Tuesday, March 18, 2008

Who is Harold Levy?

Taken from Harold's Blogspot. Please feel free to read around the blog. There is a lot of information posted on his blog.

Who is Harold Levy?

I recently retired from the Toronto Star where I have been reporting on Dr. Charles Randal Smith - a former pediatric pathologist at the Hospital for Sick Children - for the past six years. I intend, through this blog, to periodically report developments relating to Dr. Smith in the context of the on-going public inquiry, the on-going independent probe of cases he worked on between 1981 and 1991, and cases which have been launched, or will be launched in the civil courts. (Postings to begin early in October, 2007) if not earlier. I am currently researching a book on Dr. Smith and would appreciate hearing from anyone who can provide me with useful information.

TheStar.com - News - The 'forgotten victims' torn from their homes (2oo8)

The lives of 17 children were changed forever by disgraced pathologist's litany of mistakes

March 09, 2008

Theresa Boyle Staff Reporter


July 2012. This date won't come soon enough for Sherry Sherret.

It's when her first born will turn 18. And it's when the Belleville mother will finally be reunited with the son who was put up for adoption when he was only 5.

The boy, Christopher (not his real name), is one of at least 17 children whose lives were thrown into chaos after the death of a sibling. In each case, disgraced pathologist Dr. Charles Smith performed an autopsy or offered a consulting opinion on the deaths. Bad enough they had lost a sister or a brother. But Smith's mistakes helped implicate their parents and resulted in these children being removed from their homes by children's aid societies.

At least three children, including Christopher, were adopted out to other families. There is no legal recourse to undo adoptions as the Child and Family Service Act stipulates that once an adoption order is finalized, it cannot be reviewed.

The remaining children were sent to live with relatives or foster families for as long as two years.These children are from the 20 botched death investigations that have been explored at the ongoing Inquiry into Pediatric Forensic Pathology. A panel of renowned forensic pathologists determined Smith erred in all these cases.

While attention has largely been focused on potentially wrongful convictions, these children have been the "forgotten victims" of his errors, says Julie Kirkpatrick, lawyer for one family.

The upheaval they faced is "among the worst consequences of Smith's mistakes," she says, adding they are no less victims of miscarriages of justice.

One of the many issues explored at the inquiry is that of child protection. Child advocates are putting forth an array of recommendations on behalf of the displaced children, including possible reconciliation of broken-up families.

Twice a year, Sherret, 32, gets letters and pictures from Christopher. She stares at the photos intently, looking for signs of her son's growth. From a picture he sent this past Christmas, she can see his face had filled out some. He looks more like his dad, her ex, she notes. But she can see her own DNA in his eyes.

"He's a gorgeous young man. He will be 14 years old in July. I keep thinking to myself, four more years," she says.

In his letters to her, he addresses her as "Dear Sherry."

"That hurts," she says. "But it's understandable."

She signs her letters back, "Love, Mommy Sherry."

Sherret lost two sons in 1996. That January, she discovered 4-month-old Joshua dead in his playpen. Smith said the child was suffocated, as evidenced by marks on his neck. The pathologist also said the boy had a fractured skull. Sherret was charged with first-degree murder.

Years later, when Smith's work came under scrutiny, Joshua's body was exhumed. It was revealed his skull wasn't fractured and the marks on his neck were actually created by Smith, himself, during the autopsy. Experts who reviewed the case said Joshua had accidentally asphyxiated in an unsafe sleep environment. He had slept in a playpen, under a sleeping bag, comforter and blankets.

Child-welfare workers removed Christopher, then 18 months, from her custody. He was first placed with his grandparents and then with a foster family.

In January 1999, Sherret was convicted on a reduced charge of infanticide. The following June she was sentenced to a year in jail and two years probation. Meantime, Sherret learned children's aid was putting forth an application to the courts to have Christopher move from foster care to adoption. The foster family told Sherret they would be willing to make him a permanent part of their family.

Evoking the parable of King Solomon threatening to split a baby to determine its rightful mother, Sherret made the difficult decision to let this family adopt her son, fearing he could otherwise bounce around different homes. The adoption agreement included the exchange of letters, annual phone calls from Christopher's foster mother and plans for a reunion when he turns 18.

Lawyer Suzan Fraser has been representing Defence for Children International at the inquiry. The group aims to protect the rights of youngsters and is going to bat for the 17 displaced children.

"The big problem is that there is no process for dealing with apprehension or adoption orders made on the basis of flawed pathology evidence," Fraser remarks.

She says the damage inflicted on the affected children is immeasurable. "Imagine the anger and the sorrow to learn that you had been wrongfully taken from your mother or father. Imagine the taunts of the other children in foster care teasing you because your mother killed your sister.

"Imagine the horror of losing your sibling and then your mother, when your mother was actually protective rather than the killer everyone thought she was? Imagine having no power to fix it."

Fraser is fearful there may be even more children out there who were uprooted from their homes because of errors Smith made in child-death investigations. Undoing Smith's mistakes isn't so easy. The Child and Family Services Act makes no provision to appeal an adoption order except within the first 30 days after it has been made.

"The best interests and stability of a child require that the adoption order is not subject to further review, even if unjust and based on a clearly erroneous factual premise," states a paper prepared for the inquiry by Queen's law professor Nicholas Bala and McGill social work professor Nico Trocme.

"However, if it is established that a child was removed from parental custody due to an erroneous belief that the parent was responsible for the death of a sibling, it may well be in the best interests of the children to have at least some contact with the parents, depending on their age and wishes. At the very least, the adoptive parents, and through them the children, should be informed of the new circumstances," they continue.

Sherret says Christopher doesn't know why she gave him up for adoption.

He only recently learned he has a 2-year-old sister. This is Sherret's third child, the only one with her. Christopher's adoptive mother was afraid to tell him about his new sibling, lest it raise questions about why his biological mother could keep one child and not another, Sherret says.

While she dreams about the day they'll see each other again, she has nightmares about the last time she saw him. It was in a playroom at the Northumberland Children's Aid Society. Sherret knew she wouldn't see her son, then 5, again until he was 18. She kept her eye on the clock, savouring her last three hours with him.

Mom and child played for the first 2 1/2 hours, but as the end of their visit neared, Sherret pulled the lad onto her lap for a serious chat. "I told him that mommy still has some problems to deal with and that he couldn't come home," Sherret recounts.

The lad reacted angrily. "He told me I lied," she says, explaining how Christopher reminded her of a previous promise that he could come home. "He wanted to come home and he wanted to know if he could keep Whisper, his kitty."

In his letters to her now, Christopher asks if she still has Whisper. She does.

Sherret wept during her final minutes with her son. Her tears continued to flow in the car on her way home. She had lost her two sons now and was on her way to prison.

The next day, she was sent to the Vanier Centre for Women in Brampton, where other inmates called her a "baby killer." She ignored their taunts until one day it became too much. She overheard one women ask another: "Do you know how Sherry killed her baby?"

"I remember just coming around the corner and starting to beat on her," recalls Sherret, who was moved to segregation and then to another detention centre.

As devastating as it was to be blamed, jailed and taunted for Joshua's death, those experiences paled in comparison to losing custody of Christopher, she says. "Having a child taken from you is like having your life taken from you. I just didn't want to be around. I didn't want to live. But then I sat there and thought, I've got to go on because I know I'll get a chance to see him at some point."

Despite the hell a biological parent like Sherret has gone though, returning custody of a child may not be the best idea, experts warn.

"While the unmerited separation of children from their parents is a great injustice, it does not necessarily follow that returning these children to the care of their parents is in their best interest," Bala and Trocme write in their report for the inquiry.

"In particular, if children are returned to their parents' custody after several years in a stable foster home, they may well be traumatized by the stress of separation from their foster families and the experience of returning to a now unfamiliar environment," they continue.

Still, Sherret's lawyer, James Lockyer, hopes adoptive parents would be open to allowing some sort of contact between the birth parents and the children.

"What you would hope is that the adoptive parent might have the foresight, strength, courage to consider allowing the children to recontact the parent. But that's a pretty tall order," he admits, likening the struggle to Bertolt Brecht's The Caucasian Chalk Circle, a play about a literal tug-of-war over a child.

Lockyer doesn't blame children's aid societies in these cases. They were just sadly relying on bad information from sources like Smith, he notes. "Wrongful convictions have consequences way beyond someone being in jail for something they didn't do."

less than three years ago, Sherret discovered she was pregnant again. Her first reaction was panic. Her name was still on the province's child-abuse registry and she faced the prospect of having her third child taken from her, too.

Her reaction wasn't so unusual. In another case in which Smith was involved, a couple decided to have an abortion after learning of an unexpected pregnancy. Angela Veno and Anthony Kporwodu had their toddler son seized by children's aid after they were charged with the 1998 death of their infant daughter. They were told any new child would also be seized. Sherret was duty bound to report her pregnancy to CAS, which she did. This is how she discovered serious questions were being raised about Smith's work. A CAS official told her the doctor was being investigated.

Sherret contacted the Association in Defence of the Wrongly Convicted and Lockyer, who would assist her in trying to clear her name. He would also help her in her efforts to keep her third child. Initially, the CAS wanted to remove Sherret from her home when the baby was born, leaving the infant to reside with its father. Eventually they settled for a supervisory order, meaning Sherret could never be alone with the baby.

The child was born on Sept. 29, 2005.

For the first 11 months of the child's life, father Rob couldn't even go to the store without waking the baby and taking her with him.

But last April, a provincial court ruled that the supervision order be dropped. By this time, two outside experts had confirmed there was no foul play involved involved in Joshua's death.

"I believe I lost a special 11 months with her. It was an 11 months I could not be alone with my beautiful girl," Sherret says. "I had to go though hell to stay in her life."

Sherret has been diagnosed with major, chronic depression andpost-traumatic stress disorder. "I'm exhausted physically, mentally."

Her children keep her going.

"I'm mad, but I have to live every day for my daughter and (Christopher), not just me," she says.

While she dreams about the day she'll see Christopher again, she has no illusions. "He's grown up with his family pretty much most of his life and it would just be wrong to take him away from them. I just want some kind of a relationship with him."

She's kept a lot of Christopher's old toys. She watches her daughter play with them, remembering her son doing the same.

"I would be so happy if I could see them play together," she says.

'I can forgive him as a person, but...' (2oo7)

Posted By Luke Hendry

Sherry Sherret says she's ready to forgive the man who helped put her in jail, but not his actions.

The Belleville mother served eight months of a one-year infanticide sentence after evidence from Dr. Charles Smith contributed to her conviction. Later findings indicated the 1996 death of Sherret's four-month-old son was due to natural causes.

Her case is now scheduled to come before the Ontario Court of Appeal.

Sherret and her family have spent the week in Toronto listening to Smith testify at the public inquiry into his Smith's discredited work as a pathologist.

"I didn't get an apology, but I would have accepted one," Sherret, now 32, told The Intelligencer via cellular phone Friday evening. She and her family were returning from Toronto, but stuck in rush-hour traffic worsened by the day's snowstorm.

In another interview the previous evening, Sherret said Smith's week of testimony was insightful.

"We've learned quite a bit ... about him," she said.

"I can forgive him as a person, but I can't forgive his actions ... It was those actions that put me away. It's troubling to think of why he'd do that in his position, knowing full well he could actually put someone away that didn't do anything.

"My mom told me not to hate people, but hate their actions," she said, noting others should share in the blame.

"It's not 110 per cent his fault. Obviously nobody was watching, and I've stood by that. They would have said, 'This is a problem. It stops now. No more.'

"And we've found a lot of that throughout this week: that there was the lack of upper management watching him."

On Thursday, Smith apologized directly to William Mullins-Johnson, who was convicted wrongly in the death of his niece.

Smith lost his composure while speaking to Mullins-Johnson. Sherret said that was a surprising contrast to the doctor's "scripted" comments earlier in the week.

Sherret said Smith's first attempt at apologizing to the wrongly convicted didn't seem convincing.

"When he says 'sorry' or he deeply apologizes, he looks directly at his lawyer," Sherret said. "Monday seemed like a completely scripted day. As the days progressed, he seemed less scripted."

But even then, she said, Smith gave indirect answers or claimed he did not recall details.

"I'm sitting here thinking, 'How many things do you not remember?' Because this is a lot of people you've caused turmoil for in their lives, and you're sitting up there saying, 'I don't recall most of this.'

"Not once did he ever acknowledge that we were there at all, up until today," Sherret said Thursday, adding it made his sudden show of emotion that much more startling.

"The crying part caught me off-guard for sure."

Sherret said she had hoped to speak to Smith "off-record" to ask him about his work and ask him, "Well, now are you truly remorseful? Because this is the spot you put me in back in 1996."

The inquiry revealed Smith had lied under oath while testifying in past cases as an expert; Sherret said she hopes "there will be some discipline" as a result.

She added she was glad a child advocate was present at Friday's hearing, because it was made clear that children other than those who died had been affected by the pathologist's mishandling of cases. Sherret now has a daughter, but a second son was adopted by another family after her conviction, meaning she can't see him until he's 18.

Sherret said she still gets letters from and pictures of him, but "it doesn't change the fact that I don't get to see him play baseball or anything like that, and that hurts, because I hear he's a pretty good baseball player."

Once the inquiry and her court appeal are over, the Nova Scotia native said she plans to return to that province, where her family still lives.

"I want to go back home. Home is where the heart is, and it's always been there."


Remembering Austin (My oldest son) and Others Take From Us.

This is part of the transcript for February 1st, 2008 in which Ms. Fraser cross examined Mr. Charles Smith on behalf of the Defence for Children International

COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. Falconer. Ms. Fraser...?


MS. SUZAN FRASER: Sir, my name is Suzan Fraser and I'm here on behalf of an organization called Defence for Children International.

DR. CHARLES SMITH: Good morning.

MS. SUZAN FRASER: Good morning. And, sir, you came here and you stated that you have come to appreciate your mistakes, that's correct?


MS. SUZAN FRASER: All right. And throughout your examination and your cross-examination you have identified a number of mistakes, those include
that you were dogmatic?


MS. SUZAN FRASER: You were an advocate?


MS. SUZAN FRASER: You were an advocate for the Crown?


MS. SUZAN FRASER: And you gave confusing testimony?


MS. SUZAN FRASER: And you were disorganised?


MS. SUZAN FRASER: You went beyond your expertise?


MS. SUZAN FRASER: You, at times, saw yourself as a member of the prosecution team?

DR. CHARLES SMITH: Early on I did, yes.

MS. SUZAN FRASER: Yes. And you were profoundly ignorant of forensic pathology?


MS. SUZAN FRASER: And your education was woefully inadequate?

DR. CHARLES SMITH: Those were my words.

MS. SUZAN FRASER: Yes, and they are true?

DR. CHARLES SMITH: I believe they are.

MS. SUZAN FRASER: All right. And it's fair to say that you have told the Commissioner that you've given evidence in other proceedings, both in inquests?


MS. SUZAN FRASER: All right. And those would include some, if not all, of the six (6) systemic inquests held into children's deaths in 1996 and 1997. Do you remember those?

DR. CHARLES SMITH: I -- I certainly was part of the group that worked in the preparation of them. I can't remember now which inquests I actually testified

MS. SUZAN FRASER: All right. And you recall giving evidence at inquests into the death of children though.

DR. CHARLES SMITH: Oh, yes, yes.

MS. SUZAN FRASER: All right. And you also gave forensic pathology evidence or evidence in the nature of forensic pathology evidence in child protection proceedings or Family Court, as it's sometimes called.


MS. SUZAN FRASER: All right. And your - you also worked with the Paediatric Death Review Committee and provided your expertise to that Committee, correct?

DR. CHARLES SMITH: I was a member of that Committee.

MS. SUZAN FRASER: All right. And it's fair to say that the reason that you were a member is because of what at the time was thought of your leading pediatric forensic pathology knowledge; fair?

DR. CHARLES SMITH: I think I've stated the reasons why I presumed that I was asked to be on the Committee.

MS. SUZAN FRASER: All right.


MS. SUZAN FRASER: And it -- isn't it fair to say, sir, that the mistakes -- your mistakes that occurred in the criminal justice proceedings might also be found in those other proceedings, in your work in inquests and your work in the Family Court?


MS. SUZAN FRASER: All right. It doesn't -- it would illogical to say that they --


MS. SUZAN FRASER: -- would not have been repeated there?

DR. CHARLES SMITH: Yes. Yeah. No, I -- if I had made mistakes one place, I can certainly make them in another.

MS. SUZAN FRASER: All right. And you stated that you have come to appreciate your mistakes and have you come, sir, to appreciate the extent of the damage of your mistakes? Do you realize, sir, that children were taken from their parents as a result of your evidence?

DR. CHARLES SMITH: Yes, I've seen that.

MS. SUZAN FRASER: All right. And you're aware that some children, Joshua's brother, for one, was taken from his natural mother and adopted into another
family? You were aware of that, sir?

DR. CHARLES SMITH: I -- I don't know just how specific my knowledge of that was but I -- but it was my understanding that he -- he was taken away but I couldn't tell you what the decision on him was.

MS. SUZAN FRASER: All right. Sir, if you're interested in that information, --


MS. SUZAN FRASER: -- you'll find it in the overview report on Joshua. I won't take you there now.


MS. SUZAN FRASER: Sir, and you're also aware that Sharon's sister, who was three (3) years old at the time of her death, was adopted, and that her mother felt she had no choice because her prospects to contest an application, because her prospects for being released were so remote? You're aware of that, sir?

DR. CHARLES SMITH: I -- I have some knowledge of that, yes.

MS. SUZAN FRASER: Right. And you would know that from the statement of claim filed against you, sir?

DR. CHARLES SMITH: I -- I couldn't tell you the source but I recognize that.

MS. SUZAN FRASER: All right. And, Commissioner, I won't take you there now, but for the record, that's found at PFP116230. We know that Jenna's sister was in the care of the Children's Aid Society for almost two (2) years; you're aware of that?

DR. CHARLES SMITH: I -- I have some knowledge. The specifics, I -- as your two (2) years, I'm --

MS. SUZAN FRASER: All right.

DR. CHARLES SMITH: -- I -- I can't remember. But, yes, I recognize that.

MS. SUZAN FRASER: These children are also deserving of an apology, are they not, Dr. Smith?


MS. SUZAN FRASER: All right. And can you assist, sir, can you assist with providing us information on how many times you might have either assisted with an investigation of a Children's Aid Society or prevented -- presented evidence in Court either by affidavit or viva voce evidence?

DR. CHARLES SMITH: How many times?

MS. SUZAN FRASER: How many times, sir?

DR. CHARLES SMITH: I would have to be case specific. I did in Kingston in the Paolo case or -- or the case that involved Paolo's brother.

MS. SUZAN FRASER: All right. Sir, I'm not -- I'm not --

DR. CHARLES SMITH: Okay. I -- I'm, yeah, I'm not trying to waste your time here. Yes.

MS. SUZAN FRASER: I'm -- I appreciate that, sir, but I want to --


MS. SUZAN FRASER: -- just clarify the focus of my -- my --


MS. SUZAN FRASER: -- question. I think we have certain information about the cases before the Commissioner, --


MS. SUZAN FRASER: -- the twenty (20) cases here.


MS. SUZAN FRASER: And what I'm interested in, sir, --


MS. SUZAN FRASER: -- is that there would --

DR. CHARLES SMITH: -- beyond those. Yeah.

MS. SUZAN FRASER: Exactly. And you'll agree with me that there were times that you gave evidence where there -- in a -- in a child death where -- matter, where there was no underlying criminal proceeding? You're aware of that? You'd agree with me on that?

DR. CHARLES SMITH: Yes. I can think of maybe three (3) or four (4) instances, yes.

MS. SUZAN FRASER: All right. And so in the years that you provided forensic pathology services in the province of Ontario, can you give us a number as to how many children's lives you might have affected?

DR. CHARLES SMITH: In addition to the --


DR. CHARLES SMITH: -- ones here?


DR. CHARLES SMITH: The...I think it would be perhaps three (3) or four (4), but I could -- I could well stand corrected because -- oh, well actually those were, I shouldn't say children, those were the instances that I can think of where I was asked to present an autopsy or to give a second opinion on an
autopsy. Whether there was one (1) child or more than one (1) child is something that I -- I wouldn't necessarily know. But certainly families, I would say, I can think of three (3) or four (4).

MS. SUZAN FRASER: All right. And that would include, you mentioned the win's case, the twins who died in --

DR. CHARLES SMITH: That -- that --

MS. SUZAN FRASER: -- 1982?

DR. CHARLES SMITH: That would be one of them, yes.

MS. SUZAN FRASER: That man went on later, after maintaining his -- his innocence for many years, later went on to have another child? Another --

DR. CHARLES SMITH: That's my understanding.

MS. SUZAN FRASER: All right. And, Commissioner, you will find that in our documents, I won't turn it up, but it's one of the documents that's before you as part of the -- it's at Tab 1 and 2 of the Parties With Standing Overview, Volume I. Sir, and in terms of your bias, sir, sorry, just moving back. In -- in terms of those three (3) or four (4) cases, are -- going forward, sir, are you
prepared to help identify, should there be a need to examine those cases, are you prepared to help identify those cases so those children can perhaps one day be reacquainted with their natural parents?

DR. CHARLES SMITH: I -- if -- if there is a -- a reasonable and proper role for me to do that, yes. Yeah, I -- I would -- if I could help fix a wrong and it was appropriate to do that then, yes.

MS. SUZAN FRASER: Thank you, sir. And, sir, you have come here and talked about your close relationship being -- in the early days most certainly being part of the prosecution team, being invested in that role?

DR. CHARLES SMITH: In the 1980s, yes.

MS. SUZAN FRASER: All right. And is it fair to, sir -- say, sir, that -- that there are similar close working relationships in the Paediatric Death Review Committee and the Death Under Five Committees or the Death Under Two Committee, as it once were, in those committees you worked closely with police, CAS representatives, doctors, Crowns?

DR. CHARLES SMITH: Well, the -- the committee is made up of a number of experts who come along with different viewpoints and then individual cases are discussed --


DR. CHARLES SMITH: -- and ultimately a consensus or recommendations are -- are made by the committee.

MS. SUZAN FRASER: All right. So you're all working together. You're sort of working on the same side?

DR. CHARLES SMITH: Well, we are. In -- in the CAS cases those were ones where the -- apart --where the medical people were -- were usually quite silent --


DR. CHARLES SMITH: -- because they have no expertise or knowledge or may -- they may not have any insight, so, those were -- those would be the discussions and the decision making in those would be -- would -- would reflect the issues that are inherent in those --


DR. CHARLES SMITH: -- whereas if it was a complex medical case that did not involve CAS then, obviously, the discussions are going to go on in different -- on a different way but at the end of the day, Dr. Cairns' job as -- as Chair was to distill all of the information and then go forward with whatever --whatever an appropriate decision-making process reflected.

MS. SUZAN FRASER: Sir, and the -- the CAS cases, those would include where there's an open file, somebody's under the supervision of CAS' care and that might either be in the care of their parents or in another facility operated by the state like a group home or foster care?

DR. CHARLES SMITH: Yes, that's right.

MS. SUZAN FRASER: All right. And is it

COMMISSIONER STEPHEN GOUDGE: You're running out of time, Ms. Fraser.

MS. SUZAN FRASER: I'm -- I'm very close to finishing if I may, Mr. Commissioner?

COMMISSIONER STEPHEN GOUDGE: One (1) or two (2) more questions.


MS. SUZAN FRASER: Thank you. And one (1) of the things that you talked about in terms of working with the coroner's office was getting your ducks in a row. Was there a similar attitude in the PDRC?



DR. CHARLES SMITH: Never. No. No. I never sensed that at all. The PDRC was usually a look- back to see what went wrong, if anything, and trying to understand looking back to see the mistakes that happened as opposed to -- as opposed to go through all of the information so that a Crown attorney could -- the ducks in a row refers to a Crown attorney understanding the strengths and --


DR. CHARLES SMITH: -- weaknesses of -- of various medical opinions.

MS. SUZAN FRASER: All right but is it fair to say and I'm almost finished --


MS. SUZAN FRASER: -- Mr. Commissioner, if I may but it's important to my client that where -- you -- you indicated in the CAS cases you deferred to the
CAS representatives --


MS. SUZAN FRASER: -- on the committee. Is that -- was that your evidence, sir?


MS. SUZAN FRASER: All right.

DR. CHARLES SMITH: In the CAS cases I don't think there was -- in the cases that came forward, I can't ever remember pathology issues that I could speak to in -- in any significant way.

MS. SUZAN FRASER: All right. Thank you, sir. Those are my questions.

COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. Fraser. We will rise then for fifteen (15) minutes and come back with you, Mr. Gover.

My Apology (Sort Of) (2oo8)

TAKEN FROM JANUARY 28th, 2008 Transcript from the Goudge Inquiry.

During the Inquiry this day all apologies were said where he felt they needed to go. Each apology was said facing his lawyer Ms. Langford not those that he was apologizing too.

I said to the reporters "His apology is not sincere. If he meant it he would have looked at us the ones he affected who were all sitting in the Inquiry Room at that time. Not once did he make any effort to look at us."

MS. JANE LANGFORD: The reviewers, Dr. Smith, concluded that the cause of death should have been labelled "undetermined," but they also opined that Joshua likely suffocated accidentally as a result of his unsafe sleeping arrangements. Did you consider that as a possible explanation for Joshua's death at the time?

DR. CHARLES SMITH: Well, I did; I -- I recognized that unsafe sleep environments were a possible cause.

Certainly at that time I was aware that things like waterbeds were -- were dangerous or a potentially dangerous sleep environment, and the -- the knowledge or understanding of an unsafe sleep environment was growing. But I don't believe at the time that I authored this report I -- I understood that his specific sleep environment was as dangerous as it -- as it could have been, and I believe that I focussed more on the findings that were more suspicious, leg fracture and skull fracture, as opposed to the possibility of this environmental risk.

MS. JANE LANGFORD: And before we leave this case, Dr. Smith, is there anything you wish to add?

DR. CHARLES SMITH: Yes. I deeply regret the -- the diagnostic error that I made and the confusion that is attendant upon it. I understand that it has caused problems for the investigators and for the judicial system, but most importantly, it has caused a significant problem for Joshua's family and Joshua's mother, and for that, I -- I am truly sorry.