Justice Stephen Goudge delivers the inquiry report in Toronto, Wednesday, Oct. 1, 2008.
Inquiry report slams child forensic pathology
Oct. 1 2008
A final inquiry report on child forensic pathology in Ontario concludes the system is deeply flawed and has led to several wrongful prosecutions, the Canadian Press has learned.
Justice Stephen Goudge compiled a 1,000 page report after presiding over an inquiry into Dr. Charles Smith, the former chief pediatric forensic pathologist in Ontario.
Smith, who has been linked to several flawed assessments, also faces harsh criticism in the report, a source told the news agency.
Goudge's report was formally handed to the Ontario government on Tuesday. The report contains more than 160 recommendations meant to reform the system and ensure accountability and credibility into a coroner's conclusions.
The source said Goudge uses individual cases to exemplify his recommendations.
"His reforms are extensive and are aimed squarely at the accountability and oversight," said the source.
Those recommendations include:
- setting up a committee to oversee the chief coroner's office
- ensuring pathologists take better care in how they form their opinions about wrongdoing
- addressing staff shortages by increasing a pathologist's salary and setting up university programs to train them
Peter Wardle, a lawyer representing five families, said the victims of erroneous child forensic pathology findings will be scrutinizing the report and keeping a close eye on what comes out of it.
"They're going to be very important to the death-investigation process in the province," he told CP on Tuesday.
"It's going to be critical that the government act on those recommendations."
The government has said it won't publicly respond until Wednesday, after it has had a chance to review the report.
The inquiry into Smith's work found proof that the coroner erred in his conclusions in 20 of 45 autopsies. His opinion in 13 of those cases led to criminal convictions.
Williams Mullins-Johnson is just one victim of the process. He spent 12 years in jail after Smith concluded his four-year-old niece was raped and murdered. Her death was later attributed to natural causes.
The report says that Smith was a victim of a broad system that had inadequate oversight, the source said. Smith has said that he blamed his lack of training and his ignorance about how the justice system worked for his mistakes.
During the inquiry, Smith and former chief coroner James Young and his deputy Jim Cairns all offered apologies for their errors.
The inquiry heard that the coroner's office - headed at the time by Young and Cairns - failed to act on repeated complaints about Smith and failed to monitor his work.
"None of (the complaints) stuck with me," Young told the inquiry. "I regret it deeply but I can't go back and change history."
Cairns apologized for defending Smith who at the height of his career was widely regarded as the leading child forensic pathologist in the entire country.
Cairns testified that no one dared to question Smith's work because of his stellar reputation.
Smith was eventually relieved of his duties more than ten years after the coroner's office first received a complaint about him.
The scandal has prompted the province to form a specialized "child homicide team" of senior prosecutors who have experience and expertise in dealing with murdered children.
Premier Dalton McGuinty has also said he would consider compensating Smith's victims after the Goudge report was made public.
With files from The Canadian Press
Any Justice System is as good as the weakest link. Any one could be convicted by one persons mistake.