Thursday, February 28, 2008

Disgraced MD Sues

Below in this article it stats how Smith believes he was wrongfully dismissed from his position out west. I am not sure how things work out west but I know here in Ontario if you lie on your application it is grounds for dismissal. PERIOD. No ands, ifs or butts about it.

This is just another thing that I believe he thinks was wrong against him. I wonder when everything will kick in and he realizes "Oh my god, what did I do to these people?"

Disgraced forensic pathologist Dr. Charles Smith -- whose faulty testimony landed many innocent people in jail in Ontario -- is suing the Saskatoon Regional Health Authority for wrongful dismissal.

The suit comes after a 2006 tribunal ruled the health authority was "unfair, unreasonable and wrong" when it denied Smith hospital privileges in Saskatoon, cutting short a one-year contract to work as a surgical pathologist at Saskatoon City Hospital.

"There was no just cause for the dismissal of the plaintiff, nor has reasonable notice been provided, nor has the plaintiff been paid in lieu of reasonable notice," says Smith's statement of claim filed in Saskatchewan's Court of Queen's Bench.

Saskatoon lawyer Gary Bainbridge filed the suit while Ontario was holding a public inquiry that had Smith's questionable work at its focus.

Last month at the inquiry, Smith apologized repeatedly for his conduct, saying he had "woefully inadequate" training in child forensic pathology when he began doing autopsies on children who had died suspiciously.

He admitted that he had sloppy work habits and procrastinated, that he contributed to a miscarriage of justice, that he fabricated a tale about a judge who disagreed with his conclusions and that when he testified as an expert witness, he thought he was supposed to be on the Crown's side, not an independent scientist.

A review of Smith's work, which prompted the inquiry, found Smith made significant errors in 20 of 45 suspicious child deaths he helped investigate between 1991 and 2001. In 12 of those cases, people were criminally convicted.

One man was wrongfully convicted and served 12 years in jail for the rape and killing of his niece. William Mullins-Johnson was acquitted of the crime in October, and Smith offered him an emotional apology at the inquiry.

When scrutiny of Smith's work intensified in 2005, he left Toronto's Hospital for Sick Children and began a one-year contract in Saskatoon as a surgical pathologist in September of that year. He was restricted to analyzing samples collected from live patients, such as cancer biopsies. However, when it came time for the Saskatoon Health Region's board to approve his hospital privileges -- a process that's usually a rubber stamp -- the board said no.

With no hospital privileges, the health region terminated his contract in December 2005.

Smith appealed the board's decision to a rarely used provincial tribunal, and in November 2006, the tribunal ruled the regional health authority made a mistake by denying Smith privileges.

The tribunal said it would have ordered the health region to reinstate Smith, except his licence to practise medicine in the province had expired by then.

Bryan Salte, associate registrar with the College of Physicians and Surgeons of Saskatchewan, said Smith re-applied for his Saskatchewan licence, which was granted from February to December 2007. The licence was issued on the condition he not practise forensic pathology, Salte said.

Salte said it "would be extremely unlikely" Smith practised medicine during that time, since he would have to be employed by a health region to work in his specialty. Several Saskatchewan health regions contacted by The StarPhoenix said Smith is not, and has not, been working there.

Smith is paying $300 a year for an "inactive" licence in Saskatchewan, meaning he can apply to have his licence re-instated with less paperwork than starting from scratch, Salte said.

James Winkel, a spokesperson with the Saskatoon Health Region, says Smith has since applied for two job postings for anatomic pathologists in Saskatoon. He did not get either job, and the positions were filled by other candidates, Winkel said.

"He's a pediatric pathologist so the qualifications didn't fit the positions," Winkel said.

Evert van Olst, legal counsel for the health region, said he could not comment on Smith's suit because the region has not yet been formally served with a statement of claim.

"This is the first I've heard about it," van Olst said. "I'm assuming that he issued it out of some kind of abundance of caution, and maybe doesn't have an intention of serving it."

The tribunal never gave the health region a solution to deal with Smith's "unfair" treatment, van Olst said.

Smith could not be reached for comment, nor could his lawyer, Bainbridge.

In his suit, Smith is asking the health region for damages, including loss of salary, employment benefits, stipends, professional stature and emotional stress. He's also claiming damages "exceeding $50,000."

People prosecuted and sent to jail because of Smith's forensic conclusions have said their lives were devastated by his sloppy work. Peterborough, Ont., mother Brenda Waudby was charged with second-degree murder when her 21-month-old daughter was beaten to death. Smith did not turn over to police a pubic hair health-care workers found on the child's body. International experts who reviewed the case found Smith had estimated the tot's time of death incorrectly and concluded the toddler likely died when a male babysitter was caring for her. Charges against Waudby were dropped and the babysitter was convicted of manslaughter.

In 1997, Louise Reynolds was charged with second-degree murder in the stabbing death of her seven-year-old daughter. She spent nearly two years in jail awaiting trial before the Crown prosecutor withdrew the charge. A forensic expert from the U.S. found the child had actually been mauled to death by a dog.

© The StarPhoenix (Saskatoon) 2008

Tuesday, February 5, 2008

Seeking Solutions

Seeking solutions

The Goudge Inquiry ( has commissioned an extensive series of research papers. One will examine whether there is adequate legal aid funding for defence experts in criminal cases involving child deaths.

The imbalance between the financial resources of the state and ordinary citizens when it comes to hiring experts is a big issue internationally.

In England, trial judges no longer have the power to order the government to pick the costs of a defence expert. "The defence has to persuade the legal services commission to grant funding," says barrister Edward Henry.

Closer to home, Legal Aid Ontario pays psychologists and psychiatrists who testify as expert witnesses up to $325 for a half day's work — well below what many would charge privately paying clients.



What is it? Public inquiry headed by Justice Stephen Goudge on the work of Dr. Charles Smith and Ontario's pediatric forensic pathology system generally.

What prompted it? A review by international experts that found Dr. Smith made serious errors in 20 of 45 criminally suspicious deaths he investigated between 1991 and 2001.

What fallout did Dr. Smith's work have? Helped lead to homicide charges against parents and other caregivers, many of which were unwarranted.

When did the hearings start? Nov. 12, 2007

When does Dr. Smith begin testifying? Jan. 28

When is Justice Goudge's report due? No later than April 25

A Clue As To How Dr. Charles Smith Attained His Reputation As A "Forensic Pathologist"; by Harold Levy

Sunday, January 13, 2008
A Clue As To How Dr. Charles Smith Attained His Reputation As A "Forensic Pathologist";




A previous post pointed out that when he was appointed head of the newly formed Ontario Forensic Pathology Unit in 1991 Dr. Charles Smith had no formal training as a forensic pathologist.

Yet we have also learned that Dr. Smith was looked to as a forensic pathologist by his colleagues at the Hospital For Sick Children - and presumably by the judges who invariably permitted him to give opinion testimony as an expert in the criminal courtroom.

(I have talked to several judges in recent years who frankly acknowledge that they were so drawn in by Dr. Smith's impressive demeanour, confident delivery, and impressive C.V. - loaded with references to courses, conferences, periodical articles and lectures - that they dropped their guard and didn't insist on exacting evidence that he was qualified to give the testimony.)

The clue as to how Dr. Smith's colleagues and others, such as judges, crown attorney's and police officers can be found in the evidence of Dr. Dirk Huyer to the Goudge Inquiry.

When asked by Commission Counsel Linda Rothstein "did you draw any distinction between Dr. Smith as a certified pediatric pathologist and as someone who didn't have formal training as a forensic pathologist? Was that a meaningful distinction to you?

"I don't think I was aware of that," Huyer, who testified about the great respect he had for Dr. Smith's forensic work, replied.

"You weren't aware that he -- he wasn't trained as a forensic pathologist?" an apparently incredulous Rothstein shot back?

"No, he was -- he was portrayed to me as a forensic pathologist, and I interpreted that he was a forensic pathologist," Huyer replied.

"I don't know if I ever reviewed his CV or -- or understood specifically the training that he had.

He was in the role as the pathologist dealing with cases where there was significant concern and suspicion prior to my arrival is the understanding that I -- that's what I remember, anyways..."

In an interesting exchange, Commissioner Goudge suggested to Huyer that like Smith, he also lacked formal training in forensic matters - even though, as a member of the Hospital For Sick Children Suspected Child Abuse and Neglect (SCAN) team, he would be involved in cases where there was suspicion.

In Commissioner Goudge's own words: "I guess you, as a member of the SCAN Team, were involved in those cases without any formal training in forensics, as well?

Huyer's reply: "Absolutely, yeah. So I don't know if I thought that through at the time. I certainly knew what I was doing, --


In the view of this humble Blogster, it was easy for Dr. Smith to become accepted as a properly qualified forensic pathologist because he had been appointed head of a c unit which was called "The Ontario Forensic Pediatric Pathology Unit."

Whenever he testified in court, the inclusion of "Forensic" in the name of the unit, would quite reasonably suggest to the judge and anyone else involved in the criminal justice process - including jurors, prosecutors and police officers - that he was a formally trained forensic pathologist.

And Dr. Smith would be under no obligation to inform the court or any one else that he had never received specialized training in forensic pathology - which we have learned during the inquiry is a highly complex specialized field that has no room for "dabblers."

There is also the reality that forensic pathology was totally under-developed in Canada - with the consequence that Dr. Smith virtually had the field for himself - without having to prove himself to anyone else.

In short, Dr. Huyer was not the only person to assume Dr. Smith was a fully qualified forensic pathologist because he looked and played the part - many others innocently fell prey to the same mistake.

This humble Blogster is not suggesting in any way that Dr. Smith deliberately misled the public or the judicial system as to his qualifications.

He didn't have to.


Ontario Chief Coroner - Backgrounder on Dr Charles Smith

Backgrounder/ Document d’information
Office of the Chief Coroner
Bureau du coroner en chef
26 Grenville Street
Toronto ON M7A 2G9
Telephone: 416 314-4000
Facsimile: 416 314-4030
26, rue Grenville
Toronto ON M7A 2G9
Téléphone : 416 314-4000
Télécopieur : 416 314-4030
April 19, 2007


In November of 2005, Dr. Barry McLellan, Chief Coroner for Ontario, announced the scope and format of a review into 44 criminally suspicious and homicide cases, dating back to 1991, where Dr. Charles Smith had performed an autopsy or provided an opinion in consultation. The purpose of the review was to determine whether the conclusions reached by Dr. Smith in his autopsy or consultation reports, or during his testimony where applicable, could be supported by the information and materials available for independent review.

At the time of the original announcement in November 2005, 44 cases had been identified for review. They included cases where at some point in time, the death had been determined to be a homicide or criminally suspicious and where Dr. Smith was either the primary or a consulting pathologist. Of the 44 cases, 43 dated back to 1991 when the Provincial Paediatric Forensic Pathology Unit first opened, and the other case was a 1988 death that had received significant public attention. Through the process of collecting information and reviewing files, it became evident that there were 45 cases that met the review criteria.

The scope and format for the review were determined with advice from the Forensic Services Advisory Committee of the Office of the Chief Coroner. This Committee was formed to strengthen the independence and objectivity of the Office, as well as to improve communication with key stakeholders. Advice to the Chief Coroner is provided through this multidisciplinary Committee that includes representatives from the Office of the Chief Coroner, the Centre of Forensic Sciences, various police services, the Prosecution Service and the Defence Bar. Committee members share a common interest in advancing the quality and independence of all aspects of post mortem examinations conducted on coroners’ cases.
The review was conducted by a panel of internationally respected experts in forensic pathology. The members of the committee included:

Dr. John Butt - Consultant in Forensic Medicine, specializing in expert opinion and evidence, as well as education about investigation and pathology of sudden death and serious injury. Prior to setting up an independent consulting practice, Dr. Butt was the Chief Medical Examiner for the Province of Nova Scotia and before this, he was the Chief Medical Examiner for Alberta.

Professor Christopher Milroy - Professor of Forensic Pathology at the University of Sheffield, England, consultant pathologist to the British Home Office and Honorary Consultant in forensic pathology for the Sheffield Teaching Hospitals National Health Service Foundation Trust.

Professor Helen Whitwell - Professor of Forensic Pathology at the University of Sheffield and a consultant pathologist to the Home Office. She brought special knowledge and expertise to the panel in the area of neuropathology.
Professor Jack Crane - State Pathologist for Northern Ireland, a Professor of Forensic Medicine at The Queen’s University of Belfast, and a consultant pathologist of the Northern Ireland Health and Social Services Boards.

Professor Pekka Saukko - Professor and Head of the Department of Forensic Medicine at the University of Turku in Finland.

The cases were prioritized for review based on whether persons who were convicted or found to be Not Criminally Responsible, as a result of any previous court proceedings still had restrictions imposed on their liberty, including those persons who were out of custody, but on parole or on bail. An initial screening review of the investigation materials from the remaining cases by a subcommittee of the Forensic Services Advisory Committee, with forensic pathology, police, and Crown and Defence counsel members, identified 10 cases where there did not appear to be any potential controversial issues with medical evidence. These cases underwent the same structured review, but were reviewed by other senior pathologists in Ontario, in order to ensure best use of the external reviewers’ time to deal with the more potentially difficult and complex cases.

All 45 cases were reviewed through a structured process. The reviewers were specifically asked to provide their opinions on the following:
• whether they agreed that the important examinations were conducted;
• whether they agreed with the facts reported as arising from the examinations conducted and;
• whether they agreed with the interpretation of the examinations conducted with respect to the cause and where an opinion was provided, the mechanism of death.

The materials reviewed by the pathologists included:
• autopsy reports or consultation reports completed by Dr. Smith;
• the coroner’s warrant;
• any other autopsy or consultation reports arising from the investigation and, where available, second opinion pathology consultation reports;
• photographs from the autopsy and death scene;
• microscopic slides and any other pathology materials;
• police reports;
• reports from the Centre of Forensic Sciences and
• where available, selected relevant court transcripts arising from all pathology and any related medical evidence, for those cases that proceeded through the criminal courts. The review did not include, and was not designed to include, the entire Court record in each individual case.

Wherever possible, families of the 45 children who formed the basis of this review, and counsel who represented parties on matters arising from the coroner’s investigations into these deaths, were contacted directly prior to the start of the review. Wherever possible, families of the children, or their counsel, have also now been informed of the results of the review of their child’s death. Families of the children are entitled to receive the reports arising from the review of their child’s death consistent with the Coroners Act, subject to any ongoing Court proceedings, and the Office of the Chief Coroner will now be making these reports available. Families who have not yet been contacted, may call the Office of the Chief Coroner at 1-877-991-9959 at any time in order to inquire about obtaining reports.

A total of 45 cases were reviewed. The first question dealt with the examinations that were conducted, recognizing that in three cases Dr. Smith was performing a post-exhumation autopsy and in four cases he was providing an opinion in consultation, not having had the opportunity to conduct an autopsy himself. In all but one of the 45 cases, the reviewers agreed that Dr. Smith had conducted the important examinations that were indicated. In one case, there was concern that a complete examination had not taken place and in this same case that a specimen taken at autopsy had not been submitted at the time for potential testing. This concern was made known to appropriate Crown and Defence counsel who had carriage of this case prior to the case coming to conclusion in the Criminal Courts.

The second question was whether the experts agreed with the facts reported as arising from the examinations performed. In nine cases the experts did not agree with significant facts that appeared in either a written report or that came forward during expert testimony in Court. A common theme centred around the timing of certain injuries, including fractures.
The final question was whether the reviewers agreed with the interpretation of the examinations conducted with regard to the cause and where Dr. Smith provided an opinion, the mechanism of death. In 20 of the 45 cases, the reviewers had some issue with the opinion of Dr. Smith that appeared in a written report, testimony in Court, or both. The concerns raised by the reviewers in these 20 cases ranged from relatively minor to potentially more serious issues. In a number of these cases the reviewers felt that Dr. Smith had provided an opinion regarding the cause of death that was not reasonably supported by the materials available for review.
There were restrictions of liberty arising from findings of guilt, including 12 convictions and one finding of Not Criminally Responsible, in 13 of these cases where the reviewers did not agree with significant facts or with the interpretation of the examinations conducted. To date the reports of the reviewers have been provided to Crown and Defence counsel in three of these 13 cases. The reports in all of the remaining cases will be provided to the Crown and they will then be appropriately disclosed to Defence counsel.
The Chief Coroner appreciates the public concern that may arise as a result of the reviewers having expressed differing opinions in cases where there were subsequent convictions or a finding of Not Criminally Responsible. As indicated, the opinions of the external reviewers and the concerns leading to this opinion for all of these cases have been, or are in the process of being shared with appropriate Crown and Defence counsel. The significance of the concerns expressed by the reviewers, specifically with respect to the role any medical evidence may have played in a finding of guilt, will therefore be appropriately considered.

It is important to provide a context for the concerns expressed by the reviewers in two cases with respect to Dr. Smith’s opinion on the cause of death and mechanism of death. In two cases the reviewers noted that the opinions reached by Dr. Smith were not inconsistent with the body of knowledge available at the time — the early 1990’s — with respect to paediatric head injury. In fact, there is still disagreement between medical experts today as to the significance of certain findings in some cases of paediatric head injury. Although the reviewers disagreed with Dr. Smith’s opinion, they felt that his conclusions in these two cases were consistent with what other Pathologists and medical experts may well have concluded at the time he provided his opinion.

It is also important to provide a context for the overall results of this review. Dr. Smith was conducting his work as one member of a larger death investigation team. This means that Dr. Smith was, in part, relying on information provided to him by coroners, police, and other forensic experts. Dr. Smith, working as a pathologist within the Coroner’s system, frequently presented his findings and opinions at meetings and rounds where other pathologists and coroners would have had an opportunity to provide feedback and, where appropriate, disagree with the opinion being presented. In a number of these cases other pathologists may have reviewed or audited Dr. Smith’s work as part of a quality assurance process. In certain cases where expert testimony was given, Defence experts appear not to have recognized concerns that have now been brought forward as a result of this review.

Lessons have been learned in the Ontario Coroner’s System through previous cases and as a result of this review. Maintaining public confidence in the Ontario Coroner’s System was an underlying reason for conducting this review. Some of the positive changes that have taken place and some of the processes that are now in place to ensure the highest quality of forensic death investigation include:

• In 1995, the Office of the Chief Coroner developed a protocol for coroners, pathologists, police, and other members of the death investigation team to follow when investigating paediatric deaths. This protocol, focusing on deaths of children under the age of two years, has subsequently been presented at a number of educational courses and has become the standard operating procedure for all members of the death investigation team. The protocol has been shared with other jurisdictions and has been used as a template for other death investigation systems. A number of improvements have subsequently been made to the protocol. Late last year, a revised protocol was released through the Office of the Chief Coroner whereby all child deaths under the age of five years are now subjected to this standardized investigation.

• The Office of the Chief Coroner has two review committees focusing exclusively on complex paediatric deaths. The Deaths Under Five Committee reviews the investigation materials and coroners’ conclusions on all deaths under the age of five years to ensure consistency in the examinations conducted and the conclusions reached. The Paediatric Death Review Committee reviews complex paediatric deaths, including all cases where Children’s Aid was involved prior to the death.

• All autopsies conducted on children under the age of five years are now performed in only one of four centres throughout the province: London, Ottawa, Hamilton and Toronto. This change was introduced in early 2002 to ensure that these complex autopsies are performed at centres where there is the greatest expertise in pathology and paediatric specialties, and where the resources for special tests such as CT or MR imaging are most accessible.

• All forensic autopsies on criminally suspicious cases, homicides, and cases going to inquest, now undergo a standardized audit process. A process of audit began in 1995 and has subsequently undergone a number of improvements. The current audit process, under the direction of the Chief Forensic Pathologist, is intended to ensure that all important examinations have been performed and that the facts arising from these examinations and the conclusions reached are logical and clearly supported by the materials available for any independent review.

• Guidelines have been prepared for autopsies on all criminally suspicious and homicide cases, under the direction of the Chief Forensic Pathologist. These guidelines have recently been updated to include a paediatric module. The guidelines include the important examinations to be completed and the documentation and specimen retention expected, to ensure that the conclusions reached are independently reviewable.

• Guidelines have also been produced for coroners focusing on the important observations to make at scenes, documentation expected in coroners’ reports and the essential communication that is expected with pathologists and other members of the death investigation team. It is the coroner, at the conclusion of the investigation, that is responsible for certifying the death, including determining the cause and the manner of death. Arising from this review, an audit was performed of the Coroner’s Warrant for Autopsy and the Coroner’s Investigation Statements. In 11 of the 45 cases reviewed, the Warrants were completed with less information than what is currently expected based on the guidelines, although in no cases was it felt that the deficiencies identified impacted on the conclusions reached by Dr. Smith.

Regardless, there is need for better communication between coroners and pathologists. As a result of this audit, it will soon be policy for direct telephone or in person communication between the coroner and pathologist, prior to the commencement of the autopsy, for every criminally suspicious or homicide case and for all deaths under the age of five years.

• A special course has been developed for pathologists who provide expert testimony in court. With the assistance of Crown counsel, Defence counsel and pathology experts, the importance of balanced and fair testimony are emphasized through a two-day course that includes mock examination and cross-examination. This course will be offered again in June 2007.

• Early case conferences are now held following all homicides and criminally suspicious cases, wherever there are outstanding issues or significant unanswered questions following the autopsy. These case conferences include a senior coroner, the pathologist who conducted the examination, scientists from the Centre of Forensic Sciences, police and any other experts as appropriate. These case conferences are held, in part, to ensure that all members of the death investigation know what has been found at the time of the autopsy and what outstanding examinations or test results are necessary before appropriate conclusions can be reached by the pathologist.

A number of these steps to improve the quality of investigations have been, and will continue to be, shared with other jurisdictions through educational courses and presentations.

This review covered the work of Dr. Smith from 1991 to 2002. Dr. Smith did, however, also conduct autopsies and provide opinions on cases between 1981 and 1991. Given the results of this review, there may well be cases prior to 1991, which raise similar concerns. With this in mind and also being mindful of the fact that the greatest concern surrounds cases with findings of guilt and restrictions of liberty, the Office of the Chief Coroner will work with the Ministry of the Attorney General to try to identify all such cases where Dr. Smith conducted an autopsy, or provided an opinion in consultation, prior to 1991.

As this list of cases is developed, the Prosecution Service will take the lead to disclose the overall results of this review to the person whose liberty was restricted. If any such person asserts their innocence and requests that their case be reviewed, the Office of the Chief Coroner will then assist the Prosecution Service and the Defence to arrange for an independent review of Dr. Smith’s forensic pathology work and opinion. The results of the individual review will then be appropriately shared with the person requesting the review through the disclosure process.

As indicated in the original announcement, the start date of 1991 was an arbitrary one that coincided with the opening of the Paediatric Forensic Pathology Unit. This additional step is being taken at this time to ensure that cases of greatest potential concern are reviewed, regardless of when the work was conducted.
Conducting this review has been an essential step for the Office of the Chief Coroner. The Office of the Chief Coroner performs more than 20,000 death investigations and pathologists working for the Office conduct almost 7,000 autopsies every year. Coroners’ investigations lead to many important recommendations to advance public safety and information gained through death investigations is essential for the administration of justice. The public must have confidence in the death investigations conducted by this Office. The Office of the Chief Coroner is unaware of any other jurisdiction that has as many processes in place to ensure the highest quality of death investigation, including independently reviewable post mortem examinations.

Contact: Dr. Barry McLellan Chief Coroner for Ontario Ministry of Community Safety and Correctional Services 416-314-4000 or 416-314-4100
Disponible en français

Those Affected By Dr. Charles Smith's Findings - Ontario - Smith inquiry reveals details of 10 new cases
Discredited pathologist Dr. Charles Smith made questionable findings

November 14, 2007

Theresa Boyle Staff reporter

Extensive details of 10 new cases in which discredited child pathologist Dr. Charles Smith made questionable findings were unveiled at a public inquiry yesterday.

Justice Stephen Goudge, who is heading the Inquiry into Pediatric Forensic Pathology in Ontario, issued a publication ban on the names of some of the victims while others were replaced by pseudonyms.

Lawyers for individuals covered by the ban said the move was necessary to protect their clients from further hardship.

But the case files, some more than 100 pages long, reveal the details of the deaths of the 10 children – most of them infants; one almost 4-years-old.

In all of the cases yesterday, criminal charges were laid against one or both of the parents based on Smith's findings after autopsies on the victims.

The inquiry has chosen to deal with 18 of the 20 cases in which there were found to be problems. The 18 case histories released yesterday – including the 10 previously undisclosed – filled two large binders.

During testimony yesterday, the inquiry heard that senior officials in the province's chief coroner's office decided four years ago that the brakes had to be put on Smith.

"Decision by all present – he can't continue medical-legal post-mortems or committee work," state notes taken by Al O'Marra, then chief legal counsel to the office of the coroner.

He was referring to Smith, who was present at that October 2003 meeting along with then-chief coroner Jim Young, deputy coroner Jim Cairns, and acting chief coroner Barry McLellan.

The committee work referred to in O'Marra's notes were the Pediatric Death Review and Death Under Two committees. Smith sat on both.

O'Marra's notes were tabled yesterday as exhibits.

The province called for the inquiry after it was revealed that problems had been found in 20 child-death investigations in which Smith performed autopsies or rendered opinions. In 12 of those cases, individuals were convicted of crimes; in one, an individual was found not criminally responsible; and in seven, people were suspected or charged with crimes but not convicted.

O'Marra's notes from the high-level meeting indicate that Smith did not want to take responsibility for the problems.

"No insights into problems – deflects all criticism to failings of others," read the notes.

McLellan, who testified yesterday, revealed that there was some disagreement in the chief coroner's office on what to do about Smith. McLellan favoured a hard-line approach, but his boss at the time, Young, disagreed.

"We did not agree. ... Dr. Young was aware of my position. I certainly respected his position as chief coroner," McLellan said.

But when McLellan was promoted to the job of chief coroner in April 2004, he took immediate steps to remove Smith from the position of head of the Ontario Pediatric Forensic Unit, located at the Hospital for Sick Children.

"I met with Dr. Smith and I indicated that I felt he should not be continuing in that role," McLellan said.

The inquiry heard how Young had publicly stated that an internal review was necessary, after murder charges were dropped in the case of Louise Reynolds, who spent two years in jail for the death of her 7-year-old daughter. Smith had concluded the child was stabbed to death but a review by other pathologists determined she was mauled by a pit bull.

Commission counsel Linda Rothstein said evidence will be produced in the coming days showing that despite Young's call for an internal review at that time, the coroner "later determined that a review would not go ahead because of legal advice."

Smith himself had even asked his superiors to intervene after charges were withdrawn in the Reynolds case and in the case of a woman who had been charged with killing her 3-year-old stepson. Other pathologists had determined the boy died after a fall.

In a January 2001 letter to Young, Smith asked to be excused from the performance of medical-legal autopsies and that an external review be done of his work.

Concerns about Smith persisted as the number of questionable cases continued to mount, the inquiry heard.

"I personally had concerns about Dr. Smith's ongoing involvement with committees, with conducting autopsies and with being the director of the unit in the context of ongoing concerns about his work," said McLellan, who also noted that Smith had an ongoing problem with tardiness.

He said that in 2003, Cairns responded to the concerns by removing Smith from the committees that investigate child deaths.

"He was still at this time conducting autopsies on non-homicide and non-criminally suspicious cases and he was still director of the unit," McLellan noted, referring to the Hospital for Sick Children's forensic unit.

Smith's performance was eventually addressed by a forensic services advisory committee, which is expected to be further examined by the inquiry today.

The new cases

1. Baby F

Date: Born and died Nov. 28, 1996.

Case facts: Baby F’s mother, a teenager, told police she had felt sick after coming home from school. After sitting on the toilet for 30 minutes, she saw a great deal of blood. Under hypnosis, she recalled seeing a baby in the toilet covered in blood and water. She put the baby, wrapped in a towel, in a plastic bag in her closet. On July 6, 1998, she pleaded guilty to infanticide and was given a two-month “conditional sentence, to be served at home,” three years’ probation and 150 hours of community service. A psychiatric assessment indicated that Baby F’s mother had been “consistent in denying that she knew about the pregnancy” and was suffering from “acute stress disorder.”

Smith’s finding: The baby girl appeared to be full-term and survived “for a period of time” following delivery. Death was caused by asphyxia, attributed to infanticide.

Outcome: Baby F’s mother was granted a pardon on Oct. 24 last year.

2. Tamara

Date: Born Jan. 18, 1998; died Feb. 8, 1999.

Case facts: Tamara had no contact with her father until September 1998, after which her mother testified he came over three or four times a week and helped look after Tamara and her two sisters. The Children’s Aid Society was notified after Tamara was treated at Sick Kids’ hospital on Jan. 20, 1999, for a broken thigh. Tamara and one of her sisters were left in the care of Tamara’s father the morning of Feb. 8, her mother said. She called several times but he didn’t answer. He told police she was in her playpen with a bottle and he fell asleep. Tamara’s mother testified that when she came home, Tamara was lying on her back with a scrape on her forehead and a bruise on her cheek and not breathing. A radiology report found “multiple fractures in various stages of healing ... highly suspicious for nonaccidental trauma.” The father was charged with second-degree murder.

Smith’s finding: Cause of death was given as “asphyxia associated with multiple traumatic injuries.”

Outcome: Tamara’s father pleaded guilty to manslaughter Aug. 30, 2001; he was sentenced to 15 months time served and 361/2 years prison.

3. Katharina

Date: Born March 20, 1992; found dead Sept. 15, 1995.

Case facts: Katharina’s father, Lawrence Babineau, and mother, Gabriela Chaparro-Najar, married in 1993 when the baby was 11 months old. The family lived in Oshawa until June 1994, when the parents split up and the mother moved with Katharina to her sister’s home in Toronto. A custody battle began with Chaparro-Najar alleging that Babineau had abused the child and Babineau claiming she had threatened to kill Katharina rather than let him have custody. Babineau told police he feared she would flee with the child to her native Colombia. Police forced entry into the apartment. They found Katharina’s body in the bedroom and Chaparro-Najar climbing over the balcony. She was charged with murder.

Smith’s finding: Death was caused by “asphyxia in a pattern of neck or chest compression,” consistent with having been suffocated with a pillow. The exact time of death, he said, was uncertain.

Outcome: On Nov. 3, 1997, Katharina’s mother was found not criminally responsible. She was detained at the Centre for Addiction and Mental Health until April 2001. She received an absolute discharge on Dec. 13, 2001.

4 .Taylor

Date: Born April 16, 1996, in Thunder Bay; found dead July 31, 1996.

Case facts: Taylor’s parents, Lanny and Laura, were charged with second-degree murder, criminal negligence causing death and failure to provide necessities of life. The couple had had an argument, after Taylor had been put to bed, and Laura left the apartment carrying her son from a previous relationship. Lanny followed her and the couple were seen arguing and crying before the three returned home. Lanny reported he fell asleep on the couch and was woken by Laura’s screams. An autopsy revealed several broken ribs and a brain injury. Cause of death was given as acute head injury. There was information that Larry had abused a child he had with another woman.

Smith’s finding: Noting that the original radiologist’s report observed two or three fractures, Smith said a review of evidence indicated a total of 14 fractures and other possible injuries. He said the cause of death was consistent with “blunt trauma,” not shaking.

Outcome: Lanny and Laura were discharged on all counts because “there was no evidence of motive, intent or exclusive opportunity to cause the injury that resulted in Taylor’s death.”

5. Tyrell

Date: Born Feb. 1, 1994; died Jan. 23, 1998.

Case facts: Tyrell’s father, Garth, was in jail for manslaughter and the whereabouts of his mother, Janette, unknown. He lived with Garth’s former partner, Maureen, and her two children. Medical reports said Maureen said Tyrell had been running around, jumped off a couch and fell, hitting his head. He was taken to hospital Jan. 19, 1998, after she couldn’t wake him. He was transferred to the Hospital for Sick Children, where he died. Cause of death was recorded as “herniation of brain stem ..... consistent with a severe shaking episode.” Maureen’s son told police she hit Tyrell “a lot.” Maureen was charged with second-degree murder.

Smith’s finding: Smith reportedly told police that the head injury was caused “by flat object — impact.” He testified that Tyrell did not show signs of “classic shaking” but couldn’t rule out the possibility. Smith noted a contusion or discolouration to the brain that was noted by another examiner, who disagreed with his opinion that “a household fall can result in death only when there is epidural hemorrhaging.”

Outcome: The charge against Maureen was withdrawn Jan. 22, 2001.

6. Dustin

Date: Born Sept. 9, 1992; died Nov. 18, 1992.

Case facts: Dustin lived in Belleville with his parents Mary and Richard. After an argument,
Mary spent the night at a friend’s home, leaving Dustin with Richard. When she returned, there was another violent quarrel and Richard left, taking Dustin and Mary’s daughter, who was not his biological child. Richard was later seen pushing a baby carriage. Dustin was in it, a witness said, “with foam (coming) out of his nose. He was white and his eyelids were blue.” The witness told police Richard shook Dustin, but not violently. A hospital radiologist reported injuries “strongly suggestive of a shaken baby.” Cause of death was given as respiratory failure and a traumatic brain injury.

Smith’s finding: Smith commented in his report that “In the absence of a credible explanation, this injury must be regarded as non-accidental in nature.” In testimony, he said, “Though I would prefer the explanation that it was a shaking-type injury, I cannot rule out the possibility that, in fact, he was stuck by some blunt object.”

Outcome: On April 21, 1995, Richard pleaded guilty to aggravated assault and was jailed six months.

7. Gaurov

Date: Born Feb. 11, 1992; died March 20, 1992.

Case facts: On March 18, the mother of a 5-week-old boy called 911 and said he had
stopped breathing. According to the father, he had been fed at 12:30 a.m. A half-hour later the father heard the baby cry and picked him up. He took several breaths, gasped, turned blue and went limp. The father tried to resuscitate him. Emergency services and Gaurov’s aunt and uncle arrived. The aunt shook him a couple of times to try to revive him. He was rushed to hospital with no heartbeat and not breathing. He was intubated and his heartbeat restored. After tests, he was transferred to the Hospital for Sick
Children. A CT scan found brain hemorrhaging consistent with shaken baby syndrome. On March 20 baby Gaurov died.

Smith’s finding: Smith listed cause of death as “head injury.” In his autopsy report he stated the baby had acute epidural hemorrhaging of the spinal cord and acute subdural hemorrhaging.

Outcome: Gaurov’s father was charged with second-degree murder on July 1, 1992. On Dec. 3, 1992, he pleaded guilty to criminal negligence causing death and was sentenced to 90 days.

8. Delaney

Date: Born Dec. 20, 1992; died May 23, 1993.

Case facts: Five-month-old Delaney lived with his mother, Olga Policarpo, in Woodstock, Ont. On the day before his death his mother had invited her relatives to her house to pray for help for her 2-year-old niece, who had liver and heart problems. Relatives later said they communicated with the Virgin Mary. Delaney was found dead the next day. Policarpo was arrested and taken to hospital, where doctors assessed her as being in a psychotic state.

Smith’s finding: The cause of death was listed as “asphyxia.” Smith told police the baby’s death was caused by compression or blunt trauma injury and there was evidence of hemorrhaging in the upper chest and lower neck. In a request for a skeletal survey of Delaney, he wrote: “Sudden death of baby while family was involved in cult-like activities.”

Outcome: Policarpo was charged with second-degree murder. While in hospital she told Susan Garton, a nurse at London Psychiatric Hospital, that the Lady of Guadeloupe “made me kill my baby.” She was found not guilty of second-degree murder but was convicted of infanticide.

9. Amber

Date: Born March 13, 1987; died July 30, 1988.

Case facts: Amber was born in Timmins, Ont. Her parents, Francis and Richard, left her in the care of S.M., a 12-year-old babysitter, on July 28, 1988. During the day the toddler fell down five stairs, the sitter said. Paramedics found the baby with no visible injuries and breathing irregularly. On July 30, 1988, she was pronounced brain dead. The cause of death was listed by the coroner as “cerebral edema due to head injury after an accidental fall.” An autopsy was requested due to “a high level of suspicion of foul play.”

Smith’s finding: Smith testified he believed Amber had been shaken to death. He told police there was no way the fall could have killed her. The final autopsy report was signed on Nov. 28, 1988, but Smith only cited a “head injury.”

Outcome: S.M. was charged with manslaughter on Dec. 15, 1988. She was acquitted on July 25, 1991. Smith testified Amber’s injuries “don’t fit those from a fall down stairs.” The judge ruled shaking wasn’t established to his satisfaction. S.M.’s father laid a complaint against Smith at the College of Physicians and Surgeons, which ruled Smith’s approach was acceptable.

10. Kenneth

Date: Born May 18, 1991; died Oct. 12, 1993.

Case facts: At the time of his death, the almost 2-1/2-year-old lived with his mother and stepfather, Rick, in Oshawa, Ont. Kenneth’s mother was still in high school in Scarborough when the baby was born. She came from “an abusive and dysfunctional family” and had problems with alcohol abuse and parenting. Kenneth had been in Children’s Aid Society care four times. He had repeated trips to the hospital for seizures, asthma, bumps, bruises and a broken leg. On Oct. 9, after an afternoon nap, Kenneth’s mother woke to find him twisted in his sheets and blankets and unable to breathe. She got him out and called 911. Paramedics found Kenneth without any vital signs. On Oct. 11 he was termed clinically dead.

Smith’s finding: In his post-mortem report Smith said the cause of death was asphyxia. He testified his findings from the autopsy were consistent with suffocation with a soft object or a plastic bag.

Outcome: Kenneth’s mother was convicted of second-degree murder in October 1995 and sentenced to life. While awaiting trial she gave birth to a son, which the CAS took away.

The known cases

Lianne Thibeault: Smith suggested Thibeault was responsible for the death of her 11-month-old son before another pathologist concluded the cause was undetermined.

Brenda Waudby: Because of Smith’s findings, that Waudby’s 21-month-old baby died of abdominal trauma that occurred hours, even days, before her death, Waudby was wrongfully charged. A babysitter later admitted beating the baby shortly before she died.

Anisa and Marco Trotta: After Smith’s pathology reports on the death of their baby were deemed unreliable, the couple, who already spent time in jail, were granted a new trial by the Supreme Court.

Louise Reynolds: After Smith concluded that her 7-year-old daughter’s injuries were consistent with stab wounds, Reynolds was charged with the death. It was later determined that her daughter was killed by a dog.

William Mullins-Johnson: Smith consulted on the case of Mullins-Johnson’s 4-year-old niece, determining she was strangled. After Mullins-Johnson spent 12 years in jail, Smith’s testimony was reviewed and he was acquitted last month.

Angela Veno and Anthony Kporwodu: Smith was criticized for “inexplicable tardiness” in filing reports after the couple was charged with killing their baby — charges later thrown out. Smith was cited for unwillingness to provide crucial evidence in other cases as well.

Sherry Sherrett: Based on Smith’s findings, Sherrett spent six months in jail for the death of her 4-month-old. Another pathologist later determined the baby died of natural causes.

Autopsy of a flawed career - News - Autopsy of a flawed career Pathologist became `bigger than his role,' lawyer says

April 20, 2007
Isabel Teotonio Staff reporter

World-renowned forensic pathologist Dr. Charles Smith spent decades building a stellar career out of the unenviable task of examining the broken, bruised bodies of dead children.

Smith's passion for both his job and for children proved a powerful combination that made him one of Canada's undisputed experts in determining when and how children died under suspicious circumstances.

But some say his career began to slump when he crossed the line from scientist to crusader and his objectivity narrowed to tunnel vision. The results, they say, were botched autopsies and shoddy work that implicated innocent people.

"He was certainly on a crusade," recalled lawyer Jim Hauraney, who represented Brenda Waudby, charged with killing her 21-month-old daughter, Jenna, in 1997 on the basis of Smith's conclusions.

"I think he became bigger than his role was. I think he became more prosecutorial," said Hauraney, adding the former pathologist at the Hospital for Sick Children lost his objectivity when reviewing the Waudby case. "He was very reluctant to give other opinions any (weight)."

The murder charge against Waudby was eventually withdrawn after medical experts disagreed with Smith's evidence. The child's babysitter was later convicted of killing Jenna.

But Waudby's wasn't the only case that raised alarm bells. In June 2005, Ontario's chief coroner Dr. Barry McLellan expressed concern over Smith's findings in several criminal cases and ordered an independent review of 45 autopsies dating back to 1991.

Yesterday, McLellan released those findings, saying the international experts had concerns in 20 of the cases and disagreed with conclusions reached in 13 cases where people were convicted of criminal offences – one of whom is still behind bars.

Smith has said he was born at the Salvation Army's Grace Hospital in Toronto and given up for adoption at three months. He spent years trying to find his biological mother, but when he finally tracked her down by phone, on her 65th birthday, she hung up on him.

Smith spent his childhood living across Canada and in Germany because his adoptive father was in the Canadian Armed Forces. He graduated from medical school at the University of Saskatchewan in 1975. He completed his training in pathology at the University of Toronto and was certified as an anatomic pathologist, someone who studies cells, tissue and organs to diagnose diseases.

In 1981, he was hired at Sick Kids where he studied tissue samples and conducted autopsies on children who had died of natural or accidental causes. Within years, he was performing autopsies on children who had met suspicious ends.

In 1991, when the coroner's office opened a special unit at the hospital to deal only with suspicious deaths of children, Smith was named the director.

In his off hours, Smith could be found on the hobby farm he shared with his wife and their two children just north of Newmarket. He also found solace in religion. In 2005, he told the Star he worshipped with the Christian and Missionary Alliance, a Baptist-like group that filled him with the belief he had a purpose in life: to give answers to parents who lose babies. "I've got a thing about people who hurt children," he said.

Smith's career was already unravelling when he was reprimanded in 2002 by the Ontario College of Physicians and Surgeons for his work on three suspicious death cases.

Smith resigned from Sick Kids in 2005 and moved to Saskatoon to accept a yearlong contract as a surgical pathologist, but was fired four months later. He was reinstated by an appeals tribunal but was unable to practise because his licence had expired.

Wednesday, January 30, 2008

Charles Randal Smith From Wikipedia

Dr. Charles Randal Smith was the head pediatric forensic pathologist at the Hospital for Sick Children in Toronto, Canada, from 1982 to 2003. The quality of his autopsies, and the resulting criminal charges and convictions of several people have been called into question, and a full public inquiry has been promised.


Dr. Smith graduated from the University of Saskatchewan in Saskatoon, Saskatchewan, Canada in 1975. He completed his training in Pathology at the University of Toronto and was certified as an anatomical pathologist in 1980. He joined the Hospital for Sick Children in 1981 as one of the rotating team of pathologists, and shortly was doing autopsies on children who had met sudden or suspicious deaths.

In 1992 the Ontario Coroner’s Office created a pediatric forensic pathology unit at Hospital for Sick Children and Smith was appointed director. He had become almost solely responsible for investigating suspicious child deaths in Ontario. In this period he conducted hundreds of autopsies and testified in court multiple times. He conducted training sessions for lawyers on how to examine and cross-examine expert witnesses, and training for law-enforcement and medical staff on detecting child abuse. He pioneered the use of CAT-scan technology on the remains of children to detect the signs of abuse.[citation needed]

In 2002 he received a reprimand with a caution from the Ontario College of Physicians and Surgeons for his work on three suspicious death cases, and in 2003 he was removed from performing autopsies. In July 2005 he resigned to take up a position at Saskatoon City Hospital, from which he was dismissed in December 2005. He was reinstated for a period in 2006, after arbitration. He pled guilty to a charge of unprofessional conduct handed down by the College of Physicians and Surgeons of Saskatchewan, for not disclosing he was under investigation in Ontario. He currently resides in Victoria.

In 2005 the Office of the Chief Coroner of Ontario launched a full review of 44 autopsies conducted by Dr. Smith, including 13 that had resulted in criminal convictions. Released in April 2007, It concluded that at least 20 of them were unsatisfactory.

Cases of Concern

An un-named 12 year old (the names of children under 18 and their families charged with crimes cannot be released under Canadian Law) from Timmins, Ontario, was charged with manslaughter, based on Dr. Smith’s testimony, and 3 years and $150,000 later, she was completely cleared in 1991. Ontario Provincial Court Judge Patrick Dunn, after hearing from 9 other expert witnesses testifying that the cause of death was an accidental fall, criticized Dr. Smith for not even following his own prescribed autopsy procedures in accusing the Grade 6 student of shaking a 16-month-old baby to death.

Lianne Thibeault (née Gagnon) 11 month old son Nicholas died suddenly in 1995. The police investigation ruled out foul play, but a year later the chief coroner’s office asked Dr. Smith to review the case, and he concluded that it was homicide, attributable to blunt head injury. He exhumed the body, and after performing an autopsy concluded that Nicholas died from brain swelling consistent with blunt force injury, although he could not rule out asphyxiation.

When the Crown did not lay charges, Dr. Smith informed the Children’s Aid Society that he was 99% certain that Thibeault, then pregnant, had killed Nicholas. The CAS took wardship of her unborn child and placed her name on the list of known child abusers. After the birth, she was not allowed to be alone with her baby. Her father launched a court battle to clear her name, which was ultimately successful, with the Court’s own independent expert summarily dismissing Smith’s opinion. CAS did a complete about-face.

Maureen Laidley was charged with killing Tyrell Salmon, the three-year-old son of her boyfriend. Laidley says the boy had been jumping off a couch, slipped and banged his head on a marble coffee table. But police arrested her after Smith told them that injuries like that cannot cause death. The charge was abruptly stayed when outside experts testified that the injuries were fully consistent with the Laidley’s account.

William Mullins-Johnson was found guilty after a two and half week trial in September 1994, of the first-degree murder of Valin Johnson of Sault Ste. Marie. He was convicted after a jury trial in which Dr. Smith’s evidence played a major role in determining the time of death, the cause of death and whether the girl had been sexually assaulted. Mullins-Johnson had babysat Valin, 4, and her 3-year-old brother on the evening of June 26, 1993. When the girl's mother returned home, she did not check on her daughter. At 7 a.m. the next day she found Valin dead in bed.

A local pathologist performed an autopsy on Valin. Then "consultation reports" were sought from Smith and four other specialists, based on tissue samples and other evidence from the autopsy. Smith was the only consultant to conclude Valin was sexually assaulted at the time of death. That contradicted the defence's point that Valin, who had a history of vomiting in bed, might have died of natural causes. The jury convicted, which the Ontario Court of Appeal upheld 1996, and the Supreme Court dismissed a further appeal in 1998.

Attempts were made to clear his name based on available DNA technology, but the tissue could not be located by Smith, who was given the evidence by the pathologist who did the autopsy, until 2005, 11 years after the trial, when the missing tissue samples turned up in Dr. Smith’s office. William Mullins-Johnson was released on bail in 2006, pending review of his case. On July 16th, 2007, a report by three expert pathologists determined there was no evidence that the girl was sexually assaulted, and the Ontario Attorney General Michael Bryant, said that Mr. Mullins-Johnson's conviction “cannot stand” and that he should be acquitted by the appeals court. On October 15, 2007 he was acquitted by the Ontario Court of Appeals.

On the morning of January 23rd 1996, Sherry Sherret found her four month old son Joshua lying in his bed not breathing. He was rushed to the hospital where he was pronounced dead. Three and a half years later she was given the option to accept a plea of infanticide. She was convicted of infanticide without offering a defence (but offering no admission of guilt) in a plea (the delay was primarily attributable to Dr. Smith's unavailability to testify). Sherret was jailed on the basis of Smith's opinion that her four-month-old son Joshua had a skull fracture, and that he had been smothered. She was released on bail in 1996 and remained on bail until the conviction, Sherret's sentence was 1 year in jail and 2 years probation. Sherret served 8 months in total, and was entered into the child abuse registry. Her older child was removed by Children's Aid, and in order to get him out of foster care, she agreed to give him up for adoption and have no physical contact with him until he was 18.

In a new relationship, she got pregnant, as was only allowed to have contact with her baby if she was supervised. In 2006 Joshua was exhumed and re-autopsied; the report concluded that there had been no skull fracture and the marks on Joshua's neck had been caused by Dr. Smith himself during the autopsy, and that the cause of death was almost certainly a comforter bunching around his head. Children's Aid has removed the conditions on her.

Brenda Waudby of Peterborough was charged with beating her 2-year-old daughter Jenna to death on Jan. 22, 1997, on the basis of Smith's professional opinion as to what time the injuries were inflicted. The charge was dropped on June 15, 1999, when a prosecutor cited "certain medical evidence that has shifted dramatically:" five other medical experts said the toddler's injuries were inflicted on the evening of her death, when she was in the care of a 14-year-old boy. A crucial piece of evidence, a strand of pubic-like hair found on the body, went missing; it was eventually found in an envelope on Dr. Smith’s desk, where it had apparently sat for five years.

Anthony Kporwodu and Angela Veno, were charged in 1997 with murdering their infant son. Dr. Smith took more than seven months to prepare his initial autopsy report. The charges were ultimately thrown out by a judge for violating the constitutional right to a timely trial.

Louise Reynolds was a 28 year old single mother living in Kingston, Ontario, charged with 2nd degree murder for having killed her seven-year old daughter Sharon in 1997 by stabbing her more than 80 times with a pair of scissors, “because she was angry at her for having head-lice.” Much of the case rested on Dr. Smith’s 10-page autopsy report. In January 2001 the Crown abruptly dropped the charges, after numerous experts, including Crown witnesses, disagreed with Smith and agreed that a powerful dog had mauled the girl (there was a pit-bull present in the house at the time). By then, Reynolds had spent three and a half years in jail awaiting trial.

Ms. Reynolds sued, and in March 2007 the court of appeals ruled in a ground-breaking decision that the suit against Dr. Smith and other experts can go ahead; while court testimony is protected, faulty work is not.


In 2002, Dr. Smith was reprimanded with a caution by the Ontario College of Physicians and Surgeons for his work on three suspicious-death cases.

In July 2005 he resigned from Sick Children's Hospital to take up a position at Saskatoon City Hospital in Saskatchewan. In December 2005 he was dismissed. He won on appeal, but because he did not have a licence to practise in Saskatchewan, he was not re-instated. He currently resides in Victoria, British Columbia.

In June 2005, the Chief Coroner of Ontario ordered a review of 44 autopsies carried out by Dr. Smith, 13 of them in cases where there had been resulting criminal charges and convictions. The report was released in April 2007, indicating that there were substantial problems with 20 of the autopsies. In response, in April 2007, Ontario Attorney General Michael Bryant announced that there would be a full public inquiry into the matter, the Goudge Inquiry, which got underway on November 12, 2007.

Other Pathology Scandals

Some feel that the case bears uncanny similarities to that of Professor Sir Samuel Roy Meadow (born 1933), a discredited former British paediatrician best known for his 1977 academic paper on Munchausen Syndrome by Proxy (MSbP), in which parents are said to fabricate their child's illness, and his dictum that “one sudden infant death is a tragedy, two is suspicious and three is murder, until proved otherwise“, which became known as Meadow's Law.

However, Meadow was, if the charges were correct, guilty of chasing what amounted to a crackpot theory; Smith, if the charges are correct, was guilty of shoddy work and an "always guilty" approach.

Another recent pathology scandal has been the Alder Hey organs scandal, circa 1996.

The Man Behind The Public Inquiry

Last Updated April 24, 2007
CBC News

On a typical case, he might have to decide whether a child had been shaken to death or accidentally fallen from a highchair.

Dr. Charles Smith was once considered top-notch in his field of forensic child pathology. In 1999, a Fifth Estate documentary singled him out as one of four Canadians with this rare expertise.

Dr. Charles Smith was long regarded as one of Canada's best in forensic child pathology. A public inquiry was called after an Ontario coroner's inquiry questioned Smith's conclusions in 20 of 45 child autopsies. (CBC)

For 24 years, Smith worked at Toronto's Hospital for Sick Children. In the hospital's pediatric forensic pathology unit, he conducted more than 1,000 child autopsies.

But Smith no longer practises pathology. An Ontario coroner's inquiry reviewed 45 child autopsies in which Smith had concluded the cause of death was either homicide or criminally suspicious.

The coroner's review found that Smith made questionable conclusions of foul play in 20 of the cases — 13 of which had resulted in criminal convictions. After the review's findings were made public in April 2007, Ontario's government ordered a public inquiry into the doctor's practices.

Some have accused Smith of taking on a role larger than pathologist. The lawyer for Brenda Waudby said he was on a crusade and acted more like a prosecutor. Waudby was convicted in the murder of her daughter after Smith analyzed the case.

A pubic-like hair found on her daughter went missing during Smith's investigation. It was discovered he had kept the hair in his office before police found it five years later. In the end, Waudby's charges were dropped and the child's babysitter was convicted.

Smith said he had a passion for uncovering the truth in child deaths. The Ontario pathologist told media lampooning him he had "a thing against people who hurt children." He welled up when speaking about a mother looking for the cause of her baby's death.

Smith had been in search of his own personal truths. He was born in a Toronto Salvation Army hospital where he was put up for adoption three months later. After years of looking for his biological mother, he called her on her 65th birthday. But she refused to take his call.

Smith's adoptive family moved often. His father's job in the Canadian Forces took them throughout Canada and to Germany. He attended high school in Ottawa, and graduated from medical school at the University of Saskatchewan in 1975.

Sick Kids tenure

Hired by Toronto's Hospital for Sick Children in 1979, Smith worked in surgery for a year and then moved on to pathology training. A pathologist studies diseases and illnesses by assessing matter such as cells, tissues, organs and fluids. Pathologists also examine biopsy material, and give a subsequent diagnosis.

When it comes to autopsy reports, the field of pathology can be a subjective one. It's based on research and opinion, and it's especially controversial in Canada, where there is no formal training or certification process. Only a handful of practitioners in Ontario are entrusted with the job — and they've learned by doing.

With child victims, forensic analysis is rarely cut and dried. It can take an infant up to 24 hours to die of a shaking incident, which is a crime that doesn't leave evidence the way a regular killing might.

After his initial training at Sick Kids, as the Toronto hospital is known, Smith began conducting child autopsies in 1981. He started with children who had died of accidental and natural causes. By the late '90s, Smith saw more forensic child cases than any other pathologist across the country.

Smith's unit used arrest warrants to reinvestigate cases of sudden infant death syndrome (SIDS). He oversaw the autopsies of exhumed babies that led to new murder charges.

In one such case, Smith appeared before a court in the death of six-month-old Sara Podniewicz. He concluded she had been dead for up to 15 hours before her parents reported the death. The parents had told a 911 operator the girl had died just moments before. Smith's analysis led to second-degree murder charges.

First doubts

In 1991, a family in Timmins, Ont., was the first to raise questions about Smith's work. He had concluded their one-year-old baby had died from being shaken. The child had been under the care of a babysitter who said the baby had fallen down stairs.

In court, experts challenged Smith's opinion, which had resulted in the babysitter's charge of manslaughter. The judge in the case stated Smith should have taken other causes into consideration.

Once the most prolific pathologist, Smith began getting a reputation for late cases, and his disorderly desk produced samples that had gone missing.

In 2002, he received a caution from the Ontario College of Physicians and Surgeons. The college said he was being "overly dogmatic" and had a "tendency towards overstatement."

In June 2005, Dr. Barry McLellan, Ontario's chief coroner, started the review of 45 child autopsies conducted by Smith between 1991 and 2002. The review, released in April 2007, found that Smith had made mistakes in 20 cases involving the deaths of children. The review cast doubt on criminal convictions in 13 of the cases.

"I am very surprised with the overall results of the review, and concerned," McLellan said. "In a number of cases, the reviewers felt that Dr. Smith had provided an opinion regarding the cause of death that was not reasonably supported by the materials available for review."

The chief coroner said the results of the review were being shared with defence and Crown attorneys involved in all of the relevant criminal cases.

After resigning from Sick Kids in 2005, Smith accepted a pathology position in Saskatoon. He was fired after three months. A tribunal later reinstated him, but without a licence, Smith was unable to practise.

Smith told media his marriage ended in light of stress from the highly publicized events. He had lived with his wife and two children on a farm north of Newmarket, Ont.

As a member of the Christian and Missionary Alliance, Smith says he has been fuelled by his life's purpose — finding out the truth for parents who have lost babies.