1 2 3 THE INQUIRY INTO PEDIATRIC FORENSIC 4 PATHOLOGY IN ONTARIO 5 6 7 8 ******************** 9 10 11 BEFORE: THE HONOURABLE JUSTICE STEPHEN GOUDGE, 12 COMMISSIONER 13 14 15 16 17 Held at: Metropolitan Hotel 18 Toronto, Ontario 19 20 21 ******************** 22 23 24 August 8th 2007 25


1 Appearances 2 Linda Rothstein ) Commission Counsel 3 Mark Sandler ) 4 Jonathan Shime ) 5 6 Luisa Ritacca ) Office of the Chief Coroner 7 Brian Gover (np) ) for Ontario 8 9 Jane Langford (np) ) Dr. Charles Smith 10 Niels Ortved (np) ) 11 Erica Baron (np) 12 13 William Carter ) Hospital for Sick Children 14 Barbara Walker-Renshaw (np) ) 15 Kate Crawford (np) ) 16 17 Paul Cavalluzzo ) Ontario Crown Attorneys' 18 Association 19 20 Mara Greene ) Criminal Lawyers' 21 Breese Daveis ) Association 22 Joseph Di Luca (np) ) 23 24 25


1 APPEARANCES (CONT'D) 2 James Lockyer ) William Mullins-Johnson, 3 Sherry Sherret-Robinson and 4 seven unnamed persons 5 6 Peter Wardle ) Affected Families Group 7 Julie Kirkpatrick ) 8 Daniel Bernstein (np) ) 9 10 Louis Sokolov ) Association in Defence of 11 Elizabeth Widner (np) ) the Wrongly Convicted 12 Paul Copeland (np) ) 13 14 Jonathan Rudin ) Aboriginal Legal Services 15 Mandy Eason ) of Toronto and Nishnawbe 16 Kimberly Murray (np) ) Aski-Nation 17 18 Susan Fraser Defence for Children 19 International - Canada 20 21 William Manuel ) Ministry of the Attorney 22 Heather Mackay ) General for Ontario 23 Erin Rizok ) 24 25


1 TABLE OF CONTENTS 2 Page No. 3 4 Opening Comments 5 5 6 Submissions by Office of Chief Coroner for Ontario 8 7 Submissions by Hospital for Sick Children 12 8 Submissions by Ontario Crown Attorneys' Association 17 9 Submissions by Criminal Lawyers' Association 21 10 Submissions on Behalf of William-Johnson, 11 Sherret-Robinson and Seven Unnamed Persons 28 12 Submissions by Affected Families Group 41 13 Submissions by Association in Defence of the 14 Wrongly Convicted 47 15 Submissions by Aboriginal Legal Services of Toronto and 16 Nishnawbe Aski-Nation 51 17 Submissions by Defence for Children International-Canada 63 18 19 20 Certificate of transcript 72 21 22 23 24 25


1 --- Upon commencing at 10:00 a.m. 2 3 COMMISSIONER STEPHEN GOUDGE: Good 4 morning. Please be seated. Just give me a moment here 5 to open this up. 6 Well, good morning, everybody. Thank you 7 all for coming. The purpose of the Hearing this morning 8 is very straightforward. It's for me to receive oral 9 submissions about the applications for funding and 10 standing that the Inquiry has received since we 11 disseminated the information about how applications of 12 that kind should be done. 13 As all of you know I'm sure we put out our 14 rules for standing and funding in June of this year and 15 we've received I think some eleven (11) applications. 16 Before inviting Commission Counsel to 17 begin this morning, I simply want to say that those rules 18 provide for two (2) obvious things: one (1) is that 19 Commission Counsel will have standing throughout the 20 Inquiry, and the second, it provides some guidance about 21 the criteria that I propose to apply in determining 22 whether standing and funding should be accorded. 23 I have read all the applications and I 24 have asked through Commission Counsel that Counsel 25 confine their remarks to no more than fifteen (15)


1 minutes. It seems to me in the circumstances that that's 2 sufficient for you to tell me the core of why you think 3 it is that the request you make should be acceded to. 4 And so without further ado, Ms. Rothstein, 5 do you want to proceed, please? 6 MS. LINDA ROTHSTEIN: Thank you very 7 much, Commissioner. Can I say on behalf of your 8 Commission Counsel team that is here, Mr. Sandler, Mr. 9 Shime and me, that we're delighted that you've granted us 10 standing and feel quite pleased that, in effect, we won 11 our first ruling. 12 And as you noted, Commissioner, we have 13 eleven (11) applications for standing. Ten (10) of the 14 parties who sought standing are here today. Dr. Charles 15 Smith has sought standing in a written application which 16 has been filed with you, but in accordance with our rules 17 has elected not to make any oral submissions. His 18 counsel, Mr. Niels Ortved, has told us that you ought to 19 consider his application on the basis of the written 20 submission. 21 This morning we have here on behalf of the 22 Office of the Chief Coroner of Ontario, Luisa Ritacca, 23 who is the first on our list, Commissioner, to make her 24 submissions. 25 We have here on behalf of the Hospital for


1 Sick Children, Mr. William Carter. 2 On behalf of the Ontario Crown Attorneys' 3 Association, Mr. Paul Cavaluzzo. 4 On behalf of the Criminal Lawyers' 5 Association, Mara Greene and Breese Davies. 6 On behalf of a group of accused and 7 individuals who have been affected by these proceedings, 8 Mr. James Lockyer. 9 On behalf of what we are calling the 10 Affected Families Group we have Mr. Peter Wardle and 11 Julie Kirkpatrick and Daniel Bernstein. 12 On behalf of AIDWYC, Mr. Louis Sokolov. 13 On behalf of the Aboriginal Legal Services 14 of Toronto-NAN, Jonathan Rudin. 15 And on behalf of Defence of Children, we 16 have Susan Fraser. 17 So I'm going to hand up that appearance 18 sheet, Commissioner. 19 COMMISSIONER STEPHEN GOUDGE: Thank you. 20 MS. LINDA ROTHSTEIN: And call on Luisa 21 Ritacca to begin the proceedings. 22 COMMISSIONER STEPHEN GOUDGE: Ms. 23 Ritacca...? 24 MS. LUISA RITACCA: Good morning, 25 Commissioner.


1 MS. LINDA ROTHSTEIN: Just one moment. 2 Actually, sorry, Commissioner. What I neglected to note 3 in that long list is that Mr. Bill Manuel and colleagues 4 are here on behalf of the Ministry of the Attorney 5 General. They have told me that they don't have any oral 6 submissions for you but are happy to entertain your 7 questions if you see fit. 8 COMMISSIONER STEPHEN GOUDGE: Okay. 9 Thank you. 10 MS. LINDA ROTHSTEIN: Sorry, Ms. Ritacca. 11 12 SUBMISSIONS BY OFFICE OF CHIEF CORONER FOR ONTARIO: 13 MS. LUISA RITACCA: Commissioner, as Ms. 14 Rothstein has explained to you I'm here on behalf of the 15 Office of the Chief Coroner for Ontario. I, together 16 with Brian Over and Teja Rachamalla who are not present 17 today, represent the Office and those in its employ, both 18 and during the relevant period for this Inquiry. 19 And the Office of the Chief Coroner for 20 Ontario seeks standing to participate fully in all 21 aspects of this Inquiry and the Office is not seeking 22 funding. I intend to be very brief in my submissions to 23 you this morning. 24 COMMISSIONER STEPHEN GOUDGE: I don't 25 think you need to say a whole lot, Ms. Ritacca.


1 MS. LUISA RITACCA: All right, then. 2 Well then what I will do is just turn to our materials 3 for standing and say that Mr. -- Dr. Barry McClellan's 4 affidavit, which we provided in our materials, really 5 sets out, in our view, the background as to why we 6 believe that the Office is in a unique position to 7 contribute to this inquiry and that the Office has a 8 substantial and direct interest in the subject matter and 9 its outcome. 10 And I won't repeat what's in Dr. 11 McClellan's affidavit. But based on the material that's 12 before you, I submit that the Office's application meets 13 the tests set out in Section 51 of the Public Inquiries 14 Act and in paragraphs 9 and 11 of your rules of standing 15 and funding. 16 What I will say, and -- and this may be a 17 bit repetitive, but I think it's important, it is in Dr. 18 McClellan's affidavit, as you know in June of 2005 the 19 Chief Coroner announced that his office would be 20 conducting a review of criminally suspicious homicide 21 paediatric cases dating back to 1991, where Dr. Charles 22 Smith had performed an autopsy or provided an opinion and 23 consultation and ultimately 45 cases were reviewed and 24 the results of that review were announced in April, 2007. 25 And following that announcement, this Inquiry, by Order


1 in Council dated April 25th, was established. 2 And very briefly, it's our view that each 3 of the issues identified in your mandate, ultimately, 4 relates to the management, organization and structure of 5 the Office of the Chief Coroner and, in particular, to 6 the protocols, accountability, and oversight mechanisms 7 in place between 1981 and 2001, as they relate to 8 paediatric forensic pathology. 9 And as we point out in our materials, the 10 Office is in a unique position in a number of ways to 11 assist this Commission, which is set out in Dr. 12 McClellan's affidavit. But I would just say, briefly, 13 some of those ways include: 14 Assisting the Commission to understand the 15 various roles and professionals in the Coroner's death 16 investigation, including coroners and forensic 17 pathologists, and how these professionals fit within the 18 criminal justice system. 19 Informing the Commission with respect to 20 the unique aspects of paediatric forensic pathology. 21 Assisting the Commission with regard to 22 its mandate to make recommendations with regard to 23 paediatric forensic pathology in Ontario and its future 24 use in criminal proceedings. 25 And I should point at that since the


1 Inquiry was announced in April, the Office of the Chief 2 Coroner has been assisting Commission Counsel on many of 3 these issues, primarily, by making people and documents 4 readily available. 5 And finally, I just make note that the 6 Office has a substantial and direct interest, obviously, 7 in the recommendations that may be made by this 8 Commission, particularly, as they relate to the Office of 9 the Chief Coroner's oversight responsibilities, over 10 forensic pathologists in the Province, and the role of 11 the Coroner and the forensic pathologist in the criminal 12 justice system. 13 So subject to any questions you may have, 14 those are our submissions. 15 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 16 Ritacca. And I should indicate, on behalf of the 17 Inquiry, we are grateful for the cooperation of the 18 Office, particularly, in all the work you have done 19 supplying the documents that we have received from your 20 office. 21 MS. LUISA RITACCA: Thank you. 22 COMMISSIONER STEPHEN GOUDGE: So thank 23 you. Thank you. 24 MS. LINDA ROTHSTEIN: Commissioner, Mr. 25 Carter is here on behalf of the Hospital for Sick


1 Children. 2 COMMISSIONER GOUDGE: Okay. So we are 3 not going to go down this list, we are going to move 4 around? 5 Mr. Carter...? 6 MS. LINDA ROTHSTEIN: I have a schedule 7 that I -- 8 COMMISSIONER STEPHEN GOUDGE: Oh, okay. 9 Mr. Carter...? 10 11 SUBMISSIONS BY HOSPITAL FOR SICK CHILDREN: 12 MR. WILLIAM CARTER: Good morning, 13 Commissioner. I appear on behalf of the Hospital for 14 Sick Children and with me in this engagement are my 15 colleagues, Barbara Walker-Renshaw, and Kate Crawford. 16 The material that we filed in support of our application 17 for both standing and funding is found at Tab 6 -- or 18 excuse me, Tab 6 of my materials. I'm not sure what tab 19 it is of your's Commissioner. 20 Nonetheless, the position of the hospital 21 in respect of the standing application is that, as a 22 matter of fact, the Hospital for Sick Children has housed 23 and operated the forensic pathology unit, under the 24 hospices of the Chief Coroner's office for many years; 25 more than 15.


1 The Chief and the Director of that unit 2 for many years was Dr. Charles Smith who was a member of 3 the medical staff of the Hospital for Sick Children. And 4 that unit operated within the Department of Pathology at 5 the hospital for sick children and was funded, in part, 6 by a grant from the -- received from the Coroner's office 7 from various ministries over the years. That annual 8 grant was two hundred thousand dollars ($200,000) and has 9 not changed since 1991, I believe, the first year that 10 the grant was provided. 11 Those operations are part of the 12 Department of Pathology at the hospital. However, the 13 operation of the forensic pathology unit is designed to 14 assist the Coroner's office in fulfilling its mandate to 15 investigate deaths which may have criminal implications 16 within the Province of Ontario. 17 The mandate of the Hospital for Sick 18 Children, of course, is a different one. It is a public 19 hospital. It is a not-for-profit institution. It is 20 entirely funded, with the exception of the grant that I 21 referred to, by funding from the Ministry of Health Long 22 Term Care. And its mission is one directed at the 23 delivery of clinical care to sick children, research and 24 teaching that is related to that care. 25 Insofar as the activities of this


1 Commission are concerned, it is clear that the operation 2 of this unit at the Hospital for Sick Children is a 3 central feature of the investigations and activities of 4 this Commission, at least as they relate to this part of 5 the Province. And the hospital continues and intends to 6 continue to operate this unit at the behest of the 7 Coroner's office and has a real and substantial interest 8 in ensuring that the services provided at the hospital 9 are state of the art and best practices, and enhanced by 10 the conclusions and recommendations of this Commission. 11 So if I could just conclude the standing 12 part by saying, in my submission, the hospital has a 13 direct and substantial interest within the meaning of the 14 Public Inquiries Act, and I would ask that the hospital 15 be granted standing and the opportunity to participate 16 fully in the activities of this Commission. 17 In respect of funding, I would make these 18 submissions. The hospital's need to participate in this 19 Commission, in order to enhance its own ability to 20 operate the forensic pathology unit an to ensure that 21 this Commission gets all of the assistance it deserves 22 and requires, is a major undertaking from the hospital's 23 perspective. 24 Already we have identified, I think it's 25 fifty-nine (59) cartons of material that are -- bear on


1 the scope of the Commission's inquiries and we have spent 2 hundreds of hours reviewing and cataloguing this material 3 for the assistance of this Commission. This is a major 4 undertaking in a clinical institution, whose primary role 5 is the delivery of healthcare to children. And it is not 6 an activity that was anticipated when funding was made 7 available to the hospital for the delivery of healthcare. 8 In my submission, the hospital's 9 involvement in this Commission flows from its assistance 10 to the Coroner's office in assisting the Coroner in 11 delivering to the Province of Ontario, those services 12 that a Coroner's office does deliver, such as the 13 investigation of criminally suspicious deaths and 14 homicides. And it is in that public interest that the 15 hospital has been assisting the Coroner's office all 16 these years. 17 It is not directly in the hospital's 18 interest, in the delivery of healthcare to children, that 19 it provide this service and, indeed, we do not have 20 funding for our participation in this Commission. The 21 two hundred thousand dollars ($200,000) annual grant does 22 not even cover the cost of the assistance that the 23 hospital makes available to the Coroner's pathologists 24 conducting the forensic autopsies and, therefore, those 25 monies are not available to ensure that adequate legal


1 services are available to the hospital. 2 So that the legal services incurred in 3 advising and representing the hospital at this Commission 4 will be coming from healthcare dollars, which are 5 earmarked for healthcare delivery and not earmarked for 6 counsel at public inquiries. 7 And the -- there's a real public interest 8 that while the hospital ensure that the interests of the 9 hospital are represented here, it not do so at the 10 expense of its core mission, which is healthcare 11 delivery. So we are in the unenviable position of being 12 here because of the assistance we lend to the Coroner's 13 office. 14 We have a significant interest in the 15 mission and objectives of this Commission and we will 16 attend with or without funding. However, to the extent 17 that we are not funded through the funding that is 18 available from the Commission, we will be funded out of 19 healthcare dollars and that is a problem that we would 20 ask this Commission to address on behalf of the children 21 who benefit from that care. 22 Those are my submissions. 23 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 24 Carter. 25 MR. WILLIAM CARTER: Thank you.


1 COMMISSIONER STEPHEN GOUDGE: Next, Ms. 2 Rothstein? 3 MS. LINDA ROTHSTEIN: Commissioner, the 4 next on my list is Mr. Cavalluzzo for the Crown 5 Attorneys' Association. 6 7 SUBMISSIONS BY ONTARIO CROWN ATTORNEYS' ASSOCIATION: 8 MR. PAUL CAVALLUZZO: Good morning, 9 Commissioner. 10 COMMISSIONER STEPHEN GOUDGE: Good 11 morning. 12 MR. PAUL CAVALLUZZO: I, as well, will be 13 brief but would like to highlight parts of the written 14 submissions that we have filed -- 15 COMMISSIONER STEPHEN GOUDGE: Sure. 16 MR. PAUL CAVALLUZZO: -- with you this 17 morning, if you would perhaps have it before you. 18 COMMISSIONER STEPHEN GOUDGE: Yes. I 19 have them. Thanks. 20 MR. PAUL CAVALLUZZO: Okay. 21 Commissioner, the Ontario Crown Attorneys' Association, 22 as you know, is the professional association which 23 represents about eight hundred (800) Crown attorneys 24 across this province. And of course the -- who we're 25 talking about here are the -- really the non-management


1 trial and appellate counsel who operate within the Fed -- 2 the criminal courts and the Supreme Court of Canada. 3 It is essential submission and 4 representation of the Association that it does have a 5 direct and substantial interest because, of course, Crown 6 attorneys are an integral part of the administration of 7 justice, and certainly that will be the context in which 8 your findings and recommendations will be made. 9 The Association is seeking standing but is 10 not seeking funding for its participation if it is 11 granted Intervenor status. 12 In terms of the written submissions, we 13 point out in paragraph 4, the expertise which we think 14 the Association will bring to bear to these proceedings. 15 Just highlighting certain things: 16 The objects of the Association, which is a 17 professional association as well as a bargaining agent. 18 It's responsible and participates in the 19 education and training of Crown attorneys. 20 It promotes their professional interests 21 in professional manner -- matters. 22 It discusses and studies the 23 administration of criminal justice in all of its asset -- 24 aspects. 25 The expertise we highlight as well,


1 because the Association has contributed to a great extent 2 in many, many proceedings, including coroner's inquests, 3 including representations that have been made before 4 different professional working groups and committees, 5 representations that are made before committees of the 6 Legislature and Parliament and many, many other things, 7 including being an active participant in the courts as 8 amicus curiae. At the present time, for example, the 9 Association is before the Supreme Court of Canada on a 10 professional matter which affects Crown attorneys. 11 The only other matter that I would raise 12 is that we can assure you that our efforts and resources 13 will not duplicate anything that you have before you. We 14 are certainly sensitive to the fact that this Inquiry is 15 intended to be fair, thorough, and expedient and 16 certainly emphasizing the latter aspect. We will not 17 duplicate the efforts of, for example, the Government of 18 Ontario, which as you see in their written submissions 19 represents a number of varied interests including the 20 police, the Crowns, professional regulatory regimes, and 21 so on. 22 And what -- we submit respectfully, that 23 what we bring to bear is the distinct perspective of 24 Crown attorney -- Crown attorneys who are really on the 25 front lines, so to speak, and -- and we think that we can


1 contribute a great deal in a very expeditious way. 2 COMMISSIONER STEPHEN GOUDGE: I was going 3 to ask you about how you viewed your relationship with 4 the Ontario position because, obviously, there is a risk 5 there of overlap. And given the timeline that I've been 6 given, -- 7 MR. PAUL CAVALLUZZO: Mm-hm. 8 COMMISSIONER STEPHEN GOUDGE: -- I'm going 9 to be very vigilant about avoiding duplication. So 10 you've obviously turned your mind to that. 11 MR. PAUL CAVALLUZZO: Yes, we have. 12 COMMISSIONER STEPHEN GOUDGE: But that's 13 something that I'll continue to -- 14 MR. PAUL CAVALLUZZO: Right. 15 COMMISSIONER STEPHEN GOUDGE: -- ask 16 forcefully that you continue to do. 17 MR. PAUL CAVALLUZZO: Yes. And we will 18 certainly cooperate with the Government of Ontario in 19 that regard and if we don't, please jump on us and we 20 will cooperate thoroughly with you. Thank you. 21 COMMISSIONER STEPHEN GOUDGE: Thank you. 22 Next, Ms. Rothstein? 23 MS. LINDA ROTHSTEIN: Yes. We have Mr. - 24 - who is making submissions on behalf of the CLA? 25 MS. MARA GREENE: Mara Greene.


1 MS. LINDA ROTHSTEIN: Thank you. 2 COMMISSIONER STEPHEN GOUDGE: Yes, Ms. 3 Greene? 4 5 SUBMISSIONS BY CRIMINAL LAWYERS' ASSOCIATION: 6 MS. MARA GREENE: Yes. Good morning, 7 Commissioner. Myself, Ms. Davis, and Mr. Di Luca all act 8 on behalf of the Criminal Lawyers' Association. You have 9 our application outlining in detail who we are and I'm 10 not going to repeat its contents. 11 As we state in our application, however, 12 it is our belief that we should be granted standing and 13 funding for this Inquiry so that we can participate in 14 the examination and discovery of the systemic issues 15 being addressed by this Inquiry and make appropriate 16 recommendations. We would like to have input into issues 17 that relate to maintaining integrity in the criminal 18 justice system and issues that speak to the needs of 19 defence counsel to ensure that accused persons have fair 20 trials. 21 As an association of defence lawyers, we 22 have a direct interest in the Inquiry and will likely be 23 directly affected by some of its recommendations as it 24 will affect how we represents our clients and protect 25 their rights.


1 The Criminal Lawyers' Association, as an 2 association of defence lawyers, also has an interest in 3 ensuring that the issues being addressed by this 4 Commission are reviewed in a fair and accurate manner. 5 The Criminal Lawyers' Association does not intend to 6 duplication other agencies' work. We think we complement 7 each other and our focus is broader than merely looking 8 at wrongful convictions but a focus on the general 9 fairness of the proceedings. 10 The Criminal Lawyers' Association has 11 reviewed the list of issues that this Commission intends 12 to examine and evaluate and it is our position that we 13 can assist in a number of the issues raised. With 14 respect, the CLA is in the best position to address 15 defence-related issues; issues like the role of Legal Aid 16 and how Crown attorneys and defence lawyers retain and 17 use experts in a trial process. 18 We are in the best position to assist the 19 Commissioner in understanding the present limitations 20 that exist in the system and make recommendations to 21 improve the process. Moreover, when this Commission 22 addresses a number of the systemic issues it proposes to 23 address, if the general conduct of the defence bar 24 becomes an issue, we can directly speak to this. 25 While it is not our intention to defend


1 any one individual counsel, we can address defence 2 counsel conduct in general. We can also assist the 3 Commissioner, or this Commission, in understanding 4 present defence practices and developing recommendations 5 to improve defence practices and help strike the proper 6 balance between trial fairness and efficiency. 7 In addition, if recommendations made by 8 other parties relate to defence practices generally, this 9 Criminal Lawyers' Association would be able to respond 10 and help the Commissioner assess these recommendations 11 and the impact that these recommendations might have on 12 trial procedure and the rights of accused persons. 13 As an association of almost a thousand 14 (1,000) practitioners who play an integral role in the 15 criminal justice process and who frequently deal with 16 expert evidence in the courtroom, the Criminal Lawyers' 17 Association is also in a good position to highlight 18 issues relating to the process itself. 19 In particular, while the medical persons 20 involved in this Commission are in the best position to 21 address most of the issues surrounding the development of 22 best practices for pathologists, the Criminal Lawyers' 23 Association could assist the Commissioner in considering 24 how to make the reports generated by the experts more 25 accessible and understandable to both the defence bar,


1 juries, and trial judges. The Criminal Lawyers' 2 Association can also assist the Commissioner in 3 considering how expert reports get presented as evidence 4 at trial and make recommendation on how to improve this 5 process. 6 The Commission has indicated an intention 7 to examine how key institutions within our justice system 8 work together and how they -- and how well they do it. 9 The goal is to examine the interactions between the 10 paediatric forensic pathologists, the police, the Crown, 11 and the Coroner's office. But the Criminal Lawyers' 12 Association would suggest that the defence bar also has a 13 key -- is a key institution in the process that needs to 14 be included to consider access to the agencies and 15 whether or not the defence bar is using them properly. 16 Finally, the Criminal Lawyers' Association 17 can assist the Commissioner in considering how the expert 18 evidence is used at trial and make recommendations to 19 improve the present process and comment on 20 recommendations made by other parties. 21 In general, the Criminal Lawyers' 22 Association seeks standing to bring a different voice to 23 the table so that -- so as to ensure that the integrity 24 of the criminal justice system is viewed -- is explored, 25 not just from wrongful convictions but also from a trial


1 fairness perspective. We are interested in exploring 2 remedies that strike the proper balance between trial 3 efficiency and trial fairness, keeping in mind the 4 practical implications of any recommendation relating to 5 trial procedure. 6 We also, if granted standing, will require 7 funding. We are a nonprofit organization and do not have 8 the funds to fund counsel for this Inquiry. It is our 9 expectation that the work required for this Inquiry would 10 require more preparation than in-hearing time and, as a 11 result, our proposal for funding is somewhat vague at 12 this stage. 13 What we propose to do is approach it the 14 same way we approach a legal aid file; that is, be given 15 an addit -- immediate budget for some time to look at how 16 much material will be required to be reviewed, so that we 17 can get a sense of how much time is going to be needed, 18 and then come back to this -- to you and ask for more 19 time and a clear budget outlining how much time we'll 20 need once we understand the extent and the volume of 21 material to be reviewed. 22 As for the hearing days, we would request 23 for counsel, one (1) to two (2) counsel, depending on 24 what issues are being addresses on -- on any given day. 25 What we would propose is that on most days you would have


1 one (1) counsel, however, on key days we would require 2 two (2) counsel. And by "key days," I'm referring to 3 days where there are expert panels, or very complicated 4 expert evidence, or days where the Criminal Lawyers' 5 Association itself is cross-examining witnesses. 6 We would also like the opportunity to come 7 back at a later date, if need be, to address funding, if 8 we need it for experts to address any issues that may 9 arise. 10 COMMISSIONER STEPHEN GOUDGE: One (1) 11 comment and one (1) question, Ms. Greene. 12 First of all, as with Mr. Cavalluzzo, I am 13 pleased that you have flagged the possibility of a 14 duplication and avoiding it. With, for example, AIDWYC, 15 the obvious other party that's seeking standing with whom 16 you have at least a shared approach. 17 And secondly, the question about funding, 18 I am not clear about what you are seeking for 19 preparation. I mean, like what does that mean? I can 20 not get my head around it. 21 MS. MARA GREENE: I would envision that 22 funding would include days -- funding for time spent in 23 hearings where witnesses are being heard or cross- 24 examined. 25 COMMISSIONER STEPHEN GOUDGE: You are


1 talking about an upfront time? 2 MS. MARA GREENE: Exactly. Time prior 3 to -- 4 COMMISSIONER STEPHEN GOUDGE: Okay. What 5 kind of time? 6 MS. MARA GREENE: Well, the difficulty 7 that I have in sending out a number right now, is that 8 I'm not quite sure the volume of material that will need 9 to be reviewed, at this stage. So I would propose 10 something around, you know, a fairly low number, just so 11 that we can rev -- get a sense of how much is there. 12 COMMISSIONER STEPHEN GOUDGE: Yes. 13 MS. MARA GREENE: And then come back to 14 you with a very clear budget outlining how much we really 15 will need, in light of what's -- what we have to review. 16 And that way we're not, sort of, overestimating and we're 17 giving you a clear indication of where the resources are 18 going to be allocated and for what purpose. 19 COMMISSIONER STEPHEN GOUDGE: Okay. 20 Okay, thank you. 21 MS. MARA GREENE: Thank you. 22 MS. LINDA ROTHSTEIN: Commissioner, Mr. 23 Lockyer is here on behalf of Mullins-Johnson and eight 24 (8) other individuals who wish to remain anonymous. 25 COMMISSIONER STEPHEN GOUDGE: Mr.


1 Lockyer...? 2 3 SUBMISSIONS ON BEHALF OF WILLIAM-JOHNSON, SHERRET- 4 ROBINSON AND SEVEN UNNAMED PERSONS: 5 MR. James LOCKYER: Good morning, Mr. 6 Commissioner. I am indeed here for nine (9) individuals; 7 two of whom have been publicly identified and seven (7) 8 of whom have not. The two (2) who are being publicly 9 identified, Mr. Mullins-Johnson, was -- is someone whose 10 case we've been working on for a long time now, for many 11 years. It was referred to the Court of Appeal some two 12 months ago and is now expected that his appeal will be 13 heard next month, in the month of September. 14 The second identified case is that of 15 Sherry Sherret-Robinson. We've been working on that case 16 since February of last year. And her case, just a matter 17 of days ago, was filed -- or she filed an appeal in the 18 Court of Appeal with the permission of the Court when an 19 extension of time was granted to allow her to file her 20 appeal some eight (8) years after her conviction. 21 COMMISSIONER STEPHEN GOUDGE: When you 22 say "we", do you mean your office or AIDWYC? 23 MR. JAMES LOCKYER: Well, that -- really, 24 people who -- those who represent the nine (9) wear two 25 (2) hats. They wear AIDWYC hats and they wear counsel


1 hats as well. And at the moment we haven't fully 2 identified whose representing whom, but certainly for the 3 purposes of the Inquiry they've all agreed that I and any 4 other co-counsel that may be permitted by the Inquiry 5 should represent their interests at the Inquiry. 6 The difficulty is that, despite the 7 passage of time, to date, the seven (7) who remain 8 unnamed have no funding at all. And as a consequence 9 it's hard to envision how -- well, it's not hard to 10 envision but it's time consuming to work out how we can 11 represent the interests of each and every one of them on 12 a non-funded or an unfunded basis. And, indeed, that's 13 one of the issues that we will likely as the Inquiry 14 address: Should people in their situation be unfunded in 15 the way that they are? 16 You -- Mr. Commissioner, the other seven 17 (7), I think it's probably appropriate to state publicly 18 that you have met indeed all nine (9) of the individuals 19 -- you've had the privilege of meeting them -- so you 20 know only too well the people that I'm here standing for 21 and asking for standing for. 22 This collection of mothers and fathers and 23 indeed an uncle, have an extraordinary interest in this 24 Inquiry. They are you might say a collection of the 25 Thomas Soffinos (phonetic) for the Thomas Soffino


1 Inquiry, the Guy Paul Morins for the Guy Paul Morin 2 Inquiry, the Donald Marshalls for the Donald Marshall 3 Inquiry, and so on, and so on. 4 Each and every one of them has been 5 through the dreadful agony of losing a loved one and 6 still having that mark of Cain on them, having been 7 convicted of the responsibility for the death of that 8 loved one. And their shame and desire for vindication 9 are equally balanced in their application for standing 10 before you. 11 Their cases must and will make up the raw 12 material for any decisions that you are going to make; 13 the facts upon which you are going to depend in deciding 14 on your findings and recommendations at the conclusion of 15 this Inquiry. 16 And of course, therefore, each and every 17 one of them has a huge stake in this Inquiry at both a 18 personal level and, as I'll explain in a minute, at a 19 systemic level as well and, in my submission, are in the 20 best position of anyone in this room to develop the 21 evidence for you, upon which you will then base your 22 findings and recommendations. 23 If you look at the terms of reference, 24 first of all they look -- they're looking at paediatric 25 pathology in this Province, the way it's been used and


1 presented in this Province. Each and every one of them 2 has been hugely and adversely impacted by the operation 3 of paediatric forensic pathology in the Province. 4 But first blush, when you look at the 5 limits to your mandate, it would seem that there's an 6 exclusion of the interest of the nine (9) individuals, 7 but of course, in my submission, that's not so. And 8 it's important that all nine (9) of them have a chance to 9 explore the limitations of your mandate. 10 Let me give you some practical examples of 11 how they will be presenting their personal interest 12 through your mandate, as well as their systemic interest. 13 There's reference, in the preamble, to 14 this Commission, to the process in the Criminal Code that 15 they can employ to try and set aside their convictions. 16 Are those processes remotely satisfactory for truly 17 representing their interest in setting aside their 18 convictions? 19 That's a matter that, in deciding, this 20 Commission can both affect the individual interests of 21 the nine (9), the collective interests of the nine (9), 22 and the systemic interests that the nine (9) are 23 interested in, as well. 24 Secondly, how should the fact finding 25 process in their cases proceed from here? Has the


1 Attorney General of Ontario responded adequately and 2 appropriately to their circumstances or has it adopted an 3 adversarial approach to their cases, and if so, is that 4 an appropriate response to their cases? 5 As I've already mentioned, what about 6 funding for these individuals in an attempt to present 7 their cases and have them overturned through some process 8 or other, whether within or without the Criminal Code? 9 How can the Commission explore the issues 10 that it must explore, the issues of a fact from which you 11 can then examine the systemic recommendations it needs to 12 make without jeopardising the rights of the individual -- 13 of the individual nine (9), whose interests, primary 14 interests, are to challenge their own convictions? 15 And indeed, there's been a great deal of - 16 - of discussion already about that very -- those very 17 kinds of issues, between myself and Commission Counsel 18 before we've even arrived here today. And it's going to 19 be a continuing -- a continuing interest and a 20 continuing concern that I think's going to be shared by 21 Commission Counsel, as well of -- as well as the nine (9) 22 themselves. Where is the balance between the interests 23 of the Commission and the interest of the nine (9) 24 individuals? 25 Because whilst the Commission may be


1 concerned about the interests of the individuals, the 2 bottom line is the Commission is not able to ultimately 3 directly assist in overturning their convictions. 4 Although, certainly it may make recommendations that 5 makes it easier for them to overturn their convictions. 6 And perhaps the most important systemic 7 issue of all that affects each and every one of the nine 8 (9) individuals in terms of their own cases is, should 9 and does the adversarial system have a role to play in 10 these cases or is it the wrong way to approach these 11 kinds of cases? 12 And I can tell you, as a fact, it will be 13 our very strong submission from the outset, that it's the 14 wrong approach. It's the wrong system to use for these 15 kinds of cases and causes nothing but problems in an 16 attempt to resolve wrongs that have already happened. 17 And is our Court of Appeal a good forum in 18 which to explore the kinds of factual issues that each of 19 these people face? Or is it expecting too much of a 20 Court that generally deals with process and not -- or 21 deals with matters of process and not generally with 22 matters of actual innocence or actual guilt; a matter 23 that was, indeed, addressed in one of the recommendations 24 made by Commissioner Kaufman at the conclusion of the 25 Morin Inquiry, in terms of the jurisdictional needs of


1 our Court of Appeal. 2 So any recommendations in these regards 3 can and will have far reaching effects on each of the 4 nine (9) individuals that I am here for. And it will 5 help determine whether their stigma or the mark of Cain 6 that they have now will remain on them or not. 7 Their intense personal interest in their 8 individual cases, which they are -- they have -- they are 9 presenting to you through me on a collective bases, also 10 extends into systemic concerns, as well, above and beyond 11 their cases. 12 It's a fact that as you go back through 13 the last fifteen/twenty (15/20) years of inquiries to 14 individual cases, when you look at each of those 15 individuals, it's remarkable how each and every one of 16 them has continued to maintain a huge interest in the 17 cause that they were caught up in; in their own 18 individual cases; in the cause of others who are now 19 caught up in the situation that they were caught up in, 20 in the past. 21 Whether you look at the Thomas Suffino, 22 Jim Driscoll (phonetic), Guy Paul Morin, Donald Marshall 23 and so on and so forth, all of them have continued to 24 show an interest. And that's hardly surprising, and they 25 are in a tremendous position, in my submission, to have


1 that systemic interest and to be able to project helpful 2 systemic recommendations and systemic ideas to a 3 Commission such as this. 4 It's no coincidence that they can be the 5 best advocates of the cause. They are, in a sense, the 6 human face behind the issue that this Commission has been 7 mandated to explore. As well as, of course, Mr. Wardle's 8 clients and those -- some of those people who have not 9 actually sought standing through Mr. Wardle or others. 10 Their issues do overlap to some degree 11 with those of others seeking standing. Indeed, in some 12 way they overlap with each and every person or each and 13 every counsel in this room, who sought standing on behalf 14 of a particular organization or a particular individual. 15 The most obvious example where we overlap is with Mr. 16 Wardle's clients potentially, and also with the 17 Association and Defence of the Wrongly Convicted and the 18 Criminal Lawyers' Association. 19 But none of those organizations, including 20 AIDWYC itself, are can -- are or can be their anointed 21 spokesperson. Those organizations, separate and apart 22 from Mr. Wardle, are there primarily -- or will be here 23 if given standing, primarily to deal purely with systemic 24 issues, and systemic issues that do not necessarily 25 reflect, or do not reflect a personal interest or


1 personal concern in the cases in the indiv -- in any of 2 the individual cases. 3 These individuals then, in my submission, 4 have interest that extend well beyond and well outside, 5 even if at times they overlap with some of the others, if 6 not all of the others, who are seeking standing before 7 you, Mr. Commissioner. None of the individuals any more 8 than they have standing -- or any more than they have 9 funding available for their individual cases, have 10 funding available either for representation at this 11 Commission and are, therefore, seeking funding 12 accordingly. 13 And what we're seeking is funding for two 14 (2) counsel. There will of course be a sharing of 15 resources, especially with the Association of Defence of 16 the Wrongly Convicted, and I think with Mr. Wardle as 17 well; whether I will continue to be one of those counsel 18 is something that remains to be seen. I have another 19 obligation that may take me away from here, and if it 20 does, I would deeply regret that, but it's just a force 21 of circumstances. 22 But in any -- but in any event, certainly, 23 in my submission, the need for two (2) counsels to repre 24 -- two (2) counsel to represent the interest of nine (9) 25 people is not -- is not being demanding of this


1 Commission. To get one's mind around nine (9) cases is 2 quite a considerable task, and will be a considerable 3 task for two (2) counsel to do, but I believe it can be 4 done. Those are my submissions. 5 COMMISSIONER STEPHEN GOUDGE: A couple of 6 comments and questions, Mr. Lockyer. 7 MR. JAMES LOCKYER: Yes. 8 COMMISSIONER STEPHEN GOUDGE: I mean, 9 they -- with you too, as with the others that have spoken 10 so far, I am pleased that you focussed on the duplication 11 risk. Because as you know, the focus of my mandate is 12 very directed toward systemic change. And in that sense 13 there is the risk of duplication with, particularly, Mr. 14 Wardle's clients. 15 Although I appreciate that both of you 16 have the individual circumstances that provide something 17 of the underpinning you've described. 18 Secondly, as to the two questions: First, 19 let me explore a little bit with you, the seven (7) 20 unnamed. For the moment, I take it your request is that 21 they remain anonymous in any decision that I write about 22 standing. Beyond that I take it you're not -- we needn't 23 go beyond that at the moment? 24 MR. JAMES LOCKYER: No, Mr. Commissioner. 25 I'm quite hap -- if they remain anonymous for the time


1 being, it may well be that by their own choice, at some 2 point in the future, they may be asked -- they may ask 3 that their cloak of anonymity be removed or they may 4 volunteer it be removed. 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 MR. JAMES LOCKYER: But that remains to 7 be seen. 8 COMMISSIONER STEPHEN GOUDGE: In relation 9 to the seven (7), the second question I have is: I 10 understand from the AIDWYC application that they are 11 reviewing the seven (7) files, but have not yet 12 undertaken to act for the seven (7); is that correct? Am 13 I right about that or -- 14 MR. JAMES LOCKYER: I'm not sure we -- we 15 talk in term -- terms of acting. Certainly we are 16 reviewing the cases in a way, just as the Commission 17 Counsel is reviewing them. They've asked for further 18 opinions from the -- the reviewing pathologist. We're 19 very interested in that, as well. But we -- yes, we are 20 -- the -- the organization is reviewing the cases. 21 COMMISSIONER STEPHEN GOUDGE: Okay. Let 22 me come at the duplication issue. This we -- 23 MR. JAMES LOCKYER: Yes. 24 COMMISSIONER STEPHEN GOUDGE: -- I take 25 it that in terms of AIDWYC'S role, so far as you wear


1 that hat - perhaps I should be asking Mr. Sokolov this - 2 but they will be systemically oriented entirely. Your 3 brief is systemically oriented, I know, but informed by 4 the individual facts; is that a fair summary? 5 MR. JAMES LOCKYER: I think it is. I 6 sort of doffed it on, the AIDWYC hat, all the time, so to 7 speak. Yes, I can't -- I can't really avoid that. 8 COMMISSIONER STEPHEN GOUDGE: Yes. 9 MR. JAMES LOCKYER: But certainly my 10 primary, indeed my sole interest here, if -- if these 11 individuals are granted standing, is their interest -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 MR. JAMES LOCKYER: -- certainly. 14 COMMISSIONER STEPHEN GOUDGE: Right. And 15 the last question I have is about the funding. The way 16 your application reads, it is proposed that second 17 counsel in effect substitute for you if you are 18 unavailable, as opposed to two (2) counsel; that is, you 19 would not contemplate the need for two (2) counsel at the 20 hearing? 21 MR. JAMES LOCKYER: Mr. Commissioner, 22 certainly in an ideal world I would, just because there 23 are so many individuals whose interest we are seeking to 24 represent. So I -- I think -- I, frankly, forget exactly 25 how it's worded on the application.


1 COMMISSIONER STEPHEN GOUDGE: "Alternate" 2 is the -- 3 MR. JAMES LOCKYER: Is it? Oh dear. All 4 right. Well okay. Streams do change from time to time. 5 You know, as I -- as I've thought it through, I -- I just 6 think really representing the interests of nine (9) 7 people is a pretty demanding exercise for one (1) counsel 8 to have his head around at the same time. 9 But at that end of a day, well, we'll 10 manage with what -- what you grant us, Mr. Commissioner-- 11 COMMISSIONER STEPHEN GOUDGE: Yes, 12 "alternate" is my word. 13 MR. JAMES LOCKYER: -- obviously. 14 COMMISSIONER STEPHEN GOUDGE: To be fair 15 to you, that is my word, not yours. 16 MR. JAMES LOCKYER: Is that what we're -- 17 COMMISSIONER STEPHEN GOUDGE: That is the 18 way I read it, okay. I just wanted to make sure I didn't 19 -- okay. 20 Anyway, I hear what you say about what you 21 are proposing. Okay. Thank you. 22 MR. JAMES LOCKYER: Thank you very much. 23 Thank you. 24 MS. LINDA ROTHSTEIN: Mr. Wardle, on 25 behalf of the Affected Families Group, Commissioner, is


1 next. 2 COMMISSIONER STEPHEN GOUDGE: Mr. 3 Wardle...? 4 5 SUBMISSIONS BY AFFECTED FAMILIES GROUP: 6 MR. PETER WARDLE: Good morning, Mr. 7 Commissioner. My co-counsel, Julie Kirkpatrick, from 8 Millbrook, Ontario, is with me today. Our clients are a 9 group of seven (7) individuals who were directly affected 10 by the systemic failings in paediatric forensic pathology 11 in the years covered by the mandate. 12 They're all persons who were subject to an 13 in -- criminal investigation, and in three (3) cases, a 14 criminal prosecution. In all four (4) cases there was 15 child protection proceedings. So they are somewhat 16 different than Mr. Lockyer's group. None of them were 17 ever convicted, but all of them went through the criminal 18 process in one form another and all of them went through 19 child protection proceedings. 20 I'm not going to go into the details of 21 each case now because they're in the standing application 22 in some detail, but I'm simply going to outline their 23 names for you: Maurice Gagnon and Lianne Thibeault, a 24 father and daughter from Sudbury, Ontario. 25 The daughter was subject to a criminal


1 investigation arising out of the death of her infant; 2 ultimately, child protection proceedings and a child 3 taken from her at birth. Dr. Smith was the pathologist 4 who conducted the autopsy in that case; an exhumation of 5 the body. 6 Ultimately, as you know from reading the 7 material, the child protection proceedings were abandoned 8 after an expert report was obtained from the United 9 States. And that family has suffered greatly, both in 10 personal terms and in financial terms. 11 And it may be of interest to the Inquiry 12 as we go on, that Mr. Gagnon, following the termination 13 of the proceedings sought redress from a number of 14 institutions, including some of the institutions that are 15 represented before this Inquiry, but really was 16 frustrated by almost every effort he made to reach out to 17 somebody. 18 Second family is Brenda Waudby and her 19 daughter Jenna Mellor. They're a mother and daughter 20 from Peterborough, Ontario. Their case is also well 21 known. 22 Brenda's daughter died in January 1997. 23 Again, Dr. Smith conducted the autopsy. On the basis of 24 his findings about the timing of the injuries, Brenda was 25 charged with the murder of -- of her daughter. One of


1 her children, a newborn, was apprehended at birth, as a 2 result of the charges. Ultimately, the charges were 3 withdrawn by the Crown as a result of medical opinions 4 obtained by the Defence. And recently a babysitter, a 5 young offender, who had custody of the child shortly 6 before the death pleaded guilty to manslaughter. 7 The third case is also well known, Louise 8 Reynolds of -- originally from Kingston, Ontario. Her 9 daughter died in June of 1998. Dr. Smith, again, 10 conducted the autopsy and concluded that the girl had 11 been killed by seventy (70) stab wounds. Louise Reynolds 12 was charged with second degree murder, spent twenty-two 13 (22) months in protective custody awaiting trial. 14 Almost three-and-a-half (3 1/2) years 15 after the death, after a second autopsy, after a number 16 of outside opinions and after an opinion from an eminent 17 United States anthropologist, the Crown withdrew the 18 charges and it's now clear, I suggest, that Louise's 19 daughter was killed by a dog. 20 The fourth case, Angela Vino and Anthony 21 Kporwodu, a father and mother from the Toronto area is 22 also well known to you. Their daughter died in March of 23 1998, unexpectedly. Dr. Smith conducted the initial 24 autopsy. 25 There were may unexplained delays with Dr.


1 Smith's initial autopsy report. He was then asked by the 2 police to provide an opinion on the timing of the 3 injuries. There was a lengthy delay before that was 4 delivered in April of 2000. 5 Ultimately, the parents were charged with 6 the murder of their daughter. During the preliminary 7 inquiry in this case, there was an extensive examination 8 of a so-called review of Dr. Smith's cases by the Office 9 of the Chief Coroner, conducted in 2001, and we 10 anticipate that you may hear something about that review 11 during the course of your work. 12 Ultimately, as you know, the charges were 13 stayed on the basis of delay, largely attributable to Dr. 14 Smith's failings. The Court of Appeal concluded that the 15 lives of these parents had been devastated as a result of 16 the delay in the proceedings against them. And of course 17 in this case as well, there was an older child who was 18 apprehended by the Children's Aid Society. 19 So with respect to this -- the application 20 for standing, I suggest and I submit that these cases all 21 raise systemic issues. They all have issues in common. 22 They took place in a fairly narrow time window within 23 your mandate, in the period between November 1995 and 24 2001. 25 And we included with the standing material


1 a timeline and the purpose of that was simply to 2 demonstrate the overlap between these cases, because all 3 four (4) of them actually ran in parallel for a 4 significant period of time. 5 And there are common features that pop out 6 of these cases when you put them on a timeline and you 7 look what was being done by the Office of the Chief 8 Coroner in each case. 9 So there are, in my submission, common 10 issues raised by these cases which go directly to your 11 mandate. 12 The rules for standing asked why -- why do 13 your clients wish to participate? I think the answer to 14 that is fairly obvious. They wish to ensure that no one 15 ever has to go through experiences like theirs again. 16 They have a stake in this process. 17 And we've outlined in our material and I 18 won't repeat it, the contribution we expect to be able to 19 make. We suggest that we offer a unique perspective that 20 can't be duplicated by any other participants. 21 I won't deal in any detail with the 22 criteria for standing; it's set out, again, in my 23 materials. I've referred to the decisions of 24 Commissioner O'Connor in the Arar and Walkerton cases and 25 it's clear, I -- I would submit, from those cases that


1 standing under the Public Inquiries Act it's not a bright 2 line test, but a matter of your discretion taking into 3 account a number of factors. 4 My clients, I suggest, are integrally 5 involved in the events which underlie the mandate of the 6 Inquiry. We appreciate that your work will not be a 7 case-by-case analysis. Your mandate doesn't allow you to 8 do that and you don't have the time, to be frank. 9 So you have to look at the systemic 10 issues. But in order to do that you're going to have to 11 establish certain foundation facts and we anticipate that 12 some of the facts from these four (4) cases will be 13 amongst the facts that you're examining. 14 So we're simply asking for a full party 15 standing under the Public Inquiries Act. 16 With respect of funding, again, none of my 17 clients can afford legal representation at the Inquiry. 18 We've proposed a team, which essentially would be one (1) 19 senior counsel, two (2) junior counsel, with, for 20 purposes of actually appearing at public hearings, 21 limited to one (1) senior, one (1) junior, in the 22 expectation that we wouldn't both be here all the time. 23 And we've also asked for some clerk time, 24 which I think is -- in the circumstances, is self- 25 explanatory. I do want to comment briefly on


1 cooperation. I have had some discussions with Mr. 2 Lockyer already. I anticipate that we'll be working with 3 Mr. Lockyer as this matter develops and that we'll 4 jointly work in ways that will avoid overlap, because we 5 do share some common interests; not exclusive, but some 6 common interest. 7 And I have gone to some lengths in the 8 written material to suggest that you might allow us 9 alternate a -- counsel on occasion, simply because of my 10 time commitments elsewhere. 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 MR. PETER WARDLE: Thank you, sir. 13 COMMISSIONER STEPHEN GOUDGE: Yes, I 14 appreciate that. I also should say I appreciate, given 15 the systemic focus that I have got squarely in front of 16 me, the preliminary list you have provided in your 17 application. 18 MR. PETER WARDLE: Thank you, sir. 19 MS. LINDA ROTHSTEIN: Next on our list, 20 Commissioner, is AIDWYC. 21 COMMISSIONER STEPHEN GOUDGE: Mr. 22 Sokolov...? 23 24 SUBMISSIONS BY ASSOCIATION IN DEFENCE OF THE WRONGLY 25 CONVICTED:


1 MR. LOUIS SOKOLOV: Good morning, Mr. 2 Commissioner. Mr. Commissioner, you're obviously 3 familiar with AIDWYC and have read the material, so I'm 4 not going to go through it in great detail. 5 In brief, though, the -- AIDWYC is the 6 Association in Defence of the Wrongly Convicted. It's a 7 public interest organization that was formed some 8 fourteen (14) years ago by lawyers and other community 9 members involved in -- for securing bail and then helping 10 right the wrongful conviction of Guy Paul Morin. 11 In the years since, AIDWYC has become the 12 leading public interest organization in Canada, dedicated 13 to correcting individual cau -- cases of wrongful 14 conviction, promoting public education into its causes 15 and working towards reforms aimed at preventing wrongful 16 conviction. 17 AIDWYC has hosted conferences. Its 18 members regularly attend international meetings and it 19 has been repeatedly consulted by provincial and federal 20 governments. And perhaps most importantly, the lawyers 21 who work for AIDWYC, some of whom are directors, 22 including, of course, Mr. Lockyer, have been instrumental 23 in vindicating the growing list of persons we now know as 24 the wrongfully convicted in this country. 25 AIDWYC has been granted standing and


1 funding in all of the wrongful conviction Inquiries that 2 have been held in this country since Morin. The -- I 3 would ask you to consider the decision of Commission 4 Kaufman in granting standing to AIDWYC in Morin, finding 5 that it, in fact, had a substantial and direct interest 6 there. That was eleven (11) years and four (4) Inquiries 7 ago and our -- and AIDWYC's expertise and work has grown 8 since that time. 9 AIDWYC does, in my respectful submission, 10 have a substantial and direct interest in the subject 11 matter underlying this Inquiry. It has expertise and it 12 has a reputation that it can bring to this Inquiry that 13 will, in my submission, assist you in achieving your 14 mandate of restoring public confidence in the paediatric 15 forensic pathology system. 16 I'll address the issue of duplication and 17 I'll try and gain your confidence by not duplicating what 18 other people have said on the subject. There are, of 19 course, overlapping interests and complementary 20 perspectives between AIDWYC, the individuals, I expect 21 with the Criminal Lawyers' Association, and I 22 would expect with your counsel and other parties as well. 23 That, in my respectful submission, is the 24 nature of public inquiries of this kind, particularly 25 wide-ranging ones. There's nothing unique about this


1 Commission of inquiry in that regard. You can look at 2 Walkerton or any of the other inquiries. That's always a 3 concern. Indeed, it's always a challenge but it's a 4 challenge that has been met in the past by experienced 5 counsel and experienced commissioners, and I fully expect 6 it can be met in this case. 7 And I expect in this Inquiry as in other 8 inquiries that have preceded it, counsel will meet and 9 cooperate and do our best so as not to delay you in your 10 task and, in fact, provide assistance. And indeed, it's 11 the wide-ranging nature of consultation with parties, 12 which in my submission will help the Commission in its 13 task of -- of restoring public confidence. 14 With respect to funding, AIDWYC is a 15 nonprofit organization. It's a volunteer organization. 16 It cannot participate in a meaningful way in an inquiry 17 such as -- such as this one without funding. In my 18 submission, what is required for a public interest group 19 such as AIDWYC in this Inquiry is to have one (1) counsel 20 in the hearing room. There may be occasions where simply 21 because of scheduling it may be an alternate counsel, but 22 one (1) counsel in the hearing room is what's required 23 with some amount of preparation time. 24 I endorse what My Friend, Ms. Greene, said 25 with respect to preparation. Without having a look at


1 what -- at --- at the size of the brief, it's difficult 2 to -- to give you any reasonable estimate. I'd like to 3 reserve the opportunity to come back to you either in 4 person or in writing to make a submission with respect to 5 preparation, if AIDWYC is granted standing and funding. 6 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 7 Sokolov. 8 MS. LINDA ROTHSTEIN: Commissioner, the 9 next applicant is Aboriginal Legal Services of Toronto 10 and Nishnawbe Aski Nation. 11 COMMISSIONER STEPHEN GOUDGE: Mr. 12 Rudin...? 13 14 SUBMISSIONS BY ABORIGINAL LEGAL SERVICES OF TORONTO AND 15 NISHNAWBE ASKI-NATION: 16 MR. JONATHAN RUDIN: Good morning, 17 Commissioner. With me today is Mandy Eason a staff 18 lawyer with Aboriginal Legal Services of Toronto. 19 We have prepared a small book, 20 supplementary book of authorities, which contains some 21 new information that I'll be relying on today, as well as 22 more detail on some of the information we've provided in 23 our motion records so I'll just... 24 25 (BRIEF PAUSE)


1 MR. JONATHAN RUDIN: I know you've read 2 our materials, as you've mentioned. I do not plan to 3 review all that information. 4 My focus today will be on three (3) 5 issues: 6 First, information on the ALST NAN 7 Coalition and why we are seeking standing at this 8 Inquiry. 9 Second, how the ALST-NAN Coalition meets 10 the requirements for standing for the Inquiry. 11 And third, our request for funding. 12 The Order in Council that established this 13 Inquiry directed you: 14 "to make recommendations to restore and 15 enhance public confidence in paediatric 16 forensic pathology in Ontario and its 17 future use in investigations and 18 criminal proceedings." 19 We submit that it will not be possible for 20 you to meet this direction unless there is full and 21 active participation from the Aboriginal community. An 22 Inquiry that does not explicitly address the many 23 Aboriginal issues relating to the way in which the deaths 24 of Aboriginal children are investigated and prosecuted in 25 Ontario, will not be able to establish, much less


1 restore, the faith of Aboriginal people in the systems 2 that are under review by this Inquiry. 3 Tab 1 of our supplementary book of 4 authorities contains portions of a report by Statistics 5 Canada on Aboriginal populations in Canada. And page 9 6 of that report points out that Ontario has the largest 7 Aboriginal population in Canada. 8 So that's at Tab 1 and then if you go in 9 to the first bullet point, fourth -- the fourth page; The 10 Aboriginal Populations in the Province and Territories. 11 One (1) in five (5) Aboriginal people in 12 Canada live in Ontario. The -- two (2) pages on from 13 there you will see a graph looking at the distribution, 14 the age distribution, of the Aboriginal population. And 15 what you see there is that over 10 percent of the 16 Aboriginal population in Canada is 4 years of age and 17 younger. In contrast, the 0 to 4 age group is only 5 18 percent of the Canadian population. 19 In addition, as we set out in our 20 materials, infant mortality rates are two (2) to three 21 (3) times higher in Aboriginal communities. The injury 22 death rate among Aboriginal infants and preschoolers is 23 four (4) to five (5) times the Canadian rate, and 24 Aboriginal infants are three (3) times more likely to 25 experience Sudden Infant Death Syndrome.


1 Taken together, what this data makes clear 2 is that Aboriginal children and families are more likely 3 than any other group in Ontario to come into contact with 4 paediatric forensic pathology; and it means then, that 5 the distinct issues related to Aboriginal children must 6 be a focus of this Inquiry. 7 Now, we do not know how many Aboriginal 8 families have been involved with paediatric forensic 9 pathology in Ontario, because we have not had access to 10 the files that have led to the calling of this Inquiry. 11 We would not be surprised, however, to find a number of 12 Aboriginal families have been caught up in this process. 13 The ALST-NAN Coalition was established to 14 allow the diverse voices and needs of Aboriginal people 15 from across the Province to be heard. ALST has a great 16 deal of experience in serving the needs of the Aboriginal 17 community which -- the urban Aboriginal community -- 18 which is a growing population both through birthrates and 19 migration from reserves and other provinces and 20 territories. NAN provides the window into the north. 21 NAN covers two-thirds (2/3s) of Ontario. Forty-five 22 thousand (45,000) people are NAN members. 23 We often hear people speak of the 24 challenges of providing services in the north, and 25 certainly this will have to be a focus of this Inquiry as


1 well, but what must be kept in mind is that the north is 2 not monolithic. The issues of services to fly-in 3 communities, whether these be paediatric forensic, 4 police, or legal services, are very different from those 5 faced by people living in the cities and towns of the 6 north. And when we speak of the needs of fly-in 7 communities, we're speaking of the needs of Aboriginal 8 people, because it is Aboriginal people who live in fly- 9 in communities. A fly-in community is an Aboriginal 10 community. 11 ALST brings to the Inquiry its experience 12 with working with both the Coroner's Office and with the 13 criminal justice system. In addition, ALST's experience 14 in Inquiries such as this has been to bring systemic 15 issues to the fore, through the use of experts and 16 reliance on studies and data. 17 NAN not only brings the practical 18 experience of life in the north, but NAN's participation 19 also speaks to the need to address issues such as this on 20 a nation-to-nation basis. While not binding upon you as 21 Commissioner, we feel that it is important to highlight 22 the first principle in what the Province called in 2005, 23 "Ontario's new approach to Aboriginal affairs." The 24 relevant sections of that new approach are found at Tab 5 25 of our supplementary book of authorities.


1 And that first principle is respectful 2 relationships with First Nations Metis and Aboriginal 3 service providers. And the approach states, with regard 4 to that principle, and I quote: 5 "Ontario recognizes that First Nations 6 have existing governments and is 7 committed to dealing with First Nations 8 governments in a cooperative and 9 respectful manner that is consistent 10 with their status as governments. Many 11 aspects of Ontario's evolving 12 relationship with First Nations will 13 take shape from important policy 14 decisions to come." Unquote. 15 And this then brings us to how the 16 Coalition meets the test for standing, as set out by the 17 Inquiry. Section 11 of the Inquiry's rules of standing 18 set out four (4) related considerations parties will want 19 to meet. 20 First, with respect to the terms of 21 reference for this Inquiry, we have already referred to 22 the necessity for meaningful Aboriginal involvement in 23 order to establish confidence by Aboriginal people in 24 paediatric forensic pathology and with its use in 25 criminal prosecutions.


1 Second, in terms of Section 5 of the 2 Public Inquiries Act, I believe that the statistics we 3 have cited demonstrate that the Coalition meets the test 4 set out in the section, as a party with a substantial and 5 direct interest in the subject matter of the Inquiry. 6 I know you're very familiar with the 7 leading case on this issue, the -- re. The Ontario Royal 8 Commission in the Northern Environment. It's in our book 9 of authorities at Tab 3 and we've highlighted paragraphs 10 7 and 8 of that decision on determining substantial and 11 direct interest. 12 Interestingly -- that's in our -- in our 13 book of authorities, our original materials. 14 Interestingly, that decision deals with an application 15 for standing brought by the Grand Council of Treaty 9 16 Bands, a predecessor organization to NAN. And while the 17 Inquiry you are conducting is different in many ways, 18 from the one that was the subject of the application to 19 Divisional Court in the Royal Commission on the Northern 20 Environment, we think much of what the Court said at 21 paragraph 11 of that decision is relative today and I 22 just want to quote briefly from a couple of portions of 23 that. 24 The Court said: 25 "The Grand Council Treaty 9 is a


1 corporation representing the 2 democratically elected representatives 3 from forty (40) different bands of 4 Ojibway and Cree people of northern 5 Ontario. This corporation, therefore, 6 represents approximately two-thirds 7 (2/3s) of the population in the area in 8 question. These people call themselves 9 the Nishnawbe Aski which means 'the 10 people and the land.' Theirs is a 11 unique way of life, one which they have 12 lived for centuries. The Grand Council 13 is not the spokesman for a few citizens 14 who are vaguely interested in the 15 outcome of the Commission's Inquiry, 16 but rather it represents a majority of 17 the population in the region, a 18 different culture and lifestyle. This 19 exercise by necessity must profoundly 20 affect the people of the Grand 21 Council." 22 And the Court then goes on to find that 23 the Grand Council should have standing. 24 The third criteria in the Inquiry's rules 25 for standing speak to the systemic nature of the Inquiry.


1 And in your address on June 18th, 2007 you listed nine 2 (9) systemic issues you -- you plan to address. 3 In all of these nine (9) areas the 4 Coalition will have important contributions to make. We 5 have particular interest in the following four (4) areas: 6 (a) The evolving state of paediatric 7 forensic pathology and best practices in this area, with 8 specific reference to the fact that Aboriginal children 9 may be particularly susceptible to syndromes such as 10 SIDS. 11 (b) How the police, Crowns, coroners, and 12 forensic pathologists work together. The Coalition has 13 experience with the criminal law process and we know 14 quite well how the phenomenon of tunnel vision leads to 15 injustices to Aboriginal accused persons. We also have 16 an important perspective on the challenges of such 17 processes in remote fly-in communities. 18 (c) Different models of death 19 investigation. The Coalition's long history of 20 involvement with the Coroner's system and our 21 frustrations and concerns with that system have led us to 22 investigate what other models might be better able to 23 serve the needs of families who have lost loved ones, and 24 also make meaningful recommendations to prevent other 25 such deaths; and


1 (d) The Legal Aid system and the 2 challenges faced by Aboriginal people in accessing 3 services from that system and from the defence bar in 4 general. 5 The fourth criteria identified is a fair 6 and expeditious hearing. And we realize there can be 7 tension in trying to be fair to parties and conducting an 8 Inquiry such as this, which has a fixed time limit. 9 As we have repeatedly stated, we do not 10 see how this Inquiry can be seen as fair if it does not 11 allow for Aboriginal participation. No other applicant 12 for standing holds itself out as being able to represent 13 the needs of Aboriginal people. Given the Coalition's 14 interest and commitment to the subject matter of this 15 Inquiry, our involvement will be to assist the Inquiry in 16 getting the Aboriginal perspective it needs to fulfill 17 its mandate and also to do so in an expeditious manner. 18 And this then leads to the last part of 19 our submission, a request for funding for counsel. As we 20 have detailed in our materials ALST has three (3) staff 21 lawyers. In addition to the case work that the lawyers 22 are undertaking, we are representing currently nine (9) 23 families with the Coroner's Office, in dealings with the 24 Coroner's Office. 25 We will also be appearing at four (4)


1 inquests that have already been called. One (1) of them 2 which is an inquest as a result of a death -- jail fire - 3 - death as a result of a jail fire at the Kashachewan 4 First Nation in NAN Territory, is scheduled to run for 5 three (3) months and will occur during the Inquiry's 6 mandate. So as a result, the Coalition will only fully 7 be able to participate at the Inquiry if it is funded to 8 hire outside counsel. 9 It's important to stress that outside 10 counsel will work on this Inquiry with ALST as co- 11 counsel. An ALST lawyer will be at the Inquiry as often 12 as possible. When not at the Inquiry, ALST's lawyer will 13 often be involved in consulting with the broader 14 aboriginal community and with our coalition partner. 15 The arrangement we are proposing here is 16 similar to the one that we had during the Ipperwash 17 Inquiry where ALST was a party. We found that it worked 18 very effectively and we think that the final report of 19 that inquiry spoke well to the contributions we were able 20 to make. 21 The members of the ALST NAN Coalition 22 realize the commitment we are taking on by seeking 23 standing at this Inquiry. We are all very busy and we 24 have other demands for our time. However, the biggest 25 commitment we have is to the members of the Aboriginal


1 community we serve. 2 And to the members of the Aboriginal 3 community, the work of this Inquiry will be of great 4 importance. We cannot discharge our duties to our 5 community without participating in this Inquiry. 6 We hope that you will grant us standing 7 and funding to hire outside co-counsel to allow us to 8 respond to this very real need. 9 Subject to any questions... 10 COMMISSIONER STEPHEN GOUDGE: Thank you, 11 Mr. Rudin. 12 I take it you have been pretty clear that 13 the standing you are seeking focuses primarily on the 14 issues presented for Aboriginal people by the system of 15 paediatric forensic pathology? 16 MR. JONATHAN RUDIN: That is correct. 17 Now some of those may not be immediately apparent but 18 yes, that's exactly -- 19 COMMISSIONER STEPHEN GOUDGE: Okay. 20 MR. JONATHAN RUDIN: -- what we choose to 21 focus in on. 22 COMMISSIONER STEPHEN GOUDGE: Thanks. 23 MR. LINDA ROTHSTEIN: Commissioner, the 24 last organization applicant which seeks standing is 25 Defence for Children International-Canada.


1 COMMISSIONER STEPHEN GOUDGE: Ms. 2 Fraser...? 3 4 SUBMISSIONS BY DEFENCE FOR CHILDREN INTERNATIONAL-CANADA: 5 MS. SUSAN FRASER: Good morning, Mr. 6 Commissioner. As you know, I represent Defence for 7 Children International-Canada; it's an international 8 organization. The Canadian version of it is based in 9 Ontario and it seeks to allow and -- parties allow 10 children -- and most importantly, to ensure that the UN 11 Convention on the Rights of the Child is respected in the 12 countries in which it advocates. 13 On a more broad-based level, DCI has done 14 grass work -- grassroots work with children and youth in 15 the Province of Ontario and that is highlighted in the 16 affidavit material of Les Horne, and I will not repeat it 17 here. It goes without saying that DCI is the only 18 organization here before you which intends to bring a 19 children's rights perspective to the Inquiry. 20 As the Inquiry is systemic based, DCI is 21 well situated to bring forward some of the unique issues 22 that are faced when investigating the deaths of children. 23 And in particular, in its affidavit material DCI has 24 focussed on institutional care and the deaths of young 25 people in institutional care. Those are of particular


1 interest to DCI because those deaths occur behind public 2 view. 3 I wanted to, in these remarks to you, make 4 reference to the 1971 report of the Law Reform Commission 5 on the coroner system, and one quote that's relied upon 6 often by courts in dealing with the role of the Office of 7 the Coroner. And it's simply that: 8 "The death of the member of a society 9 is a public fact and the circumstances 10 surrounding that death, whether it 11 could have been avoided or prevented 12 through the actions of persons or 13 agencies under human control, or 14 matters within the legitimate scope of 15 all members of the community. And the 16 role of the Office of the Coroner must 17 keep pace with societal changes and 18 where necessary move away from the 19 confines of doctrines that are 20 inconsistent with community needs and 21 expectations in the 20th Century." 22 And this is as important now in the 21st 23 Century in that when we look at the Office of the Coroner 24 and the role of paediatric forensic psychiatry, that it 25 is informed by a broad-based social concern. And DCI can


1 bring forward the unique concerns of children and youth. 2 It, as referred to in our affidavit 3 material, intends to form a children -- a group of 4 children and youth who have been in institutional care 5 and have been involved in investigations, whether through 6 the death of a member of -- when they were in 7 institutional care or otherwise. 8 Children will most often be witnesses to 9 deaths in institutional care and there are unique 10 concerns that arise out of their participation in any 11 investigation and it's the hope that DCI, if granted 12 standing, could help you, Mr. Commissioner, understand 13 those unique issues. 14 In terms of its substantial and 15 considerable knowledge of the coroner's system, we have 16 referred in our affidavit material to two (2) reports 17 released by DCI. The first was in 2003 and the report in 18 itself was really about the need for there to be an 19 independent child advocate. 20 But part of that report -- and you'll find 21 it at pages 23 to 24 of Exhibit A to the Horne affidavit, 22 that's the first report -- it talked about the need for 23 there to be an independent child review, child death 24 review system. 25 The report did look at some of the other


1 jurisdictions and it talked about some of the failings of 2 the Paediatric Death Review Committee. The fact that, 3 while the committee could make recommendations in 4 response to death reviews, it did not have the power to 5 impose time limits or recommended actions, and it didn't 6 have the resources to conduct followup investigations or 7 monitor the implementation of recommendations. And 8 that's on page 24. 9 Also, the report highlighted some of the 10 concerns about the independence of the Paediatric Death 11 Review Committee where it was examining deaths in 12 institutional care, because some of the membership of 13 that committee was connected to the institutions; most 14 notably, the Ontario Association of Childrens' Aid 15 Societies, which was a member of the committee. 16 So DCI has been examining this issue since 17 2003 and in 2005, again called upon there to be an 18 independent advocate with the ability to do paediatric 19 death reviews. Now since that time, the work of DCI has 20 been successful in terms of the creation of an -- a 21 provincial advocate for children and youth. That has 22 come into being. The legislation has passed, although 23 not yet proclaimed, into force. But it does not have the 24 ability to conduct death review. 25 So that is still an important issue in


1 terms of DCI, is creating a credible paediatric death 2 review system. 3 DCI has, as you know from our affidavit 4 material, assisted young people in participating in 5 coroners inquests. It has assisted young people and -- 6 in terms of being victims violence, and it has also 7 engaged in litigation regarding children's right's 8 issues. 9 But for your perspective, the important 10 thing to note is that it is DCI's real hope that your 11 work can be informed by the voices of young people and 12 the expertise of people working in children's rights 13 issues, because the coroner's system is a foundation, is 14 part impartial of public safety, that the examination of 15 deaths and the recommendations that come out of a -- of 16 your Inquiry and re -- regarding the investigation of 17 deaths has bearing on change and institutional safety. 18 And so it's part and parcel, as we see it, of public 19 safety and DCI hopes to inform you in that respect. 20 So just in terms of summarizing the 21 substantial and that special knowledge possessed by DCI, 22 we feel that we have substantial special knowledge in 23 terms of the vulnerabilities of children in the care of 24 the state; in terms of the investigation of the deaths of 25 children in institutional care; in terms of paediatric


1 death review as a component of public safety; in terms of 2 the need for a process for death reviews that is 3 independent of the agencies responsible for the provision 4 of care; in terms of elevating the voices of children of 5 youth in the legal process that affect them; and in terms 6 of providing a child's rights perspective, which is both 7 unique in terms of the applicants who are before you for 8 standing today. 9 Obviously, our interests are discreet, 10 that we are more interested in the systemic issue 11 relating to the investigation of children and youth, and 12 in terms of the creation of a meaningful paediatric death 13 review system. 14 We anticipate that only one (1) counsel 15 will be needed, that it's a discreet brief. We do not 16 see there being duplication, but we -- and we are most 17 mindful of the need for you to proceed expeditiously. 18 But we are very concerned that you do have knowledge of 19 the broader based issues from a children's rights 20 perspective and it is on that basis that we hope to be 21 able to assist you. 22 On the issue of funding, I think the 23 materials make clear that DCI is a not-for-profit 24 organization and the dollars that it does have are 25 targeted by its funding bodies for projects under SEDA.


1 But essentially, it would not be able to participate 2 unless granted funding on -- by the Commission. Thank 3 you. 4 COMMISSIONER STEPHEN GOUDGE: One (1) 5 question I have for you, Ms. Fraser. 6 I take it from your submission that at 7 least a large part of the focus you seek to have, would 8 be on issues relating to, if I can put it this way, 9 children that survive in a family where there has been a 10 paediatric death and the issues that relate to them? Is 11 that...? 12 MS. SUSAN FRASER: There -- there are -- 13 are two (2) issues, I think. The affidavit of Les Horne 14 relates to the false positives issue, in terms of 15 investigations where the wrong per -- there -- there's a 16 wrong conclusion, in terms of the mechanism by which the 17 death occurred. 18 And certainly in the voices of children 19 who have been subject to -- or have been participants 20 where their parent or caregiver has been wrongly 21 identified. Those voices are important for the 22 Commission to hear. 23 The other component of that is the false 24 negatives where there is a concern that if there is not a 25 credible death review system, that some of the deaths in


1 institutional care may not be examined properly if the 2 voices of children in those institutions are not heard. 3 So it's -- it's really in two (2) parts, 4 that it is our hope that we can bring forth through our 5 knowledge of the investigation of deaths in institutional 6 care, I think that our knowledge lays more with the 7 latter in terms of bringing those voices forward and 8 improving investigations where there is a death in 9 institutional care. 10 You know, I think it's -- we can't -- 11 certainly can't speak to the individuals affected, but it 12 would be our hope that we would be able to bring forth 13 both perspectives in terms of our youth advisory group. 14 But in terms of the special knowledge, right now that 15 knowledge is more based on the second part, the -- 16 COMMISSIONER STEPHEN GOUDGE: What you 17 call a false negative? 18 MS. SUSAN FRASER: Yes, for lack of a 19 better term. 20 COMMISSIONER STEPHEN GOUDGE: Yes. 21 MS. SUSAN FRASER: But just the -- the 22 need for that paediatric death review to be meaningful 23 and independent. 24 COMMISSIONER STEPHEN GOUDGE: Okay. 25 Thanks, Ms. Fraser.


1 2 MS. SUSAN FRASER: Thank you. 3 COMMISSIONER STEPHEN GOUDGE: Ms. 4 Rothstein...? 5 MS. LINDA ROTHSTEIN: Commissioner, that 6 completes all of the Counsels' submissions who wish to 7 make submissions to orally. I hope that the record here 8 this morning is indicative of the efficiency and lack of 9 duplication of Counsel because, by my record, sir, we are 10 an hour ahead of schedule. 11 COMMISSIONER STEPHEN GOUDGE: We set 12 aside two (2) hours, so we should be done by January, on 13 that ratio. 14 Well, thank you all for your submissions 15 and thank you for being expeditious and for the thought 16 that you have put into your applications. I am obviously 17 going to reserve and I will let you have my decision in 18 the very near future and we will proceed expeditiously 19 from there, folks. 20 So thank you, again, for attending and we 21 are adjourned. 22 23 --- Upon adjourning at 11:30 a.m. 24 25


1 2 3 Certified Correct 4 5 6 7 8 __________________ 9 Wendy Warnock, Ms. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25