Sunday, February 10, 2008

Arctic coroners comb files for flawed autopsies (2oo7)

Arctic coroners comb files for flawed autopsies

The Globe and Mail

Friday, 27 April 2007

By Katherine Harding

Canada--Nunavut and Northwest Territories chief coroners are voluntarily searching their autopsy files dating back to 1981 to find out whether disgraced Toronto pathologist Charles Smith worked on any of them, The Globe and Mail has learned. "If Dr. Smith's fingerprints are on any of these files, then we will dig them out and see what they are," Northwest Territories Chief Coroner Percy Kinney said of the internal audit that was launched this week. "It's got to be done."

There is concern that Dr. Smith may have worked on some of these cases because it is standard practice for autopsies from the Eastern Arctic to be sent to the coroner's office in Toronto for examination because of Nunavut's lack of staff and facilities. Prior to 1999, the year Nunavut was created, the Northwest Territories also routinely sent autopsies originating in the Eastern Arctic to Toronto.

Earlier this week, the Ontario government announced it would hold a full public inquiry into the work of Dr. Smith. A panel of experts recently questioned the pathologist's findings in 20 of 45 autopsies they reviewed. In many of the cases, dating back to 1991, individuals were charged and convicted of criminal offences related to the deaths. Other cases did not result in convictions.

Dr. Kinney said the audit will be a lengthy process that could take months to complete because files will have to be searched manually.

He said there are plans to review files that involved deaths of people 16 or younger, who lived in the Eastern Arctic and had their autopsies sent to Toronto from 1981 to 1999.

He said that if Dr. Smith's name turns up on any of those autopsy reports, the autopsy itself will be reviewed and the body could be exhumed for further investigation.

Nunavut Chief Coroner Tim Neily said he has personally been searching autopsy files since details about Dr. Smith's mistakes were made public last week.

"As far as I know," Dr. Neily said, "he hasn't been involved in any cases, but it is being looked at just in case."

Meanwhile, a second autopsy performed on an Ontario baby whose mother was convicted of killing him has uncovered evidence that the child had pneumonia, a report by an international team of pathologists who reviewed the work of Dr. Smith says.

The evidence of pneumonia appears to reinforce the probability that the baby, Joshua Sherrett, died of natural causes.

Sherry Sherrett was convicted of infanticide in 1999, based partly on Dr. Smith's testimony that Joshua had a skull fracture and suspicious neck hemorrhages. Ms. Sherrett served a one-year jail term.

Her conviction came into serious question last year after the province's top pathologist, Michael Pollanen, exhumed Joshua's remains and conducted a second autopsy.

He found that what Dr. Smith took to be a skull fracture was apparently nothing more than a normal anatomical feature. Moreover, the neck hemorrhages that Dr. Smith had testified were cause for "consternation" appear to have been caused by a scalpel used at the autopsy.

The members of the review panel, in turn, scrutinized Dr. Pollanen's findings as well as original photographs and case samples, adding a few observations of their own. One of the panel members, Irish pathologist Jack Crane, noted that the presence of cells was indicative of bronchopneumonia, James Lockyer, Ms. Sherrett's lawyer, said.

The pathologists' report has not been released, but lawyers for some of the people involved in the cases have copies.

Mr. Lockyer was reluctant to release his copy, but quoting it concluded: "The presence of inflammatory changes in the lungs may represent an early respiration infection, which could have contributed to sudden and/or unexpected death."

"That fits right in with Sherry having taken Joshua to the hospital in the weeks before his death because he was short of breath and she was worried about his health," Mr. Lockyer said in an interview. "It is an important piece of the puzzle.

"Joshua may have had a respiratory infection that could have contributed to his sudden and unexpected death through accidental suffocation in his crib. If you have already got a respiratory infection, you are much more prone to suffocate."

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