perform the autopsies in these cases.
It is my view, however, that the Hospital should only perform autopsies on these “medical/natural death cases”.
Therefore, there would no longer be a need for a Pediatric Forensic Pathology Unit (the Unit) at the Hospital;
Furthermore, it is my view that there is an incompatibility between the principal mission of the Hospital as being dedicated to academic pursuits and research and the Chief Coroner's Office which excludes research;
I believe that the institutional link between the Hospital and the Chief Coroner's Office should be discontinued.
b) In summary, it is my view that the Division of Pathology at the Hospital, and other Pediatric Pathology services at other large academic centers, are best suited to provide high quality pediatric pathology services focusing on academic aspects that include the diagnosis and investigation of pediatric diseases.
c) However, to ensure that infants and children are protected from harm and abuse, the remaining ten per cent of cases that include clear homicides or criminally suspicious deaths are best handled by qualified forensic pathologists whose training and experience lies primarily in the examination of violent death, homicides and such.
The best setting to perform these autopsies (which total approximately 10-15 cases per year) is at the Chief Coroner's Office which has the qualified staff and required facilities to conduct the necessary investigations.
d) In terms of the pediatric disease cases, the best protection against wrongful accusations in pediatric cases is the provision of a correct diagnosis of natural disease based on a solid scientific foundation.
The diagnosis of pediatric disease in the 21st century is based on sophisticated methods of cellular and molecular biology (i.e. testing for genetic or metabolic disorders).
This testing requires special expertise and facilities, all of which are available at the Hospital, but are not available at the Chief Coroner's Office;
e) Since research and education into pediatric disease is outside the mandate of the Chief Coroner's Office, the responsibility and the provision of resources for this essentially patient-related activity should be assumed by the Ministry of Health and Long term Care.
10. What is the most cost efficient way of delivering quality pediatric forensic pathology services? For example, what are the advantages and disadvantages of using staff doctors or fee-for-service doctors?
a) Staff Pathologists based at leading Pediatric Academic Institutions, such as the Hospital for Sick Children can deliver the most cost-efficient and highest quality pediatric pathology services.
All staff are qualified and experienced Pediatric Pathologists who are also cross-appointed to the University of Toronto and thus participate fully in research and educational activities.
b) The combination of high-level diagnostic skills in diagnosing pediatric disease, research into disease pathogenesis, and education ensures that the work of these pathologists is high quality and also serves to educate the next generation of pediatric pathologists, thereby addressing the shortage of professionals in this specialty."
This Blogster has addressed the issue as to whether the Ontario Forensic Pediatric Pathology Unit should remain at the Hospital for Sick Children in an earlier post entitled, "Up-Date: Expert Evidence; Part Three: Research Questions Whether Forensic Unit Once Headed By Smith Should Remain At Sick Kids," published on March 8, 2008;
For the benefit of those readers who have not read it, that post ran as follows:
"IN ADDITION TO AN ABSENCE OF MEANINGFUL OVERSIGHT, THE INTEGRATION OF THE (UNIT) WITHIN THE PEDIATRIC PATHOLOGY UNIT AT THE HOSPITAL FOR SICK CHILDREN(INCLUDING INTERACTION WITH THE SUSPECTED CHILD ABUSE AND NEGLECT (SCAN) TEAM) MAY HAVE CREATED A PARTICULAR KIND OF INSTITUTIONAL CULTURE THAT CONTRIBUTED TO THE “THINK DIRTY” ETHOS, DISCUSSED IN OTHER RESEARCH CONDUCTED FOR THIS INQUIRY,"
PROFESSOR LORNE SOSSIN IN RESEARCH PAPER PREPARED FOR THE GOUDGE INQUIRY;
Ontario's Pediatric Forensic Pathology Unit, once headed by Dr. Charles Smith, risks being tainted by its proximity to the Hospital for Sick Children's Sick Children's Suspected Child Abuse and Neglect (SCAN) team, a researcher suggests.
University of Toronto law professor Lorne Sossin, recommends that Ontario should rethink retention of the Unit at the (Hospital) in a paper commissioned by the Goudge Inquiry entitled, "oversight and accountability." (The paper is posted on the Inquiry's Web-site;)
"In addition to an absence of meaningful oversight, the integration of the (Unit) within the pediatric pathology unit at the Hospital for Sick Children(including interaction with the Suspected Child Abuse and Neglect (SCAN) team) may have created a particular kind of institutional culture that contributed to the “think dirty” ethos, discussed in other research conducted for this Inquiry," writes Sossin;
"While there may have been good reasons to establish the (Unit) and locate it in (the Hospital) the viability and desirability of this arrangement continuing should be the subject of further study."
This Bloggist focused this issue in a previous posting entitled "A glimpse of understanding: Part Three; A dangerous mix: Dr Charles Smith and the Hospital for Sick Children SCAN team." (Jan, 2, 2008;"
"In two recent recent postings I have linked Dr. Charles Smith's ability to have such a disastrous effect on Ontario's criminal justice system directly to the decision to appoint him to head the new Ontario Forensic Pediatric Pathology Unit which would be located at the Hospital for Sick Children in Ontario. (A glimmer of understanding; Parts One and Two);" the Blog began.
"One of the unfortunate by-products of this decision is that Smith would have increased influence with the Hospital for Sick Children's Suspected Child Abuse and Neglect (SCAN) Program," it continued.
"Smith, as director of the new prestigious new unit, and the hospital's SCAN unit would prove to be a dangerous mix.
Hospital literature described the SCAN Program as "a hospital-based, multidisciplinary team that offers care, support, and assessment to children and adolescents who may have been abused."
However, as a criminal lawyer, and Editor of the Criminal Lawyers Association Newsletter, In the 1980's I began hearing stories which indicated that the team had a propensity for turning tragic but innocent situations into criminal assaults.
In 1985, I learned about a case which confirmed my worse fears about the program - and wrote bout the case in the Toronto Star, under a headline that read: "They were caring parents, not child abusers"
"Sometimes, people acting with the best of intentions end up achieving the worst possible result," the story began.
"Such was the case in a recent dispute involving a northern Ontario couple and the Catholic Children's Aid Society of Metro Toronto.
The couple were plunged into a nightmare in which they were branded as child abusers of their then one-year-old son and had both of their children taken from them.
In fact, as later became clear when the case landed in court, their son, Tyler,
suffered from a rare bone disease and hadn't been abused at all.
After it became evident that Tyler wasn't developing properly and x-rays had revealed some bone lesions, his parents, whose identity cannot be published, asked their family physician in Elliot Lake to refer the child to Toronto's Hospital for Sick Children for examination by specialists.
But they returned home disappointed, early in January, 1985, as the hospital was unable to pinpoint the disease.
They were unaware that the head of the radiology department had concluded
that the x-rays "were suggestive of child abuse."
They were also unaware that a hospital child abuse team had met in their absence and had asked the medical staff to have the couple return to the hospital with both of their children.
On their arrival, officials of the Metro Children's Aid Society were waiting to "apprehend" both children under a law that permits children at "substantial risk" to be taken from their parents, pending a court hearing.
Bewildered, they returned alone to Elliot Lake to discover that their nightmare had only just begun.
The radiologist's diagnosis that the x-rays were "suggestive" of child abuse had mushroomed into the conclusion by a member of the abuse team that there was "a clear possibility of child abuse."
And the Metro Catholic Children's Aid Society, which had taken over the case, was planning to place Tyler in a foster home and the other child with his natural father.
This move was blocked following the intervention of a lawyer and a private social worker retained by the parents. That led to the children's placement with grandparents.
But the parents couldn't persuade the society to take further steps to find out what was wrong with Tyler, even though a renowned bone disease expert in California had concluded, after viewing the x-rays from the Hospital for Sick Children, that the
lesions were more consistent with bone disease than with fracture.
The expert had suggested to the hospital that certain tests should be carried out, but the hospital declined to perform these particular tests.
The parents were then forced to go to court on April, 22, 1986, to free Tyler so that he could be taken to California, partially at their own expense, and with the help of OHIP, for testing and diagnosis.
After a four-day hearing contested by the society, Family Court Judge Peter Nasmith granted the parents' application and made the decision that led to the proof that Tyler was a sick child, not an abused one, and that the parents were caring human
beings and not child abusers.
The California doctor confirmed his original diagnosis, and after doctors at an Ottawa hospital provided additional confirmation, the society finally withdrew the application to make the boy a crown ward.
What went wrong?
The key is provided by Judge Nasmith's comments at the hearing, where he took the unusual step of telling the society to pay costs to the parents for the legal proceedings.
Having concluded that, "the medical evidence was inconclusive and any evidence of possible abuse was of a very unreliable nature," and noting the difficulties the society faced because of the number of agencies involved and the fact that it was
"obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children," the judge said: "The fact remains that there was embarrassingly little effort to follow up on what had become a devastating allegation . . . I
think the position (the society) took was unreasonable and even arbitrary."
As to the heart of the problem, Judge Nasmith said: "No doubt the real fly in the ointment here is the child abuse team at the Hospital for Sick Children as they moved from a position of possible abuse to a diagnosis of abuse. This was a surprising stance for them to take, and I think it underlines the need for
a protection agency receiving reports under (child) protection legislation and for courts in these cases to continue to scrutinize the zeal of the well-meaning people who are so understandably devoted to fighting the scourge that is child abuse. This zeal has created a subtle dynamic that can somehow convert a suspicion of child abuse into a presumption of child abuse."
One can sympathize with children's aid societies because of the heavy pressures they face and their dilemma when confronted by complex medical information provided by experts.
But Nasmith's ruling spells out the high standards to be expected of them, and of the experts involved in the medical and social investigation of child abuse, because of the awesome legal and persuasive powers that they possess.
If Tyler's parents hadn't had sufficient commitment and ability - and the support of OHIP, the Ontario Legal Aid Plan, and a dedicated lawyer - what would the situation be now? Sound familiar?
The dangerous mix between Dr. Charles Smith and the Hospital for Sick Children SCAN team was all too apparent in a case before the Inquiry which I have been referring to as "the Timmin's case" in previous postings.
The case is the subject of a court decision released by Provincial Court Judge Patrick Dunn on July 25, 1991, the year the Ontario Forensic Pediatric Pathology Unit was formed and several years after the Nasmith decision. (Dr. Smith had been at the hospital since 1981);
As Dunn noted: "I am not the only person who believed (the babysitter). The Community believed her too until the Crown's shaking theory surfaced. When first presented, the Crown's case appeared quite plausible. But after the evidence of the defence experts (Dr. Smith and the Hospital for Sick Children SCAN team) it is riddled with reasonable doubts."Why would the babysitter shake Amber to death?
"Dr. Smith suggested by way of provocation that perhaps Amber was a "bear", like his son, when she woke up," Dunn wrote in his powerful 24-page judgment which resonates to this very day.
"In other words, that the child would be provocative by her irritable manner. This is not true on the facts and it was unfair to suggest the possibility because there was no basis for it."
(Dunn also ruled that, "I cannot find that (The Hospital for Sick Children) properly considered the relationship between the Babysitter and Amber or Amber's gentle and non-provocative disposition," as he blasted both Smith and the SCAN team for failing to obtain "a complete and accurate psycho-social history" - even though they new "the importance" of having it.")
I don't propose to dwell on the details case as I have previously addressed it in several postings on this Blog.
Suffice it to point out for now that Dunn expressed, "serious concerns about the manner in which certain physicians at the Hospital for Sick Children ... formulated their diagnosis." (Dunn stressed that wherever the evidence of the SCAN team members clashed with the defence witnesses, "I prefer to accept the evidence of the defence experts."
Dunn stressed that there were flaws in the Hospital for Sick Children approach - "and hence their opinion about shaking should not be given great weight.
"I am not talking now about whether shaking exists or whether it or some other mechanism killed Amber," he explained."
"I mean that the fact gathering process, the communication procedures, and the documentation of the Hospital for Sick Children doctors, involved in this case are such that I am led to question the conclusion they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
Similar comments were made about Dr. Charles Smith's work by the independent reviewers who studied so many of his cases.
A very dangerous mix indeed."
Sossin makes a compelling argument for removing the Unit from the Hospital - which in this Blogster's view has not demonstrated over many years that it deserves the public trust.
This is yet another tough bullet for Commissioner Goudge to bite."
Harold Levy...hlevy15@gmail.com;
HOWEVER, TO ENSURE THAT INFANTS AND CHILDREN ARE PROTECTED FROM HARM AND ABUSE, THE REMAINING TEN PER CENT OF CASES THAT INCLUDE CLEAR HOMICIDES OR CRIMINALLY SUSPICIOUS DEATHS ARE BEST HANDLED BY QUALIFIED FORENSIC PATHOLOGISTS WHOSE TRAINING AND EXPERIENCE LIES PRIMARILY IN THE EXAMINATION OF VIOLENT DEATH, HOMICIDES AND SUCH.
THE BEST SETTING TO PERFORM THESE AUTOPSIES (WHICH TOTAL APPROXIMATELY 10-15 CASES PER YEAR) IS AT THE CHIEF CORONER'S OFFICE WHICH HAS THE QUALIFIED STAFF AND REQUIRED FACILITIES TO CONDUCT THE NECESSARY INVESTIGATIONS."
DR. ERNEST CUTZ: RECOMMENDATIONS TO GOUDGE INQUIRY;
-------------------------------------------------------------------------------
Dr. Ernest Cutz, a distinguished pathologist at the Hospital for Sick Children in Toronto, has drafted his personal recommendations for the Goudge Inquiry, which have been posted on the Inquiry's Web-site.
Dr. Cutz's views are well worth considering because he has been at the Hospital for several decades and is steeped in all aspects of the Pathology Department -including the Ontario Forensic Pediatric Pathology Unit.
This Blog is therefore publishing Dr. Cutz's submissions - beginning with his recommendation that the hospital should cease performing forensic autopsies - and focus, rather, on what he calls, "medical/natural death cases."
"I have reviewed the “List of Systemic Issues” currently available on the website of the Inquiry into Pediatric Forensic Pathology in Ontario," this portion of Dr. Cutz's submissions begins.
"The following document reflects my own personal views and comments on select questions posed in that list" it continues;
"My comments reflect over 35 years of experience in Pediatric Pathology, including pediatric forensic pathology.
I. Institutional Considerations: Should Ontario have an institutional setting dedicated to pediatric forensic pathology, or should pediatric services be delivered within a forensic pathology institutional setting?
In essence, it is my view that the pediatric pathology work performed in Ontario should not be all be performed by the same institution.
Rather, pediatric autopsy work should be divided between the Hospital for Sick Children (the Hospital) and the Office of the Chief Coroner of Ontario. (The Chief Coroner's Office);
I say this for the following reasons:
a) Approximately 90 per cent of pediatric cases investigated under the Coroner’s Warrant result from death due to natural causes or pediatric disease.
These cases are thus not “forensic” by nature.
It is appropriate that pediatric pathologists from the Hospital for Sick Children perform the autopsies in these cases.
It is my view, however, that the Hospital should only perform autopsies on these “medical/natural death cases”.
Therefore, there would no longer be a need for a Pediatric Forensic Pathology Unit (the Unit) at the Hospital;
Furthermore, it is my view that there is an incompatibility between the principal mission of the Hospital as being dedicated to academic pursuits and research and the Chief Coroner's Office which excludes research;
I believe that the institutional link between the Hospital and the Chief Coroner's Office should be discontinued.
b) In summary, it is my view that the Division of Pathology at the Hospital, and other Pediatric Pathology services at other large academic centers, are best suited to provide high quality pediatric pathology services focusing on academic aspects that include the diagnosis and investigation of pediatric diseases.
c) However, to ensure that infants and children are protected from harm and abuse, the remaining ten per cent of cases that include clear homicides or criminally suspicious deaths are best handled by qualified forensic pathologists whose training and experience lies primarily in the examination of violent death, homicides and such.
The best setting to perform these autopsies (which total approximately 10-15 cases per year) is at the Chief Coroner's Office which has the qualified staff and required facilities to conduct the necessary investigations.
d) In terms of the pediatric disease cases, the best protection against wrongful accusations in pediatric cases is the provision of a correct diagnosis of natural disease based on a solid scientific foundation.
The diagnosis of pediatric disease in the 21st century is based on sophisticated methods of cellular and molecular biology (i.e. testing for genetic or metabolic disorders).
This testing requires special expertise and facilities, all of which are available at the Hospital, but are not available at the Chief Coroner's Office;
e) Since research and education into pediatric disease is outside the mandate of the Chief Coroner's Office, the responsibility and the provision of resources for this essentially patient-related activity should be assumed by the Ministry of Health and Long term Care.
10. What is the most cost efficient way of delivering quality pediatric forensic pathology services? For example, what are the advantages and disadvantages of using staff doctors or fee-for-service doctors?
a) Staff Pathologists based at leading Pediatric Academic Institutions, such as the Hospital for Sick Children can deliver the most cost-efficient and highest quality pediatric pathology services.
All staff are qualified and experienced Pediatric Pathologists who are also cross-appointed to the University of Toronto and thus participate fully in research and educational activities.
b) The combination of high-level diagnostic skills in diagnosing pediatric disease, research into disease pathogenesis, and education ensures that the work of these pathologists is high quality and also serves to educate the next generation of pediatric pathologists, thereby addressing the shortage of professionals in this specialty."
This Blogster has addressed the issue as to whether the Ontario Forensic Pediatric Pathology Unit should remain at the Hospital for Sick Children in an earlier post entitled, "Up-Date: Expert Evidence; Part Three: Research Questions Whether Forensic Unit Once Headed By Smith Should Remain At Sick Kids," published on March 8, 2008;
For the benefit of those readers who have not read it, that post ran as follows:
"IN ADDITION TO AN ABSENCE OF MEANINGFUL OVERSIGHT, THE INTEGRATION OF THE (UNIT) WITHIN THE PEDIATRIC PATHOLOGY UNIT AT THE HOSPITAL FOR SICK CHILDREN(INCLUDING INTERACTION WITH THE SUSPECTED CHILD ABUSE AND NEGLECT (SCAN) TEAM) MAY HAVE CREATED A PARTICULAR KIND OF INSTITUTIONAL CULTURE THAT CONTRIBUTED TO THE “THINK DIRTY” ETHOS, DISCUSSED IN OTHER RESEARCH CONDUCTED FOR THIS INQUIRY,"
PROFESSOR LORNE SOSSIN IN RESEARCH PAPER PREPARED FOR THE GOUDGE INQUIRY;
Ontario's Pediatric Forensic Pathology Unit, once headed by Dr. Charles Smith, risks being tainted by its proximity to the Hospital for Sick Children's Sick Children's Suspected Child Abuse and Neglect (SCAN) team, a researcher suggests.
University of Toronto law professor Lorne Sossin, recommends that Ontario should rethink retention of the Unit at the (Hospital) in a paper commissioned by the Goudge Inquiry entitled, "oversight and accountability." (The paper is posted on the Inquiry's Web-site;)
"In addition to an absence of meaningful oversight, the integration of the (Unit) within the pediatric pathology unit at the Hospital for Sick Children(including interaction with the Suspected Child Abuse and Neglect (SCAN) team) may have created a particular kind of institutional culture that contributed to the “think dirty” ethos, discussed in other research conducted for this Inquiry," writes Sossin;
"While there may have been good reasons to establish the (Unit) and locate it in (the Hospital) the viability and desirability of this arrangement continuing should be the subject of further study."
This Bloggist focused this issue in a previous posting entitled "A glimpse of understanding: Part Three; A dangerous mix: Dr Charles Smith and the Hospital for Sick Children SCAN team." (Jan, 2, 2008;"
"In two recent recent postings I have linked Dr. Charles Smith's ability to have such a disastrous effect on Ontario's criminal justice system directly to the decision to appoint him to head the new Ontario Forensic Pediatric Pathology Unit which would be located at the Hospital for Sick Children in Ontario. (A glimmer of understanding; Parts One and Two);" the Blog began.
"One of the unfortunate by-products of this decision is that Smith would have increased influence with the Hospital for Sick Children's Suspected Child Abuse and Neglect (SCAN) Program," it continued.
"Smith, as director of the new prestigious new unit, and the hospital's SCAN unit would prove to be a dangerous mix.
Hospital literature described the SCAN Program as "a hospital-based, multidisciplinary team that offers care, support, and assessment to children and adolescents who may have been abused."
However, as a criminal lawyer, and Editor of the Criminal Lawyers Association Newsletter, In the 1980's I began hearing stories which indicated that the team had a propensity for turning tragic but innocent situations into criminal assaults.
In 1985, I learned about a case which confirmed my worse fears about the program - and wrote bout the case in the Toronto Star, under a headline that read: "They were caring parents, not child abusers"
"Sometimes, people acting with the best of intentions end up achieving the worst possible result," the story began.
"Such was the case in a recent dispute involving a northern Ontario couple and the Catholic Children's Aid Society of Metro Toronto.
The couple were plunged into a nightmare in which they were branded as child abusers of their then one-year-old son and had both of their children taken from them.
In fact, as later became clear when the case landed in court, their son, Tyler,
suffered from a rare bone disease and hadn't been abused at all.
After it became evident that Tyler wasn't developing properly and x-rays had revealed some bone lesions, his parents, whose identity cannot be published, asked their family physician in Elliot Lake to refer the child to Toronto's Hospital for Sick Children for examination by specialists.
But they returned home disappointed, early in January, 1985, as the hospital was unable to pinpoint the disease.
They were unaware that the head of the radiology department had concluded
that the x-rays "were suggestive of child abuse."
They were also unaware that a hospital child abuse team had met in their absence and had asked the medical staff to have the couple return to the hospital with both of their children.
On their arrival, officials of the Metro Children's Aid Society were waiting to "apprehend" both children under a law that permits children at "substantial risk" to be taken from their parents, pending a court hearing.
Bewildered, they returned alone to Elliot Lake to discover that their nightmare had only just begun.
The radiologist's diagnosis that the x-rays were "suggestive" of child abuse had mushroomed into the conclusion by a member of the abuse team that there was "a clear possibility of child abuse."
And the Metro Catholic Children's Aid Society, which had taken over the case, was planning to place Tyler in a foster home and the other child with his natural father.
This move was blocked following the intervention of a lawyer and a private social worker retained by the parents. That led to the children's placement with grandparents.
But the parents couldn't persuade the society to take further steps to find out what was wrong with Tyler, even though a renowned bone disease expert in California had concluded, after viewing the x-rays from the Hospital for Sick Children, that the
lesions were more consistent with bone disease than with fracture.
The expert had suggested to the hospital that certain tests should be carried out, but the hospital declined to perform these particular tests.
The parents were then forced to go to court on April, 22, 1986, to free Tyler so that he could be taken to California, partially at their own expense, and with the help of OHIP, for testing and diagnosis.
After a four-day hearing contested by the society, Family Court Judge Peter Nasmith granted the parents' application and made the decision that led to the proof that Tyler was a sick child, not an abused one, and that the parents were caring human
beings and not child abusers.
The California doctor confirmed his original diagnosis, and after doctors at an Ottawa hospital provided additional confirmation, the society finally withdrew the application to make the boy a crown ward.
What went wrong?
The key is provided by Judge Nasmith's comments at the hearing, where he took the unusual step of telling the society to pay costs to the parents for the legal proceedings.
Having concluded that, "the medical evidence was inconclusive and any evidence of possible abuse was of a very unreliable nature," and noting the difficulties the society faced because of the number of agencies involved and the fact that it was
"obviously influenced (perhaps controlled) by the child abuse team at the Hospital for Sick Children," the judge said: "The fact remains that there was embarrassingly little effort to follow up on what had become a devastating allegation . . . I
think the position (the society) took was unreasonable and even arbitrary."
As to the heart of the problem, Judge Nasmith said: "No doubt the real fly in the ointment here is the child abuse team at the Hospital for Sick Children as they moved from a position of possible abuse to a diagnosis of abuse. This was a surprising stance for them to take, and I think it underlines the need for
a protection agency receiving reports under (child) protection legislation and for courts in these cases to continue to scrutinize the zeal of the well-meaning people who are so understandably devoted to fighting the scourge that is child abuse. This zeal has created a subtle dynamic that can somehow convert a suspicion of child abuse into a presumption of child abuse."
One can sympathize with children's aid societies because of the heavy pressures they face and their dilemma when confronted by complex medical information provided by experts.
But Nasmith's ruling spells out the high standards to be expected of them, and of the experts involved in the medical and social investigation of child abuse, because of the awesome legal and persuasive powers that they possess.
If Tyler's parents hadn't had sufficient commitment and ability - and the support of OHIP, the Ontario Legal Aid Plan, and a dedicated lawyer - what would the situation be now? Sound familiar?
The dangerous mix between Dr. Charles Smith and the Hospital for Sick Children SCAN team was all too apparent in a case before the Inquiry which I have been referring to as "the Timmin's case" in previous postings.
The case is the subject of a court decision released by Provincial Court Judge Patrick Dunn on July 25, 1991, the year the Ontario Forensic Pediatric Pathology Unit was formed and several years after the Nasmith decision. (Dr. Smith had been at the hospital since 1981);
As Dunn noted: "I am not the only person who believed (the babysitter). The Community believed her too until the Crown's shaking theory surfaced. When first presented, the Crown's case appeared quite plausible. But after the evidence of the defence experts (Dr. Smith and the Hospital for Sick Children SCAN team) it is riddled with reasonable doubts."Why would the babysitter shake Amber to death?
"Dr. Smith suggested by way of provocation that perhaps Amber was a "bear", like his son, when she woke up," Dunn wrote in his powerful 24-page judgment which resonates to this very day.
"In other words, that the child would be provocative by her irritable manner. This is not true on the facts and it was unfair to suggest the possibility because there was no basis for it."
(Dunn also ruled that, "I cannot find that (The Hospital for Sick Children) properly considered the relationship between the Babysitter and Amber or Amber's gentle and non-provocative disposition," as he blasted both Smith and the SCAN team for failing to obtain "a complete and accurate psycho-social history" - even though they new "the importance" of having it.")
I don't propose to dwell on the details case as I have previously addressed it in several postings on this Blog.
Suffice it to point out for now that Dunn expressed, "serious concerns about the manner in which certain physicians at the Hospital for Sick Children ... formulated their diagnosis." (Dunn stressed that wherever the evidence of the SCAN team members clashed with the defence witnesses, "I prefer to accept the evidence of the defence experts."
Dunn stressed that there were flaws in the Hospital for Sick Children approach - "and hence their opinion about shaking should not be given great weight.
"I am not talking now about whether shaking exists or whether it or some other mechanism killed Amber," he explained."
"I mean that the fact gathering process, the communication procedures, and the documentation of the Hospital for Sick Children doctors, involved in this case are such that I am led to question the conclusion they drew, based on the facts as these erstwhile and well-meaning doctors understood them."
Similar comments were made about Dr. Charles Smith's work by the independent reviewers who studied so many of his cases.
A very dangerous mix indeed."
Sossin makes a compelling argument for removing the Unit from the Hospital - which in this Blogster's view has not demonstrated over many years that it deserves the public trust.
This is yet another tough bullet for Commissioner Goudge to bite."
Harold Levy...hlevy15@gmail.com;
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...
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