JUSTICE GOUDGE'S FINDINGS; PART TEN; THE ASPHYXIA CASES; (SMITH); TIFFANI; KATHARINA; DELANEY AND TAYLOR;

Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.

I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.

I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.

Justice Goudge's findings relating to the various cases have been scattered throughout the report.

My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;

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Overview reports prepared by Commission staff on the four cases which Justice Goudge refers to in his section called "Diagnosing Asphyxia" - Tiffani's case, Katharina's case, Delaney's case, and Taylor's case - read as follows

Tiffani's case:

Tiffani was born in Kingston,Ontario on March 24, 1993;

Tiffani was the child of Mary and William;

Tiffani died on July 4, 1993 in Glen Miller, Ontario;

Tiffani was three and a half months old at the time of her death;

Criminal proceedings were initiated against Mary and William;

On May 12, 1995, Mary and William pleaded guilty to the offence of failure to provide the necessities of life.

Mary received a suspended sentence and probation of two years (plus three days pre-trial custody) and William received a sentence of five months imprisonment;

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Katharina's case:;

Katharina was born in Toronto, Ontario on March 20, 1992;

Katharina was the only child of Lawrence Babineau and Gabriela Chaparro-Najar; (Ms. Babineau);

Katharina was found dead in her mother's apartment on September 15, 1995, in Toronto at the age of three and a half;

Criminal proceedings were initiated against Ms. Babineau on September 15, 1995;

On November 3, 1997, Ms. Babineau was found not criminally responsible for Katharina's death.

She received an absolute discharge from the Ontario Review Board on December 13, 2001;

The Toronto Catholic Children's Aid Society was involved with this family from October 17, 1994, until September 15, 1995;

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Delaney's case:

Delaney was born in Woodstock, Ontario on December 20, 1992;

Delaney was the child of Olga Policarpo and Fernando Policarpo;

Delaney was pronounced dead on May 23, 1993, at Woodstock General Hospital.

Delaney was five months old at the time of his death;

Criminal proceedings were initiated against Olga Policarpo.

On April 25, 1994, Ms.Policarpo was convicted by a jury of infanticide.

On June 20, 1994, Ms. Policarpo was given a suspended sentence and three years probation;

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Taylor's case;

Taylor was born on April 16, 1996, in Thunder Bay.

Taylor was found dead in his cradle on July 31, 1996;

Taylor was three and a half months old at the time of his death;

Taylor lived with his mother and father, Lanny and Laura, in Thunder Bay.

Also living in the home was Laura's son from a previous relationship (Taylor's brother), who was 20 months when Taylor died;

The Children's Aid Society was involved with respect to Taylor's brother following Taylor's death;

Lanny and Laura were charged with second degree murder in relation to Taylor's death on November 30, 1996;

They were also charged with criminal negligence causing death and failure to provide the necessities of life.

On June 30, 1997, Lanny and Laura were discharged on all counts following their preliminary inquiry.

The Crown brought an application in the nature of certiorari to quash the discharges which was dismissed on September 21, 199;

An appeal to the Ontario Court of Appeal was launched in October 1999 and was ultimately abandoned by the Crown in January 2000;

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According to Justice Goudge, one of the principal reasons Dr. Smith erred in the cases where he wrongfully concluded a child had died a suspicious death because of asphyxia was his misinterpretation of "non-specific findings" such as petechial hemorrhages in the thoracic viscera, congestion and edema of the lungs, cyanosis of the fingernails and cerebral edema, as indications of suspicious death.

But Justice Goudge noted that as early as 1974 forensic pathology textbooks were referring to those criteria as "obsolete" because they can appear on a body for many reasons - and without more evidence cannot be said to be diagnostic of asphyxia.

"Nonetheless, Dr. Smith determined that asphyxia was the cause of death in nine of the 18 cases the Commission studied in detail," he said.

Here are some of Justice Goudge's comments in the four cases referred to above:

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Tiffani:

Justice Goudge concludes that all of Dr. Smith's criteria were "non-specific and therefore non-diagnostic" - and that "the diagnosis of asphyxia was not available to him on the basis of the findings."

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Katharina:

As in Delaney's case (below), the independent experts diagreed with Smith's finding that the cause of death was asphyxia - and said that if he had diagnosed asphyxia based on the circumstantial, rather than the pathology evidence, he should have at least said so in his report.

"Instead, his reports were silent on the issue."

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Delaney:

The panel of independent experts disagreed with Smith's assertion that the pathological evidence established that Delaney's airway had been obstructed.

"According to Dr. Saukko, the toxicology, radiology and histology examinations did not reveal any specific or significant findings that could explain Delaney's death," said Goudge.

"Although the circumstances suggest homicide, there were no pathology findings to substantiate it or exclude it."

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Taylor;

This was a case where Smith did not find asphyxia to be the cause of death but determined there was an "asphyxial component" to the death

But Justice Goudge finds that Dr. Smith based this conclusion entirely on non-specific findings and that "there was no other evidence to suggest that asphyxia played a part in Taylor's death.

"Contrary to Dr. Smith's assertion that he did not diagnose asphyxia based on non-specific findings alone, he did exactly that in Taylor's case."

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There you have it;

Four cases in which none of the parents should have been put through the agony of being charged criminally with the death of a child;

Look at the consequences:

Tiffani: On May 12, 1995, Mary and William pleaded guilty to the offence of failure to provide the necessities of life.Mary received a suspended sentence and probation of two years (plus three days pre-trial custody) and William received a sentence of five months imprisonment;

Katharina: Criminal proceedings were initiated against Ms. Babineau on September 15, 1995; On November 3, 1997, Ms. Babineau was found not criminally responsible for Katharina's death.

Delaney: On April 25, 1994, Ms.Policarpo was convicted by a jury of infanticide. On June 20, 1994, Ms. Policarpo was given a suspended sentence and three years probation;

Taylor: Lanny and Laura were charged with second degree murder in relation to Taylor's death on November 30, 1996; They were also charged with criminal negligence causing death and failure to provide the necessities of life. On June 30, 1997, Lanny and Laura were discharged on all counts following their preliminary inquiry. The Crown brought an application in the nature of certiorari to quash the discharges which was dismissed on September 21, 1999; An appeal to the Ontario Court of Appeal was launched in October 1999 and was ultimately abandoned by the Crown in January 2000;

Harold Levy...hlevy15@gmail.com;

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"Fall from Grace": An insightful documentary;

The CBC's insightful documentary on Charles Smith, aptly entitled "Fall From Grace" was broadcast on the National on Sept. 4, 2007.



Produced by Anita Mielewczyk and hosted by Maureen Taylor, "Fall From Grace" set out to answer the question "How and why did Ontario pathologist Dr. Charles Smith prepare autopsies that wrongly implicated at least twelve parents in the deaths of their children. Taylor gives her personal perspective in a fascinating "field note" published on the National's Web site.



"Dr. Charles Smith remains an enigma," Taylor says.


"Of course, we set out to delve right into his innermost thoughts, to understand what motivated him as he pursued people he thought were child abusers, with sometimes tragic consequences.
What we have, are clues.


With painstaking research by producer, Anita Mielewczyk, we were able to piece together Dr. Smith's career as a pathologist. For me, the most surprising information Anita uncovered was Dr. Smith's link to the infamous murder investigations in 1981 at the Hospital for Sick Children, where Nurse Susan Nelles was wrongfully accused of killing 4 babies with an overdose of a heart drug.


These were among the first autopsies Dr. Smith ever performed, and although there is no evidence that his work was anything but professional, it does make one wonder how that experience may have shaped his approach to suspicious deaths over the next 26 years.


We always strive for balance in these stories. Families who were wrongly accused because of Dr. Smith's reports are critical of those at the Chief Coroner's Office who were supervising Smith. They want answers, accountability. Perhaps they'll get those answers at the public inquiry the Ontario government has called.



Unfortunately, our requests for interviews with the people at the coroner's office were turned down.


Above all, when I heard the pain in the voices of the parents who had been wrongly accused of killing their children, based on evidence from Charles Smith, I realized how important it is not to rush to judgement.



There is a reason our justice system is based on the principle of innocent until proven guilty. Even those in positions of power, knowledge and authority, can still get it very, very wrong."

Harold levy hlevy15@gmail.com