Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
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Athena died in Toronto on March 6, 1998 at the age of three months;
Dr. Smith performed the autopsy the next day;
He waited six weeks before submitting samples taken from the autopsy to the C Ontario's Centre of Forensic Sciences for analysis;
The Centre in turn took five months to complete its report;
Dr. Smith produced his report of post-mortem examination one month after that, and Athena's father was charged with manslaughter;
There was thus a seven-and-a-half month delay between the autopsy and the production of Dr. Smith's report on October 26, 1998;
On June 23, 2003, Superior Court Justice Brian Trafford stayed the proceedings against Athena's parents - her mother had also been charged - on the basis that the overall delay violated their Charter right to be tried in a reasonable time.
--------------------------------------------------------------------------------
Justice Goudge reported that Smith's delay in submitting the samples "was not the most troubling aspect of his conduct of the case."
"Many months later, in July 1999, Dr. Smith told the police and Crown Counsel that the liver injury took place within 12 hours of Athena's death.
Athena's parents had told the police that they were with Athena during the entire 24-hour period before her death.
In light of Dr. Smith's opinion on the timing of the liver injury, the police believed they had reasonable and probable grounds to charge both parents with second-degree murder.
But they wanted Dr. Smith's opinion in writing.
Shortly after the meeting, the police asked Dr. Smith to prepare an addendum to his initial report, outlining his opinion on the timing of Athena's injuries."
"Dr. Smith failed to produce the requested addendum," Goudge continued.
In the fall of 1999, an officer phoned Dr. Smith on numerous occasion, requesting the report, but he continued to delay.
In the winter of 2000, an officer and Crown counsel sent letters to Dr. Smith, formally requesting the report and stressing that it was urgently needed.
Still, Dr. Smith delayed.
Finally, in April 2000, on the very day that the police issued a subpoena for the production of his addendum, Dr. Smith produced a one and a half page letter outlining his opinion.
That was eight-and-a-half months after the initial request;
Justice Goudge notes that the Ontario Court of Appeal rejected the Crown's appeal after finding "among other things" that the failings of Dr. Smith caused the matter to be delayed "for the better part of two years."
"Thus, the concerns with Dr. Smith's work were not limited to misdiagnosis and overstated opinions," Goudge concluded.
"They included a complete dereliction of his duties as an expert to assist the Chief Coroner's Office and serve the criminal justice system."
Justice Goudge rejected Smith's feeble explanation that he was not aware of his legal obligations to make timely disclosure, saying, "by 1998, Dr. Smith knew the importance of complying with requests from the police and Crown counsel for a written opinion."
"Although I accept Dr. Smith's evidence that he found it a burden to prepare a supplementary report, his failure to respond promptly to the requests made by the police and Crown counsel was inexcusable."
"As a professional, the pathologist has a duty to ensure that any reasonable requests from the police and the Crown are answered in a timely manner, regardless of how burdensome the requests may be."
Too bad Dr. Smith lacked the humanity to consider the unbearable burden his delays must have imposed on Athena's bereaved parents.
The expert's attacks on his colleagues;
In a section of his report called "The expert's attacks on his colleagues" Justice Goudge criticizes Smith ofr "his unprofessional and unwarranted criticism of professionals."
This misconduct is particularly noticeable in Athena's case, where, during the preliminary hearing in November 2001, counsel questioned him on his opinion of several experts, including Dr. James (Rex) Ferris, a forensic pathologist.
"When asked if he respected Dr. Ferris' work, Dr. Smith testified that he did not respect Dr. Ferris' opinions in pediatric forensic pathology and did not know anyone in the field who did," wrote Goudge.
"According to Dr. Smith, Dr. Ferris did not have any special expertise in the area and his opinions were often "misleading"; Dr. Smith had never seen one that was close to reasonable."
In response to Smith's explanations that he had answered the questions truthfully, though uncharitably and unkindly, Goudge ruled: "In my view, Dr. Smith's comments about Dr. Ferris were not only uncharitable and unkind but also untrue."
Were I the Commissioner I don't think I could ever have been so constrained;
For Dr. Smith, a dishonest and unprincipled expert witness, to attack a real forensic pathologist and consummate professional such as Dr. Rex Ferris, is utterly disgusting - especially when he is under oath and trying to convict an accused person for the Crown;
End of rant!
End of post!
Harold Levy...hlevy15@gmail.com;
Wednesday, November 5, 2008
Tuesday, November 4, 2008
JUSTICE GOUDGE'S FINDINGS: PART FOUR; SHARON'S CASE; (2) YOUNG AND CAIRNS;
Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Sharon's case prepared by Commission staff indicates that:
"Sharon was born in Kingston, Ontario, on December 28, 1989. She was the child of Louise Reynolds and David, Sharon died on June 12, 1997, at the age of seven and a half years.
On June 26, 1997, Ms. Reynolds was charged with second degree murder in the death of Sharon. The preliminary inquiry was conducted from April to November 1998. On November 19,1998, the Honourable Mr. Justice Megginson committed Ms. Reynolds to trial on the charge. She was remanded without bail from June 26, 1997, until April 26, 1999 when she was released with the consent of the Crown, on certain terms and conditions.
The Crown withdrew the charge against Ms. Reynolds on January 2, 201, indicating that it did not have a reasonable prospect of conviction."
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Justice Goudge describes the second autopsy on Sharon's case as "another missed warning sign."
He says that the Chief Coroner's Office should have been deeply concerned by the fact that the results of the second autopsy were so different from Smith's initial opinion on cause of death and his testimony at the preliminary hearing - that this discrepancy like the changed opinions in Jenna's case, should have triggered a more formal review.
"The Chief Coroner's Office now had evidence available to it that, viewed objectively, raised concerns about Smith's work in the cases involving Amber, Nicholas, Jenna and Sharon," he adds.
"But this evidence was discounted, minimized, or missed altogether."
"Instead, Dr. Young and Dr. Cairns continued to maintain their confidence in Dr. Smith's capabilities even after his opinion unravelled, attributing Dr. Smith's errors to a "team failure..." Goudge continues.
"Once again, Dr. Cairns and Dr. Young failed to take any corrective steps regarding Dr. Smith."
"They exercised no oversight and required no accountability from Dr. Smith."
To make matters even worse, even though Dr. Young told the media he intended to order an independent review of Dr. Smith's work in Sharon's case and several other cases, Dr. Young quietly abandoned this review - later using a civil lawsuit launched by Louise Reynold's as his purported excuse.
"In Dr. Young's mind, the sole purpose of any external review was to determine whether Dr. Smith was fit to return to work for the Chief Coroner's Office," said Goudge.
"He did not consider that an examination of Dr. Smith's cases might also be in the public interest to determine what pathology lessons might be learned or whether there were possible wrongful convictions in cases involving Dr. Smith's work."
Although AIDWYC lawyer James Lockyer wrote Young in April 2001, requesting a thorough review of Smith's work, Goudge notes Young's testimony at the Inquiry that, at the time, he did not consider this request from Lockyer a request for a broad review of Dr. Smith's past cases.
"He was familiar with Mr. Lockyer, whom he described as "very persistent" and "like a dog with a bone," says Goudge.
"He thought that if Mr. Lockyer wanted to call for a broad review of Dr. Smith's cases, he would have done so publicly and in a much more forceful manner than in a letter."
"However, it is difficult to see how Mr. Lockyer's letter could have been clearer."
Harold Levy...hlevy15@gmail.com;
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Sharon's case prepared by Commission staff indicates that:
"Sharon was born in Kingston, Ontario, on December 28, 1989. She was the child of Louise Reynolds and David, Sharon died on June 12, 1997, at the age of seven and a half years.
On June 26, 1997, Ms. Reynolds was charged with second degree murder in the death of Sharon. The preliminary inquiry was conducted from April to November 1998. On November 19,1998, the Honourable Mr. Justice Megginson committed Ms. Reynolds to trial on the charge. She was remanded without bail from June 26, 1997, until April 26, 1999 when she was released with the consent of the Crown, on certain terms and conditions.
The Crown withdrew the charge against Ms. Reynolds on January 2, 201, indicating that it did not have a reasonable prospect of conviction."
-------------------------------------------------------------------------------
Justice Goudge describes the second autopsy on Sharon's case as "another missed warning sign."
He says that the Chief Coroner's Office should have been deeply concerned by the fact that the results of the second autopsy were so different from Smith's initial opinion on cause of death and his testimony at the preliminary hearing - that this discrepancy like the changed opinions in Jenna's case, should have triggered a more formal review.
"The Chief Coroner's Office now had evidence available to it that, viewed objectively, raised concerns about Smith's work in the cases involving Amber, Nicholas, Jenna and Sharon," he adds.
"But this evidence was discounted, minimized, or missed altogether."
"Instead, Dr. Young and Dr. Cairns continued to maintain their confidence in Dr. Smith's capabilities even after his opinion unravelled, attributing Dr. Smith's errors to a "team failure..." Goudge continues.
"Once again, Dr. Cairns and Dr. Young failed to take any corrective steps regarding Dr. Smith."
"They exercised no oversight and required no accountability from Dr. Smith."
To make matters even worse, even though Dr. Young told the media he intended to order an independent review of Dr. Smith's work in Sharon's case and several other cases, Dr. Young quietly abandoned this review - later using a civil lawsuit launched by Louise Reynold's as his purported excuse.
"In Dr. Young's mind, the sole purpose of any external review was to determine whether Dr. Smith was fit to return to work for the Chief Coroner's Office," said Goudge.
"He did not consider that an examination of Dr. Smith's cases might also be in the public interest to determine what pathology lessons might be learned or whether there were possible wrongful convictions in cases involving Dr. Smith's work."
Although AIDWYC lawyer James Lockyer wrote Young in April 2001, requesting a thorough review of Smith's work, Goudge notes Young's testimony at the Inquiry that, at the time, he did not consider this request from Lockyer a request for a broad review of Dr. Smith's past cases.
"He was familiar with Mr. Lockyer, whom he described as "very persistent" and "like a dog with a bone," says Goudge.
"He thought that if Mr. Lockyer wanted to call for a broad review of Dr. Smith's cases, he would have done so publicly and in a much more forceful manner than in a letter."
"However, it is difficult to see how Mr. Lockyer's letter could have been clearer."
Harold Levy...hlevy15@gmail.com;
Monday, November 3, 2008
JUSTICE GOUDGE'S FINDINGS: PART FOUR; SHARON'S CASE (1); SMITH;
Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Sharon's case prepared by Commission staff indicates that:
"Sharon was born in Kingston, Ontario, on December 28, 1989. She was the child of Louise Reynolds and David, Sharon died on June 12, 1997, at the age of seven and a half years.
On June 26, 1997, Ms. Reynolds was charged with second degree murder in the death of Sharon. The preliminary inquiry was conducted from April to November 1998. On November 19,1998, the Honourable Mr. Justice Megginson committed Ms. Reynolds to trial on the charge. She was remanded without bail from June 26, 1997, until April 26, 1999 when she was released with the consent of the Crown, on certain terms and conditions.
The Crown withdrew the charge against Ms. Reynolds on January 2, 201, indicating that it did not have a reasonable prospect of conviction."
-------------------------------------------------------------------------------
One of Justice Goudge's first criticisms of Charles Smith in Sharon's case is that "he performed the autopsy anyway" - even though, "at the time, he had very little experience with penetrating wounds, having seen only one or two cases involving stab wounds and one or two other cases involving dog bites."
This is the case where prosecutors had to make repeated requests to Dr.Smith for his report - and even had to issue a subpoena requiring him to attend court and produce it.
He finally produced the report to the Crown on March 8, 1998, nine months after completing the post-mortem examination;
Justice Goudge also criticizes Smith's categorical denial of suggestions by defence counsel that a dog had attacked Sharon,saying dismissively: "As absurd as it is to think that a polar bear attacked Sharon, so it is equally absurd that it's a dog wound," which, of course,it was.
As Justice Goudge put it:
"Dr. Smith's errors in Sharon's case were basic. He lacked the forensic pathology training and experience required to assess properly Sharon's penetrating wounds. Yet he took the case on anyway. The results were catastrophic. He turned what forensically qualified experts say are clearly dog bites into something much more sinister, Dr. Smith's misdiagnosis in Sharon's case might have been prevented had he had the appropriate training and expertise in forensic pathology,or if he had consulted with someone with such a background.
Justice Goudge did not buy Smith's argument in closing submissions that other experts, including a forensic ondontologist, had also misinterpreted Sharon's wounds, saying: "This is true, but does not excuse Dr. Smith's errors in the case."
Autopsy practice:
It was only on reading the Goudge report that I realized that Dr. Smith's conduct of the autopsy in Sharon's case was as deficient - as replete with "serious errors" - as his post-mortem on Baby Jenna which has been referred to earlier in this series.
Goudge points out that Dr. Smith:
0: Did not shave the hair to conduct a detailed assessment of the wound margins when examining Sharon's scalp injury; (standard procedure - like the swab in Jenna's case);
0: Did not take swabs of the wounds to test for saliva;
0: Did not dissect the spinal canal and cord as he should have , given that the injuries went down to the spine;
0: Failed to measure the depth of key injuries, such as a penetrating wound in the neck. (An important measurement to determine if a dog could have caused Sharon's injuries);
0: Did not examine the scalp adequately under the microscope during the ancillary testing phase of the autopsy;
Reporting in a timely fashion;
In addition to an "inexcusable" nine and a half month delay in in providing his report, Goudge blasts Smith for failing to respond to defence lawyers and prosecutors who were seeking it, as he tells us: "Two days before his scheduled court date, Dr. Smith completed his report of post-mortem examination and faxed it to the Crown;
Justice Goudge also refers to Smith's failure to understand "that his role as an expert witness is not to support the Crown."
In this respectful Bloggist's view, this interpretation of Smith's performance is far too kind. Dr. Smith stressed the importance of being a neutral witness in his lectures to medical students.
He knew damn well what he was doing - helping the Crown win the case - through himself into the task and did it very well.
The overstated expertise of the expert:
Justice Goudge points out that, "rather than acknowledging the limits to his expertise, Dr. Smith sometimes mislead the court by overstating his knowledge in a particular area.
In Sharon's case this was typified by the impression he left at Louise Reynold's preliminary hearing that he had a significant expertise with both stab and dog wounds, by saying: "I've seen dog wounds. I've seen coyote wounds,I've seen wolf wounds. I recently went to an archipelago of islands owned by another country near the North Pole and had the occasion to study osteology and look at patterns of wounding from Polar Bears."
"His attempt to so exaggerate his abilities disguised his lack of relevant expertise," said Goudge.
Loss of forensic materials from the case that should have been safeguarded;
Justice Smith points out that Smith lost forensic materials in Sharon's case that he had a professional responsibility to protect: a cast of Sharon's skull and a set of x-rays.
The loss of the cast was significant: Louise Reynold's lawyers believed that it was important for their defences and had it not been lost it may not have been necessary to exhume Sharon's body with all of the emotional pain and suffering this would mean for her family.
Although the loss of the X-Rays was less consequential, Goudge reported that the loss of these materials was a sign of Smith's "disorganization, carelessness and sloppiness."
In this Blogster's view something far more insidious is involved: Smith tended to "lose" exhibits which would may have assisted the defence or proven that in the Waudby case his opinion was wrong such as the skull cast, the hair found in Baby Jenna's genital area, and the microscopic slides in the Mullins-Johnson case.
Forces much darker than "disorganization,carelessness and sloppiness" were at play.
Harold Levy...hlevy15@gmail.com;
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Sharon's case prepared by Commission staff indicates that:
"Sharon was born in Kingston, Ontario, on December 28, 1989. She was the child of Louise Reynolds and David, Sharon died on June 12, 1997, at the age of seven and a half years.
On June 26, 1997, Ms. Reynolds was charged with second degree murder in the death of Sharon. The preliminary inquiry was conducted from April to November 1998. On November 19,1998, the Honourable Mr. Justice Megginson committed Ms. Reynolds to trial on the charge. She was remanded without bail from June 26, 1997, until April 26, 1999 when she was released with the consent of the Crown, on certain terms and conditions.
The Crown withdrew the charge against Ms. Reynolds on January 2, 201, indicating that it did not have a reasonable prospect of conviction."
-------------------------------------------------------------------------------
One of Justice Goudge's first criticisms of Charles Smith in Sharon's case is that "he performed the autopsy anyway" - even though, "at the time, he had very little experience with penetrating wounds, having seen only one or two cases involving stab wounds and one or two other cases involving dog bites."
This is the case where prosecutors had to make repeated requests to Dr.Smith for his report - and even had to issue a subpoena requiring him to attend court and produce it.
He finally produced the report to the Crown on March 8, 1998, nine months after completing the post-mortem examination;
Justice Goudge also criticizes Smith's categorical denial of suggestions by defence counsel that a dog had attacked Sharon,saying dismissively: "As absurd as it is to think that a polar bear attacked Sharon, so it is equally absurd that it's a dog wound," which, of course,it was.
As Justice Goudge put it:
"Dr. Smith's errors in Sharon's case were basic. He lacked the forensic pathology training and experience required to assess properly Sharon's penetrating wounds. Yet he took the case on anyway. The results were catastrophic. He turned what forensically qualified experts say are clearly dog bites into something much more sinister, Dr. Smith's misdiagnosis in Sharon's case might have been prevented had he had the appropriate training and expertise in forensic pathology,or if he had consulted with someone with such a background.
Justice Goudge did not buy Smith's argument in closing submissions that other experts, including a forensic ondontologist, had also misinterpreted Sharon's wounds, saying: "This is true, but does not excuse Dr. Smith's errors in the case."
Autopsy practice:
It was only on reading the Goudge report that I realized that Dr. Smith's conduct of the autopsy in Sharon's case was as deficient - as replete with "serious errors" - as his post-mortem on Baby Jenna which has been referred to earlier in this series.
Goudge points out that Dr. Smith:
0: Did not shave the hair to conduct a detailed assessment of the wound margins when examining Sharon's scalp injury; (standard procedure - like the swab in Jenna's case);
0: Did not take swabs of the wounds to test for saliva;
0: Did not dissect the spinal canal and cord as he should have , given that the injuries went down to the spine;
0: Failed to measure the depth of key injuries, such as a penetrating wound in the neck. (An important measurement to determine if a dog could have caused Sharon's injuries);
0: Did not examine the scalp adequately under the microscope during the ancillary testing phase of the autopsy;
Reporting in a timely fashion;
In addition to an "inexcusable" nine and a half month delay in in providing his report, Goudge blasts Smith for failing to respond to defence lawyers and prosecutors who were seeking it, as he tells us: "Two days before his scheduled court date, Dr. Smith completed his report of post-mortem examination and faxed it to the Crown;
Justice Goudge also refers to Smith's failure to understand "that his role as an expert witness is not to support the Crown."
In this respectful Bloggist's view, this interpretation of Smith's performance is far too kind. Dr. Smith stressed the importance of being a neutral witness in his lectures to medical students.
He knew damn well what he was doing - helping the Crown win the case - through himself into the task and did it very well.
The overstated expertise of the expert:
Justice Goudge points out that, "rather than acknowledging the limits to his expertise, Dr. Smith sometimes mislead the court by overstating his knowledge in a particular area.
In Sharon's case this was typified by the impression he left at Louise Reynold's preliminary hearing that he had a significant expertise with both stab and dog wounds, by saying: "I've seen dog wounds. I've seen coyote wounds,I've seen wolf wounds. I recently went to an archipelago of islands owned by another country near the North Pole and had the occasion to study osteology and look at patterns of wounding from Polar Bears."
"His attempt to so exaggerate his abilities disguised his lack of relevant expertise," said Goudge.
Loss of forensic materials from the case that should have been safeguarded;
Justice Smith points out that Smith lost forensic materials in Sharon's case that he had a professional responsibility to protect: a cast of Sharon's skull and a set of x-rays.
The loss of the cast was significant: Louise Reynold's lawyers believed that it was important for their defences and had it not been lost it may not have been necessary to exhume Sharon's body with all of the emotional pain and suffering this would mean for her family.
Although the loss of the X-Rays was less consequential, Goudge reported that the loss of these materials was a sign of Smith's "disorganization, carelessness and sloppiness."
In this Blogster's view something far more insidious is involved: Smith tended to "lose" exhibits which would may have assisted the defence or proven that in the Waudby case his opinion was wrong such as the skull cast, the hair found in Baby Jenna's genital area, and the microscopic slides in the Mullins-Johnson case.
Forces much darker than "disorganization,carelessness and sloppiness" were at play.
Harold Levy...hlevy15@gmail.com;
Sunday, November 2, 2008
PAINFUL ENDING TO BOTCHED CANCER TEST NEWFOUNDLAND INQUIRY; CANADIAN PRESS REPORT;
CHES CROSBIE, A LAWYER LEADING A CLASS-ACTION LAWSUIT AGAINST EASTERN HEALTH, SAID HE REMAINS SUSPICIOUS OF CLAIMS THAT EASTERN HEALTH HAS A HANDLE ON THE SCOPE OF THE MISTAKES.
"EVERY TIME EASTERN HEALTH RELEASED INFORMATION OR DEALT WITH THE QUESTION OF DISCLOSURE, THEY DID SO IN A WAY SO AS TO MINIMIZE THE DAMAGE AND SPIN IT IN A ROSY GLOW," CROSBIE SAID.
-------------------------------------------------------------------------------
The Canadian Press has reported that the Newfoundland Inquiry into botched cancer tests ended on a painful note in a story by Tara Brautigam which ran yesterday under the heading: "Breast cancer probe's final witness reveals she only learned this year her test was flawed."
ST. JOHN'S, Nfld.–A public inquiry into hundreds of botched breast cancer tests in Newfoundland concluded on a distressing note yesterday as a Labrador woman testified she didn't learn her test was flawed until this summer – eight years after she was diagnosed with the disease," the story begins;
"The revelation stoked fears that the province still doesn't have a grasp of how many people may have missed out on potentially life-saving treatment because of the mishandled tests," it continues;
"Elizabeth Finlayson, 68, told the inquiry she wondered about the veracity of her breast cancer test after watching media coverage of other patients testifying at the probe in March.
"I saw on the TV about this inquiry that was going on," said Finlayson, the final witness to testify. "There was people on the stand and they were talking and I thought, `That sounds like me.'"
With the help of her daughter, she prodded medical officials for information about the status of her breast cancer test.
They were told that hers was missed in a review of more than 2,000 tests from 1997 to 2005.
It wasn't until this summer that Finlayson, who had her left breast removed in 2000, learned her breast cancer test was misread and that she was disqualified from hormone therapy.
Officials with the Eastern Health authority, the province's largest health board, didn't apologize for the error or for overlooking her in their review of breast cancer tests, Finlayson said.
Ches Crosbie, a lawyer leading a class-action lawsuit against Eastern Health, said he remains suspicious of claims that Eastern Health has a handle on the scope of the mistakes.
"Every time Eastern Health released information or dealt with the question of disclosure, they did so in a way so as to minimize the damage and spin it in a rosy glow," Crosbie said.
"There have been some serious missteps, to say the least, in this lady's treatment. ... She illustrates, I guess in a way, some of the serious slip-ups that have happened all through this sorry tale."
For seven months, the inquiry has heard evidence that the St. John's laboratory that processed the tests was marred by staff shortages, improper training and a lack of internal controls.
Witnesses have also testified to infighting among medical staff, communication lapses between the provincial government and Eastern Health, and failed exercises in damage control.
Patients say they had no inkling there were any problems with their breast cancer tests until October 2005, when a local weekly newspaper reported a small number of patients had questionable test results.
For up to two years, patients and their relatives complained Eastern Health wasn't informing them of reviewed test results.
The general extent of the mistakes wasn't known until last year, after documents were filed with the province's Supreme Court as part of the class-action lawsuit.
Earlier this week, Premier Danny Williams apologized at the inquiry to patients and their families who were affected by the errors on behalf of his and previous provincial governments.
He called the inquiry last year, but was critical of the way it operated, accusing it of conducting an inquisition in the way it questioned government officials.
The inquiry was asked to determine how an estimated 400 patients under Eastern Health's care were given inaccurate results on their breast cancer tests, and whether it responded to patients and the public in an appropriate and timely manner.
Justice Margaret Cameron is expected to deliver a final report with recommendations to the provincial government by the end of February."
Harold Levy...hlevy15@gmail.com;
"EVERY TIME EASTERN HEALTH RELEASED INFORMATION OR DEALT WITH THE QUESTION OF DISCLOSURE, THEY DID SO IN A WAY SO AS TO MINIMIZE THE DAMAGE AND SPIN IT IN A ROSY GLOW," CROSBIE SAID.
-------------------------------------------------------------------------------
The Canadian Press has reported that the Newfoundland Inquiry into botched cancer tests ended on a painful note in a story by Tara Brautigam which ran yesterday under the heading: "Breast cancer probe's final witness reveals she only learned this year her test was flawed."
ST. JOHN'S, Nfld.–A public inquiry into hundreds of botched breast cancer tests in Newfoundland concluded on a distressing note yesterday as a Labrador woman testified she didn't learn her test was flawed until this summer – eight years after she was diagnosed with the disease," the story begins;
"The revelation stoked fears that the province still doesn't have a grasp of how many people may have missed out on potentially life-saving treatment because of the mishandled tests," it continues;
"Elizabeth Finlayson, 68, told the inquiry she wondered about the veracity of her breast cancer test after watching media coverage of other patients testifying at the probe in March.
"I saw on the TV about this inquiry that was going on," said Finlayson, the final witness to testify. "There was people on the stand and they were talking and I thought, `That sounds like me.'"
With the help of her daughter, she prodded medical officials for information about the status of her breast cancer test.
They were told that hers was missed in a review of more than 2,000 tests from 1997 to 2005.
It wasn't until this summer that Finlayson, who had her left breast removed in 2000, learned her breast cancer test was misread and that she was disqualified from hormone therapy.
Officials with the Eastern Health authority, the province's largest health board, didn't apologize for the error or for overlooking her in their review of breast cancer tests, Finlayson said.
Ches Crosbie, a lawyer leading a class-action lawsuit against Eastern Health, said he remains suspicious of claims that Eastern Health has a handle on the scope of the mistakes.
"Every time Eastern Health released information or dealt with the question of disclosure, they did so in a way so as to minimize the damage and spin it in a rosy glow," Crosbie said.
"There have been some serious missteps, to say the least, in this lady's treatment. ... She illustrates, I guess in a way, some of the serious slip-ups that have happened all through this sorry tale."
For seven months, the inquiry has heard evidence that the St. John's laboratory that processed the tests was marred by staff shortages, improper training and a lack of internal controls.
Witnesses have also testified to infighting among medical staff, communication lapses between the provincial government and Eastern Health, and failed exercises in damage control.
Patients say they had no inkling there were any problems with their breast cancer tests until October 2005, when a local weekly newspaper reported a small number of patients had questionable test results.
For up to two years, patients and their relatives complained Eastern Health wasn't informing them of reviewed test results.
The general extent of the mistakes wasn't known until last year, after documents were filed with the province's Supreme Court as part of the class-action lawsuit.
Earlier this week, Premier Danny Williams apologized at the inquiry to patients and their families who were affected by the errors on behalf of his and previous provincial governments.
He called the inquiry last year, but was critical of the way it operated, accusing it of conducting an inquisition in the way it questioned government officials.
The inquiry was asked to determine how an estimated 400 patients under Eastern Health's care were given inaccurate results on their breast cancer tests, and whether it responded to patients and the public in an appropriate and timely manner.
Justice Margaret Cameron is expected to deliver a final report with recommendations to the provincial government by the end of February."
Harold Levy...hlevy15@gmail.com;
JUSTICE GOUDGE'S FINDINGS; PART THREE; JENNA'S CASE (3): THE COLLEGE;
Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Jenna's case prepared by Goudge Inquiry staff tells us that:
Jenna was born in Peterborough, Ontario on April 21, 1995 to Randy and Brenda Waudby. Jenna died on January 22, 1997, at the age of 21-months in Peterborough; Mrs. Waudby was charged with second-degree murder on Sept. 18 1997. The criminal proceeding concluded on June 15, 1999, when the charge was withdrawn. The local Children's Aid Society apprehended Ms. Waudby's older child, Justine, on the day of Jenna's death and placed her in temporary foster care. She remained in foster care until January 27, 1997, when she moved in with Tom and Kim Waudby, her maternal aunt and uncle. She remained there until March 27, 1997, at which time she was again placed in foster care. She was ordered returned to Ms. Waudby's care on May 2, 1997, pursuant to an Order of Justice A.P.Ingram and remained in her care until Sept. 18, 1997, the day of Ms. Waudby's arrest. She was later re-apprehended on the date of Ms. Waudby's arrest. The Children's Aid Society also apprehended a second child, M.W. born after Jenna's death, and placed him with his father. On July 23, 1999, subsequent to the withdrawal of Ms. Waudby's murder charge, Justine was ordered returned to her mother's care. That same day, access was also granted to M.W. who would continue to reside with his father. The Children's Aid Society appealed the decision. On August 13, 1999, the appeal was dismissed. On Dec. 28, 2006, the youth who was babysitting Jenna the night she died was charged with second-degree murder. On December 14, 2006, J.D. pleaded guilty to manslaughter. The criminal proceeding concluded on March 1, 2007, when he was sentenced as a youth to 22 months incarceration followed by 11 months of community supervision;
-------------------------------------------------------------------------------
Buried toward the back of Volume Two of the Goudge report are some findings relating to the College of Physicians and Surgeons that were largely ignored in the aftermath of the report's release.
They relate to steps taken by the College after its then Registrar, Dr John Carlisle was informed by former Deputy Chief Coroner Dr. Jim Cairns in April, 2002, about Dr. Smith's admissions to him of misconduct relating to the hair he seized, without testing, in Jenna's case.
Having received such disturbing information - which could indicate criminality on Smith's part - one would expect that Carlisle would have have passed this information on to his officials who were investigating the complaints against Smith.
But Justice Goudge tells us that Dr. Carlisle merely responded by writing a memo to file and sending a memo to the investigator which did not relate any details from his conversation with Cairns or from his detailed memo to file.
Carlisle's memo to file indicated that he had the conversation with Cairns, and that Cairns had told him:
0: He had not conducted a rape kit examination;
0: He had not taken any of the samples or specimen that would ordinarily be associated with such an examination;
0: He had found what he believed to be "a hair."
0: He had collected the hair and placed it in a sealed envelope, which he kept in his possession since the time of the investigation;
0: He had not revealed the existence of the hair to anyone;
0: He had not submitted it for analysis;
0: He had not given it to the police;
One can easily imagine how different the outcomes of the complaints would have been if Dr. Carlisle had passed this information on to his staff investigators - so they would be fully apprised and could do their job effectively.
At this point I expected Justice Goudge's voice to have rung out in well justified anger at the frustration of the accountability process and the lost opportunity to do something about Dr. Smith.
Instead, he says he is satisfied that such a transgression will not happen again. In Justice Goudge's words:
"When asked about the April 10, 2002, memo to file at the Inquiry, Dr. Rocco Gerace, Current Registrar, testified, " I would not consider the practice (of writing a memo that would not form part of a file) to be advisable. In fact that practice would not occur at the present time." He went on to describe the current approach to the receipt of information:
"We have a practice at the College that if information comes to any member of the staff about a member, that the person providing that information is told up front that the information will be acted upon.
There are no confidential documents that are not acted on. So, if a conversation of this sort were to have occurred today, I would send a note to the relevant individuals outlining the content of that conversation;"
Says Justice Goudge: "I agree with the College's current approach."
To this humble Blogster, so much about the College's failure to rein in Dr. Smith remains unsaid.
Harold Levy...hlevy15@gmail.com;
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Jenna's case prepared by Goudge Inquiry staff tells us that:
Jenna was born in Peterborough, Ontario on April 21, 1995 to Randy and Brenda Waudby. Jenna died on January 22, 1997, at the age of 21-months in Peterborough; Mrs. Waudby was charged with second-degree murder on Sept. 18 1997. The criminal proceeding concluded on June 15, 1999, when the charge was withdrawn. The local Children's Aid Society apprehended Ms. Waudby's older child, Justine, on the day of Jenna's death and placed her in temporary foster care. She remained in foster care until January 27, 1997, when she moved in with Tom and Kim Waudby, her maternal aunt and uncle. She remained there until March 27, 1997, at which time she was again placed in foster care. She was ordered returned to Ms. Waudby's care on May 2, 1997, pursuant to an Order of Justice A.P.Ingram and remained in her care until Sept. 18, 1997, the day of Ms. Waudby's arrest. She was later re-apprehended on the date of Ms. Waudby's arrest. The Children's Aid Society also apprehended a second child, M.W. born after Jenna's death, and placed him with his father. On July 23, 1999, subsequent to the withdrawal of Ms. Waudby's murder charge, Justine was ordered returned to her mother's care. That same day, access was also granted to M.W. who would continue to reside with his father. The Children's Aid Society appealed the decision. On August 13, 1999, the appeal was dismissed. On Dec. 28, 2006, the youth who was babysitting Jenna the night she died was charged with second-degree murder. On December 14, 2006, J.D. pleaded guilty to manslaughter. The criminal proceeding concluded on March 1, 2007, when he was sentenced as a youth to 22 months incarceration followed by 11 months of community supervision;
-------------------------------------------------------------------------------
Buried toward the back of Volume Two of the Goudge report are some findings relating to the College of Physicians and Surgeons that were largely ignored in the aftermath of the report's release.
They relate to steps taken by the College after its then Registrar, Dr John Carlisle was informed by former Deputy Chief Coroner Dr. Jim Cairns in April, 2002, about Dr. Smith's admissions to him of misconduct relating to the hair he seized, without testing, in Jenna's case.
Having received such disturbing information - which could indicate criminality on Smith's part - one would expect that Carlisle would have have passed this information on to his officials who were investigating the complaints against Smith.
But Justice Goudge tells us that Dr. Carlisle merely responded by writing a memo to file and sending a memo to the investigator which did not relate any details from his conversation with Cairns or from his detailed memo to file.
Carlisle's memo to file indicated that he had the conversation with Cairns, and that Cairns had told him:
0: He had not conducted a rape kit examination;
0: He had not taken any of the samples or specimen that would ordinarily be associated with such an examination;
0: He had found what he believed to be "a hair."
0: He had collected the hair and placed it in a sealed envelope, which he kept in his possession since the time of the investigation;
0: He had not revealed the existence of the hair to anyone;
0: He had not submitted it for analysis;
0: He had not given it to the police;
One can easily imagine how different the outcomes of the complaints would have been if Dr. Carlisle had passed this information on to his staff investigators - so they would be fully apprised and could do their job effectively.
At this point I expected Justice Goudge's voice to have rung out in well justified anger at the frustration of the accountability process and the lost opportunity to do something about Dr. Smith.
Instead, he says he is satisfied that such a transgression will not happen again. In Justice Goudge's words:
"When asked about the April 10, 2002, memo to file at the Inquiry, Dr. Rocco Gerace, Current Registrar, testified, " I would not consider the practice (of writing a memo that would not form part of a file) to be advisable. In fact that practice would not occur at the present time." He went on to describe the current approach to the receipt of information:
"We have a practice at the College that if information comes to any member of the staff about a member, that the person providing that information is told up front that the information will be acted upon.
There are no confidential documents that are not acted on. So, if a conversation of this sort were to have occurred today, I would send a note to the relevant individuals outlining the content of that conversation;"
Says Justice Goudge: "I agree with the College's current approach."
To this humble Blogster, so much about the College's failure to rein in Dr. Smith remains unsaid.
Harold Levy...hlevy15@gmail.com;
Saturday, November 1, 2008
CRITICAL COMMENT: DR. CHARLES SMITH; THE CHIEF CORONER'S OFFICE, AND OTHER SKELETON'S IN ONTARIO'S CLOSET; ERIC DOWD; QUEEN'S PARK COLUMN;
"A PUBLIC INQUIRY BY A JUDGE HAS FOUND A FORENSIC PATHOLOGIST IN THE ONTARIO CORONER'S OFFICE, DR. CHARLES SMITH, VOLUNTEERED INACCURATE TESTIMONY OVER TWO DECADES, SUPPOSEDLY IN HIS ENTHUSIASM TO COMBAT CHILD ABUSE, THAT LED TO AT LEAST 12 PEOPLE BEING JAILED, OTHERS WRONGLY ACCUSED AND CHILDREN REMOVED FROM THEIR PARENTS, DEVASTATING MANY LIVES.
SENIOR OFFICIALS IN THE CORONER'S OFFICE, PART OF THE MINISTRY OF COMMUNITY SAFETY AND CORRECTIONAL SERVICES, WERE FOUND TO HAVE FAILED TO SUPERVISE THE DOCTOR, DEFENDED HIM AND IN THE END TRIED TO PROTECT THEIR OFFICE'S REPUTATION INSTEAD OF THE PUBLIC AND GAVE COMMUNITY SAFETY A LOW PRIORITY."
QUEEN'S PARK COLUMNIST ERIC DOWD: ORANGEVILLE CITIZEN;
-------------------------------------------------------------------------------
Queen's Park columnist Eric Dowd sets out his perspective on Dr. Smith and those who were supposed to be protecting the citizens of Ontario from him, in a column which ran Friday in the Orangeville Citizen.
"Every time someone looks into a government closet in Ontario, a skeleton falls out and residents must be wondering whether any branch of government works properly," the column begins.
"The recent examples include Ombudsman Andre Marin's review of the Special Investigations Unit, which was set up to probe incidents in which someone is killed or seriously injured by police to avoid police being shown favoritism, and has boasted it is 'a world leader" in this balancing act," it continues.
"The Ombudsman found its investigators, mostly former police officers, are too timid and deferential toward police to do their job effectively and government after government has been content if they soothe police and the community rather than investigate effectively.
This is not much progress when for more than 40 years politicians have said they want to see residents treated fairly in their dealings with police.
A public inquiry by a judge has found a forensic pathologist in the Ontario coroner's office, Dr. Charles Smith, volunteered inaccurate testimony over two decades, supposedly in his enthusiasm to combat child abuse, that led to at least 12 people being jailed, others wrongly accused and children removed from their parents, devastating many lives.
Senior officials in the coroner's office, part of the ministry of community safety and correctional services, were found to have failed to supervise the doctor, defended him and in the end tried to protect their office's reputation instead of the public and gave community safety a low priority.
When a huge explosion destroyed a privately owned propane storage depot in Toronto and damaged more than 500 homes at a time fuel was being transferred illegally between trucks, the province was found to have left a little-known body run by the fuel industry, the Technical Standards and Safety Authority, to regulate and inspect the depots.
The province is now considering taking over regulating, but there is not much confidence these days in government being a strict supervisor.
The Ombudsman, who has looked behind more closed doors and exposed more skeletons than anyone, has examined the Criminal Injuries Compensation Board, which is responsible for providing financial help to victims of violent crime.
He found the board commonly treats applicants with suspicion and indifference and goes out of its way to use technicalities to avoid compensating them, so they wait an average three years for rulings.
He called the board a "colossal failure" and blamed successive governments of all parties that have allotted it unrealistic funds, although they express fervently in the legislature their determination to help victims of crime.
Ontario's auditor general, who looks mainly at whether the province gets value for money, studied children's aid societies and found it pays for some of their officials to drive expensive, top-of-the-line SUVs and alleviates their stress with $2,000-a-year gym memberships, although the organizations lack funds to provide children's programs.
The auditor general also cast his eye over whether the province's efforts to prevent and control infections, including the rapidly spreading C. difficile, in hospitals, are effective and found many health care workers, particularly doctors, contribute by not washing hands between seeing patients.
Virtually whenever a public institution has been subjected to searching scrutiny, it has been found to have serious failings.
This suggests most, and perhaps all, government programs fail to do their jobs as effectively as they should, let down those they are supposed to serve and therefore waste huge amounts of taxpayers' money.
Many public institutions are not subject to such scrutiny. The Ombudsman, the most aggressive investigator, has no mandate to look at complaints about hospitals, school boards, universities, municipalities except on the narrow issue of closed meetings, and police generally, as distinct from the Special Investigations Unit.
Marin has asked the province for authority to investigate complaints about hospitals and the opposition Progressive Conservatives and New Democrats support him, but Premier Dalton McGuinty has refused, saying this is unnecessary.
The premier needs to show that there are branches of his government that work properly, but he is more afraid of finding more skeletons."
Harold Levy...hlevy15@gmail.com;
SENIOR OFFICIALS IN THE CORONER'S OFFICE, PART OF THE MINISTRY OF COMMUNITY SAFETY AND CORRECTIONAL SERVICES, WERE FOUND TO HAVE FAILED TO SUPERVISE THE DOCTOR, DEFENDED HIM AND IN THE END TRIED TO PROTECT THEIR OFFICE'S REPUTATION INSTEAD OF THE PUBLIC AND GAVE COMMUNITY SAFETY A LOW PRIORITY."
QUEEN'S PARK COLUMNIST ERIC DOWD: ORANGEVILLE CITIZEN;
-------------------------------------------------------------------------------
Queen's Park columnist Eric Dowd sets out his perspective on Dr. Smith and those who were supposed to be protecting the citizens of Ontario from him, in a column which ran Friday in the Orangeville Citizen.
"Every time someone looks into a government closet in Ontario, a skeleton falls out and residents must be wondering whether any branch of government works properly," the column begins.
"The recent examples include Ombudsman Andre Marin's review of the Special Investigations Unit, which was set up to probe incidents in which someone is killed or seriously injured by police to avoid police being shown favoritism, and has boasted it is 'a world leader" in this balancing act," it continues.
"The Ombudsman found its investigators, mostly former police officers, are too timid and deferential toward police to do their job effectively and government after government has been content if they soothe police and the community rather than investigate effectively.
This is not much progress when for more than 40 years politicians have said they want to see residents treated fairly in their dealings with police.
A public inquiry by a judge has found a forensic pathologist in the Ontario coroner's office, Dr. Charles Smith, volunteered inaccurate testimony over two decades, supposedly in his enthusiasm to combat child abuse, that led to at least 12 people being jailed, others wrongly accused and children removed from their parents, devastating many lives.
Senior officials in the coroner's office, part of the ministry of community safety and correctional services, were found to have failed to supervise the doctor, defended him and in the end tried to protect their office's reputation instead of the public and gave community safety a low priority.
When a huge explosion destroyed a privately owned propane storage depot in Toronto and damaged more than 500 homes at a time fuel was being transferred illegally between trucks, the province was found to have left a little-known body run by the fuel industry, the Technical Standards and Safety Authority, to regulate and inspect the depots.
The province is now considering taking over regulating, but there is not much confidence these days in government being a strict supervisor.
The Ombudsman, who has looked behind more closed doors and exposed more skeletons than anyone, has examined the Criminal Injuries Compensation Board, which is responsible for providing financial help to victims of violent crime.
He found the board commonly treats applicants with suspicion and indifference and goes out of its way to use technicalities to avoid compensating them, so they wait an average three years for rulings.
He called the board a "colossal failure" and blamed successive governments of all parties that have allotted it unrealistic funds, although they express fervently in the legislature their determination to help victims of crime.
Ontario's auditor general, who looks mainly at whether the province gets value for money, studied children's aid societies and found it pays for some of their officials to drive expensive, top-of-the-line SUVs and alleviates their stress with $2,000-a-year gym memberships, although the organizations lack funds to provide children's programs.
The auditor general also cast his eye over whether the province's efforts to prevent and control infections, including the rapidly spreading C. difficile, in hospitals, are effective and found many health care workers, particularly doctors, contribute by not washing hands between seeing patients.
Virtually whenever a public institution has been subjected to searching scrutiny, it has been found to have serious failings.
This suggests most, and perhaps all, government programs fail to do their jobs as effectively as they should, let down those they are supposed to serve and therefore waste huge amounts of taxpayers' money.
Many public institutions are not subject to such scrutiny. The Ombudsman, the most aggressive investigator, has no mandate to look at complaints about hospitals, school boards, universities, municipalities except on the narrow issue of closed meetings, and police generally, as distinct from the Special Investigations Unit.
Marin has asked the province for authority to investigate complaints about hospitals and the opposition Progressive Conservatives and New Democrats support him, but Premier Dalton McGuinty has refused, saying this is unnecessary.
The premier needs to show that there are branches of his government that work properly, but he is more afraid of finding more skeletons."
Harold Levy...hlevy15@gmail.com;
JUSTICE GOUDGE'S FINDINGS: PART THREE; JENNA'S CASE; (2); YOUNG AND CAIRNS;
Over the past eighteen months I have used this Blog to intensively report on developments relating to Dr. Charles Smith culminating with the recently concluded Goudge Inquiry.
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Jenna's case prepared by Goudge Inquiry staff tells us that:
Jenna was born in Peterborough, Ontario on April 21, 1995 to Randy and Brenda Waudby. Jenna died on January 22, 1997, at the age of 21-months in Peterborough; Mrs. Waudby was charged with second-degree murder on Sept. 18 1997. The criminal proceeding concluded on June 15, 1999, when the charge was withdrawn. The local Children's Aid Society apprehended Ms. Waudby's older child, Justine, on the day of Jenna's death and placed her in temporary foster care. She remained in foster care until January 27, 1997, when she moved in with Tom and Kim Waudby, her maternal aunt and uncle. She remained there until March 27, 1997, at which time she was again placed in foster care. She was ordered returned to Ms. Waudby's care on May 2, 1997, pursuant to an Order of Justice A.P.Ingram and remained in her care until Sept. 18, 1997, the day of Ms. Waudby's arrest. She was later re-apprehended on the date of Ms. Waudby's arrest. The Children's Aid Society also apprehended a second child, M.W. born after Jenna's death, and placed him with his father. On July 23, 1999, subsequent to the withdrawal of Ms. Waudby's murder charge, Justine was ordered returned to her mother's care. That same day, access was also granted to M.W. who would continue to reside with his father. The Children's Aid Society appealed the decision. On August 13, 1999, the appeal was dismissed. On Dec. 28, 2006, the youth who was babysitting Jenna the night she died was charged with second-degree murder. On December 14, 2006, J.D. pleaded guilty to manslaughter. The criminal proceeding concluded on March 1, 2007, when he was sentenced as a youth to 22 months incarceration followed by 11 months of community supervision;
-------------------------------------------------------------------------------
Justice Goudge reaches the astonishing conclusion that even by the time the former chief coroner, Dr. James Young testified at the Inquiry, "he did not see any problems with the pathology evidence provided by Dr. Smith in Jenna's case."
In short, he stood up for Dr. Smith right to the very end - even though Dr. Benita Porter, his colleague in the Chief Coroner's Office, had provided her own opinion, based on her expertise and the opinion of several pathology experts, that the time between Jenna's injuries and her death was less than six hours (Which, of course, put her in the exclusive company of J.D. the teenage baby-sitter, when the fatal injuries were inflicted.
"Even by the time Dr. Young testified at the Inquiry, he did not see any problems with the pathology evidence provided by Dr. Smith in Jenna's case," wrote Goudge.
"He was not concerned that other experts disagreed with Dr. Smith about the timing of the fatal injuries.
He testified that he thought it was problematic when experts gave too narrow a window of time, but was not concerned if an expert provided a window that was too broad.
Dr. Young maintained that Dr. Smith was not wrong, given that the injuries were inflicted within 24 hours before death.
In his view, Dr. Smith just did not narrow the time period as far as he could have to six hours before death.
Dr. Michael Pollanen, the present Chief Forensic Pathologist, testified at the Inquiry that Dr. Young's analysis of Dr. Smith's pathology opinion was simply incorrect.
He said that, although it is often the counsel of caution to give a broader window for time of death or the time that injuries were inflicted, the principle does not apply where part of the broader time frame is excluded by the pathology evidence, as was the case here.
It is of fundamental importance to identify precisely when the injuries were inflicted wherever that is possible.
In this case, the pathology clearly indicated that the fatal injuries were inflicted within hours of death, and that they could not have been inflicted earlier;"
Justice Goudge reaches the pointed conclusion that coroners, like Smith and Cairns, should not have been supervising pathologists like Smith.
"Jenna's case illustrates the danger of having coroners provide oversight of of pathologists who do forensic work," Goudge ruled.
"This structural weakness contributed greatly to the failure of oversight with regard to Dr. Smith.
Without the training in forensic pathology necessary for meaningful oversight of pathologists, Dr. Young and Dr. Cairns simply could not see this red flag."
This humble Blogster respects the systemic point being made by Justice Goudge.
I have to add, however, that there appear to be curious personal ties of some significant nature between the three men - Smith, Cairns and Young - which had nothing to do with their training but strongly affected their decision making process;
Justice Goudge so points out that although Drs. Young and Cairns ultimately developed concerns about Dr. Smith's conduct in Jenna's case, Dr. Smith's status at the Chief Coroner's Office did not change after a confrontation with Dr. Cairns, he continued to sit on two influential committees (the Pediatric Death Review Committee and the Deaths Under Two Committee), and he continued to hold on to the position of director of the Ontario Pediatric Forensic Pathology Unit.
Goudge notes Dr. Cairn's explanation that the Chief Coroner's Office thought Smith's role was sufficiently limited because he could not perform post-mortem examinations in any more criminally suspicious cases - and the Office was concerned that, if it took further steps regarding Dr. Smith, it might harm the on-going criminal investigation in Jenna's case.
"However, looking back on the episode when he testified at the Inquiry, Dr. Young could not muster any explanation for his on-going support and trust in Dr. Smith as of April 2002, stating rather forlornly, "I don't know why we didn't stop him from doing anything at that time...I just don't know."
Harold Levy...hlevy15@gmail.com;
I am now winding up this phase of the Blog - to be replaced eventually by periodic reporting of developments relating to Dr. Smith and related issues as they occur - with an examination of Justice Goudge's findings in the cases reviewed by the Inquiry.
I think it is important to take this closer look at the report in this Blog, because the mainstream media, which has done an admirable job in reporting the inquiry, have gone on to other stories.
Justice Goudge's findings relating to the various cases have been scattered throughout the report.
My approach is to weave together the findings relating to all of the principal actors - so we can get a fuller picture of Justice Goudge's findings as to their conduct;
-------------------------------------------------------------------------------
An overview of Jenna's case prepared by Goudge Inquiry staff tells us that:
Jenna was born in Peterborough, Ontario on April 21, 1995 to Randy and Brenda Waudby. Jenna died on January 22, 1997, at the age of 21-months in Peterborough; Mrs. Waudby was charged with second-degree murder on Sept. 18 1997. The criminal proceeding concluded on June 15, 1999, when the charge was withdrawn. The local Children's Aid Society apprehended Ms. Waudby's older child, Justine, on the day of Jenna's death and placed her in temporary foster care. She remained in foster care until January 27, 1997, when she moved in with Tom and Kim Waudby, her maternal aunt and uncle. She remained there until March 27, 1997, at which time she was again placed in foster care. She was ordered returned to Ms. Waudby's care on May 2, 1997, pursuant to an Order of Justice A.P.Ingram and remained in her care until Sept. 18, 1997, the day of Ms. Waudby's arrest. She was later re-apprehended on the date of Ms. Waudby's arrest. The Children's Aid Society also apprehended a second child, M.W. born after Jenna's death, and placed him with his father. On July 23, 1999, subsequent to the withdrawal of Ms. Waudby's murder charge, Justine was ordered returned to her mother's care. That same day, access was also granted to M.W. who would continue to reside with his father. The Children's Aid Society appealed the decision. On August 13, 1999, the appeal was dismissed. On Dec. 28, 2006, the youth who was babysitting Jenna the night she died was charged with second-degree murder. On December 14, 2006, J.D. pleaded guilty to manslaughter. The criminal proceeding concluded on March 1, 2007, when he was sentenced as a youth to 22 months incarceration followed by 11 months of community supervision;
-------------------------------------------------------------------------------
Justice Goudge reaches the astonishing conclusion that even by the time the former chief coroner, Dr. James Young testified at the Inquiry, "he did not see any problems with the pathology evidence provided by Dr. Smith in Jenna's case."
In short, he stood up for Dr. Smith right to the very end - even though Dr. Benita Porter, his colleague in the Chief Coroner's Office, had provided her own opinion, based on her expertise and the opinion of several pathology experts, that the time between Jenna's injuries and her death was less than six hours (Which, of course, put her in the exclusive company of J.D. the teenage baby-sitter, when the fatal injuries were inflicted.
"Even by the time Dr. Young testified at the Inquiry, he did not see any problems with the pathology evidence provided by Dr. Smith in Jenna's case," wrote Goudge.
"He was not concerned that other experts disagreed with Dr. Smith about the timing of the fatal injuries.
He testified that he thought it was problematic when experts gave too narrow a window of time, but was not concerned if an expert provided a window that was too broad.
Dr. Young maintained that Dr. Smith was not wrong, given that the injuries were inflicted within 24 hours before death.
In his view, Dr. Smith just did not narrow the time period as far as he could have to six hours before death.
Dr. Michael Pollanen, the present Chief Forensic Pathologist, testified at the Inquiry that Dr. Young's analysis of Dr. Smith's pathology opinion was simply incorrect.
He said that, although it is often the counsel of caution to give a broader window for time of death or the time that injuries were inflicted, the principle does not apply where part of the broader time frame is excluded by the pathology evidence, as was the case here.
It is of fundamental importance to identify precisely when the injuries were inflicted wherever that is possible.
In this case, the pathology clearly indicated that the fatal injuries were inflicted within hours of death, and that they could not have been inflicted earlier;"
Justice Goudge reaches the pointed conclusion that coroners, like Smith and Cairns, should not have been supervising pathologists like Smith.
"Jenna's case illustrates the danger of having coroners provide oversight of of pathologists who do forensic work," Goudge ruled.
"This structural weakness contributed greatly to the failure of oversight with regard to Dr. Smith.
Without the training in forensic pathology necessary for meaningful oversight of pathologists, Dr. Young and Dr. Cairns simply could not see this red flag."
This humble Blogster respects the systemic point being made by Justice Goudge.
I have to add, however, that there appear to be curious personal ties of some significant nature between the three men - Smith, Cairns and Young - which had nothing to do with their training but strongly affected their decision making process;
Justice Goudge so points out that although Drs. Young and Cairns ultimately developed concerns about Dr. Smith's conduct in Jenna's case, Dr. Smith's status at the Chief Coroner's Office did not change after a confrontation with Dr. Cairns, he continued to sit on two influential committees (the Pediatric Death Review Committee and the Deaths Under Two Committee), and he continued to hold on to the position of director of the Ontario Pediatric Forensic Pathology Unit.
Goudge notes Dr. Cairn's explanation that the Chief Coroner's Office thought Smith's role was sufficiently limited because he could not perform post-mortem examinations in any more criminally suspicious cases - and the Office was concerned that, if it took further steps regarding Dr. Smith, it might harm the on-going criminal investigation in Jenna's case.
"However, looking back on the episode when he testified at the Inquiry, Dr. Young could not muster any explanation for his on-going support and trust in Dr. Smith as of April 2002, stating rather forlornly, "I don't know why we didn't stop him from doing anything at that time...I just don't know."
Harold Levy...hlevy15@gmail.com;
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