CTV Videos (2oo8)

http://beta.ctvdigital.net/servlet/an/local/CTVNews/20080128/smith_pathologist_080128?hub=BritishColumbiaHome


Here is a link to CTV.ca I was unable to copy the links to the Videos they have here.

There is 4 Videos, hopefully you are all able to see them.

Pathologist's training was 'woefully inadequate' (2oo8)

View larger image Dr. Charles Smith sits on the stand at the Goudge inquiry in Toronto on Monday, Jan. 28. 2008. (Adrian Wyld / THE CANADIAN PRESS) Sherry Sherrett, who was convicted in the death of her son based on Smith's findings, speaks with Canada AM on Monday, Jan. 28, 2008. Updated: Mon Jan. 28 2008 10:29:47 CTV.ca News Staff Disgraced pathologist Dr. Charles Smith, whose child death investigations resulted in a number of wrongful convictions, testified today that his training as a pathologist was "woefully inadequate." Smith is testifying at a public inquiry in Toronto into systemic errors in the field of pediatric forensics. The inquiry was ordered after serious doubts were raised about opinions given by Smith in roughly 20 cases of suspicious child deaths. In more than 12 of those cases, Smith's decisions led to criminal investigations or convictions. Smith opened his testimony with an apology for his "mistakes." "I do accept full responsibility for my work, for my opinions and for my action," said Smith. "I do recognize that many people have questions for me and I will answer and provide testimony as best I can to help clarify these questions.'' He admitted that his training in forensic pathology was "minimal,'' that he was basically "self taught'' and that his behaviour at times was unprofessional. Smith also said that despite the numerous cases in which he gave expert testimony, he now recognizes that he was "profoundly ignorant" of the role of expert witnesses and the way the criminal justice system works. However, when asked about being described in the media as someone who saw abuse in every child's death, he said the description was "grossly erroneous." The inquiry has heard months of testimony from experts and former colleagues. Victims seek answers One father spent more than a decade in prison for the death of his niece before being exonerated, and several mothers spent years in prison before the cases against them fell apart. Sherry Sherret, who was convicted of killing her son based on an autopsy by Smith, travelled to Toronto to attend the hearing in hopes of getting some answers. "I guess (I hope to receive) the answers," she told CTV's Canada AM. "Why? If you needed help, why didn't you ask, why did you choose to do this? Why did you not ask for the help, say, 'could someone else go over this just to make sure it's right,'? It's just confusing as to why, honestly." Sherret's own conviction in the death of her young son, who was sleeping in a playpen when he died, turned her life upside down, she told Canada AM. She lost custody of her older son, who she hasn't seen since 1999 and is now being raised by his adoptive family. Sherret also spent several years in jail, and at times felt her life was over. "It's been a long journey," she said, noting that she has since remarried and has a young daughter, but still looks forward to her son's 18th birthday, when she can see him again. William Mullins-Johnson was also convicted based on Smith's findings. He spent 12 years in jail for the death of his niece before his conviction was quashed after six experts found no evidence to support Smith's finding that the girl had been sodomized and asphyxiated. Lawyer Peter Wardle told The Canadian Press the parents and families affected by Smith's mistakes will be expecting more than just an apology. "Many of them have waited 10 -- in one case 20 -- years to hear him give his side of the story," said Wardle, who represents several of the families. "They all have questions they want answered." Although his clients felt the apology delivered in November was "too little, too late," they're anxious to hear what Smith has to say, Wardle added. The mandate of the inquiry is broader than just Smith's work, however. Its objective is to take a look at errors that exist in Ontario's pediatric pathology system. Smith is facing a room full of lawyers seeking insight into how his work in pediatric pathology often served only to worsen the tragedy of a child's death. With files from The Canadian Press

Victims Of Pathologist Say Apology Not Good Enough (2oo8)

2008/01/28 | CityNews.ca Staff

They suffered three times by the actions of a single man. First by the accusations that they killed their own children or young relatives. Then by being put through the court system and in some cases serving time in jail for a crime they never committed. And finally for the lingering suspicion that will forever surround them, despite being proven innocent.

They are the victims of Dr. Charles Smith, the pathologist whose findings helped cast a cloud around dozens of people over the past two decades. While the scientist publicly apologized for his grievous mistakes Monday at an inquiry called to explore his actions, those who became victims of the physician's terrible errors aren't quite so ready to forgive and forget.

For William Mullins-Johnson (top left), who was sentenced to life in prison and spent a dozen years behind bars for molesting and killing his own niece, no apologies, no matter how heartfelt, will ever be enough to make up for what he lost.

"He put me in an environment where I could have been killed any day, any given day, based on lies," he notes bitterly. "So I don't hold much stock in apologies from him. I don't hold much stock in apologies from anybody in the field at the time, because they were propping him up. They were protecting him. I wasn't. I was doing the life sentence for something that didn't even happen."

Sherry Sherrett can feel his pain, because she shared it. The Trenton, Ontario mother was convicted of killing her four-month-old son in 1996, based mostly on Smith's sworn testimony.

She spent a year in jail on first-degree murder charges after the doctor found her infant died from a skull fracture and neck trauma in 1996. He believed the evidence pointed directly at the then-20-year-old, but when other pathologists re-examined the case, they discovered the death was actually caused by the baby getting his head caught in his bedding.

Now she wonders how he can live with himself after putting so many through so much.

"I would want to ask him face-to-face off the record, you know, why did he do it? How does he feel? And, you know, does he regret anything that he did? Because he doesn't know what it's like to be locked up, and, you know, you get called names. Your life is threatened when you're away and nothing can ever change that."

Sherrett knows if she can become an innocent victim so can anyone. And when the weight of the justice system is brought down with all the force of law on a person of limited means, it's a crushing force that's all but inescapable.

She questions what it takes to become deemed a true 'expert' in the field. "He's not a forensic pathologist," she insists. "He wasn't trained to do forensics. I watch CSI all the time. Can I be one?"

And she's not prepared to accept Smith's mea culpa. "He's turned so many people's lives upside down, it's time for him to answer."

Sherett's tragedy has been compounded because she lost custody of her other son, who has since been adopted.

Mullins-Johnson believes the doctor's performance was the proverbial crocodile tears. "Sugarcoated apology as far as I can see," he condemns. "There's really not much there to redeem him."

He's slowly repairing the terrible rift the case has put on his once loving family. How does he get through each day knowing some people still suspect him of such a heinous crime? "The old saying goes, keep a stiff upper lip and the best revenge is to live well, you know? And that's what I'm trying to do."

Mullins-Johnson was officially cleared of all charges in an emotional courtroom scene last October. He's expected to seek compensation for the life he lost while in prison. It's not yet clear how much he might ask for or how much he may be offered.

Sherrett is hoping the Crown will also acknowledge her innocence. She'll have her day in court next fall. Until then, she's been released from jail - but her conviction stands.

Most of the others who've felt the sting of Smith's trials of tribulations felt the same way and think more than just an apology is warranted.

For a review of just some of the cases where Smith's testimony led to a false or questionable conviction, click here.

Review all pathologist's cases: experts (2oo8)

Dr. Charles Smith

Tom Blackwell, National Post Published: Tuesday, January 08, 2008

Authorities should consider reviewing every child-welfare case where Dr. Charles Smith played a key role--and return apprehended children to their parents if appropriate, two leading experts have urged.

Most of the controversy around the Ontario pathologist's flawed child-death investigations has stemmed from the wrongful homicide prosecutions his opinions triggered. But in a paper commissioned by the Goudge judicial inquiry, professors at Queen's and McGill universities discuss another scenario: parents whose surviving children were taken from them because Dr. Smith erroneously concluded they killed another offspring.

"If forensic pediatric pathology reports are unreliable, there are likely to be profound implications in the child protection system," said the paper by Nick Bala and Nico Trocme.

Prof. Bala is a family law expert at Queen's and Prof. Trocme, a social-work faculty member at McGill, is a leading expert in child abuse.

They note that a review of child-welfare cases was conducted in Britain after a similar affair involving a pediatrician's discredited court testimony. Children were reunited with their parents in two of the doctor's cases.

It is unclear how many, if any, siblings apprehended after deaths that Dr. Smith investigated are still in the care of children's aid societies here. If some are and it is in their interests to rejoin their families, "the agency should … take all reasonable steps to support the reunification of parents and child," the report says.

However, if the children have already been adopted, it would be too traumatizing to remove them from that family now. It might be beneficial, though, to allow the birth parents some access to the children, the professors say.

The inquiry was called after an outside review found that Dr. Smith made significant errors in 20 of 45 criminally suspicious child deaths he investigated between 1991 and 2001. Parents and caregivers were charged with homicide offences in most deaths, though many have since been cleared. In at least seven of those cases, children's aid societies seized other children from the parents following the death. In some instances, they were returned to their families. In others, it is unclear from case summaries produced by the inquiry what happened to the siblings after being removed.

When the baby known as Joshua died at age four months in 1996 and his mother, Sherry Sherrett, was charged with first-degree murder, the infant's brother was apprehended and later adopted out. Authorities also tried, unsuccessfully, to seize another child born to Ms. Sherrett in 2005. Ms. Sherrett was eventually found guilty of the lesser offence of infanticide but is fighting to have that conviction overturned in light of Dr. Smith's questioned evidence.

The paper submitted to the inquiry outlines three other cases where the pathologist testified at hearings held to determine if a child should be taken from the parents.

In one instance, Dr. Smith's testimony was instrumental at a 1995 case involving the future of a newborn baby. The father had been convicted of manslaughter 10 years earlier in the death of another child, largely based on the pathologist's evidence, though other witnesses described him as being of a "gentle nature" and his wife insisted he was innocent. At the 1995 hearing, Dr. Smith reiterated his earlier testimony, and the newborn was removed from the parents' care.

The paper does not criticize the children's aid societies.

tblackwell@nationalpost.com

Ontario Acts On Goudge Recommendations

Ontario Acts On Goudge Recommendations

<<>>

TORONTO, Oct. 23, 2008 /CNW/ - NEWS

Ontario's death investigation system would be stronger, more accountable
and provide for greater oversight and transparency under proposed legislation
introduced by Community Safety and Correctional Services Minister Rick
Bartolucci today. Highlights of the bill include a new oversight council,
complaints committee and a provincial forensic pathology service.
The proposed legislation addresses all the recommended legislative
amendments in the report of the Honourable Justice Stephen Goudge's Inquiry
into Pediatric Forensic Pathology in Ontario. This includes amendments to the
Coroners Act that would establish a framework to strengthen the death
investigation system in Ontario.

The new death investigation oversight council, made up of experts from
the medical, legal and government communities, would oversee the work of the
chief coroner and chief forensic pathologist to ensure the quality of the
system.

The Ontario Forensic Pathology Service recognizes the complex and
important role forensic pathology plays in death investigations. The new
service will centralize forensic pathology under the chief forensic
pathologist, ensuring consistent, high-quality standards for forensic
pathology across the province.

<<>>

QUOTES

"Commissioner Goudge gave us the roadmap to a stronger more accountable
death investigation system. This legislation takes us a long way down that
road. If passed, it would ensure we have the checks and balances in place to
prevent a similar tragedy in the future," said Community Safety and
Correctional Services Minister Rick Bartolucci
(http://www.mcscs.jus.gov.on.ca/english/about_min/bio.html).

"This legislation would provide us the framework we need to truly
revitalize the system, and to help us build on the work we've already done to
earn back the trust of the people of Ontario," said Ontario's Chief Coroner
Dr. Andrew McCallum (http://webx.newswire.ca/click/?id=2e478d1bd6e0ea3).

"By recognizing the importance of a professional forensic pathology
service, this legislation would help us to take the next step towards
delivering the consistent high quality service the people of Ontario deserve,"
said Ontario's Chief Forensic Pathologist Dr. Michael Pollanen.

<<>>

LEARN MORE

Learn more about Ontario's coroners
(http://webx.newswire.ca/click/?id=7493768864254bc).

Read Justice Goudge's report and recommendations
(http://www.goudgeinquiry.ca/).

<< --------------------------

-----------------------------------------------
ontario.ca/safety-news
Disponible en français


BACKGROUNDER
-------------------------------------------------------------------------

STRENGTHENING ONTARIO'S DEATH INVESTIGATION SYSTEM
>>

Proposed new legislation would, if passed, amend the Coroners Act to
improve oversight, accountability and quality assurance within Ontario's death
investigation system. The proposed changes respond to recommendations made by
the Honourable Justice Stephen Goudge following his Inquiry into Pediatric
Forensic Pathology in Ontario.

Key changes under the new legislation would include:

ESTABLISHING EFFECTIVE OVERSIGHT

Proposed changes in the legislation would make it easier for the public
to understand how the death investigation system works and would make the
system itself more accessible, transparent and accountable.

A new death investigation oversight council would be created to oversee
the work of the chief coroner and the chief forensic pathologist. This is in
response to Commissioner Goudge's recommendations that an independent
oversight mechanism be established to oversee Ontario's death investigation
system. The council will ensure that the chief coroner and chief forensic
pathologist are held accountable for the quality of death investigations in
Ontario.

Ontario's Lieutenant Governor would appoint members of the oversight
council which would include representatives from the judicial, medical, and
government communities and as such would bring specialized expertise to advise
and oversee the chief coroner and chief forensic pathologist.

STRENGTHENING THE COMPLAINTS PROCESS

A new complaints committee would be established that would report to the
oversight council. The committee would track complaints made about the
handling of a particular death investigation or about the conduct of a coroner
or pathologist during an investigation.

In general terms, complaints concerning the medical roles of coroners and
pathologists would be directed to the College of Physicians and Surgeons,
while complaints related to the non-medical roles of coroners and pathologists
(e.g., providing evidence in criminal proceedings) would be directed to the
chief coroner and chief forensic pathologist respectively.

The committee would ensure the chief coroner and chief forensic
pathologist respond to complaints quickly and thoroughly. If a complainant is
not satisfied with the response provided by the chief coroner or the chief
forensic pathologist, the complaints committee has the authority to review the
complaint. The committee would also review any complaints against the chief
coroner and the chief forensic pathologist.

ENSURING HIGH-QUALITY FORENSIC PATHOLOGY SERVICES

In his report, Commissioner Goudge identified the vital role that
forensic pathology plays in Ontario's death investigation system. He made
several recommendations directed at improving the oversight of forensic
pathologists, defining their roles and ensuring quality within the system.
These recommendations are addressed in the proposed legislation.


Roles and Responsibilities

The chief forensic pathologist would be established in law as the head of
forensic pathology in the province. This would allow him or her to ensure the
quality and consistency of services being provided by forensic pathologists
across the province. Currently the chief forensic pathologist does not have
this legislated responsibility.


Forensic Pathology Service

A new Forensic Pathology Service would be created reporting to the chief
forensic pathologist. The new service would bring all of the province's
forensic pathology services under one umbrella to ensure consistency,
accountability and oversight. Currently, the province's forensic pathology
services are decentralized and run by regional forensic pathology units and
other hospital facilities where autopsies are performed.


Registry of Pathologists

A registry of pathologists authorized to perform post-mortem examinations
would be created and maintained by the chief forensic pathologist. This would
ensure that all pathologists providing services in Ontario are appropriately
qualified and experienced and have met the strict quality requirement set out
by the chief forensic pathologist.



MAKING ONTARIO SAFER

The chief coroner has a responsibility to protect public safety, and
needs to be given the clear authority to share information for this purpose.
Providing the chief coroner with authority to decide when it is appropriate to
share information to advance public safety will help coroners to protect the
public by preventing similar deaths. In such cases, the coroner would make
every effort to protect privacy by withholding identifying information where
possible.

The current legislation allows the coroner to release the results of
death investigations only to family members of the deceased, but does not
allow the coroner to release the results to other groups or to the public.
In some cases, the coroner has a need to share information when not doing
so would put the public at significant risk. For example, if widely used
medical equipment were faulty and caused a death, the public would need to be
informed.



ENSURING AN INDEPENDENT DEATH INVESTIGATION SYSTEM

The intent of the proposed legislation is to build a stronger death
investigation system based on the principles of professionalism and
accountability. Under such a system, it is the Office of the Chief Coroner who
has the expertise and experience needed to determine if an inquest should be
held. Decisions on inquests can undergo three levels of review within the
Office of the Chief Coroner: local investigating coroner; regional supervising
coroner; and the chief coroner.

If the minister made a decision contrary to the chief coroner's, it would
be inconsistent with the arm's-length relationship between the Office of the
Chief Coroner and government. For this reason, the proposed legislation would
remove the power of the Minister of Community Safety and Correctional Services
to call an inquest.

The chief coroner's decision regarding an inquest could still be the
subject of judicial review, if there was a desire to appeal his or her ruling.
Under this proposed change, by removing any potential for political
intervention, the final decision is based on science.



FOCUSING RESOURCES ON PUBLIC SAFETY

All deaths of adult inmates in correctional institutions are, and will
continue to be, thoroughly investigated by a coroner who is able to make
recommendations to prevent similar deaths. Currently, a coroner must hold an
inquest into all such deaths. Where the initial investigation determines that
a death in custody was by natural causes, the resulting inquest rarely
provides meaningful recommendations to improve public or inmate safety.
Under the new legislation, a death by natural causes in an adult
correctional facility would no longer be the subject of a mandatory inquest. A
coroner would still be able to call an inquest in such cases if he or she
believes an inquest will lead to improvements in public safety.
This change would allow coroners to focus on those complex cases where an
inquest could result in meaningful recommendations to make Ontario safer.



IMPROVING SERVICES TO NORTHERN, FIRST NATIONS AND REMOTE COMMUNITIES

All Ontarians deserve high-quality services and that includes death
investigations. In his report, Commissioner Goudge recognized that delivering
this service is challenging in some areas of the province. The current
shortage of doctors in northern, First Nations, and remote communities results
in long response times in the event of a death and sometimes coroners are
unable to attend a death scene at all.

As recommended by Commissioner Goudge, the new legislation would provide
for the appointment of individuals other than medical doctors or police
officers to perform coroner's duties. If passed, this amendment will give
coroners the flexibility to meet local needs and improve service to northern
and remote communities. However, the final decision as to whether or not an
inquest is required would continue to rest with the Office of the Chief
Coroner.



DEFINING THE PURPOSE OF DEATH INVESTIGATIONS

It is not always clear to the public what the purpose of a death
investigation is and this can cause confusion while the investigation is
underway. The proposed new legislation would establish in law for the first
time the reasons why a death investigation is undertaken.

<<>>

The results of an investigation are used to determine whether
recommendations are needed to prevent similar deaths or whether the death
requires the additional public scrutiny of an inquest.

An inquest is a public hearing held under the authority of the Coroners
Act for the purpose of presenting evidence to a jury of five members of the
community in which a person died. After hearing the evidence and other matters
relevant to the circumstances of the death, the jury must answer the above
five questions. They also may make recommendations based on evidence heard
that if implemented, might avoid deaths in similar circumstances.

The Goudge Report

Well everyone normally I post things for people to read. The report I will not be able to post. But I will be able to provide you with the link to the report to read.

The report is currently over a 1000 pages long.

http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/report/index.html

You can also find transcripts from the Goudge Report at:

http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html

Report on child deaths out today (2oo8)

TheStar.com - Ontario - Report on child deaths out today

October 01, 2008

Theresa Boyle Staff Reporter

Wholesale changes to the way Ontario child deaths are medically investigated are expected to be recommended today by a commission probing serious flaws in the system that led to wrongful prosecutions of parents and caregivers.

The final report of the Public Inquiry into Pediatric Forensic Pathology, to be released at noon by Commissioner Stephen Goudge, will aim to ensure that no one in future will be charged, convicted or have their family pulled apart because of faulty pathology.

"I think it will (recommend) a major overhaul. It's way overdue," remarked Peter Wardle, a lawyer representing wronged individuals as a result of botched investigations into the deaths of Ontario children between 1991 and 2001.

The Canadian Press has learned the 1,000-page report contains harsh criticism of disgraced pathologist Dr. Charles Smith and his superiors, former chief coroner Dr. Jim Young and former deputy chief coroner Dr. Jim Cairns.

The inquiry was prompted by mistakes made by Smith in 20 child-death investigations. His errors included bungling autopsies, misdiagnosing causes of death, overstating his expertise and jumping to conclusions about family members based on their socio-economic status.

Wardle is anticipating a call for major changes to the Office of the Chief Coroner of Ontario to ensure more checks and balances in child-death investigations. He wants to see a committee created that would be responsible for oversight of the coroner's office.

While the commission can't assign blame, it can point to critical failures in the system, noted Harold Levy, a lawyer and former Star reporter who is researching a book and writing a blog about the saga.

"Justice Goudge must provide us with his unfettered views on the actions or failures to act – of the institutions and people who were supposed to protect us," Levy said.

Kathryn Clarke, spokesperson for the regulatory College of Physicians and Surgeons, said Smith no longer has a licence to practise in Ontario. It expired in August and he didn't renew it. She said the college is still investigating allegations of professional misconduct by Smith.

Goudge is expected to address the use of expert witnesses in the criminal courts, in particular those from medical fields. Courts put too much stock in expert witnesses and give them too much free rein, the inquiry heard.

"My number-one choice is a requirement that a criminal charge can never be laid against a parent or caregiver (based solely on) the mere opinion of a pathologist," Levy said.

The recurring mistakes of Smith and others in the forensic pathology system led to some parents and caregivers spending months, even years, behind bars, and having surviving children removed from their custody, sometimes permanently. Families spent life savings trying to defend themselves.

TheStar.com - Ontario - Payout urged in Smith probe

TheStar.com - Ontario - Payout urged in Smith probe

October 01, 2008
Theresa Boyle Tracey Tyler
Staff Reporters

People unjustly convicted through the work of disgraced pathologist Dr. Charles Smith deserve compensation, the final report of the Public Inquiry into Pediatric Forensic Pathology in Ontario concludes.

The four-volume report released today by Justice Stephen Goudge also calls on the province to review additional cases of child deaths that may have resulted in wrongful convictions.

The report lists 169 recommendations to restore the public confidence in a system that saw innocent family members and caregivers wrongly convicted, charged or suspected in the deaths of children.

"My recommendations are the steps that I have concluded must be taken to restore and enhance public confidence in pediatric forensic pathology in Ontario, and its future use in the criminal justice system," Goudge said.

"If acted upon, they represent the best way to protect the administration of justice from flawed pathology, to leave behind the dark times of the recent past, and to create the forensic pathology service that the criminal justice system needs and the people of Ontario deserve.

"It is important that there be improvements in the way forensic pathology is practiced in individual cases in Ontario. . . At autopsy, the forensic pathologist should `think truth' rather than `think dirty.'

"To do so requires an independent and evidence-based approach that emphasizes the importance of thinking objectively. The pathology evidence must be observed accurately and must be followed wherever it leads, even if that is to an undetermined outcome."

While it's harshly critical of Smith, whose litany of mistakes sparked the inquiry, it's particularly critical of his bosses, who failed to rein him in. Ontario's former chief coroner, Dr. James Young, has been singled out for failing to heed years of warnings about Smith.

The inquiry, which ran over five months beginning last November, was prompted by mistakes made by Smith in 20 child-death investigations.

His errors included bungling autopsies, misdiagnosing causes of death, overstating his expertise and jumping to conclusions about family members based on their socio-economic status.

"When the pathology is flawed, or there is a failure of the oversight required to ensure its quality, the consequences are devastating," Goudge said. "Sadly, in the years I examined, both occurred in Ontario.

"For more than a decade, Dr. Charles Smith was viewed as one of Canada's leading experts in pediatric forensic pathology, and the leading expert in Ontario. Yet he had little forensic expertise, and his training was, as he himself described, 'woefully in adequate.'

"He achieved the status of a leading expert in the field in large part because there was no one who had the training, experience, and expertise to take him on. He worked ... too much in isolation.

"The situation was prolonged because there was then, as there is now, a severe shortage of forensic pathologists in Ontario and even fewer with the knowledge and experience to do pediatric forensic cases or to provide the culture of peer review on which quality depends.

"The serious mistakes he made, with the terribly unfortunate consequences that resulted, were on clear display at the inquiry.

"But the tragic story of pediatric forensic pathology in Ontario from 1981 to 2001 is not just the story of Dr. Smith. It is equally the story of failed oversight. The oversight and accountability mechanisms that existed were not only inadequate to the task, but were inadequately employed by those responsible for using them.

"The challenge ahead is to correct the failings that permitted these things to happen. We must do all that we can to ensure that, so far as possible, this history is not repeated.

"This is the objective of the 169 recommendations I have made."

While Goudge didn't have the mandate to order compensation, he did nudge the province to do so, something that many victims and their lawyers had desperately hoped he would do.

"I urge the Province of Ontario to see if ... a viable compensation process can be set up," he wrote.

The commissioner noted that many individuals became "entangled in the criminal justice system simply because of flawed pediatric forensic pathology and through no fault of their own."

Indeed, William-Mullins Johnson, of Sault Ste. Marie, was wrongly convicted for the rape and murder of his four-year-old niece, crimes for which he spent 12 years in jail.

Sherry Sherret, of Belleville was convicted of infanticide in the death of her 4-month-old son, largely based on Smith's evidence. She spent a year in jail and lost permanent custody of an older son.

Other families spent their life savings trying to defend their loved ones.

"I think the report has far reaching implications, not just for the future of pediatric forensic pathology in this case, but for the criminal justice system as whole," said James Lockyer, a lawyer representing Mullins-Johnson and eight other families.

"We all have a lot to learn from the report.

"I'm obviously pleased there's a recommendation for a review of shaken baby syndrome cases," Lockyer added.
Like so many today, Mullins-Johnson described Goudge’s report as “a start.” But by Mullins-Johnson’s definition, real accountability will only come if the Crown attorney’s office reviews the conduct of Smith and his two former superiors in the Ontario coroner’s office — Young and former Deputy Chief Coroner Dr. Jim Cairns — with a view to laying criminal charges.

Mullins-Johnson said he wants to see all three men prosecuted criminally for obstruction of justice.

They fabricated a crime that never took place — one he paid for with 12 years of his life, he told reporters.

“They invented a crime here,” he added in an interview with The Star. “They just basically took it out of the air and said, ‘Let’s get him.’”

Goudge’s report provides “tough answers to what were tough questions,” said Julian Falconer, a lawyer representing Aboriginal Legal Services of Toronto.

“It was, quite frankly, painfully obvious to everyone at the start of this inquiry the incompetencies exhibited by Dr. Smith. The question really was, how could it have been allowed to go on so long.”

The answers pointed to the man at the top of the coroner’s system, who was too busy in other high-profile government jobs to keep tabs on what Smith was doing, Falconer said.

Goudge’s report concludes “the Chief Coroner of Ontario, Dr. Young, misled the College of Physicians and Surgeons in 2002 with respect to Dr. Smith,” said Falconer. “It points out that Dr. Young was unable to fulfill the oversight role of the Chief Coroner because he accepted ore senior oversight positions, taking him elsewhere.”

“He (Goudge) identified a complete failure of oversight on the part of the Ontario coroner’s office,” said Frank Addario, president of the Criminal Lawyers Association.

“We see this as step one.”

“Step two is the government’s response. They need to step up to the plate as quickly as possible and build some confidence back into the system,” he said.

Exactly ten years ago, the public learned, during the inquiry into the Guy Paul Morin’s wrongful 1992 murder conviction, that “the forensic science system in Ontario has flaws,” Addario noted. “We’ve learned it again during this inquiry.”

In addition to insisting on standards of excellence generally through the system, Addario suggested it may also be time to insist that judges be required to undertake some training in basic sciences and scientific principles if they’re going to preside at homicide trials.

In urging the province to review old cases of child deaths, Goudge noted that science has evolved and some deaths once deemed criminally suspicious would now be attributed to natural causes.

"The significant evolution in pediatric forensic pathology relating to shaken baby syndrome and pediatric head injuries warrants a review of certain past cases because of the concern, in light of the change in knowledge, there may have been convictions that should now be seen as miscarriages of justice," he said.

In taking aim at Young, Goudge said as former chief coroner, the buck stopped with him.

"In the end, as Chief Coroner, Dr. Young must bear the ultimate responsibility for the failure of oversight," he wrote.

Of the report's 169 recommendations to restore public confidence in the system, 23 focus on improving oversight and accountability, including the creation of a governing council to ensure more objective and independent governance of the Office of the Chief Coroner of Ontario.

Goudge was also critical of Cairns, noting that those in the senior ranks of the Office of the Chief Coroner ignored warning signs about Smith for more than a decade.

"Because of their positions, (Young and Cairns) clearly had authority over Dr. Smith in his role as director of the (Ontario Pediatric Forensic Pathology Unit) and in his work on individual cases had they chosen to exercise it. Ultimately they could have removed him from both functions. Unfortunately, this authority was never translated into effective oversight," the report states.

Commenting on Smith's rise through the ranks despite a lack of training, Goudge called for higher standards in the profession of forensic pathology

"For more than a decade, Dr. Smith was viewed as one of Canada's leading experts in pediatric forensic pathology and the leading expert in Ontario. Yet he had little forensic expertise and his training, as he himself described was `woefully inadequate,' " he wrote.

Goudge said the profession of forensic pathology needs to be beefed up with better education, more recruitment and more funding to grow the field. He also called for an amendment to the Coroner's Act to formally recognize the role of forensic pathologists and define their duties.

Key recommendations

Justice Stephen Goudge makes 169 recommendations to improve Ontario's pediatric forensic pathology system. They include:

- Further review of other child deaths to determine if any resulted in potentially wrongful convictions — particularly cases that involved shaken baby syndrome or pediatric head injuries — given significant advances in the past two decades in what pathology knows about these cases.

- During autopsies, forensic pathologists should stop thinking "dirty" — approaching cases with a high level of suspicion, as preached by Smith and his superiors — and start thinking "truth."

- The Royal College of Physicians and Surgeons of Canada approve year-long programs in Canadian medical schools to train and certify doctors as forensic pathologists. (Smith had no formal training in forensic pathology, which has largely been the norm for Canadians doctors practicing in this field).

- Amending Ontario's Coroners Act to ensure the work of forensic pathologists is supervised, including the creation of a Governing Council to oversee the duties and responsibilities of the Office of the Chief Coroner.

- "Significant" increase in legal aid funding for serious criminal cases involving pediatric forensic pathology to ensure parents defended by skilled and experienced lawyers.

- Ontario hospitals should create policies for mandatory reporting of any serious concerns about the work of any hospital pathologist who performs autopsies under a coroner's warrant. Ontario's coroner's office should create similar policies.

- Forensic pathologists must ensure their work at autopsies is "transparent" and independently reviewable, which means preserving any information received before an autopsy, what they did during an autopsy and any evidence collected. (Smith lost, misplaced and withheld evidence).

- In their reports and testimony, forensic pathologists must ensure their opinion addresses other explanations for what they found during a post-mortem.

- The Ontario government should investigate whether a "viable" process can be set up to compensate affected families. (Goudge's mandate precluded him from making recommendations about individual compensation.)

- Trial judges must function as "gatekeepers" in cases involving "expert" scientific evidence — assessing, before that witness testifies, the reliability of their field of science and the reliability of their opinion, among other things.

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

WAYNE HIEBERT FOR THE TORONTO STAR

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.

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...?

CROSS-EXAMINATION BY MS. SUZAN 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?

DR. CHARLES SMITH: Yes.

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?

DR. CHARLES SMITH: Yes.

MS. SUZAN FRASER: You were an advocate?

DR. CHARLES SMITH: Yes.

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

DR. CHARLES SMITH: Yes.

MS. SUZAN FRASER: And you gave confusing testimony?

DR. CHARLES SMITH: Yes.

MS. SUZAN FRASER: And you were disorganised?

DR. CHARLES SMITH: Yes.

MS. SUZAN FRASER: You went beyond your expertise?

DR. CHARLES SMITH: Yes.

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?

DR. CHARLES SMITH: Yes.

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?

DR. CHARLES SMITH: Yes.

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
at.

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.

DR. CHARLES SMITH: Yes, I have.

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.

DR. CHARLES SMITH: Mm-hm.

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?

DR. CHARLES SMITH: Yes.

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

DR. CHARLES SMITH: That --

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, --

DR. CHARLES SMITH: Mm-hm.

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

DR. CHARLES SMITH: Okay.

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?

DR. CHARLES SMITH: Yes.

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 --

DR. CHARLES SMITH: Yeah.

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

DR. CHARLES SMITH: Okay.

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

DR. CHARLES SMITH: Oh, I see.

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

DR. CHARLES SMITH: Okay.

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

DR. CHARLES SMITH: Are --

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 --

MS. SUZAN FRASER: Yes, sir.

DR. CHARLES SMITH: -- ones here?

MS. SUZAN FRASER: Yes, sir.

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 --

MS. SUZAN FRASER: Yes?

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 --

MS. SUZAN FRASER: Yes.

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 --

MS. SUZAN FRASER: Yes?

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.

CONTINUED BY MS. SUZAN FRASER:

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.

MS. SUZAN FRASER: Never?

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 --

MS. SUZAN FRASER: Yes.

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 --

DR. CHARLES SMITH: Mm-hm.

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 --

DR. CHARLES SMITH: Mm-hm.

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

DR. CHARLES SMITH: Yes. Yes.

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.