Showing posts with label trenton. Show all posts
Showing posts with label trenton. Show all posts

Monday, April 21, 2008

When Innocent Parents Plead Guilty: The Aftermath Of Dr. Charles Smith's Intrusion In Their Lives;

In a previous posting, I reported Brenda Waudby's lawyer's allegation that prosecutors would not would not withdraw a charge of murdering her daughter, Baby Jenna, unless she first pleaded guilty to a Family Court allegation that had previously physically assaulted her; (See Part Three; Case Studies' Systemic Factors; The "Jenna" Case; April 17, 2008);

Two problems:

First problem; The prosecutors were withdrawing the charge because they had received evidence indicating that Waudby could not possibly have committed the crime. (Jenna's babysitter later admitted killing Baby Jenna and sexually assaulting her);

Second problem: Waudby had never physically assaulted Baby Jenna - (another flawed opinion of Dr. Charles Smith. She only pleaded guilty - with all of the consequences relating to her family vis @ vis the local Children's Aid Society that the guilty plea would entail - to get rid of the horrific murder charge.

Sadly, Waudby is not the only one of Dr. Smith's victims who felt compelled to plead guilty to an offence they did not commit in a prosecution involving Dr. Charles Smith;

Previous postings to this Blog have shown how an innocent mother named Sherry Sherrett felt she had no choice but to agree to be convicted of infanticide in connection with the death of her beloved son Joshua in order to avoid being found guilty of murdering him - and going to prison for life - because of Dr. Charles Smith's celebrated prowess over jurors.

This Blog has also looked at the the direct consequences to Sherrett - including a year spent in prison and the collateral damage caused to her family. (See recent posting: Collateral damage; Part One and Part Two;)

I was absolutely stunned to hear defence lawyer Bruce Hillyer's account at the Goudge Inquiry as to how he had to assist Sherrett with an unusual "nolo contendere" plea - in which there is no acknowledgment of guilt - even though he was confident that the medical evidence he would call pointed to her innocence;

Hillyer made clear to Commission Counsel Mark Sandler that Sherrett never ever admitted guilt to him, that she insisted she had never hurt Joshua or done anything unlawful to him, and that she believed Joshua died because of mould or the unconventional bed she had recently put him in.

A loving, utterly innocent mother, mother spent a year in prison following her pragmatic plea;

Outrageous;

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By way of brief introduction:

Joshua died in January of 1996 at the age of four (4) months in Trenton.

At the time of Joshua's death, Sherry, his mother, was twenty (20) years old.

On March the 27th of 1996, she was charged with first degree murder.

She was committed on that charge after a preliminary inquiry.

That committal was subsequently quashed and a charge of second degree murder substituted.

On January the 4th of 1999, a new indictment charging infanticide was placed before the Court.

She entered a plea of not guilty.

The Crown read into the record certain agreed facts.

The defence called no evidence in response to those facts and did not dispute them.

As a result, he was convicted of infanticide and sentenced to a one
(1) year custodial term followed by probation.

Related Children's Aid proceedings involving Joshua's brother and another child, a daughter, that was born to Sherry in September of 2005.


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The following excerpts from the transcript paint an excellent picture of what Hellyer faced as defence counsel in this case - and of Sherrett's brutal predicament:

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Excerpt One: Hillyer's view of the merit's of the Crown's case:


MR. MARK SANDLER: So when you look at the merits of the case, here you were at the end of the preliminary inquiry, and I'll -- I'll take you to the end of the period where you successfully brought a certiorari to -- to quash the first degree charge, and the second degree charge was substituted. How did you feel about the strength of the defence case?

MR. BRUCE HILLYER: On the medical side, I -- well it -- it -- the problem was from my experience as a jury trial lawyer, you know, the -- the unknown is there. I mean, I -- I had -- it was going to come down to my client's word against a fellow like Smith who, s Mr. Struthers says, was very articulate, well spoken, good posture; would quickly, as you can see from the transcript, go off on tangents, and talk about other issues with some purported degree of expertise.
And, you know, that was -- it was going to be -- I was troubled by -- by it, but I was -- academically, I wasn't worried about the medicine, assuming I had a trier of fact that could cut the wheat from the chaff. I guess I was worried a jury might not be able to do that.


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Excerpt Two: The Judges's out of court view of Dr. Smith's reputation:

MR. MARK SANDLER: All right. Did you have any dialogue with Dr. Smith outside of the courtroom prior to, during, or after the preliminary inquiry?

MR. BRUCE HILLYER: I don't think so.

MR. MARK SANDLER: All right.

MR. BRUCE HILLYER: But I did with the -- with the preliminary hearing judge.

MR. MARK SANDLER: All right.

MR. BRUCE HILLYER: The only reason I mention that is that he was -- he took me aside afterwards, and it's a very small town; very small
courtroom; and said, You know, Dr. Smith's a very good witness, and they were -- he was very proud of him. I guess Dr. Smith -- I don't whether he'd done any -- any
of his work down in the Belleville area, but they -- he was certainly well known down there. And you know, it was just more information to assimilate. He was -- the judge was encouraging me to enter into plea negotiations with -- with the Crown.

MR. MARK SANDLER: All right.

MR. BRUCE HILLYER: Who I understood he was -- he jogged with.

MR. MARK SANDLER: All right. I mean, you're not suggesting anything improper --

MR. BRUCE HILLYER: No, not at all. No, no. I have high regard for Ms. Walsh. She handled herself very well.


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Ecerpt Three: How the Crown initiated plea discussions: -

MR. MARK SANDLER: And it reflects that on October 15th of 1998, Ms. Walsh sent a memorandum to Staff Sergeant MacLellan in which she stated: "Since our last conversation, I've spoken to Bruce Hillyer about our offer of a plea of guilty to infanticide. Today, he agreed to give a firm answer by November 15. By that time, he should be able to have arranged for a psychiatric evaluation of Sherry to canvass the issues relevant to infanticide which will hopefully also
address sentencing issues and to meet ith her." Were discussions taking place as between you and Sheila Walsh about a potential resolution to infanticide?

MR. BRUCE HILLYER: Well, how that all ar -- we'd already had a pretrial -- a judicial pretrial -- where we were talking about the length of the trial, whether there would be challenge for cause. I think challenge for cause was more -- more liberal then, than it is now. There was a window of time where it was, anyway. And we may have had discussions then, but I indicated there would be no plea being offered. And as we got closer to -- to the trial date, I think Sheila called me, and asked me to -- I think her first -- asked me to consider was manslaughter, and I -- I just -- I said I'll pass it on, but I don't -- I'm sure the answer will be no, and it was. And then she called back, and surprisingly said, Well you gotta give me something. She was very uneasy about -- about prosecuting the case. And I said, Well, I don't know what it could be. And, so I said, But I'll have a look, which was sort of -- I sort of didn't think that it would amount to anything. And then I started wandering through the - the criminal code, and the charge of infanticide caught my attention, because I'd never dealt with it before.
And the only way I could even think that it would possibly be an appropriate charge would be on the basis that my client had -- was well aware of the health problems the child was having, and she, in fact, had gone out of her way to report the matter to the landlord, to the local health authorities, but she was a
single -- single mother on, I believe, social assistance, you know, very -- very -- not very -- no resources. And then we got to the -- and in discussions with the bedding, she was concerned that .. all these loose sleeping bags and blanket was --
wasn't an appropriate way to deal with -- to deal with bedding for such a young child, because I think the baby had just moved from a -- from a crib setting into this -- into this more unconventional setting. And, you know, she was communicating to me, if only I had gotten up in the night or whatever, and
-- and that was the only way I could -- I could even justify it in my own mind, and without speaking to my client, I communicated that to Ms. Walsh.

MR. MARK SANDLER: And just stopping there for a moment. What I -- what I'm hearing you saying is that a plea of guilt based upon omission as
opposed to commission.

MR. BRUCE HILLYER: Right.

MR. MARK SANDLER: Okay.

MR. BRUCE HILLYER: Yes. And Ms. Walsh came back and said, No, she would insist on -- on commission, and so I -- I just said, Well, is -- are you
saying you'll do that? And she said she would, so I said, Well, I'll put it to -- I'll put it to my client.

MR. MARK SANDLER: Now, just stopping there for a moment. Just to be clear, who had initiated this discussion as to possible resolution?

MR. BRUCE HILLYER: The Crown.

MR. MARK SANDLER: And you said that she had some discomfort or expressed some concern about -- about the case. Did she tell you what it was that --

MR. BRUCE HILLYER: No.

MR. MARK SANDLER: -- caused that --

MR. BRUCE HILLYER: I mean I didn't -- I didn't understand what was going on then, what -- what I've seen here now. I just assumed it was -- well, I
hoped, I guess, in a perfect world that she thought that the medical evidence was not going to go very far. There were some evidentiary issues that were going to get revisited at the trial with respect to the KGB statements that we had -- we had spent all our time on at the preliminary hearing, virtually, anyway, or was she just was feeling sorry for my client; I didn't know -- I didn't know what it was.

MR. MARK SANDLER: All right.

MR. BRUCE HILLYER: But it was just a desire to -- to find a resolution that was nowhere near manslaughter or murder.


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Excerpt Four: Hellyer puts the Crowns's plea offer to Sherrett:

MR. MARK SANDLER: So, could -- could you give the Commissioner a sense, first of all, of -- of how the conversation then went with your client that
ultimately resulted in what transpired in Court?

MR. BRUCE HILLYER: Yeah, well, this is - I know it was -- it was re -- I think it was recorded somehow, but it was done in Mr. Bonn's office. I asked
that -- that my client and -- and her parents go into Mr. Bonn's office in Trenton and that --

MR. MARK SANDLER: Mr. Bonn was who?

MR. BRUCE HILLYER: He was the lawyer whose office had asked me to help.

MR. MARK SANDLER: All right.

MR. BRUCE HILLYER: For lack of a better description, the solicitor. And I was on the line at the other end and I put to -- I put them -- I put the options to my client, discussed the -- what -- what the -- what
could happen. And I'm assuming she made the decision right away, but I'm not sure, but she made it clear that she would not plead guilty to anything. And so -- and I
don't know whether it was during that phone call or whether it was later -- I assume it was during that phone call because I've -- I've done a lot of work in the
states. I'm a member of the Board of Governors of the American Trial Lawyers Association, which is now the American Association for Justice. And I've par -- taken part in their -- not only their civil sections, but their criminal sections,
as well, and I was always interested in this nolo contendere or whatever they call it down there, nolo pros. And I ran it by my partner of the day, who's now Justice Forsyth, who actually wrote a paper on -- on the need for -- in the Criminal Lawyers Quarterly, I think, on the need for a nolo pros procedure, because, of course, I had to face -- I had to look myself in the mirror when -- at the end of the day and hope I had done the right thing. And -- and then I called -- I think I must have gotten instructions that if -- if we can do it that way, she would do it, and then I contacted Ms. Walsh and put that proposal to her which she accepted.

MR. MARK SANDLER: All right. Had -- throughout the process, up to and including the time that the case was dealt with in Court, did the client ever
admit guilt?

MR. BRUCE HILLYER: No.

MR. MARK SANDLER: And did you have a sense of the factors that informed her decision to proceed by way of nolo contendere rather than to proceed
to trial?

MR. BRUCE HILLYER: Could you say that again, please?

MR. MARK SANDLER: Did you have a sense or did you discuss with her what factors informed her decision to take that offer?

MR. BRUCE HILLYER: I guess it would just be a fear of going to trial and being found guilty of second or manslaughter and having an extensive period of -- a far more lengthy period of time in jail.

MR. MARK SANDLER: Okay. Now, if you go to -- well, I'll ask you this. It's probably implicit, if not explicit, in what you've already said, but you had consulted Dr. Plunkett; you'd consulted Dr. Jaffe. We've heard what Dr. Jaffe had had to say about the case. What level of confidence did you have in ultimate success on the murder trial, had it proceeded to trial?

MR. BRUCE HILLYER: I had a good level of confidence on the medical evidence. What I didn't have a good level of confidence on was in my client. She was extremely stressed and upset over the events surrounding
the death of Joshua. She -- you've got to appreciate the -- this is a small town. The Children's Aid had -- first of all, the fact that anyone would think that -- that she killed her child; second of all, the Children's Aid had taken away her -- her other child. She was -- I won't say irrational, but she was -- she was difficult. It was very difficult to sort of communicate effectively with her in a very logical -- logical sense, because she was consumed with -- with all the emotional, whether it was guilt in her mind for not having gotten up that night or whether the way the bed was made, or whether it was the social pressure that she
was -- she was getting from the community. She was telling me stories about people
making fun of her and speaking unkindly of her. She was really in a mess intellectually and emotionally, in terms of making decisions which is why I insisted that she have her parents there and Mr. Bond, the solicitor, to hopefully, effectively communicate what the options were. I mean, if -- at the end of the day,
looking forward in the crystal ball, you don't know how a jury is going to perceive something. I've got Doctor -- or I've got Judge Hunter telling me what a great witness this guy is; Jaffe is telling me what a great witness he is. I hadn't -- I didn't dance with him at the preliminary because -- I was ready to. If you see in the material, I had a whole pile of medical stuff I was ready to go at him with, but he didn't -- he didn't hurt me in- chief. I just drew a circle around him and left him alone. So I was reasonably confident, but it's not me that has to do the time, so I wasn't prepared to recommend that she gamble.

MR. MARK SANDLER: All right. If you go to page 100 of the overview report, we see that paragraph 199, that on September the 7th of 2005 you drafted a letter on Sherry's behalf to assist her with the family law proceedings. And you reflected: "I was quite perplexed in representing her about whether or not the Crown could establish that her child had, indeed, died as a result of an unlawful
act. The Crown's case rested primarily on the opinion of Dr. Smith, the forensic pathologist with the Centre of Forensic Sciences in Toronto, who, at the time, had a very high reputation in his field. In preparing the defence, I had commissioned opinions from Dr. Jaffe, a forensic pathologist from Toronto, and I also consulted with American doctors who I spoke with on the telephone. They were all deeply troubled by what Dr. Smith reported but, in essence, they deferred to him,
with the exception of Dr. Jaffe, with respect to his conclusions and findings." Just stopping there for a moment. Does hat assist in refreshing your memory as to what you ight have received from -- from those other than Dr. Jaffe about the case?

MR. BRUCE HILLYER: Not really.

MR. MARK SANDLER: Okay.

MR. BRUCE HILLYER: Don't forget, I wrote that letter in '05, so. Yeah, I'm not so sure that that comment is correct; it may be but I don't know.

MR. MARK SANDLER: And then you reflect: "Faced with the prospect of a conviction and all that flows from that, I vigorously represented Sherry, and at the eleventh hour, the Crown's office, no doubt for good reasons, elected to resolve the matter by way of a plea for the rarely used charge of infanticide on the basis that at the time, Sherry was suffering from post partum depression. The compromise was seen as a way out for both sides. The Crown fearing they couldn't get a conviction of any kind, and the defence fearing a conviction for murder, while not justified, would result in a lengthy period of incarceration." And then you reflect some of the
psychological or psychiatric opinions that were rendered, and then you say:
"Some cases come back to haunt you, and this is one (1) of them." Ad then you reflect certain -- more recent information that have cau -- that has called into
question Dr. Smith's testimony, and you say: "It's far to late to ever know what
happened -- really happened with respect to the death of Sherry's child, but I'd like to think in all the circumstances, and in particular, with respect to the reports that I have enclosed and were commissioned so many years, that one (1) shouldn't have any concerns now. In my view, even then with respect to Sherry's ability to ook after a child and to be a lovingand caring mother." And did that represent your views of the case?

MR. BRUCE HILLYER: It certainly did.


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Excerpt Five: How to reconcile Sherrett's unbending denial with the opinions of other experts? (Doctors and psychologists);

MR. MARK SANDLER: Now, one (1) of the things I just want to ask you about very briefly, and I won't take you to all the documentation, but it would
appear that -- that the various psychologists, or psychiatrists weighed in on Sherry's case, gave some conflicting views on -- on how to analyze her situation. And -- and am I right that one (1) of the factors that appears to explain some of the different views is -- is how to reconcile what it was that she had been found guilty with, with her continuing denial that she had committed the offense?

MR. BRUCE HILLYER: I -- yeah. I -- yeah, it -- it's hard for me to answer that question. I mean, it -- I suspect the -- the doctors must have
assumed that -- that she smothered her child and that they were sort of working with that as part of their hypothesis. With -- and -- and they were struggling
with coming up with a -- with a diagnosis. This --


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Excerpt Six: The lack of remorse conundrum:

MR. MARK SANDLER: And we also see that the presiding justice appeared to rely upon the absence of remorse in determining what the appropriate sentence was. Am I right?

MR. BRUCE HILLYER: Yes. In fairness to Justice Byers, she was very -- I don't know whether you know this, but once this became known about Dr. Smith and this -- and this case has been back in the news, was -- I'm told publically commented on it in the local media down in Trenton, and sort of regretted the way that it had all unravelled.


Harold Levy...hlevy15@gmail.com;

Sunday, February 10, 2008

"System Failure": A Journalist's Perspective;

"THE SYSTEM - AN AMORPHOUS COLLECTIVE OF POLICE, PROSECUTORS, DEFENCE LAWYERS, DOCTORS AND SCIENTISTS - DOES NOT OPERATE WITH THE RUTHLESS EFFICIENCY OF A TV CRIME DRAMA, EVIDENCE AT THE INQUIRY HAS SHOWN. AT TIMES, IT APPEARS FRIGHTENINGLY INEPT, BOTH AT DOING THE WORK THAT IS ITS RAISON D'ETRE AND AT MONITORING ITS OWN PERFORMANCE".

FROM "SYSTEM FAILURE" BY ROBB TRIPP; KINGSTON WHIG-STANDARD;

Several of our readers have suggested that I highlight "System failure" - an analysis of many of the important things that have been learned thus far at the Goudge Inquiry.

The story is by reporter Robb trip who has distinguished himself by his fine reporting on "Sharon's Case" and the larger context involving Dr. Charles Smith and Ontario's badly broken pediatric forensic pathology system, for the Kingston Whig-Standard;

It is particularly relevant in view of the recently filed witness statement in which Dr. Martin Queen says he heard Kingston police making disparaging comments about Sharon's mother during Sharon's autopsy. (See: Kingston Police disparaged Sharon's mother during autopsy; Witness Statement; Sunday Feb. 10, 2009);

"More than 50 days of testimony at a provincial inquiry did not foster any certainty about how Sharon, a seven-year-old Kingston girl, died in a filthy basement 11 years ago," the story begins.

"No certainty, although the case is central to the work of the inquiry as it reviews more than a decade of faulty child-death investigations in Ontario.

There is certainty now about two things.

The pathologist who conducted the autopsy on the mutilated body of the child, Dr. Charles Smith, was stunningly inept and poorly supervised.

The system in which he worked failed miserably in its narrow-minded quest to affix blame for Sharon's death.

"Justice is never going to be served for that little girl," says Lynn Bergeron, a factory worker in Cornwall.

Bergeron lived four doors away from Louise Reynolds and her daughter Sharon on June 12, 1997, the night Sharon's body was found in the basement of her Rosemund Crescent townhouse.

Bergeron took the distraught mother into her home, comforted her and helped search the neighbourhood that night when Sharon could not be found.

"It still haunts me," says Bergeron. "Not a week goes by that I don't think of her."

It frustrates her that the inquiry has deepened, not resolved, the mystery.

"Everyone's forgetting about this little girl," she says.

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The Goudge commission was established by the province after a shocking review by the Office of the Chief Coroner.

It found that Smith, once considered the country's leading expert on suspicious child deaths, made mistakes in 20 cases, including at least a dozen in which wrongful convictions may have occurred.

The inquiry's mandate is to find out what went wrong and offer recommendations to restore public confidence and to fix a badly broken system. It was not charged with uncovering the truth about how 20 children died.

That may never be possible, particularly in Sharon's case.

Louise Reynolds was charged with second-degree murder in June 1997, two weeks after her daughter died.

Sharon had been savaged.

There were more than 80 wounds to her arms, neck and head. A large portion of her scalp was torn from her head and tossed on the floor a metre from her body.

Police theorized that Reynolds, a single mother living on welfare, stabbed her third-born child in a fit of rage over recurring head lice.

Smith was assigned by his boss, chief coroner Dr. James Young, to do the autopsy, he has testified.

Smith had virtually no experience with penetrating injuries or animal attacks, the inquiry heard, although by then he had been doing coroner's autopsies for 16 years.

Smith concluded that Sharon was stabbed to death. When the defence raised the notion that a pit bull terrier that was in the basement that night attacked the child, Smith was unequivocal.

It was "absurd" to suggest a dog had anything to do with the child's death, Smith testified at a preliminary hearing in Kingston in 1998. A judge ordered Reynolds to stand trial for murder.

With that, the justice system bore down on the accused mother, unrelentingly for another three years, until prosecutors withdrew the charge in the face of uncertain forensic evidence.

After a second autopsy, other experts concluded that most of Sharon's injuries were attributable to a dog attack. Smith changed his opinion.

In January 2001, the system released its grip on Reynolds.

For many observers, the story was concluded - a dog did it.

This tidy explanation hasn't satisfied everyone, the inquiry revealed.

Insp. Brian Begbie, one of the key Kingston Police investigators on the case, made it clear he still has doubts about what happened.

"Not one defence expert ... has been able to definitively say all of these wounds - all of these wounds - were caused by a dog," Begbie testified.

Begbie alluded to mountains of other circumstantial evidence the police amassed that was never tested in a courtroom.

There were signs of a cleanup in the basement that night.

There were conflicting accounts from witnesses that the man who owned the pit bull in the basement that night found Sharon's body long before police officers did.

There were conflicting statements about whether Sharon's body was found covered in garbage bags - although no bags covered her when she was found by police.

A large sweatshirt, soaked in blood, was found near Sharon's body.

Begbie still has doubts about the forensic findings. He noted that one of the final experts to consider the evidence, a renowned forensic anthropologist in Tennessee, found marks on Sharon's skull that he didn't think were dog injuries.

"The dog didn't put the marks there, so what did?" Begbie responded under questioning by Peter Wardle, a lawyer who represents Reynolds. Wardle said some experts believe that those marks were made during the first autopsy.

Begbie said police investigated the possibility and were told that no one used a scalpel on the child's skull in the area where the marks appear.

Begbie is not alone in his doubt.

Dr. Robert Wood, a forensic dentist and bite-mark expert who mistook dog injuries for stab wounds when he first considered the case, testified that he still has misgivings.

"I even believe that some of the marks were stab marks in the head," Wood told the inquiry.

Smith did not use his testimony at the inquiry as a chance to permanently distance himself from the mystery of Sharon's death.

Instead, he said he was never convinced that Louise Reynolds was guilty.

"I always recognized that she could have been innocent," Smith testified. "The determination of who was responsible for Sharon's death was not mine."

Begbie also noted, cryptically, that Kingston Police continue to work on the case, although he did not elaborate.

Smith's appearance at the inquiry solidified any remaining doubt about his incompetence. During a week of sometimes solemn, sometimes tearful testimony, the doctor acknowledged his many mistakes.

He apologized profusely and said he was embarrassed and truly sorry. But Smith afforded himself absolution, professing that he didn't know, as he bungled case after case, that he should have been better trained.

"Retrospectively, I didn't realize how extraordinarily limited was my knowledge or expertise and so I didn't recognize how potentially dangerous it was, if I can use that expression, to do that work," Smith testified of his autopsy on Sharon.

The disastrous public failure of the Reynolds prosecution, coupled with several other botched cases, eventually led to the review that exposed Smith's mistakes.

The public inquiry that followed has exposed the failings of the entire system.

Dr. James Young, who was chief coroner from 1990 to 2004, testified that he should have realized sooner that there were serious problems with Smith's work.

Young said that "sadly," he never read a blistering judgment issued by a Timmins judge in 1991, who acquitted a young girl charged with killing a child she was babysitting.

The judge harshly criticized Smith's opinions, which were contradicted by nine other experts. The judgment cast serious doubt on Smith's work. Young testified that he never read the judgment until the Goudge commission began its work.

Eight years after the Timmins case, after another bungled child death investigation involving Smith, Young received a complaint from the father of a Sudbury woman wrongly accused of killing her child, based on Smith's faulty work.

The man quoted the 1991 judgment in his letter of complaint.

Young testified that he read only the first portion of the 1999 letter of complaint.

"So I very likely stopped reading at that point 'cause I have absolutely no recollection, and I was - I think it would be fair to say - dumbfounded in your office when you showed me the [1991] judgment and referred to it the first time," Young told a lawyer for the inquiry.

While Young testified at the inquiry that he read only part of the 1999 letter, that's not what he told the Sudbury man who sent it.

"I have read your brief in detail and considered it very carefully," Young wrote in a May 1999 response entered into evidence at the inquiry.

Eventually, Young dismissed the complaints against Smith.

Young also sought to block the Ontario College of Physicians and Surgeons from hearing complaints against Smith, arguing that the college had no jurisdiction over Smith's work done on contract for the Office of the Chief Coroner.

Eventually the college did hear the complaints, and censured Smith for troubling deficiencies in his work.

There was no detailed investigation of Smith's work until a new chief coroner, Dr. Barry McLellan, was in place.

While Smith's errors are alarming, he was just one component in a process - a justice system in Ontario that grinds through more than half a million criminal prosecutions each year.

The system - an amorphous collective of police, prosecutors, defence lawyers, doctors and scientists - does not operate with the ruthless efficiency of a TV crime drama, evidence at the inquiry has shown.

At times, it appears frighteningly inept, both at doing the work that is its raison d'etre and at monitoring its own performance.

The inquiry heard that:

The branch of the justice system that prosecutes, Crown attorneys, has no central system of monitoring and tracking the performance of expert witnesses. Senior Crown officials rely on word-of-mouth to uncover problems.

In some parts of Ontario, local coroners never attend death scenes. In the Reynolds case, local coroner Dr. Ross McIlquham visited the death scene the morning after Sharon's body was found. He did not get close to the body, pronouncing her dead from a distance.

Local coroners have virtually no forensic training, although they are often the only person with a medical background to visit a death scene. Most are family doctors.

Virtually no one with forensic medical expertise attends at death scenes in Ontario.

Pathologists virtually never attend death scenes, unlike practices in parts of the U.S. and England.

When a two-month-old Belleville boy died in 1992, there was suspicion he had been shaken to death. Examination of his brain was important, yet staff at Kingston General Hospital accidentally destroyed the brain before it could be microscopically examined. No one took responsibility for placing the brain in a bucket of water, rather than preservative. Despite this significant error, the child's father was convicted in the boy's death.

The death of a four-month-old Trenton boy in 1996, Joshua, was investigated by a police officer with no experience in suspicious deaths. The officer testified that he'd never even been to an autopsy before he watched Smith examine Joshua.

The inquiry also heard that Smith operated in an unattractive and highly specialized field. Few doctors seek to specialize in forensic medicine and, although a certification system is in the works, there is still no formal accreditation and education process for forensic pathologists in Canada.

The inquiry will now conduct 11 days of round-table discussions on systemic issues..."



As I said in the previous posting:

"It boggles this Blogster's mind that the Kingston force cannot admit that it made a horrible mistake that put a grieving mother and her family through hell, refuses to learn whatever it can from the experience, and is unable to just get on with it."

For shame!

Harold Levy...hlevy15@gmail.com;