Drs. Charles Smith And Rajgopal Menon: Their Colleagues Saw Nothing To Be Concerned About; A Sense Of Deja Vu;

The New Brunswick Inquiry into the flawed work of Dr. Rajgopal Menon has been informed that his colleagues had no idea that there were serious problems with the pathologist's work.

The commission of inquiry into pathology services in New Brunswick was struck after an audit of the laboratory work of Dr. Rajgopal Menon, 73, found a significant number of errors and missed diagnoses, especially in relation to prostate and breast cancers.

(Menon, who will testify at the inquiry later this month, has defended his work, calling the review "unjustified and unfair." He has also filed a civil suit against the regional health authority.)

As reported by the Canadian Press yesterday, in a story headed, "NB inquiry into pathology errors told lack of professionals," this evidence came from Nora Kelly, a former deputy minister of health in New Brunswick.

"Kelly said she had no inkling of serious problems with Menon's work", the story, datelined Moncton, N.B. says.

"She said there were general comments from his colleagues about his slow work habits, his tardiness and missing slides, but no one suggested his work might be sub-standard.

"They didn't like the way he operated, but they never said that he was incompetent," Kelly told commissioner Paul Creaghan, a retired judge."

Slow work...tardiness...missing slides!

Hmmm...Sounded familiar;

Where had I heard that before.

Or, as I had a chance to use my best French in a recent posting, was there not an epic sense of "deja vu?"

As I read these words, I thought back to testimony given to the Goudge Inquiry by Drs. Dirk Huyer, once head of the Suspected Child Abuse and Neglect (SCAN) Unit at the hospital for several years, under cross-examination by Commission Counsel Linda Rothstein;

Try this for size...

MS. LINDA ROTHSTEIN: Dr. Huyer, do you remember what year it was that you last saw Dr. Smith?

DR. DIRK HUYER: I suspect it was 2001.

MS. LINDA ROTHSTEIN: All right. And you would have first met him then 1989?

DR. DIRK HUYER: In January, 1990.

MS. LINDA ROTHSTEIN: 1990. During that period, at any stage, did you develop any concerns about Dr. Smith, as a professional, of course?

DR. DIRK HUYER: There were a number of times where I was notified about issues relating to Dr. Smith.

Primarily, those were issues about timeliness of reports.

And that was a recurrent pattern for me, and timeliness of -- of findings.

So, for example, I've done some talks out West, where police and Children's Aid have been there and made -- and I developed some acquaintances.

And I had been contacted by a RCP -- RCMP officer -- and I can't remember from which province -- who said to me, you know, I sent something to Dr. Smith for an opinion.

It's been a year and a half, and I can't get him.

He won't answer my call.

I -- and I need that material, because court's coming up.

And can you help me, because otherwise I'm going to have to call the
College to -- to get that stuff back.

And so I would go to Charles -- or I went to Charles and I said, Charles, you know, this officer has called me.

What -- what's up?

And then I didn't hear anything more of it following that time, so I made a presumption that he returned the material.

I had heard various things, as I say, about delay and -- and opinions being provided.

And I had heard, although I have no -- no ability to sort through this, that at times his opinion might be different at the time of the autopsy and then his final report."

So what was Dr. Huyer's opinion of his colleague?

DR. DIRK HUYER: Yes. Now, my direct observations of Dr. Smith in the autopsy suite, to me, seemed very thorough, very patient, very methodical in
his approach in doing the autopsies and watching the autopsies.

I never developed a concern about that.

And -- and as -- as you know, I have a very broad experience in watching autopsies with a variety of different pathologists.

So I did not develop any concerns during that time.

Reading his reports, which I had done on a frequent basis, again, concerns didn't jump out to me in -- in the spectrum of other pathology reports that I read.

Obviously, I can't analyse or understand the histopathology, so I couldn't evaluate that in any -- to any -- any degree.

But I -- things were not jumping out to me as being a concern.

His office was pretty cluttered and pretty much on the extreme end of what I would describe as cluttered.

But I'll tell you, I've been in a lot of cluttered offices and that, to me, isn't a definite marker of a problem."

Deja vu?

(At a general level, the comments of Menon's and Smith's colleagues raise crucial questions about hospital culture; Are there pressures on doctors and hospital staff to keep silent about other physicians - even when they have knowledge that the public could be harmed? Is this culture reflected in hospital administrations ad the various self-regulating colleges? Why don't Doctors get more actively involved in cleaning up their professions? Is there a "thin white line?")

Harold Levy...hlevy15@gmail.com;

Part Five: Who Is Edward Charles Splatt? From Guy Paul Morin to Edward Splatt: Lessons Unfortunately Not Learned;

Guy Paul Morin;



Edward Charles Splatt with journalist Stuart Cockburn;

"INDEED, AT THE VERY SAME TIME THAT THE COMMISSION OF INQUIRY ON PROCEEDINGS INVOLVING GUY PAUL MORIN WAS SCRUTINIZING AND REPORTING ON THE INADEQUACIES OF THE CENTRE FOR FORENSIC SCIENCES THAT CONTRIBUTED TO THE WRONGFUL CONVICTION OF GUY PAUL MORIN, MANY SIMILAR OR ANALOGOUS PRACTICES WERE TAKING PLACE A STONE’S THROW AWAY AT THE OFFICE OF THE CHIEF CORONER FOR ONTARIO. IT IS IRONIC THAT AT THAT TIME, BOTH INSTITUTIONS WERE HEADED BY THE SAME PERSON."

CLOSING SUBMISSIONS; ASSOCIATION IN DEFENCE OF THE WRONGLY CONVICTED AND MULLINS-JOHNSON GROUP;

-------------------------------------------------------------------------------

One of the most important perspectives coming out of the Goudge inquiry was provided by lawyers Louis Sokolov on behalf of the Association in Defence of the Wrongly Convicted (AIDWYC) in his closing submissions.

Sokolov pointed out that many of the flaws in the area of forensic science identified by Justice Fred Kaufman as contributing to the wrongful conviction of Guy Paul Morin had been observed in cases involving Dr. Charles Smith being studied by Commissioner Goudge.

Justice Kaufman presided over the Inquiry into the wrongful conviction of Guy Paul Morin: See earlier posts: Part Three: Who Is Edward Charles Splatt? The Guy Paul Morin Connection; Part Four; Who is Edward Charles Splatt? More on the Guy Paul Morin Connection;

The link between the Kaufman Inquiry and the injustices attributed to Dr. Charles Smith was made by lawyers representing the Association in Defence of the Wrongly Convicted (AIDWYC) and the Mullins-Johnson Group in their closing submissions to the Goudge Commission.

"This is the seventh commission of inquiry in this country arising from miscarriages of justice, and the sixth that AIDWYC has taken part in," the lawyers pointed out.

"There is much in these submissions that has been said before by AIDWYC and others in the context of the other public inquiries, but nonetheless bears repeating because many of the factors than contribute to miscarriages of justice (e.g. tunnel vision, inadequate scientific evidence, poorly resourced defence counsel, lack of an independent and effective error correction body) continually reappear notwithstanding the good efforts of those commissions," they continued.

"Indeed, at the very same time that the Commission of Inquiry on Proceedings Involving Guy Paul Morin was scrutinizing and reporting on the inadequacies of the Centre For Forensic Sciences that contributed to the wrongful conviction of Guy Paul Morin, many similar or analogous practices were taking place a stone’s throw away at the Office of the Chief Coroner for Ontario. It is ironic that at that time, both institutions were headed by the same person."

I have focused on Sokolov's submissions in an article published in the most recent issue of the AIDWYC Journal entitled, "AIDWYC lawyers cross-examine Dr. James Young at the Goudge Inquiry" - and sub-titled "Deja Vu."

According to the Internet Dictionary: "The phrase "Déjà vu" is French for "already seen" and is used to refer to when a person experiences the feeling that they have seen, experienced, or been someplace before even when they are sure that that is not really true."

"As the Goudge Inquiry winds to a close, most of us want to believe that important lessons will be learned so that in the future innocent parents and caregivers will be spared the horror of being cast as murderers because of the failings of forensic science and forensic scientists," the article began.

"However, the cross-examination of former Chief Coroner Dr. James Young by AIDWYC lawyers Lewis Sokolov and Vanora Simpson – with its evocation of the abuses of forensic science that led to the wrongful conviction of Guy Paul Morin, might somewhat temper our optimism," it continued.

"After all, Dr. Young was also a witness at the Kaufman Inquiry into Morin's wrongful conviction as Assistant Deputy Solicitor General with responsibility for the Centre for Forensic Science which had come under intensive scrutiny for its role in connection with the Morin case.

Indeed, Justice Fred Kaufman concluded in his 1998 report that:

"A large number of CFS scientists perform their work with distinction. On the other hand, it would be a serious mistake to assume that the failings identified are confined to two (2) scientists. A number of those failings are rooted in systemic problems, many of which transcend, even the CFS and have been noted in cases worldwide where science has been misused. Dr. -- Dr. James Young, assistant Deputy, Solicitor General with responsibility for the CFS, apologized on behalf of the CFS for any role in Guy Paul Moran's conviction and advised the Commissioner that he had not appreciated the depth of issues which – which would arise at the Inquiry."

Flash forward almost ten years to 2007, and Dr. Young is in the hot-seat at the Goudge Inquiry where he is being questioned in the context of the positions he held as Assistant Deputy Minister and Chief Coroner for many years.

I could not help but feel an enormous sense of "déjà vu" as Sokolov drew Dr Young's attention to some of Justice Kaufman's findings in Morin, including:

0: The limitations upon scientific findings were not accurately or adequately communicated to police, prosecutors, the defence, and – to the courts;

0: Scientific findings were overstated at times;

0: Evidence was lost;

0: There were at times a loss of object -- objectivity inconsistent with the proper role of a forensic scientist.

0: Forensic reports were not being reduced to writing so that they could later be viewed by others for purposes of certainty and accountability; (Justice Kaufman recommended that there should be a written policy for forensic reports);

Young agreed with Sokolov that, "Much of the findings and indeed the recommendations regarding the Morin Report, need not only concern the (Centre of Forensic Sciences) but concern the wider issues of forensic science."

Coming back to my sense of "déjà vu," here we were ten years later, Dr. Young was in the witness box admitting errors in the system, and we had spent the last three months hearing a mountain of evidence involving overstatement of scientific opinions, failure to disclose the limitations on scientific findings, sloppy forensic reports, loss of evidence - and, above all, forensic scientists testifying for the state who displayed lack of objectivity consistent with the proper role of a social scientist.

Haven't we heard that before?"

I concluded by signing the article: "Harold Levy; (Who in spite of all this believes the Goudge inquiry is immensely important, believes compensation for Dr. Smith's victims cannot come soon enough, and remains an incurable optimist)."

Admittedly, when one considers all of the alarm bells relating to Dr. Charles Smith over the years - and the failure of his superiors in the Chief Coroner's Office and the Hospital for Sick Children to reign him in - it is getting harder and harder to retain that sense of optimism.

Harold Levy...hlevy@gmail.com