In the most recent posting - Can of Worms; Part Two - I focused on the call by Ottawa defence lawyers for a probe of the forensic examinations conducted by Dr. Brian Johnston, who headed a forensic unit in Eastern Ontario.
The posting referred to Dr. David Chaisson's testimony at the Goudge Inquiry that Johnston was permitted to hold on to his job for nine years even though senior officials of the Chief Coroner's Office were aware that he was error-prone.
(Chaisson is the former chief forensic pathologist of Ontario;)
Here is Dr. Chiasson's unedited testimony in response to questions posed by Goudge Commission Counsel Linda Rothstein:
MS. LINDA ROTHSTEIN: But before we turn to those, I -- I do want to touch on at least what you've just raised, which is the oversight issues that you confronted, apart from those that arose at Sick Kids. I'm quite right, am I, Dr. Chiasson, that the Hospital for Sick Children was not the only forensic unit that you viewed as needing some improvement?
DR. DAVID CHIASSON: That's correct.
MS. LINDA ROTHSTEIN: And in particular, am I right that you -- during this same period of time were confronting some fairly significant problems in the Eastern Ontario Regional Forensic Unit?
DR. DAVID CHIASSON: I was.
MS. LINDA ROTHSTEIN: All right. Am I right that that is a unit that started in January of 1994, again, just shortly before you assumed the position as the Chief Forensic Pathologist?
DR. DAVID CHIASSON: Yes. And so I had nothing to do with creation of the unit -- of that unit.
MS. LINDA ROTHSTEIN: And am I right that that was a unit that restricted its cases to adult cases?
DR. DAVID CHIASSON: Yes.
MS. LINDA ROTHSTEIN: And the children's cases had historically, I think you and I talked about this this morning, been routed to CHEO, the Children's Hospital in Eastern Ontario?
DR. DAVID CHIASSON: Yes.
MS. LINDA ROTHSTEIN: Who headed up the Eastern Ontario Regional Forensic Unit which in the documents is referred to, Commissioner, as the EORFPU?
DR. DAVID CHIASSON: Dr. Brian Johnston.
MS. LINDA ROTHSTEIN: Okay. What was his background, Dr. Chiasson?
DR. DAVID CHIASSON: As I understand around the time in the Unit, he was a hospital pathologist working, I think it was at the Riverside
Hospital. He was doing a -- a large number of forensic cases, coroner's cases, in the -- as part of his role although he was a hospital pathologist and doing other -- other things. His background, as I understood it was that he had done some form of training, I think in Winnipeg. This wouldn't have been, I don't think, a formal training program in the extent of that of -- as I'm unclear. I do not believe at that time that he had any formal certification in forensic pathology.
COMMISSIONER STEPHEN GOUDGE: But the training was forensic that he had in Winnipeg, or do you know?
DR. DAVID CHIASSON: Well, and I don't know when I learned this as opposed to what I knew at the time. I -- I think there was some indication of some additional training in Winnipeg doing -- doing forensic
cases, but I don't think it was a formal training program. I could be wrong about that.
MS. LINDA ROTHSTEIN: Now can you tell the Commissioner, very briefly, but by way of overview, Dr. Chiasson, whether you had some concerns about Dr. Johnston's unit, and indeed about his own forensic pathology work in this period; '95, '96, '97?
DR. DAVID CHIASSON: Yes. I -- I had significant concerns about the work that was coming out of this unit, and specifically the work of Dr. Johnston. I'd reviewed a number of his cases as part of the quality control review process that I had instigated and I was identifying, what I thought were significant forensic pathology issues. Most notably was a case where he
concluded that an individual had been strangled. In reviewing his pm report, it was clear that there were other potential explanations for the death including significant coronary artery disease, including a significant level of methadone in -- in the blood. I therefore carried out a formal review. And I -- I should say that Dr. Johnston had given a preliminary opinion at the time of autopsy that the cause of death was strangulation, which in itself was in my view, problematic.
COMMISSIONER STEPHEN GOUDGE: What? The preliminary part?
DR. DAVID CHIASSON: Yes, the preliminary part of the diagnosis of manual strangulation in the setting of other significant pathology findings and in the setting of -- you don't know what the toxicology
report is yet to -- to find. So an individual, as I understand, was
arrested, was in custody at the time. I performed a detailed review, including review of the histologic slides, reviewing of the hyoid bone which was an issue as to whether it was fractured or not, and all the photographs. I met with the Ottawa police investigator involved in the case and eventually issued my own report indicating that I did not think that the diagnosis of
strangulation could be substantiated as being certainly the most likely cause of death. I thought that there was significant -- or there were other very real possibilities. I think ultimately we concluded, I think was, most likely he died
of a combination of drug intoxication and a significant coronary heart disease.
MS. LINDA ROTHSTEIN: And indeed, the result down the line was that there were some civil litigation that arose out of that case. Am I right about that?
DR. DAVID CHIASSON: Well, the initial result was that the accused in this matter was released from custody and -- and charges were dropped.
Subsequently, a civil lawsuit against Dr. Johnston -- and I think the Ottawa police and some other parties was -- was instigated, yes.
MS. LINDA ROTHSTEIN: Indeed, Commissioner, we have a copy of that in your Volume III, the Decision from the Superior Court of Justice in that case at 141947, that's Tab 17. The name of the deceased in that case, am
I correct, Dr. Chiasson, was Marcel Vaness (phonetic)?
DR. DAVID CHIASSON: Yes.
MS. LINDA ROTHSTEIN: And you, somehow, escaped involvement in the civil litigation. You may want to postulate as to why that happened. But I don't see you mentioned. Were you a witness, Dr. Chiasson?
DR. DAVID CHIASSON: I was not a witness in the civil litigation. I don't know why. I mean, it's obviously, it's -- it's not my job to subpoena myself in such circumstances.
MS. LINDA ROTHSTEIN: You -- you may be interested to note though, Commissioner, that Dr. John Butt at paragraph 12 was the expert forensic pathologist testifying on behalf of the plaintiff and Dr. Peter Marcustein (phonetic) was the expert forensic pathologist testifying on behalf of Dr. Johnston. Let's look at one other example arising from that unit, by no means exhaustive of your concerns, but as a way of perhaps illustrating what kind of
comments you were occasionally -- or when necessary -- making on the post-mortem reports that you actually received. And that's the case that we now have on the screen involving, I understand, a deceased by the name of Dan Jones.
Is that right?
DR. DAVID CHIASSON: Yes. I don't see the name there but I think that's the -- the reference --
MS. LINDA ROTHSTEIN: So if we look at that and, Commissioner, with that, you may also want to turn up Tab 4 of Volume III which is 141753.
But, Registrar, if you could just leave this so Dr. Chiasson has both the two (2) page autopsy report prepared by Dr. Johnston and his notes of it. And, Dr. Chiasson, if you would take us through your note which you'll find at Tab 4 of Volume III and assist the Commissioner with the sorts of concerns that you were attempting to address as part of your review of -- of provincial post-mortem reports.
DR. DAVID CHIASSON: Well, there's a number of issues here that -- that caused me concern. As a pathologist working in a coroner's system, the
determination of manner is not part of his responsibility and there's clearly references to the manner of death here in -- in the -- in the report. I'm not arguing that that isn't the right manner of death in this case. I'm
saying that a pathologist working in a coroner's system should avoid references to the manner of death, and he's making clearly a reference to homicidal in -- in the title. The issue of close range which is made
there; in fact, if you look in the report, it's not really well-defined what he means by -- by close range firing. And certainly, that is a significant forensic pathology issue when one's dealing with a gunshot wound. And especially if one is opining that it's homicidal; if it's, in fact, it's close range there's, you know, the alternative that it is suicidal is always,
you know, needs to be considered. The reference to 12 gauge shotgun which is
not in the title -- the title you could argue is -- is kind of trying to describe the case in some kind of summary fashion. But, in fact, the reference in the summary of findings that this is a single 12 gauge shotgun blast
is clearly something that can't be established by a pathologist examining a body. You can't tell what kind of -- you can say it's a shotgun blast or -- but not 12 gauge or -- or whatever unless you're a firearms expert concurrently and have examined the weapon, in my view. And then in the summary part of this
report, there's reference to death occurring within three (3) to four (4) minutes. And this is a comment that -- it goes back to the opinions and how much opinion you should put into a report. It's an opinion in this case that, yes,
it's on page 2 and it's at the end there. It's an opinion that in all likelihood how long somebody survived is not -- is in all likelihood not -- not that critical one and is one that I don't think you can substantiate. The degree of accuracy with which you can determine how long somebody survives and injury is -- is not an exact science. It's a difficult thing, and -- and to opine such a thing in a report, to me is -- is misleading and suggests the degree of accuracy which I don't think can be supported. There's reference in the history to the decedent; possible cocaine dealer and being treated for
psychotic psychiatric illness. It's arguable as to how - - how relevant that is to the establishment that he's a homicide victim and whether that could be somehow deemed to be unnecessary prejudicial information. There's also reference to a history of hay fever and being treated would react -- and I mean there - - there's too much information here that is inconsequential as far as the forensic pathology side of things. So there are -- there is this issue about
history and what you put in. I think one tries to be concise and try to restrict your history to that part that is relevant to your forensic pathology work. And then when you're rendering forensic pathology opinions -- the thing here, he doesn't really expand on his close-range firing which is an important
forensic pathology issue, but yet, he gives a time of survival post-injury which I don't think is -- is forensically accurate and is really probably of limited
importance. So there's all sorts of, what I consider, forensic pathology issues in this report.
MS. LINDA ROTHSTEIN: So turning to the next tab if you would, Dr. Chiasson, Mr. Commissioner as well, Tab 5 of Volume III, 141787. There you've
documented in some reform some of the concerns as of February 13th; I'm not sure if it's '96, '97, '98.
DR. DAVID CHIASSON: I think it's '96.
MS. LINDA ROTHSTEIN: Okay. So you record: "Isolationist attitude. Has never requested assistance with any cases. Was offered opportunity to visit, came for a few days, no changes. Reports confusing; poorly organized, repetitious, makes unwarranted conclusions, administrative apparently not reviewing any cases from the unit..." And so on. Help us. How serious was that level of concern?
DR. DAVID CHIASSON: Well, it -- it was of concern, I mean, in -- we've already talked about the Vaness case. The Vaness case caused me extreme concern. This -- this is -- this case is of less concern, I think.
I don't think it had any criminal court proceeding impact issue, but it -- it suggests a background of forensic pathology approach that -- that I have difficulty reconciling. And then the administrative stuff is, you
know, again it's -- it's relatively minor considering what I thought to be the important -- the very important issue as to the actual nature of the reports that were being produced and the -- and the PMs that were being performed.
MS. LINDA ROTHSTEIN: Did you engage in discussions with the Regional Supervising Coroner and Dr. Johnston's superior, Dr. Micheau (phonetic) and indeed Dr. Young, in attempt to try and improve the situation in Ottawa?
DR. DAVID CHIASSON: Yes, I did.
MS. LINDA ROTHSTEIN: And what did you
try to do?
DR. DAVID CHIASSON: Well, I had a number of meetings over a time period with Dr. Bechard who -- we worked together as -- he was Regional Coroner situated in Kingston. We met with Dr. Johnston. We suggested
certain remedial activities. We invited them to come to Toronto for several months in order to work within the unit; get a sense of what we were doing, get a sense of what my expectations were, the way we approach things. So it was -- it was a remedial form of activity.
MS. LINDA ROTHSTEIN: And was Dr. Johnston amenable to those suggestions?
DR. DAVID CHIASSON: No.
MS. LINDA ROTHSTEIN: So what happened?
DR. DAVID CHIASSON: I wrote a member -- memo to Dr. Young indicating basically a summary of -- of the events and what was going on in -- in Ottawa. I suggested that he be removed as the Director of the Ottawa Unit. And he could continue to work as a forensic pathologist, but that we needed to seek out a new director and hopefully have him continue to work but under -- under somebody else's direction.
MS. LINDA ROTHSTEIN: And is that your memo that we find at Tab 13, dated February 3, 1998?
DR. DAVID CHIASSON: Yes, it is.
MS. LINDA ROTHSTEIN: And can -- Registrar, that's 141866. So the bottom line for you then was that a new director needed to be recruited?
DR. DAVID CHIASSON: Yes. And for the benefit of those present, this is the draft memorandum. There's actually, just before it --
MS. LINDA ROTHSTEIN: Oh, sorry. Thank
you.
DR. DAVID CHIASSON: -- in the book there
is the actual memorandum.
MS. LINDA ROTHSTEIN: 130640. Thank you
for that.
DR. DAVID CHIASSON: I think they're both very similar, but that's -- a formal memo was issued to Dr. Young.
MS. LINDA ROTHSTEIN: What was Dr. Young's view?
DR. DAVID CHIASSON: I -- I don't have a specific recall of -- of his view. I mean, what I'm proposing here is that we need to find somebody to try
and -- to find somebody to take over the Unit. And we did work towards doing that. We tried to recruit a Dr. Irvine who was just finishing up her training. And we saw that there were issues obviously with having a junior take over a unit where there's a fairly seriou -- sig -- sorry, senior person involved. But we needed somebody that we could work with who -- who sort of followed more standard
forensic pathology approaches, could oversee the work of Dr. Johnston. So Dr. Young -- I never did get a formal reply from Dr. Young to my memorandum. We talked about it, we're trying to do what we could in terms of recruiting. In the meantime, however, Dr. Johnston remained the director.
MS. LINDA ROTHSTEIN: And indeed remained the director until the time that you left your position as the Chief Forensic Pathologist, am I right?
DR. DAVID CHIASSON: That's correct, yes.
MS. LINDA ROTHSTEIN: And, Commissioner, you will find in the rest of that volume, some of the documents that chronicle the story after Dr. Chiasson's involvement, and indeed the issue again became of some concern, I think you'll see, for doctors Pollanen and McLellan. And you can read through the documents which will bring that to light. I take it, Dr. Chiasson, you can't really shed a lot of light from personal knowledge on what
happened after your resignation as the Chief Forensic Pathologist, or -- or do you know in fact?
DR. DAVID CHIASSON: Well, I -- I know that Dr. McLellan did contact me to find out, you know, what information that I had that could be helpful to him in terms of the past while I was there, and I provided a copy of this memo and some other documents related to that.
COMMISSIONER STEPHEN GOUDGE: Is Dr.
Johnston still there?
DR. DAVID CHIASSON: Dr. Johnston is still working at the Unit as -- as far as I know, yes.
COMMISSIONER STEPHEN GOUDGE: Is he the Director? Or do you know?
DR. DAVID CHIASSON: I don't know whether he's still the Director or not.
MS. LINDA ROTHSTEIN: He's about to retire, Commissioner. But it's -- when you read through the documents, Commissioner, you -- the story I think is more or less told in those documents that you have, in the rest of that binder.
COMMISSIONER STEPHEN GOUDGE: Okay.
Thanks.
Monday, January 7, 2008
Goudge Inquiry: Can Of Worms: Part Two: Ottawa Defence Lawyers Call For Probe Of Yet Another "Forensic" Pathologist;
"IN 1998, CHIASSON WROTE A MEMO TO THEN-CHIEF CORONER DR. JAMES YOUNG EXPRESSING HIS CONCERNS ABOUT JOHNSTON'S COMPETENCE, SAYING PROBLEMS WITH HIS WORK DATED BACK TO 1994 AND JOHNSTON "FLATLY REJECTED" TAKING REMEDIAL COURSES TO UPDATE HIS SKILLS. CHIASSON NEVER RECEIVED A REPLY FROM YOUNG;"
THERESA BOYLE, TORONTO STAR: DECEMBER 12, 2007;
Another disturbing aspect of the can of worms opened up by the Goudge Inquiry is the story of a problem-prone pathologist named Dr. Brian Johnston.
who worked out of Ottawa as a regional director of the Coroner's Office.
(See previous posting: Goudge Inquiry: Can of Worms: Part One; Opposition parties call for review of more than two hundred cases;"
The problems relating to Dr. Johnson came out through the testimony of Dr. David Chiasson, Ontario's former chief forensic pathologist.
The "can of worms" Chiasson's evidence opened is illustrated by a CBC News report published earlier today which began with the lead, "A group of Ottawa lawyers want a review of dozens of suspicious death cases using autopsy evidence from a local pathologist whose work led to a murder charge against an innocent man."
"Mark Ertel, president of the Defence Counsel Association of Ottawa, said Monday that the group wants a "significant independent review" of the work done by Dr. Brian Johnston, who was head of the Eastern Ontario Forensic Pathology Unit until 2007, on "all of his cases," the story continued.
"And when those cases are reviewed then they should be looked into further if it looks like there's any red flags anyplace," Ertel said. "I'll be shocked if there isn't."
Johnston declined a request for an interview with CBC.
Ertel said Johnston's work was "demonstrably inaccurate" in his autopsy on the 1998 death of 40-year-old Marcel Vanasse "and there may be other cases out there."
Michael Burns of Ottawa, then 28, was charged with second-degree murder after Johnston concluded that Vanasse was strangled. The prosecution withdrew the charges after Johnston changed his mind and said Vanasse died of a drug overdose.
Johnston, who was based in Ottawa, was ordered in February 2007 not to do any more autopsies on criminally suspicious cases due to questions about the quality of his work. He was also dismissed from his post as the head of the Eastern Ontario Forensic Pathology Unit.
However, his work again came under scrutiny in December during the Goudge Commission, which is examining the work of another pathologist, Dr. Charles Smith.
At the inquiry, Dr. David Chiasson, the former chief forensic pathologist of Ontario, said there had been concerns about Johnston's competency for years, and presented notes from the mid-1990s that said Johnston made "unwarranted conclusions" and his reports were confusing and poorly organized.
Ottawa defence lawyer Lawrence Greenspon, who represented Burns in a civil case against Johnston that was dismissed in 2003, said the pathologists' decisions are critical to the liberties of other individuals and the cost of their mistakes is too high.
"In this case, Michael Burns spent 3½ months in jail facing … murder charges until Dr. Johnston changed his opinion for the cause of death," said Greenspon.
He added that the level of protection given to pathologists under Ontario law "seriously has to be looked at and changed."
Since Johnston's dismissal, suspicious death cases in Ottawa have been sent to Toronto or Kingston for autopsy.
Ertel said he has been told a new forensic pathology unit will be up and running in Ottawa in the summer, after two new pathologists start work."
For a take on Chiasson's evidence at the inquiry, here is the story filed by my former Toronto Star Colleague Theresa Boyle on Dec. 12, 2007, under the headline,
"Pathologist avoided dismissal for 9 years, inquiry told."
"It took nine years to replace an error-prone practitioner as head forensic pathologist in Eastern Ontario because the issue was put on the backburner, a public inquiry has been told," the story began.
"Dr. Brian Johnston was only recently replaced as Ottawa-based regional director even though his failings were identified in 1998.
"It perhaps just fell through the cracks," Ontario's former chief forensic pathologist, Dr. David Chiasson, admitted yesterday when asked about the delay.
"I guess at some point (there was) frustration about (the) inability to deal with the problem. It was just left there on the backburner," he added.
In 1998, Chiasson wrote a memo to then-chief coroner Dr. Jim Young expressing his concerns about Johnston's competence, saying problems with his work dated back to 1994 and Johnston "flatly rejected" taking remedial courses to update his skills.
Chiasson never received a reply from Young.
Handwritten notes by Chiasson, dated February 1996, detailed some major concerns with Johnston's work.
"Makes unwarranted conclusions," Chiasson wrote, describing Johnston's reports as confusing, poorly organized and repetitious.
"Isolationist attitude," Chiasson continued, adding that Johnston never requested help with cases.
In one case, he wrongly determined that a man had been strangled, documents show, when in fact he died of coronary artery disease, resulting in a false arrest.
It was only in February of this year that Johnston was ordered not to do any more autopsies on criminally suspicious cases.
Chiasson in part blamed the delay on a major shortage of forensic pathologists. "There was just nobody to take up the slack," he said."
One of the common refrains of witnesses from the Chief Coroner's Office at the Goudge Inquiry is that the shortfalls in resources.
This humble Blogster recognizes the the Coroner's system in Ontario has consistently been neglected by successive governments- and that Commissioner Goudge can usefully recommend an infusion of funds along with the necessary overhaul.
But a lack of resources cannot excuse the failure of the Officials entrusted to run the system to act firmly and promptly to protect the public by removing pathologists such as Smith and Johnson from positions where they could do harm as soon as they became aware of their shortcomings.
Harold Levy...hlevy15@gmail.com;
THERESA BOYLE, TORONTO STAR: DECEMBER 12, 2007;
Another disturbing aspect of the can of worms opened up by the Goudge Inquiry is the story of a problem-prone pathologist named Dr. Brian Johnston.
who worked out of Ottawa as a regional director of the Coroner's Office.
(See previous posting: Goudge Inquiry: Can of Worms: Part One; Opposition parties call for review of more than two hundred cases;"
The problems relating to Dr. Johnson came out through the testimony of Dr. David Chiasson, Ontario's former chief forensic pathologist.
The "can of worms" Chiasson's evidence opened is illustrated by a CBC News report published earlier today which began with the lead, "A group of Ottawa lawyers want a review of dozens of suspicious death cases using autopsy evidence from a local pathologist whose work led to a murder charge against an innocent man."
"Mark Ertel, president of the Defence Counsel Association of Ottawa, said Monday that the group wants a "significant independent review" of the work done by Dr. Brian Johnston, who was head of the Eastern Ontario Forensic Pathology Unit until 2007, on "all of his cases," the story continued.
"And when those cases are reviewed then they should be looked into further if it looks like there's any red flags anyplace," Ertel said. "I'll be shocked if there isn't."
Johnston declined a request for an interview with CBC.
Ertel said Johnston's work was "demonstrably inaccurate" in his autopsy on the 1998 death of 40-year-old Marcel Vanasse "and there may be other cases out there."
Michael Burns of Ottawa, then 28, was charged with second-degree murder after Johnston concluded that Vanasse was strangled. The prosecution withdrew the charges after Johnston changed his mind and said Vanasse died of a drug overdose.
Johnston, who was based in Ottawa, was ordered in February 2007 not to do any more autopsies on criminally suspicious cases due to questions about the quality of his work. He was also dismissed from his post as the head of the Eastern Ontario Forensic Pathology Unit.
However, his work again came under scrutiny in December during the Goudge Commission, which is examining the work of another pathologist, Dr. Charles Smith.
At the inquiry, Dr. David Chiasson, the former chief forensic pathologist of Ontario, said there had been concerns about Johnston's competency for years, and presented notes from the mid-1990s that said Johnston made "unwarranted conclusions" and his reports were confusing and poorly organized.
Ottawa defence lawyer Lawrence Greenspon, who represented Burns in a civil case against Johnston that was dismissed in 2003, said the pathologists' decisions are critical to the liberties of other individuals and the cost of their mistakes is too high.
"In this case, Michael Burns spent 3½ months in jail facing … murder charges until Dr. Johnston changed his opinion for the cause of death," said Greenspon.
He added that the level of protection given to pathologists under Ontario law "seriously has to be looked at and changed."
Since Johnston's dismissal, suspicious death cases in Ottawa have been sent to Toronto or Kingston for autopsy.
Ertel said he has been told a new forensic pathology unit will be up and running in Ottawa in the summer, after two new pathologists start work."
For a take on Chiasson's evidence at the inquiry, here is the story filed by my former Toronto Star Colleague Theresa Boyle on Dec. 12, 2007, under the headline,
"Pathologist avoided dismissal for 9 years, inquiry told."
"It took nine years to replace an error-prone practitioner as head forensic pathologist in Eastern Ontario because the issue was put on the backburner, a public inquiry has been told," the story began.
"Dr. Brian Johnston was only recently replaced as Ottawa-based regional director even though his failings were identified in 1998.
"It perhaps just fell through the cracks," Ontario's former chief forensic pathologist, Dr. David Chiasson, admitted yesterday when asked about the delay.
"I guess at some point (there was) frustration about (the) inability to deal with the problem. It was just left there on the backburner," he added.
In 1998, Chiasson wrote a memo to then-chief coroner Dr. Jim Young expressing his concerns about Johnston's competence, saying problems with his work dated back to 1994 and Johnston "flatly rejected" taking remedial courses to update his skills.
Chiasson never received a reply from Young.
Handwritten notes by Chiasson, dated February 1996, detailed some major concerns with Johnston's work.
"Makes unwarranted conclusions," Chiasson wrote, describing Johnston's reports as confusing, poorly organized and repetitious.
"Isolationist attitude," Chiasson continued, adding that Johnston never requested help with cases.
In one case, he wrongly determined that a man had been strangled, documents show, when in fact he died of coronary artery disease, resulting in a false arrest.
It was only in February of this year that Johnston was ordered not to do any more autopsies on criminally suspicious cases.
Chiasson in part blamed the delay on a major shortage of forensic pathologists. "There was just nobody to take up the slack," he said."
One of the common refrains of witnesses from the Chief Coroner's Office at the Goudge Inquiry is that the shortfalls in resources.
This humble Blogster recognizes the the Coroner's system in Ontario has consistently been neglected by successive governments- and that Commissioner Goudge can usefully recommend an infusion of funds along with the necessary overhaul.
But a lack of resources cannot excuse the failure of the Officials entrusted to run the system to act firmly and promptly to protect the public by removing pathologists such as Smith and Johnson from positions where they could do harm as soon as they became aware of their shortcomings.
Harold Levy...hlevy15@gmail.com;
Sunday, January 6, 2008
The Hospital For Sick Children's Irreparable Breach Of An Important Public Trust;
"AFTER A COLOSTOMY, FECES LEAVE THE PATIENT'S BODY THROUGH THE STOMA, AND COLLECT IN A POUCH ATTACHED TO THE PATIENT'S ABDOMEN WHICH IS CHANGED WHEN NECESSARY."
FROM WIKIPEDIA DEFINITION OF COLOSTOMY;
After a colostomy, feces leave the patient's body through the stoma, and collect in a pouch attached to the patient's abdomen which is changed when necessary.
One of the most devastating examples of Dr. Charles Smith's incompetence involved an infant at the Hospital for Sick Children in Toronto who was forced to undergo a colostomy because of Dr. Smith's mistaken diagnosis.
The example was provided to the Inquiry by Dr. Ernest Cutz who testified that he had been told about the case by Dr. Barry Shandling, a Surgeon at the Hospital.
Dr. Cutz said he learned that the operation was necessary because Smith had concluded from a biopsy that a newborn child was lacking ganglion cells - an indication that the intestines may not be functioning properly.
However, it was ultimately determined after the fact that the ganglions had been present all along and that the operation was therefore surgically unnecessary.
Cutz told Commissioner Stephen Goudge that, "I think Dr. Shandling was very concerned because he has to explain this to the parents."
Wikipedia describes a colostomy as, "a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall, leaving the patient with an opening on the abdomen called a stoma."
"This opening is formed from the end of the large intestine drawn out through the incision and sutured to the skin," the definition continues.
"After a colostomy, feces leave the patient's body through the stoma, and collect in a pouch attached to the patient's abdomen which is changed when necessary.
This humble Bloggist finds it unthinkable that such an operation would have to be conducted on a newborn infant because of a mistaken diagnosis.
I also find it unthinkable that the Hospital did not inform the College of Physicians and Surgeons - the governing body of the medical profession in Ontario, that the botched diagnosis and unnecessary surgery on an infant had occurred.
(If the Inquiry had not been called, it is unlikely that this horrific incident involving Dr. Smith - and the Hospital's suppression of it - would ever have seen the light of day);
There were so many other incidents in which Dr. Smith apparently erred that some of his colleagues sent an anxious letter to his then-department head, the late Dr. Larry Becker, which is detailed in an earlier Blog.
The Blog, which ran under the heading, "Goudge Inquiry: Stunning Revelations: Smith removed from non-forensic duties at Hospital For Sick Children in 1997 after colleagues complained about errors" is worth repeating in light of subsequent evidence called at the Inquiry.
"The Goudge Inquiry heard the stunning revelation Monday that Dr. Charles Smith's errors were not confined to his work on coroner's autopsies," the Blog began.
"Several of his colleagues at the Hospital for Sick Children - including pathologists and Surgeons - had complained in 1997 that Dr. Smith had made errors in his interpretation of histological samples on four cases handled as a surgical pathologist on the hospital's staff.
In short, he misinterpreted what he observed under the microscope in each of the four cases.
Dr. Jim Cairns, who was Director of Investigations for the Chief Coroner's Office at the time, also revealed that the Hospital ultimately curtailed his responsibilities in surgical pathology and reduced his salary accordingly - until reinstating him at a later date.
Cairns also delivered the startling revelation that the Hospital for Sick Children did not inform the Chief Coroner's office, about the serious problems that the Hospital had encountered with Smith's work - and the remedial steps it had been forced to take - (including a requirement that he take continuing education courses);
Moreover, Dr. Cairns testified that Dr. Smith had fallen seriously behind in his paper work on hospital matters (just as he had problems delivering his forensic reports in a timely manner H.L.)
While leading Dr. Cairns evidence, Commission Counsel Linda Rothstein introduced into evidence a letter from Dr. Laurence Becker, Smith's superior at the hospital, "re surgical complaints."
"Since my return from the pathology conference in Orlando I have come across four (4) recent cases of Dr. Smith's in which there are diagnostic discrepancies. I am outlining the events below as I understand them," the letter begins.
Cairns informed Rothstein that, "these are issues where other colleagues at the hospital are saying that he is not interpreting histological slides appropriately, and that "one of the fundamental things about a pathologist is the ability to diagnose things down the microscope."
Cairns said he "very much" agreed with Rothstein that it would have been relevant for himself and other members of the (Chief Coroner's office) to know that Dr. Smith's colleagues at the Hospital for Sick Children had identified errors in his surgical pathology diagnostic skills.
Rothstein also read to Cairns a second letter to Smith from Becker, dated April 18, 1997, which read in part:
"Dear Charles:
As you are aware, the surgical reports for which you've been responsible have not been completed according to the established standards agreed upon in 1994. You have received regular reminders over the past two (2) years about the delays in completion of reports.
An example of such a letter covering the last several months is enclosed.
In addition, during the limited number of weeks per year that you have been
responsible for completion of the surgical reports, there have been a disproportion in the number of complaints about diagnostic 1 inconsistencies from pediatricians and surgeons."
And, then, continued in the second paragraph:
"Neither Paul nor I can see any improvement in the reporting time or the accuracy of the reports over the past two (2) years.
Therefore, I regret to inform you that I must curtail your responsibilities in
surgical pathology until you prove to me evidence of successful completion of continuing education courses that will improve your skills in surgical pathology.
You must also demonstrate that all records in the division are completed in a timely fashion, consistent with standards established by the hospital.
You will not be doing surgical pathology on a regular rotation and, accordingly, the salary from the Division of Pathology will be reduced by twenty thousand
(20,000) for 1997."
Asked by Rothstein if it had ever come to his attention that the Hospital had taken that measure, Dr. Cairns tersely replied, "No, it did not."
Rothstein's examination of Dr. Cairns continued as follows:
MS. LINDA ROTHSTEIN: Did it ever come to your attention that the hospital was taking the position that Dr. Smith needed more education in the area of surgical pathology?
DR. CAIRNS: No, it did not.
MS. LINDA ROTHSTEIN: And what, if any, influence would that have had on your confidence in Dr. Smith?
DR. CAIRNS: Well, part of the role and -- of-- the pathologist, particularly in children's autopsy, would be the histological examination; what he was seeing down the microscope.
It was our belief that Dr. Smith was a pathologist at the Hospital for Sick Kids with an excellent reputation and be diagnostically accurate in histological samples.
The histological samples that he'd be doing in his hospital work may well be very similar to the type of histological samples he'd be looking for us.
So this -- this would indicate a serious concern about his diagnostic abilities.
MS. LINDA ROTHSTEIN: And looked at systemically, Dr. Cairns, is this evidence of a disconnect between the Hospital for Sick Children, on the one hand, and the (Chief Coroner's office) on the other?
DR. CAIRNS: Yes, it -- it is my feeling that it would have been very helpful if, when Dr. Chiasson and myself were having meetings with Dr. Becker and sharing our concerns -- and our concerns were primarily with his delay, but that it would have been extremely helpful for there had been some sharing of this information with us.
It obviously would have made a significant difference. What the legalities of that are, I can't answer.
But, certainly, it would have been of great assistance to us.
Because we were never in the position where we felt his histology was -- was questionable.
COMMISSIONER STEPHEN GOUDGE: Did Dr. Becker ever say, We had the same problems about delay that you're complaining to us about?
DR. CAIRNS: No. No, he didn't...;
This humble Bloggist cannot deny that the unpleasant words "cover up" entered his mind as he listened to Dr. Cairn's testimony.
But the more balanced part of me says let's withhold our judgment until Hospital For Sick Children officials take the witness stand in the coming months.
They certainly have a great deal to explain.
Subsequent evidence called at the Inquiry has raised a question as to whether the letter from the late Dr. Becker was ever sent to Dr. Smith.
But is relatively clear from testimony given by Dr. Glenn Taylor, the current head of the Hospital's pathology department, and Dr.Ernest Cutz, that Dr. Smith never interrupted his surgical pathology work, that his salary was never reduced, and that he never took any remedial courses.
It is also clear from cross-examination of Dr. Taylor by Carolyn Silver, Counsel for the Chief Coroner's Office, that the Hospital covered up Dr. Smith's sub-standard work in the identified case from both the Chief Coroner's Office and the College.
Silver was hovering close to the truth when she asked the following questions of Dr. Taylor and got the following terse answers.
MS. CAROLYN SILVER: Both of you have given evidence about the concerns you had or the concerns that you were aware of with respect to Dr. Smith's work
as a pathologist while he worked at Sick Kids, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And I'll -- I'll just ask one (1) of you to answer and if there's any disagreement from the other, perhaps you could indicate so? And there were concerns with respect to Dr. Smith's surgical pathology, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And concerns with respect to his opinions regarding cause of death in certain forensic cases, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And there were certainly concerns about the timeliness of his reports, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And that's all been gone over in some detail, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And in terms of addressing those concerns, some of those concerns were brought up with Dr. Smith in correspondence by the hospital, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And certain concerns were brought up at rounds by people, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And you've heard evidence from the Coroner's Office that they thought some of those concerns were significant, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And you're aware that -- at least, Dr. Cairns gave evidence that some of that information -- it might have been helpful to share that with the Coroner's Office, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And that much of that information was not shared with the Coroner's Office, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And we've also heard evidence about information that the Coroner's Office had with respect to Dr. Smith that was not shared with Sick Kids, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And the concerns about Dr. Smith's work as a pathologist at the Hospital for Sick Kids was present from, at least, let's say, 1995 through to, at least, the early 2000s, correct?
DR. GLENN TAYLOR: Yes.Commissioner Goudge did not permit Silver to directly ask Taylor and Cutz, in her words, "whether they would agree that the Hospital for Sick Kids should have shared their concerns with the regulatory body of the College?"
I, however, am under no such restraints and am disturbed that the Hospital, through its lawyer William Carter, suggested that the law did not oblige the hospital to report these matters involving Dr. Smith to the College.
That the hospital should try and shield itself by the law sends me the message that it is lacking a moral compass - and that it still doesn't understand that by taking on the Forensic Pediatric Unit for the province it was taking on an important public trust.
Why didn't the hospital exercise its moral, if not legal obligations?
I have several theories - and the readers of this Blog likely have some of their own.
At the most innocent level, the Hospital For Sick Children is a complex institution composed of many elements of which the Pediatric Forensic Pathology Unit was only a tiny component which was not likely on the radar of senior administrators.
To be utterly fair, the Hospital had not had much experience with forensic autopsies before the unit was established, and there is no evidence that the Chief Coroner's office had gone out of its way to ensure the hospital understood its role and was fully equipped to do its important job.
Also to be fair, it was the Chief Coroner's Office - not the hospital - that allowed Dr. Smith to be propelled to super-star status - and the more important Dr. Smith became the harder it would have been for the hospital to take him to task without serious public relation's ramifications.
That said, the Hospital's failure to reign in Dr. Smith in spite of mounting evidence that his incompetence was harming patients - and its admitted failure to share this information with the Chief Coroner's Office and the College of Physicians and Surgeons of Ontario is unforgivable.
Also unforgivable, is for the Hospital For Sick Children to have allowed Dr. Smith to maintain for years a sorely cluttered office which has become a disturbing symbol of the Inquiry.
As a former secretary testified at the Inquiry: "There were some tissues, you know, that were dried out in plastic containers. There was some sort of of just skeletal bones in another little dish. There was a little, sort of, wrist bead. Those kids, the children who were usually sick; They make beads for their wrists. So each time they have a procedure you have a bead. There was one of those." (See earlier Blog: Dr. Smith's office: Part Three);
This disgusting office was also a symbol of the numerous forensic exhibits lost or misplaced by Dr. Smith over the years which would have made a critical difference for wrongly accused persons protesting their innocence.
Hospital officials have allowed this ugly blot to remain in front of their eyes day after day, year after year.
In this Bloggist's view, the hospital violated its public trust to such an irreparable degree that the Unit should be shut down and placed elsewhere under the direct control of the Chief Coroner's office.
That can't happen soon enough.
Harold Levy...hlevy15@gmail.com;
FROM WIKIPEDIA DEFINITION OF COLOSTOMY;
After a colostomy, feces leave the patient's body through the stoma, and collect in a pouch attached to the patient's abdomen which is changed when necessary.
One of the most devastating examples of Dr. Charles Smith's incompetence involved an infant at the Hospital for Sick Children in Toronto who was forced to undergo a colostomy because of Dr. Smith's mistaken diagnosis.
The example was provided to the Inquiry by Dr. Ernest Cutz who testified that he had been told about the case by Dr. Barry Shandling, a Surgeon at the Hospital.
Dr. Cutz said he learned that the operation was necessary because Smith had concluded from a biopsy that a newborn child was lacking ganglion cells - an indication that the intestines may not be functioning properly.
However, it was ultimately determined after the fact that the ganglions had been present all along and that the operation was therefore surgically unnecessary.
Cutz told Commissioner Stephen Goudge that, "I think Dr. Shandling was very concerned because he has to explain this to the parents."
Wikipedia describes a colostomy as, "a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall, leaving the patient with an opening on the abdomen called a stoma."
"This opening is formed from the end of the large intestine drawn out through the incision and sutured to the skin," the definition continues.
"After a colostomy, feces leave the patient's body through the stoma, and collect in a pouch attached to the patient's abdomen which is changed when necessary.
This humble Bloggist finds it unthinkable that such an operation would have to be conducted on a newborn infant because of a mistaken diagnosis.
I also find it unthinkable that the Hospital did not inform the College of Physicians and Surgeons - the governing body of the medical profession in Ontario, that the botched diagnosis and unnecessary surgery on an infant had occurred.
(If the Inquiry had not been called, it is unlikely that this horrific incident involving Dr. Smith - and the Hospital's suppression of it - would ever have seen the light of day);
There were so many other incidents in which Dr. Smith apparently erred that some of his colleagues sent an anxious letter to his then-department head, the late Dr. Larry Becker, which is detailed in an earlier Blog.
The Blog, which ran under the heading, "Goudge Inquiry: Stunning Revelations: Smith removed from non-forensic duties at Hospital For Sick Children in 1997 after colleagues complained about errors" is worth repeating in light of subsequent evidence called at the Inquiry.
"The Goudge Inquiry heard the stunning revelation Monday that Dr. Charles Smith's errors were not confined to his work on coroner's autopsies," the Blog began.
"Several of his colleagues at the Hospital for Sick Children - including pathologists and Surgeons - had complained in 1997 that Dr. Smith had made errors in his interpretation of histological samples on four cases handled as a surgical pathologist on the hospital's staff.
In short, he misinterpreted what he observed under the microscope in each of the four cases.
Dr. Jim Cairns, who was Director of Investigations for the Chief Coroner's Office at the time, also revealed that the Hospital ultimately curtailed his responsibilities in surgical pathology and reduced his salary accordingly - until reinstating him at a later date.
Cairns also delivered the startling revelation that the Hospital for Sick Children did not inform the Chief Coroner's office, about the serious problems that the Hospital had encountered with Smith's work - and the remedial steps it had been forced to take - (including a requirement that he take continuing education courses);
Moreover, Dr. Cairns testified that Dr. Smith had fallen seriously behind in his paper work on hospital matters (just as he had problems delivering his forensic reports in a timely manner H.L.)
While leading Dr. Cairns evidence, Commission Counsel Linda Rothstein introduced into evidence a letter from Dr. Laurence Becker, Smith's superior at the hospital, "re surgical complaints."
"Since my return from the pathology conference in Orlando I have come across four (4) recent cases of Dr. Smith's in which there are diagnostic discrepancies. I am outlining the events below as I understand them," the letter begins.
Cairns informed Rothstein that, "these are issues where other colleagues at the hospital are saying that he is not interpreting histological slides appropriately, and that "one of the fundamental things about a pathologist is the ability to diagnose things down the microscope."
Cairns said he "very much" agreed with Rothstein that it would have been relevant for himself and other members of the (Chief Coroner's office) to know that Dr. Smith's colleagues at the Hospital for Sick Children had identified errors in his surgical pathology diagnostic skills.
Rothstein also read to Cairns a second letter to Smith from Becker, dated April 18, 1997, which read in part:
"Dear Charles:
As you are aware, the surgical reports for which you've been responsible have not been completed according to the established standards agreed upon in 1994. You have received regular reminders over the past two (2) years about the delays in completion of reports.
An example of such a letter covering the last several months is enclosed.
In addition, during the limited number of weeks per year that you have been
responsible for completion of the surgical reports, there have been a disproportion in the number of complaints about diagnostic 1 inconsistencies from pediatricians and surgeons."
And, then, continued in the second paragraph:
"Neither Paul nor I can see any improvement in the reporting time or the accuracy of the reports over the past two (2) years.
Therefore, I regret to inform you that I must curtail your responsibilities in
surgical pathology until you prove to me evidence of successful completion of continuing education courses that will improve your skills in surgical pathology.
You must also demonstrate that all records in the division are completed in a timely fashion, consistent with standards established by the hospital.
You will not be doing surgical pathology on a regular rotation and, accordingly, the salary from the Division of Pathology will be reduced by twenty thousand
(20,000) for 1997."
Asked by Rothstein if it had ever come to his attention that the Hospital had taken that measure, Dr. Cairns tersely replied, "No, it did not."
Rothstein's examination of Dr. Cairns continued as follows:
MS. LINDA ROTHSTEIN: Did it ever come to your attention that the hospital was taking the position that Dr. Smith needed more education in the area of surgical pathology?
DR. CAIRNS: No, it did not.
MS. LINDA ROTHSTEIN: And what, if any, influence would that have had on your confidence in Dr. Smith?
DR. CAIRNS: Well, part of the role and -- of-- the pathologist, particularly in children's autopsy, would be the histological examination; what he was seeing down the microscope.
It was our belief that Dr. Smith was a pathologist at the Hospital for Sick Kids with an excellent reputation and be diagnostically accurate in histological samples.
The histological samples that he'd be doing in his hospital work may well be very similar to the type of histological samples he'd be looking for us.
So this -- this would indicate a serious concern about his diagnostic abilities.
MS. LINDA ROTHSTEIN: And looked at systemically, Dr. Cairns, is this evidence of a disconnect between the Hospital for Sick Children, on the one hand, and the (Chief Coroner's office) on the other?
DR. CAIRNS: Yes, it -- it is my feeling that it would have been very helpful if, when Dr. Chiasson and myself were having meetings with Dr. Becker and sharing our concerns -- and our concerns were primarily with his delay, but that it would have been extremely helpful for there had been some sharing of this information with us.
It obviously would have made a significant difference. What the legalities of that are, I can't answer.
But, certainly, it would have been of great assistance to us.
Because we were never in the position where we felt his histology was -- was questionable.
COMMISSIONER STEPHEN GOUDGE: Did Dr. Becker ever say, We had the same problems about delay that you're complaining to us about?
DR. CAIRNS: No. No, he didn't...;
This humble Bloggist cannot deny that the unpleasant words "cover up" entered his mind as he listened to Dr. Cairn's testimony.
But the more balanced part of me says let's withhold our judgment until Hospital For Sick Children officials take the witness stand in the coming months.
They certainly have a great deal to explain.
Subsequent evidence called at the Inquiry has raised a question as to whether the letter from the late Dr. Becker was ever sent to Dr. Smith.
But is relatively clear from testimony given by Dr. Glenn Taylor, the current head of the Hospital's pathology department, and Dr.Ernest Cutz, that Dr. Smith never interrupted his surgical pathology work, that his salary was never reduced, and that he never took any remedial courses.
It is also clear from cross-examination of Dr. Taylor by Carolyn Silver, Counsel for the Chief Coroner's Office, that the Hospital covered up Dr. Smith's sub-standard work in the identified case from both the Chief Coroner's Office and the College.
Silver was hovering close to the truth when she asked the following questions of Dr. Taylor and got the following terse answers.
MS. CAROLYN SILVER: Both of you have given evidence about the concerns you had or the concerns that you were aware of with respect to Dr. Smith's work
as a pathologist while he worked at Sick Kids, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And I'll -- I'll just ask one (1) of you to answer and if there's any disagreement from the other, perhaps you could indicate so? And there were concerns with respect to Dr. Smith's surgical pathology, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And concerns with respect to his opinions regarding cause of death in certain forensic cases, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And there were certainly concerns about the timeliness of his reports, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And that's all been gone over in some detail, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And in terms of addressing those concerns, some of those concerns were brought up with Dr. Smith in correspondence by the hospital, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And certain concerns were brought up at rounds by people, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And you've heard evidence from the Coroner's Office that they thought some of those concerns were significant, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And you're aware that -- at least, Dr. Cairns gave evidence that some of that information -- it might have been helpful to share that with the Coroner's Office, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And that much of that information was not shared with the Coroner's Office, fair enough?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And we've also heard evidence about information that the Coroner's Office had with respect to Dr. Smith that was not shared with Sick Kids, correct?
DR. GLENN TAYLOR: Yes.
MS. CAROLYN SILVER: And the concerns about Dr. Smith's work as a pathologist at the Hospital for Sick Kids was present from, at least, let's say, 1995 through to, at least, the early 2000s, correct?
DR. GLENN TAYLOR: Yes.Commissioner Goudge did not permit Silver to directly ask Taylor and Cutz, in her words, "whether they would agree that the Hospital for Sick Kids should have shared their concerns with the regulatory body of the College?"
I, however, am under no such restraints and am disturbed that the Hospital, through its lawyer William Carter, suggested that the law did not oblige the hospital to report these matters involving Dr. Smith to the College.
That the hospital should try and shield itself by the law sends me the message that it is lacking a moral compass - and that it still doesn't understand that by taking on the Forensic Pediatric Unit for the province it was taking on an important public trust.
Why didn't the hospital exercise its moral, if not legal obligations?
I have several theories - and the readers of this Blog likely have some of their own.
At the most innocent level, the Hospital For Sick Children is a complex institution composed of many elements of which the Pediatric Forensic Pathology Unit was only a tiny component which was not likely on the radar of senior administrators.
To be utterly fair, the Hospital had not had much experience with forensic autopsies before the unit was established, and there is no evidence that the Chief Coroner's office had gone out of its way to ensure the hospital understood its role and was fully equipped to do its important job.
Also to be fair, it was the Chief Coroner's Office - not the hospital - that allowed Dr. Smith to be propelled to super-star status - and the more important Dr. Smith became the harder it would have been for the hospital to take him to task without serious public relation's ramifications.
That said, the Hospital's failure to reign in Dr. Smith in spite of mounting evidence that his incompetence was harming patients - and its admitted failure to share this information with the Chief Coroner's Office and the College of Physicians and Surgeons of Ontario is unforgivable.
Also unforgivable, is for the Hospital For Sick Children to have allowed Dr. Smith to maintain for years a sorely cluttered office which has become a disturbing symbol of the Inquiry.
As a former secretary testified at the Inquiry: "There were some tissues, you know, that were dried out in plastic containers. There was some sort of of just skeletal bones in another little dish. There was a little, sort of, wrist bead. Those kids, the children who were usually sick; They make beads for their wrists. So each time they have a procedure you have a bead. There was one of those." (See earlier Blog: Dr. Smith's office: Part Three);
This disgusting office was also a symbol of the numerous forensic exhibits lost or misplaced by Dr. Smith over the years which would have made a critical difference for wrongly accused persons protesting their innocence.
Hospital officials have allowed this ugly blot to remain in front of their eyes day after day, year after year.
In this Bloggist's view, the hospital violated its public trust to such an irreparable degree that the Unit should be shut down and placed elsewhere under the direct control of the Chief Coroner's office.
That can't happen soon enough.
Harold Levy...hlevy15@gmail.com;
Saturday, January 5, 2008
Dr. Charles Randal Smith: A Disaster Waiting to Happen;
"THE EVENTS SET OUT IN THE OVERVIEW REPORTS ARE THE PREDICTABLE OUTCOME OF THE HISTORY OF FORENSIC PATHOLOGY IN CANADA";
DR. MICHAEL POLLANEN;
An earlier posting featured evidence from an independent forensic pathologist that Dr. Charles Smith was ignorant to the extent that he did not correctly understand "rigor mortis" -an extremely basic concept of forensic pathology. (See previous posting: A Glimmer of Understanding: Part One);
At the same time, however, he was holding himself out as a skilled forensic pathologist - both inside and outside of the courts.
How could he get away with this?
A possible answer is provided by Dr. Michael Pollanen, Ontario's Chief Coroner, in his evidence to the Goudge Inquiry.
"Canadian forensic pathology has been neglected for decades," Dr. Pollanen wrote in a paper he prepared for the Goudge Inquiry.
"The events set out in "overview reports" (reports prepared by Commission staff on the Smith cases being probed by the Inquiry) "are the predictable outcome of the history of forensic pathology in Canada."
If Charles Smith was not a surgeon he would not have been permitted to holds himself out as having a surgeon's skills - or testifying to that effect in court - he could have been prosecuted in Ontario for professional misconduct.
However, as Canada lacked a certification process for forensic pathology in Canada, Dr. Smith could safely transform himself into the learned Dr. Charles Randal Smith who was respected throughout the world as an expert in his field without fearing professional consequences.
Dr. Pollanen makes several other observations that are relevant to Dr. Smith in his paper.
One is that, "the lack of domestic postgraduate training programs has encouraged the rise of "self-taught" and "part-time" pathologists rather than full-time forensic experts."
Another is that in Canada there has been, "a failure to develop guidelines, standards, and a code of practice for forensic pathology."
These gaps in Canadian forensic pathology do not get Dr. Smith off the hook;
In this Bloggist's humble view, it was this very vagueness that allowed Dr. Smith to flourish with minimal accountability.
The only safe-guards lay in the hope that the Hospital for Sick Children, The Chief Coroner's Office and the Ontario College of Physicians and Surgeons would keep Dr. Smith in line and protect the public.
Sadly, that didn't happen.
Harold Levy...hlevy15@gmail.com;
DR. MICHAEL POLLANEN;
An earlier posting featured evidence from an independent forensic pathologist that Dr. Charles Smith was ignorant to the extent that he did not correctly understand "rigor mortis" -an extremely basic concept of forensic pathology. (See previous posting: A Glimmer of Understanding: Part One);
At the same time, however, he was holding himself out as a skilled forensic pathologist - both inside and outside of the courts.
How could he get away with this?
A possible answer is provided by Dr. Michael Pollanen, Ontario's Chief Coroner, in his evidence to the Goudge Inquiry.
"Canadian forensic pathology has been neglected for decades," Dr. Pollanen wrote in a paper he prepared for the Goudge Inquiry.
"The events set out in "overview reports" (reports prepared by Commission staff on the Smith cases being probed by the Inquiry) "are the predictable outcome of the history of forensic pathology in Canada."
If Charles Smith was not a surgeon he would not have been permitted to holds himself out as having a surgeon's skills - or testifying to that effect in court - he could have been prosecuted in Ontario for professional misconduct.
However, as Canada lacked a certification process for forensic pathology in Canada, Dr. Smith could safely transform himself into the learned Dr. Charles Randal Smith who was respected throughout the world as an expert in his field without fearing professional consequences.
Dr. Pollanen makes several other observations that are relevant to Dr. Smith in his paper.
One is that, "the lack of domestic postgraduate training programs has encouraged the rise of "self-taught" and "part-time" pathologists rather than full-time forensic experts."
Another is that in Canada there has been, "a failure to develop guidelines, standards, and a code of practice for forensic pathology."
These gaps in Canadian forensic pathology do not get Dr. Smith off the hook;
In this Bloggist's humble view, it was this very vagueness that allowed Dr. Smith to flourish with minimal accountability.
The only safe-guards lay in the hope that the Hospital for Sick Children, The Chief Coroner's Office and the Ontario College of Physicians and Surgeons would keep Dr. Smith in line and protect the public.
Sadly, that didn't happen.
Harold Levy...hlevy15@gmail.com;
Goudge Inquiry: Can Of Worms: Part One; Opposition Parties Call For Review Of More Than Two Hundred Cases;
It is unusual for a public inquiry to prompt calls for change from opposition parties - even before it has issued it's report.
However, as reporter Theresa Boyle reports in today's Toronto Star, both the Progressive Conservative Party and the New Democratic Party are seeking a review of about two hundred child deaths involving other pathologists than Dr. Charles Smith.
In short, the inquiry has opened up a proverbial "can of worms" - as it should since it involves deaths of children, possible miscarriages of justice on an even more massive scale than was feared to date, and all-too justified reason for the public to distrust the province's Coroner's system.
The calls for reviews by Conservative leader John Tory and N.D.P. leader Peter Kormos are a great testament to the Goudge Inquiry which was established by former Liberal Attorney Michael Bryant on April 25, 2007, and must deliver its final report by April 25, 208.
It is proof that the Inquiry is fearlessly doing its job.
As Boyle points out, reviews are being sought in connection with:
0: 50 child deaths that occurred between 1991 and 2001 referred to by Deputy Chief Coroner Dr. James Cairns in his testimony;
0: More than fifty deaths involving infant or childhood head injuries which occurred between 1986 and 2000 and were coded as homicides; (found by Ontario's chief forensic pathologist, Dr. Michael Pollanen while searching his database);
0: 142 infant deaths attributable to "shaken baby syndrome" between 1986 and 2006 which might be diagnosed differently today.
0: Cases involving Dr. Charles Smith that occurred between 1981 and 1991. (There are some disturbing ones); The Inquiry is limited to Smith cases between 1991, and,
0: Investigations of criminally suspicious deaths and homicides investigated by the Ottawa pathology unit;
I would add to this list a review of all cases in which a child was seized from its parents as a result of Dr. Smith's opinions.
This particular review is recommended by the authors of a research paper commissioned by the Inquiry. See previous postings: "Smith's testimony in three child protection cases" and "Children's Aid Societies should review every case in which Dr. Smith's opinion was involved.")
A caveat;
Pathologists do a wide variety of important research work and diagnostic work in the province's health system.
Criticism should be focused on a relatively small number of forensic pathologists who did work of the Chief Coroner's office in recent decades without adequate supervision.
A Second caveat;
The Inquiry has heard that some of the problems relating to incorrect opinions leading to wrongful convictions stem from not so much from pathologists but from limitations on forensic pathology itself.
More about that in a future posting;
Here is Theresa Boyle's story as it appeared today under the heading: "More than 200 cases could be revisited amid fears of errors by other pathologists."
"Provincial opposition parties and legal groups are calling for a review of roughly 200 investigations into child deaths.
Indications of potential problems with these cases have only come to light at the Inquiry into Pediatric Forensic Pathology in Ontario, which resumes public hearings Monday after the Christmas break.
The inquiry is looking at mistakes made by pathologist Dr. Charles Smith in 20 child deaths in which people were criminally convicted or charged.
But there are concerns that other pathologists also made errors, resulting in wrongful convictions.
"If we're in the process of opening old wounds and trying to produce, by doing that, some healing, we should open them all and look at all these cases," Conservative Leader John Tory said yesterday.
"As a result of the current inquiry, the spectre of wrongful convictions has grown bigger and darker and it falls upon the government to initiate a thorough review," said NDP justice critic Peter Kormos.
Louis Sokolov is a director with the Association in Defence of the Wrongly Convicted and has been serving as counsel to the organization at the inquiry.
Sokolov said it has become increasingly evident since hearings started in mid-November that problems with the practice of pathology in the province run deeper than originally suspected.
"What we've heard from the inquiry is that the problems appear to go far beyond the 20-odd Dr. Smith cases that are the subject of the inquiry. They go beyond that time frame and go beyond Dr. Smith himself," he said.
All the cases in question involve about 200 criminally suspicious deaths and homicides of children. They include 50 deaths that occurred between 1991 and 2001 and more than 50 head injury deaths deemed homicides between 1986 and 2000. Also included are 142 deaths caused by "shaken baby syndrome" between 1986 and 2006.
The inquiry has heard that there was little oversight of pathologists going back to 1981. While Smith's errors were the most egregious, others made mistakes, too. For example, in the highly publicized wrongful conviction of William Mullins Johnson, it was a Sault Ste. Marie pathologist, with others in attendance, who first determined that his niece had been the victim of chronic abuse and had likely been strangled or smothered. Smith was only the consulting pathologist in the case, which resulted in Mullins Johnson spending 12 years in jail.
"What we do know is that for a long period of time, there has been inadequate supervision of pathologists in the province of Ontario. ... We are gravely concerned that there are other people who have been wrongfully convicted and wrongfully prosecuted as a result of flawed pathology in the province of Ontario and all of those cases need to be examined," Sokolov said.
"The pathologists assigned to the tasks of doing autopsies in these cases were very often not up to scratch," charged James Lockyer, counsel at the inquiry for individuals charged or convicted of child deaths in cases on which Smith had worked. "It's hard to isolate the ones who were and the ones who weren't. I think the best way of dealing with it and clearing the air once and for all and uncovering any possible wrongful convictions that are out there, is to just look at the whole lot."
Lockyer believes the "think dirty" edict issued by the chief coroner's office in 1995 was likely behind some of the mistakes. It directed pathologists and others working on child-death investigations to consider foul play.
Among the cases Sokolov wants reviewed are:
50 child deaths that occurred between 1991 and 2001, which outgoing deputy chief coroner Dr. Jim Cairns cited at the inquiry. Pathologists other than Smith carried out the autopsies.
More than 50 deaths involving infant or childhood head injuries, which Ontario's chief forensic pathologist Dr. Michael Pollanen, raised at the inquiry. He said he found these by searching the coroner's information database. They occurred between 1986 and 2000 and while they were "coded" as homicides, it's uncertain how many of these cases resulted in convictions.
142 infant deaths attributed to "shaken baby syndrome" between 1986 and 2006. Pollanen told the inquiry that a review of these deaths might be advisable. There has been an evolution in the debate about the syndrome over the last two decades and such deaths might be diagnosed differently today.
Sokolov also wants the review to look at criminally suspicious deaths and homicides investigated by the Ottawa pathology unit. The inquiry has heard that there were major problems at that pathology unit, dating back years. These death investigations involved adults as well as children.
"I don't think that we can have faith that adult forensic pathology is much more trustworthy than infant pathology," he said.
Sokolov said there is also a need to review Smith's older cases, going back to 1981 when the pathologist started doing coroner's autopsies. These are not being probed at the inquiry, which is focusing only on his work from 1991 to 2001. But the inquiry has heard that the coroner's office is combing through Smith's old cases to see if there are any red flags. Pollanen has indicated that they'll likely find some.
"There is a reasonable basis to believe that problems might exist with Dr. Smith's cases prior to 1991," he wrote in a Jan. 8, 2007 memo to the province's then-chief coroner Barry McLellan.
Sokolov said it's not necessary to hold another inquiry into the cases in question. A review could consist of looking for old cases where individuals were charged or convicted of crimes based on the findings of pathologists.
"The first step is to find out if there are more William Mullins Johnsons out there who are sitting and rotting in jail for things that they didn't do," he said.
Then it's a matter of getting reputable pathologists to take a look at the cases "and pinpoint those that are problematic," he added.
Sokolov acknowledged it will be a major undertaking, but argued that it's necessary.
But Lockyer argued that it doesn't have to be a massive undertaking. He said he would be satisfied with looking back at 15 years' worth of prosecutions involving the deaths of children under 2. He said he hopes Justice Stephen Goudge, who is overseeing the inquiry, will make such a recommendation.
However, Tory said the mandate of the current inquiry should be expanded to look at the additional cases.
Kormos said that if there is an indication more mistakes have been made by pathologists it's imperative to investigate.
Sheamus Murphy, spokesperson for Attorney General Chris Bentley, said it wouldn't be appropriate for his minister to comment until after the inquiry is completed."
Harold Levy...hlevy15@gmail.com;
However, as reporter Theresa Boyle reports in today's Toronto Star, both the Progressive Conservative Party and the New Democratic Party are seeking a review of about two hundred child deaths involving other pathologists than Dr. Charles Smith.
In short, the inquiry has opened up a proverbial "can of worms" - as it should since it involves deaths of children, possible miscarriages of justice on an even more massive scale than was feared to date, and all-too justified reason for the public to distrust the province's Coroner's system.
The calls for reviews by Conservative leader John Tory and N.D.P. leader Peter Kormos are a great testament to the Goudge Inquiry which was established by former Liberal Attorney Michael Bryant on April 25, 2007, and must deliver its final report by April 25, 208.
It is proof that the Inquiry is fearlessly doing its job.
As Boyle points out, reviews are being sought in connection with:
0: 50 child deaths that occurred between 1991 and 2001 referred to by Deputy Chief Coroner Dr. James Cairns in his testimony;
0: More than fifty deaths involving infant or childhood head injuries which occurred between 1986 and 2000 and were coded as homicides; (found by Ontario's chief forensic pathologist, Dr. Michael Pollanen while searching his database);
0: 142 infant deaths attributable to "shaken baby syndrome" between 1986 and 2006 which might be diagnosed differently today.
0: Cases involving Dr. Charles Smith that occurred between 1981 and 1991. (There are some disturbing ones); The Inquiry is limited to Smith cases between 1991, and,
0: Investigations of criminally suspicious deaths and homicides investigated by the Ottawa pathology unit;
I would add to this list a review of all cases in which a child was seized from its parents as a result of Dr. Smith's opinions.
This particular review is recommended by the authors of a research paper commissioned by the Inquiry. See previous postings: "Smith's testimony in three child protection cases" and "Children's Aid Societies should review every case in which Dr. Smith's opinion was involved.")
A caveat;
Pathologists do a wide variety of important research work and diagnostic work in the province's health system.
Criticism should be focused on a relatively small number of forensic pathologists who did work of the Chief Coroner's office in recent decades without adequate supervision.
A Second caveat;
The Inquiry has heard that some of the problems relating to incorrect opinions leading to wrongful convictions stem from not so much from pathologists but from limitations on forensic pathology itself.
More about that in a future posting;
Here is Theresa Boyle's story as it appeared today under the heading: "More than 200 cases could be revisited amid fears of errors by other pathologists."
"Provincial opposition parties and legal groups are calling for a review of roughly 200 investigations into child deaths.
Indications of potential problems with these cases have only come to light at the Inquiry into Pediatric Forensic Pathology in Ontario, which resumes public hearings Monday after the Christmas break.
The inquiry is looking at mistakes made by pathologist Dr. Charles Smith in 20 child deaths in which people were criminally convicted or charged.
But there are concerns that other pathologists also made errors, resulting in wrongful convictions.
"If we're in the process of opening old wounds and trying to produce, by doing that, some healing, we should open them all and look at all these cases," Conservative Leader John Tory said yesterday.
"As a result of the current inquiry, the spectre of wrongful convictions has grown bigger and darker and it falls upon the government to initiate a thorough review," said NDP justice critic Peter Kormos.
Louis Sokolov is a director with the Association in Defence of the Wrongly Convicted and has been serving as counsel to the organization at the inquiry.
Sokolov said it has become increasingly evident since hearings started in mid-November that problems with the practice of pathology in the province run deeper than originally suspected.
"What we've heard from the inquiry is that the problems appear to go far beyond the 20-odd Dr. Smith cases that are the subject of the inquiry. They go beyond that time frame and go beyond Dr. Smith himself," he said.
All the cases in question involve about 200 criminally suspicious deaths and homicides of children. They include 50 deaths that occurred between 1991 and 2001 and more than 50 head injury deaths deemed homicides between 1986 and 2000. Also included are 142 deaths caused by "shaken baby syndrome" between 1986 and 2006.
The inquiry has heard that there was little oversight of pathologists going back to 1981. While Smith's errors were the most egregious, others made mistakes, too. For example, in the highly publicized wrongful conviction of William Mullins Johnson, it was a Sault Ste. Marie pathologist, with others in attendance, who first determined that his niece had been the victim of chronic abuse and had likely been strangled or smothered. Smith was only the consulting pathologist in the case, which resulted in Mullins Johnson spending 12 years in jail.
"What we do know is that for a long period of time, there has been inadequate supervision of pathologists in the province of Ontario. ... We are gravely concerned that there are other people who have been wrongfully convicted and wrongfully prosecuted as a result of flawed pathology in the province of Ontario and all of those cases need to be examined," Sokolov said.
"The pathologists assigned to the tasks of doing autopsies in these cases were very often not up to scratch," charged James Lockyer, counsel at the inquiry for individuals charged or convicted of child deaths in cases on which Smith had worked. "It's hard to isolate the ones who were and the ones who weren't. I think the best way of dealing with it and clearing the air once and for all and uncovering any possible wrongful convictions that are out there, is to just look at the whole lot."
Lockyer believes the "think dirty" edict issued by the chief coroner's office in 1995 was likely behind some of the mistakes. It directed pathologists and others working on child-death investigations to consider foul play.
Among the cases Sokolov wants reviewed are:
50 child deaths that occurred between 1991 and 2001, which outgoing deputy chief coroner Dr. Jim Cairns cited at the inquiry. Pathologists other than Smith carried out the autopsies.
More than 50 deaths involving infant or childhood head injuries, which Ontario's chief forensic pathologist Dr. Michael Pollanen, raised at the inquiry. He said he found these by searching the coroner's information database. They occurred between 1986 and 2000 and while they were "coded" as homicides, it's uncertain how many of these cases resulted in convictions.
142 infant deaths attributed to "shaken baby syndrome" between 1986 and 2006. Pollanen told the inquiry that a review of these deaths might be advisable. There has been an evolution in the debate about the syndrome over the last two decades and such deaths might be diagnosed differently today.
Sokolov also wants the review to look at criminally suspicious deaths and homicides investigated by the Ottawa pathology unit. The inquiry has heard that there were major problems at that pathology unit, dating back years. These death investigations involved adults as well as children.
"I don't think that we can have faith that adult forensic pathology is much more trustworthy than infant pathology," he said.
Sokolov said there is also a need to review Smith's older cases, going back to 1981 when the pathologist started doing coroner's autopsies. These are not being probed at the inquiry, which is focusing only on his work from 1991 to 2001. But the inquiry has heard that the coroner's office is combing through Smith's old cases to see if there are any red flags. Pollanen has indicated that they'll likely find some.
"There is a reasonable basis to believe that problems might exist with Dr. Smith's cases prior to 1991," he wrote in a Jan. 8, 2007 memo to the province's then-chief coroner Barry McLellan.
Sokolov said it's not necessary to hold another inquiry into the cases in question. A review could consist of looking for old cases where individuals were charged or convicted of crimes based on the findings of pathologists.
"The first step is to find out if there are more William Mullins Johnsons out there who are sitting and rotting in jail for things that they didn't do," he said.
Then it's a matter of getting reputable pathologists to take a look at the cases "and pinpoint those that are problematic," he added.
Sokolov acknowledged it will be a major undertaking, but argued that it's necessary.
But Lockyer argued that it doesn't have to be a massive undertaking. He said he would be satisfied with looking back at 15 years' worth of prosecutions involving the deaths of children under 2. He said he hopes Justice Stephen Goudge, who is overseeing the inquiry, will make such a recommendation.
However, Tory said the mandate of the current inquiry should be expanded to look at the additional cases.
Kormos said that if there is an indication more mistakes have been made by pathologists it's imperative to investigate.
Sheamus Murphy, spokesperson for Attorney General Chris Bentley, said it wouldn't be appropriate for his minister to comment until after the inquiry is completed."
Harold Levy...hlevy15@gmail.com;
Wednesday, January 2, 2008
A Glimmer of Understanding; Part Three: A Dangerous Mix: Dr. Charles Smith and the Hospital for Sick Children SCAN Team ;
"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."
JUDGE PETER NASMITH;
"I AM NOT TALKING NOW ABOUT WHETHER SHAKING EXISTS OR WHETHER IT OR SOME OTHER MECHANISM KILLED AMBER", HE (JUDGE PATRICK DUNN) EXPLAINED.
"I MEAN THAT THE FACT FINDING 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.
JUDGE PATRICK DUNN;
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);
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.
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.
CHARLES SMITH BLOG ALERT: ON January 9 and 10 three members of the Hospital for Sick Children will testify at the Goudge Inquiry: They are: Dr. Katy Driver (who played a key role in SCAN teams investigation in the Timmins case), Dr. Dirk Huyer, and Dr. Michelle Shouldice.
COMING SOON: The Hospital for Sick Children: Breach of a public trust;
Harold Levy: hlevy15@gmail.com;
JUDGE PETER NASMITH;
"I AM NOT TALKING NOW ABOUT WHETHER SHAKING EXISTS OR WHETHER IT OR SOME OTHER MECHANISM KILLED AMBER", HE (JUDGE PATRICK DUNN) EXPLAINED.
"I MEAN THAT THE FACT FINDING 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.
JUDGE PATRICK DUNN;
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);
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.
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.
CHARLES SMITH BLOG ALERT: ON January 9 and 10 three members of the Hospital for Sick Children will testify at the Goudge Inquiry: They are: Dr. Katy Driver (who played a key role in SCAN teams investigation in the Timmins case), Dr. Dirk Huyer, and Dr. Michelle Shouldice.
COMING SOON: The Hospital for Sick Children: Breach of a public trust;
Harold Levy: hlevy15@gmail.com;
Tuesday, January 1, 2008
A Glimmer of Understanding; A Fatal Decision Part Two: The Illusion;
In yesterday's posting, I passed on my glimmer of understanding as to how Dr. Charles Smith was able to have such a disastrous effect on Ontario's criminal justice system. (A glimmer of understanding: Part One);
The pivotal event was the fatal decision to appoint a relatively self-taught man who had no formal qualifications in forensic pathology as head of a new unit - the Ontario Pediatric Forensic Pathology Unit - which was created in 1991 at the Hospital for Sick Children in Toronto.
An examination of his curriculum Vitae, shows that Smith received his medical degree from the University of Saskatchewan in 1975 and then was hired to work full-time in the Hospital for Sick Children's pathology department six years later.
By 1991 when he was appointed head of the new unit, Dr. Smith still had not acquired any formal qualifications in the area of forensic pathology, and had, according to Dr. Ernest Cutz, one of his colleagues at the hospital, effectively learned on the job through the occasional autopsy involving a suspicious death.
In short, the appointment gave Doctor Smith, a relatively small fish in the world of forensic pathology, power and prestige which was far beyond that which he had previously enjoyed, which Smith could then trade upon in order to create the illusion that he was truly an accomplished authority in the area.
(Although Dr. Smith's resume is loaded with references to his many periodical articles, I was unable to find a single one which had under-gone a peer-review process by a specialist in forensic pathology);
The appointment would serve to elevate Dr. Smith's status at the Hospital for Sick Children, where other pathologists doing work for the unit would have to provide their forensic reports to him. (The Inquiry has learned that his own reports did not come under scrutiny);
It would also enhance his reputation in the Coroner's office, where, as Dr. Cutz testified then Chief Coroner Dr. James Young - took him under his wing and served as his mentor.
There were only two specialized Units for performing forensic autopsies in Ontario and Dr. Charles Smith was now head of one of them.
Ontario Forensic Pediatric Pathology Unit Smith would hobnob with top officials in government and in the Coroner's establishment.
I don't think in my years of reporting on Dr. Smith that I have come across one high official who did not refer to him affectionately as "Charles."
His new position would open the door to invitations to attend prestigious national and international conferences and to lecture to students, police officers, and prosecutors - and to being adored by the media.
The illustrious Dr. Charles Randal Smith was born.
Next: A glimmer of understanding: Part Three; Dr. Smith and the Hospital for Sick Children SCAN (Suspected Child Abuse and Neglect) team): a dangerous mix;
Harold Levy: hlevy15@gmail.com;
The pivotal event was the fatal decision to appoint a relatively self-taught man who had no formal qualifications in forensic pathology as head of a new unit - the Ontario Pediatric Forensic Pathology Unit - which was created in 1991 at the Hospital for Sick Children in Toronto.
An examination of his curriculum Vitae, shows that Smith received his medical degree from the University of Saskatchewan in 1975 and then was hired to work full-time in the Hospital for Sick Children's pathology department six years later.
By 1991 when he was appointed head of the new unit, Dr. Smith still had not acquired any formal qualifications in the area of forensic pathology, and had, according to Dr. Ernest Cutz, one of his colleagues at the hospital, effectively learned on the job through the occasional autopsy involving a suspicious death.
In short, the appointment gave Doctor Smith, a relatively small fish in the world of forensic pathology, power and prestige which was far beyond that which he had previously enjoyed, which Smith could then trade upon in order to create the illusion that he was truly an accomplished authority in the area.
(Although Dr. Smith's resume is loaded with references to his many periodical articles, I was unable to find a single one which had under-gone a peer-review process by a specialist in forensic pathology);
The appointment would serve to elevate Dr. Smith's status at the Hospital for Sick Children, where other pathologists doing work for the unit would have to provide their forensic reports to him. (The Inquiry has learned that his own reports did not come under scrutiny);
It would also enhance his reputation in the Coroner's office, where, as Dr. Cutz testified then Chief Coroner Dr. James Young - took him under his wing and served as his mentor.
There were only two specialized Units for performing forensic autopsies in Ontario and Dr. Charles Smith was now head of one of them.
Ontario Forensic Pediatric Pathology Unit Smith would hobnob with top officials in government and in the Coroner's establishment.
I don't think in my years of reporting on Dr. Smith that I have come across one high official who did not refer to him affectionately as "Charles."
His new position would open the door to invitations to attend prestigious national and international conferences and to lecture to students, police officers, and prosecutors - and to being adored by the media.
The illustrious Dr. Charles Randal Smith was born.
Next: A glimmer of understanding: Part Three; Dr. Smith and the Hospital for Sick Children SCAN (Suspected Child Abuse and Neglect) team): a dangerous mix;
Harold Levy: hlevy15@gmail.com;
Subscribe to:
Posts (Atom)
