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;
Showing posts with label office. Show all posts
Showing posts with label office. Show all posts
Tuesday, May 6, 2008
Sunday, February 10, 2008
More Insights On Search Of Dr. Charles Smith's Office For The Missing Mullins-Johnson Slides; Witness Statements;
"MS. ZWOLAKOWSKI FOUND SEVERAL UNUSUAL ITEMS IN DR. SMITH'S OFFICE," HER WITNESS STATEMENT SAYS;
I have devoted many postings to the search for the missing Mullins-Johnson slides - the only evidence that could possibly show that William Mullins-Johnson was innocent.
Dorothy Zwolakowski, an official in the Chief Coroner's Office, describes the search in detail - as well as an audit of all forensic exhibits at the Ontario Pediatric Forensic Pathology Unit - in a witness statement that has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of interviews of potential witnesses conducted by Goudge Inquiry staff);
Our readers are invited to read her entire statement on the Goudge Inquiry Web-page at www.goudgeinquiry.ca; (Go into transcripts and then click "witness statements";
For now, I just want to highlight a few of her observations which intrigue me.
First, Zwolakowski’s comments on the events of Nov. 26, 2004, when she and Dr. Cairns visited Dr. Smith at the Unit to ask him about and for the missing materials from the Mullins-Johnson case;
"They met with Dr. Smith in the pathology boardroom," the statement says.
"Dr. Cairns asked Dr. Smith about the material, but Dr. Smith did not appear recall that he had been involved in such a file.
Ms. Zwolakowski recalls being surprised that Dr. Smith did not go and look for the material, given the urgency of the situation."
This is pretty shocking.
Police, prosecutors, and Mullins=Johnson’s lawyer’s, had been trying desperately to get their hands on these microscopic slides and tissue blocks which were of life and death importance to Mullins-Johnson - and Dr. Smith did not see the urgency.
Something is hugely wrong with that picture;
The least Dr. Smith could have done - if he had any human feelings as to how his intransigence was affecting Mullins-Johnson - would have been to throw himself into the search and stick with it until the missing items were found.
(Unless, of course, he knew that the missing slides were somewhere else);
Secondly, Zwolakowski told the Inquiry that that it was clear to her when she was attempting to locate the materials that, "there were numerous slides in Dr. Smith’s office at the Unit”;
"Ms. Zwolakowski believes that this would have been obvious to anyone in his
office," her witness statement says.
"Ms. Zwolakowski was concerned that the slides were not stored in the storage room where they would normally be filed."
The message I get here is that the Hospital For Sick Children had utterly abdicated its responsibility to protect the public by supervising its employee, Dr. Smith - and that the hospital had failed to put the most basic systems for storing forensic materials in place;
The blame for that appalling lack of supervision cannot be placed entirely on the Chief Coroner's Office;
Lastly, Zwolakowski describes a grizzly find she made after the audit had been conducted and it was finally possible to get a grip on the contents of Dr. Smith's office:
"Ms. Zwolakowski found several unusual items in Dr. Smith’s office," her witness statement says.
For example, she discovered containers that once contained human wet tissue, but whose contents were now dried out because the formalin had evaporated.
"In addition, Ms. Zwolakowski located a Tupperware container that appeared to contain the rib cage of an infant".
Ms. Zwolakowski found this to be unusual."
Unusual?
It goes without saying that wet tissue has to be carefully protected in controlled temperatures so that it will not became degraded;
But it is the apparent anonymous rib-cage of an infant that tears my heart out.
No tags;
No protection - other than a tupperware container;
No recognition that this was once a child - somebody's child.
I don't like what this tells me about Dr. Smith;
Harold Levy...hlevy15@gmail.com;
I have devoted many postings to the search for the missing Mullins-Johnson slides - the only evidence that could possibly show that William Mullins-Johnson was innocent.
Dorothy Zwolakowski, an official in the Chief Coroner's Office, describes the search in detail - as well as an audit of all forensic exhibits at the Ontario Pediatric Forensic Pathology Unit - in a witness statement that has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of interviews of potential witnesses conducted by Goudge Inquiry staff);
Our readers are invited to read her entire statement on the Goudge Inquiry Web-page at www.goudgeinquiry.ca; (Go into transcripts and then click "witness statements";
For now, I just want to highlight a few of her observations which intrigue me.
First, Zwolakowski’s comments on the events of Nov. 26, 2004, when she and Dr. Cairns visited Dr. Smith at the Unit to ask him about and for the missing materials from the Mullins-Johnson case;
"They met with Dr. Smith in the pathology boardroom," the statement says.
"Dr. Cairns asked Dr. Smith about the material, but Dr. Smith did not appear recall that he had been involved in such a file.
Ms. Zwolakowski recalls being surprised that Dr. Smith did not go and look for the material, given the urgency of the situation."
This is pretty shocking.
Police, prosecutors, and Mullins=Johnson’s lawyer’s, had been trying desperately to get their hands on these microscopic slides and tissue blocks which were of life and death importance to Mullins-Johnson - and Dr. Smith did not see the urgency.
Something is hugely wrong with that picture;
The least Dr. Smith could have done - if he had any human feelings as to how his intransigence was affecting Mullins-Johnson - would have been to throw himself into the search and stick with it until the missing items were found.
(Unless, of course, he knew that the missing slides were somewhere else);
Secondly, Zwolakowski told the Inquiry that that it was clear to her when she was attempting to locate the materials that, "there were numerous slides in Dr. Smith’s office at the Unit”;
"Ms. Zwolakowski believes that this would have been obvious to anyone in his
office," her witness statement says.
"Ms. Zwolakowski was concerned that the slides were not stored in the storage room where they would normally be filed."
The message I get here is that the Hospital For Sick Children had utterly abdicated its responsibility to protect the public by supervising its employee, Dr. Smith - and that the hospital had failed to put the most basic systems for storing forensic materials in place;
The blame for that appalling lack of supervision cannot be placed entirely on the Chief Coroner's Office;
Lastly, Zwolakowski describes a grizzly find she made after the audit had been conducted and it was finally possible to get a grip on the contents of Dr. Smith's office:
"Ms. Zwolakowski found several unusual items in Dr. Smith’s office," her witness statement says.
For example, she discovered containers that once contained human wet tissue, but whose contents were now dried out because the formalin had evaporated.
"In addition, Ms. Zwolakowski located a Tupperware container that appeared to contain the rib cage of an infant".
Ms. Zwolakowski found this to be unusual."
Unusual?
It goes without saying that wet tissue has to be carefully protected in controlled temperatures so that it will not became degraded;
But it is the apparent anonymous rib-cage of an infant that tears my heart out.
No tags;
No protection - other than a tupperware container;
No recognition that this was once a child - somebody's child.
I don't like what this tells me about Dr. Smith;
Harold Levy...hlevy15@gmail.com;
Unopened Envelopes Containing Potential Evidence From Criminal Cases Found In Dr. Smith's Office At Hospital For Sick Children; Witness Statements;
"SHE OBSERVED THAT THE BOXES CONTAINED A VARIETY OF POTENTIALLY IMPORTANT MATERIAL, AND INCLUDED UNOPENED ENVELOPES THAT APPEARED TO CONTAIN EVIDENCE FROM CRIMINAL PROCEEDINGS IN OTHER JURISDICTIONS."
"FROM WITNESS STATEMENT OF DOROTHY ZWOLAKOWSKI FILED INTO EVIDENCE AT THE GOUDGE INQUIRY';
An official from the Ontario Chief Coroner's Office says she discovered potentially important evidence relating to criminal cases in unopened envelopes in boxes in Dr. Charles Smith's office at the Hospital For Sick Children.
This revelation comes from a "witness statement" made by Dorothy Zwolakowski, an official of the Ontario Chief Coroner's office, which has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of statements of potential witnesses provided to Inquiry staff);
According to this statement:
"Ms. Zwolakowski reported that at the end of the audit (in the spring of 2005 H.L.), Dr. Smith’s office was much more orderly than before.
Ms. Zwolakowski recalls that (Hospital For Sick Children) needed the office and the pathology department was moving.
Hospital For Sick Children) staff placed the contents of Dr. Smith’s office into 59 boxes.
Ms. Zwolakowski was concerned that the (Ontario Chief Coroner's Office) might need future access to the contents of the boxes, and that (the Hospital For Sick Children) might at some point send the boxes to Dr. Smith.
She observed that the boxes contained a variety of potentially important material, and included unopened envelopes that appeared to contain evidence from criminal proceedings in other jurisdictions."
The witness statement dies not indicate what steps the Chief Coroner's office criminal cases were involved - and what steps, if any, were taken to ensure that they were brought to the respective police officers, crown attorneys, and defence lawyers.
Nor is there any indication as to whether these criminal cases where still before the courts - or had been concluded.
It would seem to this Blogster that the public has a strong interest in learning the number of these envelopes, their contents, the criminal cases involved, how long they had been sitting in unopened envelopes in Dr. Smith's office, and the steps taken in the aftermath of their discovery.
Harold Levy...hlevy15@gmail.com;
"FROM WITNESS STATEMENT OF DOROTHY ZWOLAKOWSKI FILED INTO EVIDENCE AT THE GOUDGE INQUIRY';
An official from the Ontario Chief Coroner's Office says she discovered potentially important evidence relating to criminal cases in unopened envelopes in boxes in Dr. Charles Smith's office at the Hospital For Sick Children.
This revelation comes from a "witness statement" made by Dorothy Zwolakowski, an official of the Ontario Chief Coroner's office, which has been filed in evidence at the Goudge Inquiry.
(The "witness statements" are actually summaries of statements of potential witnesses provided to Inquiry staff);
According to this statement:
"Ms. Zwolakowski reported that at the end of the audit (in the spring of 2005 H.L.), Dr. Smith’s office was much more orderly than before.
Ms. Zwolakowski recalls that (Hospital For Sick Children) needed the office and the pathology department was moving.
Hospital For Sick Children) staff placed the contents of Dr. Smith’s office into 59 boxes.
Ms. Zwolakowski was concerned that the (Ontario Chief Coroner's Office) might need future access to the contents of the boxes, and that (the Hospital For Sick Children) might at some point send the boxes to Dr. Smith.
She observed that the boxes contained a variety of potentially important material, and included unopened envelopes that appeared to contain evidence from criminal proceedings in other jurisdictions."
The witness statement dies not indicate what steps the Chief Coroner's office criminal cases were involved - and what steps, if any, were taken to ensure that they were brought to the respective police officers, crown attorneys, and defence lawyers.
Nor is there any indication as to whether these criminal cases where still before the courts - or had been concluded.
It would seem to this Blogster that the public has a strong interest in learning the number of these envelopes, their contents, the criminal cases involved, how long they had been sitting in unopened envelopes in Dr. Smith's office, and the steps taken in the aftermath of their discovery.
Harold Levy...hlevy15@gmail.com;
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