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 Held at: 17 Offices of the Inquiry 18 180 Dundas Street West, 22nd Floor 19 Toronto, Ontario 20 21 22 ******************** 23 24 December 7th, 2007 25


1 Appearances 2 Linda Rothstein ) Commission Counsel 3 Mark Sandler (np) ) 4 Robert Centa (np) ) 5 Jennifer McAleer (np) ) 6 Johnathan Shime (np) ) 7 Ava Arbuck ) 8 9 Brian Gover (np) ) Office of the Chief Coroner 10 Luisa Ritacca ) for Ontario 11 Teja Rachamalla (np) ) 12 13 Jane Langford (np) ) Dr. Charles Smith 14 Niels Ortved (np) ) 15 Erica Baron ) 16 Grant Hoole ) 17 18 William Carter ) Hospital for Sick Children 19 Barbara Walker-Renshaw(np) ) 20 Kate Crawford ) 21 22 Paul Cavalluzzo (np) ) Ontario Crown Attorneys' 23 Association 24 25


1 APPEARANCES (CONT'D) 2 3 Mara Greene (np) ) Criminal Lawyers' 4 Breese Davies ) Association 5 Joseph Di Luca (np) ) 6 Jeffery Manishen (np) ) 7 8 James Lockyer (np) ) William Mullins-Johnson, 9 Alison Craig (np) ) Sherry Sherret-Robinson and 10 Phil Campbell (np) ) seven unnamed persons 11 12 Peter Wardle (np) ) Affected Families Group 13 Julie Kirkpatrick ) 14 Daniel Bernstein (np) ) 15 16 Louis Sokolov ) Association in Defence of 17 Vanora Simpson (np) ) the Wrongly Convicted 18 Elizabeth Widner (np) ) 19 Paul Copeland (np) ) 20 21 Jackie Esmonde (np) ) Aboriginal Legal Services 22 Kimberly Murray ) of Toronto and Nishnawbe 23 Sheila Cuthbertson (np) ) Aski-Nation 24 Julian Falconer (np) ) 25


1 APPEARANCES (cont'd) 2 3 Suzan Fraser ) Defence for Children 4 ) International - Canada 5 6 William Manuel (np) ) Ministry of the Attorney 7 Heather Mackay (np) ) General for Ontario 8 Erin Rizok (np) ) 9 Kim Twohig ) 10 11 Natasha Egan (np) ) College of Physicians and 12 Carolyn Silver (np) ) Surgeons 13 14 Michael Lomer (np) ) For Marco Trotta 15 Jaki Freeman (np) ) 16 17 18 19 20 21 22 23 24 25


1 TABLE OF CONTENTS Page No. 2 3 DAVID ALEXANDER CHIASSON, Sworn 4 5 Examination-In-Chief by Ms. Linda Rothstein 6 6 7 Certificate of transcript 244 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25


1 --- Upon commencing at 9:30 a.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Morning. 6 Ms. Rothstein...? 7 MS. LINDA ROTHSTEIN: Good morning, 8 Commissioner. Our witness today is Dr. David Chiasson 9 and, Registrar, would you be good enough to swear him in? 10 11 DAVID ALEXANDER CHIASSON, Sworn 12 13 EXAMINATION-IN-CHIEF BY MS. LINDA ROTHSTEIN: 14 MS. LINDA ROTHSTEIN: Good morning, Dr. 15 Chiasson. 16 DR. DAVID CHIASSON: Good morning, Ms. 17 Rothstein. 18 MS. LINDA ROTHSTEIN: If you would be 19 good enough to turn up Volume I, Tab 1. It's going to 20 get harder after that, but we do start with the first fab 21 of the first volume. It is a copy of your curriculum 22 vitae, sir. I'd like to review with you, your 23 background if I may. And you can find it at 129336. 24 I understand, Dr. Chiasson, that you hail 25 from Cape Breton?


1 DR. DAVID CHIASSON: I do, yes. 2 MS. LINDA ROTHSTEIN: You received your 3 Bachelor of Science from Dalhousie University in 1975? 4 DR. DAVID CHIASSON: Correct. 5 MS. LINDA ROTHSTEIN: And MD in 1979, 6 also from Dalhousie? 7 DR. DAVID CHIASSON: Yes. 8 MS. LINDA ROTHSTEIN: And am I correct, 9 sir, that you first became interested in pathology in 10 medical school? 11 DR. DAVID CHIASSON: I did, yes. 12 MS. LINDA ROTHSTEIN: Tell us about that. 13 DR. DAVID CHIASSON: I was very much 14 influenced by the professor. The Chair of the Department 15 of Pathology was a Dr. David Janagen (phonetic) at 16 Dalhousie. He was a very impressive teacher and -- and 17 certainly impressed me and sort of -- that was the first 18 introduction I had to pathology, and as a potential 19 career. 20 MS. LINDA ROTHSTEIN: And, indeed, my 21 recollection, Dr. Chiasson, is that you actually took a 22 one (1) month rotation in forensic pathology during your 23 medical school career. 24 Is that right? 25 DR. DAVID CHIASSON: Yes. As a fourth


1 year elective I spent a month with a Dr. Donald Clark 2 (phonetic) who happened to be a Nova Scotioner that had 3 transplanted to Denver, Colorado. So I spent a month in 4 Colorado with him. 5 MS. LINDA ROTHSTEIN: You considered 6 going directly into pathology, or not? 7 DR. DAVID CHIASSON: I did, yes. At that 8 stage there was an option, instead of doing a rotating 9 medical internship, to in fact do a straight rotation in 10 pathology -- was to go into it straight away. But I -- I 11 decided to do a regular medical internship rotation 12 instead. 13 MS. LINDA ROTHSTEIN: All right. And if 14 we would turn to page 4 of 129336. I understand, Dr. 15 Chiasson, that from 1980 to 1982, you were a general 16 medical practitioner practising in Antigonish, right? 17 DR. DAVID CHIASSON: Yes. 18 MS. LINDA ROTHSTEIN: And starting in 19 1981, you also acted as an assistant medical examiner? 20 DR. DAVID CHIASSON: That's correct. 21 That was my first professional exposure really, to death 22 investigation was as an assistant medical examiner. And 23 to be clear, in Nova Scotia the term was medical 24 examiner, but in fact it's very much equivalent to a 25 coroner.


1 I was not performing autopsies, that 2 wasn't part of my function. 3 MS. LINDA ROTHSTEIN: All right. In the 4 same period it would appear you worked in the emergency 5 department of the New Waterford Consolidated Hospital in 6 Nova Scotia? 7 DR. DAVID CHIASSON: Yes. I went back to 8 my hometown for a couple of months -- 9 MS. LINDA ROTHSTEIN: All right. 10 DR. DAVID CHIASSON: -- during that time. 11 MS. LINDA ROTHSTEIN: And then between 12 '83 and '87 you came to Toronto so you could do training 13 in anatomic pathology at the University of Toronto. 14 DR. DAVID CHIASSON: Correct. 15 MS. LINDA ROTHSTEIN: A four and a half 16 (4 1/2) year program, if I'm right? 17 DR. DAVID CHIASSON: It's a four (4) year 18 program. I -- I ended up doing an -- an extra half year, 19 yes. 20 MS. LINDA ROTHSTEIN: Am I right, sir, 21 that part of your training included a time at the 22 Hospital for Sick Children? 23 DR. DAVID CHIASSON: Yes, at that time, 24 as part of the regular pathology residency, residents 25 spent six (6) months in pediatric pathology, which is


1 much more than they do now; most of them spend three (3), 2 some -- some only two (2) months. 3 In addition, I was interested in pediatric 4 pathology, so towards -- I spent an additional nine (9) 5 months; the last months of my residency training were in 6 fact in pediatric pathology at the Hospital for Sick 7 Children. 8 MS. LINDA ROTHSTEIN: And while there -- 9 which would be the latter part of '87, is that right? 10 DR. DAVID CHIASSON: That's correct, yes. 11 MS. LINDA ROTHSTEIN: You first met Dr. 12 Charles Smith. 13 DR. DAVID CHIASSON: I would have first 14 met him in 1984 -- 15 MS. LINDA ROTHSTEIN: Okay. 16 DR. DAVID CHIASSON: -- during my first 17 rotation in pediatric pathology, yes. 18 MS. LINDA ROTHSTEIN: Dr. Smith was at 19 the time the Residency Training Director in Anatomic 20 Pathology at the U of T? 21 DR. DAVID CHIASSON: Yes. I think he had 22 just assumed that position about that time, yes. 23 MS. LINDA ROTHSTEIN: So he assumed it, 24 about '84 or '87, which of those two (2)? 25 DR. DAVID CHIASSON: I'm sorry, '84.


1 MS. LINDA ROTHSTEIN: Okay. And I 2 understand that in the latter part of your residency -- 3 so like I take it from what you're telling us that would 4 be the '87 period that you were the resident 5 representative on the Residency Training Committee, and 6 so in that capacity you would have had further 7 interaction with Dr. Smith. 8 DR. DAVID CHIASSON: Yes. Actually, I 9 think the residency training representation I had was pro 10 -- the latter part, in my third and fourth years of 11 training. 12 MS. LINDA ROTHSTEIN: What was your role? 13 You were sort of getting the best terms and conditions of 14 work for your -- your colleagues, is that the -- the 15 nature of it? 16 DR. DAVID CHIASSON: That -- that, I 17 guess in an idealistic way. The practical thing was to 18 argue points for -- for the residents in terms of the 19 program, and -- and there were two (2) representatives, 20 and -- and that's continued. 21 MS. LINDA ROTHSTEIN: And looking back to 22 1987, let's use that as our yardstick, how high up the 23 totem pole was Dr. Smith at the time in relation to you? 24 Was he considered a fairly senior member of both sick 25 kids in the University Pathology Department at the time


1 or...? 2 DR. DAVID CHIASSON: No, back in the 3 '80's he would have been a relatively junior staff person 4 within the hospital. I think his appointment was at the 5 Assistant Professor level, so he was still on his way up 6 the hierarchy, obviously, but not -- not that high at 7 that time. 8 MS. LINDA ROTHSTEIN: Needless to say, 9 Dr. Chiasson, you and I will spend some time today 10 talking about the relationship you had with Dr. Smith, 11 but in that early period what are your recollections of 12 the -- of the -- of Dr. Charles Smith then? 13 DR. DAVID CHIASSON: Dr. Charles Smith 14 was a very approachable person; he was a few years older 15 than -- than I was, but I -- I felt comfortable in -- in 16 dealing with him. He tended to have a relaxed demeanor. 17 Because of his interest in residency matters he did spend 18 a significant -- of time with all the residence in -- in 19 trying to develop a rapport with them. 20 I had a very good, I think, relationship 21 with him, a very positive one. 22 MS. LINDA ROTHSTEIN: Can we turn to page 23 3 of that document, please. 24 Did you consider at any stage going into 25 pediatric pathology as a specialty?


1 DR. DAVID CHIASSON: Yes, at that time I 2 was seriously considering pediatric pathology. And one 3 (1) of the reasons that I was in fact taking on the extra 4 training, I was looking at a -- at a position in 5 pediatric pathology back at -- in Halifax at the Isaac 6 Walton Killam Hospital. 7 MS. LINDA ROTHSTEIN: But I gather that 8 instead you were offered and accepted a job at the 9 Toronto Western Hospital. 10 DR. DAVID CHIASSON: Yes, I -- I looked 11 at the position in Halifax. I wasn't accepted initially. 12 I ended up going back and getting accepted. But in the 13 meantime I was approached by the -- the head of 14 pathology, Dr. Allen Kates (phonetic) at the Toronto 15 Western, whether I would be interested in -- in doing 16 cardiac pathology as my primary focus at that time. 17 The chair of the department, Dr. Silver, 18 was a cardiac pathologist, Dr. Butany was there, they 19 needed help primarily because of all the transplants. 20 The heart transplants involved heart transplant biopsies, 21 so it was quite a service load. 22 I had spent six (6) months of my training 23 in cardiac pathology. I was interested in cardiac 24 pathology. This was a wonderful opportunity for somebody 25 to come out of residency and to be offered a staff


1 position in an area that I was very much interested in. 2 I -- I accepted the offer. 3 MS. LINDA ROTHSTEIN: So your CV makes 4 clear that between '89 and '91 you worked as a staff 5 pathologist at the Toronto Western Hospital. 6 DR. DAVID CHIASSON: That was my primary 7 role, yes. 8 MS. LINDA ROTHSTEIN: So explain to us 9 how you made the transition into forensic pathology, if 10 you would. 11 DR. DAVID CHIASSON: Well, I'd always 12 been interested in forensic pathology. I'd done my 13 elective back then. And I think in the back of my mind 14 was -- was a thought that at some point I -- I would like 15 to -- to do that. 16 I approached Dr. Hillsdon Smith, who was 17 the Chief Forensic Pathologist about that time, about 18 working at the Coroner's Office. At that time, most of 19 the work was being done a fee-for-service basis by 20 pathologists who had other positions and/or had retired. 21 And -- and he was open to the idea that I could in fact 22 come onboard and start doing some cases on the side, and 23 -- and work -- work that way -- work -- develop the way 24 the other pathologists had. 25 I -- I spoke to him and it was my


1 impression at that time, given the nature that I was 2 young, I wanted to do this as a ser -- serious career 3 option that I would in fact, if I was going to do it, 4 get formally trained in forensic pathology. During -- 5 MS. LINDA ROTHSTEIN: And stopping there 6 for a moment, because that was an unusual step for 7 someone in our jurisdiction to -- to come -- or an 8 unusual decision for someone in our jurisdiction to come 9 to at that time. 10 Is that -- is that fair? 11 DR. DAVID CHIASSON: Well, there were not 12 very many board certified formally trained forensic 13 pathologists around. There was none in Toronto, other 14 than Dr. Hillsdon Smith who -- who came through the 15 British system. There were no training programs, for 16 example, at that time, I don't believe. 17 And so it was unusual. But I -- I had 18 sufficient knowledge of what was going on in the United 19 States that -- and having spent a month in Denver, I knew 20 there were board certification -- 21 MS. LINDA ROTHSTEIN: Right. 22 DR. DAVID CHIASSON: -- there in forensic 23 pathology. 24 MS. LINDA ROTHSTEIN: Right. 25 COMMISSIONER STEVEN GOUDGE: What


1 exposure had you had to forensic pathology during your 2 time in anatomical? 3 DR. DAVID CHIASSON: During my -- as a 4 staff pathologist -- 5 COMMISSIONER STEVEN GOUDGE: No, during 6 your training. 7 DR. DAVID CHIASSON: Actually, during my 8 training, interestingly most residents would spend a 9 month in their senior year doing forensic pathology. I - 10 - I had done my elective. I had other things I was 11 doing. I -- I never did actually spend that month 12 period. 13 I was a locum pathologist in Barrie at the 14 Royal Victoria Hospital for a couple of summers. Even as 15 a pathology resident they accepted people to help out 16 during the summer and I did get some exposure to doing 17 coroner's autopsies during that -- that period of time. 18 But as a resident, I in fact never formally had any 19 formal exposure to forensic pathology. 20 COMMISSIONER STEVEN GOUDGE: Right. But 21 the curriculum, if I can call it that, in anatomical 22 pathology had a one (1) month rotation? 23 DR. DAVID CHIASSON: That was what was -- 24 COMMISSIONER STEVEN GOUDGE: That was the 25 norm?


1 DR. DAVID CHIASSON: That was the norm. 2 And in fact, it continues up until now, I think to be the 3 norm to do so -- solely one (1) month. 4 5 CONTINUED BY MS. LINDA ROTHSTEIN: 6 MS. LINDA ROTHSTEIN: So with the goal in 7 mind of getting formal certification from the US, I 8 suppose there's a huge issue of how one funds that. 9 DR. DAVID CHIASSON: Yes. I mean, I'd 10 all ready gotten used to, if you will, to having a -- a 11 staff salary over a number of years. There were 12 fellowship positions that were paid, so you would have 13 been paid as a fellow, but that was considerably less 14 than what I was getting paid as a junior pathologist. 15 I had a meeting with Dr. Young. I -- I 16 met Dr. Young through his wife, who happened to be a 17 transplant coordinator at the Toronto Hospital at that 18 time, and I -- I had a lot of ongoing contact with her 19 because of her role with heart transplants, and my role 20 reading heart transplant biopsies. 21 And I ex -- talked to her, expressed my 22 interest in forensic pathology, and through her met at 23 lunch with Dr. Young, and -- and with his wife Aileen and 24 expressed my interests. And Dr. Young certainly seemed 25 to be interested in the fact that there was somebody that


1 was interested in doing forensic pathology. I think he 2 was looking to the future. 3 And to make a long story short, I 4 approached my -- the Chair, Dr. Silver, about my wish to 5 -- to do forensic pathology, and he was very supportive. 6 I -- I owe Dr. Smith a great deal of gratitude -- 7 MS. LINDA ROTHSTEIN: Silver. 8 COMMISSIONER STEVEN GOUDGE: Silver. 9 DR. DAVID CHIASSON: Sorry, Dr. Silver, 10 yes. 11 Dr. Silver a great deal of gratitude for 12 actually providing me with additional funding, giving me 13 a -- a leave of absence to do it. Given that forensic 14 pathology, in terms of the Toronto Hospital, we weren't 15 doing any, so this was -- this was outside of what my 16 usual -- my job was. 17 Especially given that he was a cardiac 18 pathologist, and I was indicating that I was wanting to 19 get trained in another direction, I think he showed a lot 20 of class and -- and confidence, I guess, in me to 21 actually provide me with financial support, and 22 ultimately the Coroner's Office also provided me with 23 financial support. 24 MS. LINDA ROTHSTEIN: And I gather that 25 you had two options for your training; Miami and


1 Baltimore? 2 DR. DAVID CHIASSON: Well, there were 3 many more options but it narrowed down to two (2) in the 4 end. These were both large offices with very good 5 reputations. I interviewed in both places, had a very 6 positive reception from Dr. Joe Davis (phonetic), who is 7 the head in -- in Miami, and from Dr. John Smialek, who 8 is the head in Baltimore. 9 Dr. Smialek happened to be from -- from 10 Toronto, although he had done -- most of his forensic 11 pathology career was in the United States. So we had the 12 Canadian connection if you will. 13 And Miami in November I found to be 14 extremely humid and uncomfortable, from that point of 15 view. Baltimore was -- was nice, so I -- I opted for the 16 more northern clime. But -- but in large part that's 17 because of Dr. Smialek, I'm being a little bit facetious 18 about the weather. 19 So I ended up going to Baltimore, getting 20 accept -- applying and getting accepted in Baltimore. 21 MS. LINDA ROTHSTEIN: And spent the year 22 there between 1991 and 1992? 23 DR. DAVID CHIASSON: Yes. 24 MS. LINDA ROTHSTEIN: Okay. So tell us 25 about the experience training in Baltimore, what their


1 sort of mission was, what their approach to forensic 2 pathology was, how looking back it compares to what you 3 now think is the appropriate way to train forensic 4 pathologists? 5 DR. DAVID CHIASSON: I -- I had a 6 wonderful experience at the office of the Chief Medical 7 Examiner in Baltimore. There it is a medical examiner 8 system, as opposed to a coroner system, so they're not 9 only in charge of doing post-mortem examinations or 10 responsible for post-mortem examinations, they're 11 responsible for the complete death investigation. 12 It's a busy office. About the time that I 13 went down there was a book had just come out about the 14 homicide unit in Baltimore; the fact that there was a 15 homicide a day basically at -- at that time. A little 16 scary when I was thinking about going down there to live 17 for a year, but in fact as a -- from forensic pathology 18 point of view this is exactly what you want, you want a 19 large volume experience. You had that. 20 The office was staffed not only by the 21 Chief Medical Examiner but by two (2) Deputy Chief 22 Medical Examiners, experienced people, and one of whom 23 was Dr. Ann Dixon who was a wonderful, extremely, really 24 a great forensic pathologist. I learned from -- from 25 her.


1 And there was an additional, I think, six 2 (6) or seven (7) forensic pathologists, as well as, I 3 think we had three (3) other pathology trainee -- 4 trainees there. 5 COMMISSIONER STEPHEN GOUDGE: Like you? 6 DR. DAVID CHIASSON: Yes. Fellows. 7 COMMISSIONER STEPHEN GOUDGE: And were 8 their backgrounds similar, that is, they had completed 9 their residency in anatomical or some other form of 10 pathology and were doing post-residency in forensics? 11 DR. DAVID CHIASSON: Yes, exactly. In -- 12 in the United States in order to become a forensic 13 pathologist you had to train in anatomical pathology, 14 which is a broader area or in general pathology or what 15 call anatomic and clinical pathology. 16 So they were -- completed their basic 17 training. It was -- they were variable, one -- one was 18 actually a -- he was in his fifties (50s), he had done 19 hospital pathology for many years and decided to do 20 forensic pathology. 21 COMMISSIONER STEPHEN GOUDGE: And was an 22 additional year the stand post-residency required to get 23 the forensic qualification? 24 DR. DAVID CHIASSON: Yes. You needed to 25 do -- it was -- in order to write the exam based on your


1 training you had to do one (1) year in an accredited 2 facility or institution. So that was standard. Some 3 places would offer two (2) years of -- of training but 4 most it was one (1) year training program. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 MS. LINDA ROTHSTEIN: And just to give it 7 some -- some concrete focus, I gather you went to about 8 two (2) dozen scenes during that year? 9 DR. DAVID CHIASSON: Something like that, 10 yeah. And the medical examiner system is -- the medical 11 examiner doesn't usually himself go to the scene, they 12 had forensic investigators who were not only responsible 13 for going to the scene and collecting information from 14 the police, collecting basic information and, about the 15 death but also were responsible for transporting the 16 body, so they actually -- multi-tasking, if you will. 17 So they went to all -- all the scenes, the 18 medical examiners would go to select scenes you -- and -- 19 and certainly not even all homicides. The vast majority 20 of homicides there would be no attendance by the -- by a 21 medical examiner. 22 But it would be the unusual ones, one of 23 the first ones I recall going to was a woman who was 24 found deceased in a decomposed state in a wooded area of 25 Baltimore.


1 That was the kind of case that was a 2 little complicated, and I think the police, when they see 3 a decomposed body, they were happy to have the medical 4 examiner do -- do the more formal examination. 5 So that would be, you know, the kind of 6 case. An unusual situation, but I did go to about a 7 couple of dozen scenes while I was there. 8 MS. LINDA ROTHSTEIN: You testified in 9 court? 10 DR. DAVID CHIASSON: I did. The court 11 system there seemed to run a little more quickly then my 12 experience in Ontario. So, in fact, the early cases I 13 did, I was able to testify at trial, not the preliminary. 14 In the preliminaries, it was very unusual 15 for the medical examiner to actually testify at a 16 preliminary. They -- the reports were usually accepted, 17 and that was not part of the usual practice. 18 So I actually testified at a number of 19 trials. 20 MS. LINDA ROTHSTEIN: When we talk about 21 the speed of the justice system just by -- by way of 22 interest, how long did it normally take for a post-mortem 23 report to be prepared in Baltimore? 24 DR. DAVID CHIASSON: Well, it varied on 25 the, you know, complexity of -- of the case. And


1 certainly homicides were -- were given a high priority. 2 The toxicologists were actually employed 3 by the Medical Examiner's Office, so we had pretty good 4 turn around as far as the toxicology, which was standard 5 as part of the homicide. 6 A lot of the homicides were -- were gun 7 shot wounds. I -- I did over a hundred (100) homicides 8 in one (1) year. And if you think about that, that's -- 9 that would be -- that's more then what the Toronto office 10 does in an entire year, and I'm just one (1) fellow in -- 11 in that office. 12 The -- the number of gun shot wound cases 13 was -- I'd probably -- two thirds of them were gun shot 14 wound cases. So they're -- they're relatively easy to 15 complete. They're relatively uncomplicated as far as 16 issues of cause of death. 17 The turnaround time, I think was expected, 18 would be two (2) or three (3) months. Now we're 19 trainees, so I mean, we're -- we're trying to look good, 20 so we try to keep that going. It's a little harder to 21 manage staff pathologists then trainees, I think, in that 22 regards. 23 MS. LINDA ROTHSTEIN: And I gather, in 24 general, you had a lot of opportunity to deal with 25 homicide investigators, police officers, and so on?


1 DR. DAVID CHIASSON: I did, yes, by 2 attending scenes. But they routinely would attend the 3 post-mortem examinations. If any -- anyone recalls the - 4 - the television series Homicide, back, I think, in the 5 '90's, it was based on -- it's based on the book, which 6 was a real journalist following the homicide detectives 7 for a year. 8 And the homicide detectives would 9 routinely attend the -- the autopsies, and in fact, you 10 know, there was -- there was the local bar. You would 11 socialize with them as well, get some sense of what their 12 life was like. I became friends with a number of them 13 while I was there. 14 So I had -- I had a good interaction, a 15 good experience in the sense of what the homicide 16 investigator's function is in a -- in a city like 17 Baltimore. 18 MS. LINDA ROTHSTEIN: And without 19 contemplating any alteration of our current system from 20 coronial to medical examiner, were there some lessons 21 that you learned from watching that system that you think 22 our system could benefit from? 23 DR. DAVID CHIASSON: Yes. Clearly, and I 24 -- I think what was -- was impressive about working in 25 Baltimore, is that you had people -- you had an office


1 that was staffed by dedicated forensic pathologists. 2 This is what they wou -- they would do. 3 There was -- it was a clear career path within forensic 4 pathology. Junior staff, deputy, go off to a small 5 office potentially, because there is, of course, a 6 multitude of -- of opportunities, come back as the Chief 7 Forensic Pathologist. 8 When -- Dr. Smialek for example, his 9 career path was started in the -- trained in -- in 10 Detroit, Michigan under Werner Spitz. Anyone -- the 11 standard textbook of -- of pathology -- of forensic 12 pathology in the US is medicolegal investigation of 13 death, which was originally co-edited, written by Dr. 14 Spitz with Dr. Fisher. 15 Dr. Fisher used to be the Chief Medical 16 Examiner in -- in Baltimore. And so Dr. Smialek trained 17 under Dr. Spitz, stayed on as a junior pathologist for 18 about ten (10) years or so, went to Albuquerque as the 19 Chief Medical Examiner and then came around to -- back to 20 Baltimore as the Chief Medical Examiner, where he 21 remained until his really tragic death at the age of 58, 22 while still there. 23 MS. LINDA ROTHSTEIN: What about the 24 death investigation process? Are there some aspects of 25 the Medical Examiner's System about the kind of


1 communication or issues of that sort that you think we 2 should pay heed to in Ontario? 3 DR. DAVID CHIASSON: Well, in terms of 4 death investigation, it's a little different in the sense 5 there is such a focus on homicides. The number of 6 homicides is really strikingly different, and that's 7 really a primary focus of the medical examiner. 8 There's less of a focus on medical cases. 9 There's many cases in Ontario that -- that are routinely 10 autopsied where there's family concerns, potential 11 malpractice. That the -- in most of those cases, unless 12 there was something blatant, somebody dying after a 13 routine appendix, medical examiner would assume 14 responsibility for a case like that. 15 However, somebody with complicated medical 16 disease and they're 70 years old and they die in 17 hospital, then somebody might be complaining about the 18 medical care, but that was felt to be -- that's -- that's 19 a family issue. If they want to get a pathologist to do 20 an autopsy, they can go ahead and do that, but medical 21 examiners wouldn't assume jurisdiction. 22 So -- so the systems are -- are different 23 in that regards. They're much more focussed on -- on 24 criminal issues. And so from an investigation point, I 25 mean, in a lot of ways the coroner's system there's --


1 there's much more -- I mean, if you have a medical 2 coroner actually attending most scenes and being 3 involved, you know, in that way. 4 There's -- there's actually, I think, a 5 lot to be said about the coroner's system from a -- from 6 a death investigation point of view. 7 The -- the big advantage within the 8 medical examiner's system, at least the ones that are 9 well established and well defined, is the forensic 10 pathology was -- was very well established, well 11 defined, and you had high quality forensic pathology by 12 people that were dedicated at doing -- at doing this kind 13 of work. 14 MS. LINDA ROTHSTEIN: Okay. Now, what 15 about experience with pediatric cases during your year in 16 bal -- in Baltimore? 17 DR. DAVID CHIASSON: Well, it was 18 interesting. I went in with some background in -- in 19 hospital pathology and especially cardiac pathology and 20 an interest in pediatric pathology. So -- so these kinds 21 of cases, I -- I probably did more than some of my 22 Fellows and the medical examiners. There was nobody 23 there that was a pediatric pathologist, for example, or 24 really had any terribly strong interest in pediatric 25 pathology.


1 The -- Dr. Smialek had done some work in 2 the past on -- on SIDS, Sudden Infant Death Syndrome, and 3 deaths related to that. He had an interest in that area, 4 but he, in fact, -- his job was mostly administrative. 5 They were done as part of the -- the work 6 that you would do. I probably did perhaps 7 proportionately a few more because of my background and - 8 - and interest. There was a pathologist assistant from 9 the University of Maryland, which is what the office was 10 affiliated with, who would assist in the taking of -- of 11 samples. Some of these would be used for research 12 projects, et cetera, but the -- so it was basically part 13 of the -- the caseload. 14 There was no really specific area, sub- 15 specialty area, within the department. 16 MS. LINDA ROTHSTEIN: Today, it's more 17 than fifteen (15) years since you did your training in 18 Baltimore. What importance would you assign to that 19 formal training in the development of your skills and 20 expertise as a forensic pathologist? 21 DR. DAVID CHIASSON: I think that that's 22 -- I mean that's the smartest thing I ever did in terms 23 of becoming a forensic pathologist. I -- I can't over- 24 emphasize the importance of -- of being formally trained, 25 working with people who, in my court experience, was


1 limited, but I was, on a daily basis, interacting with 2 individuals who have gone to court many times. 3 You -- you learned how -- you know what 4 your role is as a death investigator; what your role is 5 as a forensic pathology. A lot of it is almost 6 philosophical sort of training, but it did give you a 7 grounding in -- in where -- where -- what you as a 8 forensic pathologist/medical examiner's role should be 9 within the system, so it provided a conceptual framework, 10 as well as providing, you know, experience in a 11 concentrated fashion. It was -- it was kind of high 12 speed learning in some ways, and that's -- that mean I 13 continue to -- to benefit from my experience. 14 COMMISSIONER STEPHEN GOUDGE: So it's 15 really -- it's over simplifying it, but there is sort of 16 two (2) dimensions you've described; one (1) is high 17 speed learning in criminally suspicious death 18 investigations, and the other is how the medical 19 pathologist fits into the justice system. 20 DR. DAVID CHIASSON: Correct, yes. You 21 know what your role is. You know there was certain 22 practices about how -- how we would do a report, for 23 example. And, you know, how you would testify in court 24 and what's -- what is your role. It -- it wasn't Quincy. 25 We had to sort of unlearn Quincy; another influence --


1 extracurricular influence on my career development, 2 but... 3 MS. LINDA ROTHSTEIN: So, you returned to 4 Toronto from Baltimore in 1992, -- 5 DR. DAVID CHIASSON: Yes. 6 MS. LINDA ROTHSTEIN: -- as I understand 7 it, and for two (2) years you work in autopsy and 8 cardiovascular pathology at the Toronto Hospital. That's 9 60 percent of your time and income, am I right? 10 DR. DAVID CHIASSON: Yes. 11 MS. LINDA ROTHSTEIN: And the other 12 40 percent of your time in income is working at the 13 Toronto Forensic Pathology Unit as a part-time fee-for- 14 service forensic pathologist? 15 DR. DAVID CHIASSON: Yes. Basically, my 16 salary continued from the hospital, it was just that the 17 coroner's office was the supp -- or -- or reimbursing 18 them -- 19 MS. LINDA ROTHSTEIN: Okay. 20 DR. DAVID CHIASSON: -- for my 40 percent 21 of time there. 22 MS. LINDA ROTHSTEIN: All right. So 23 you're actually -- the salary from the TPFU was paid to 24 the hospital. You weren't a fee-for-service in that 25 technical sense?


1 DR. DAVID CHIASSON: Not for the weekday 2 work. The weekend work I did work on a fee-for-service 3 basis. 4 MS. LINDA ROTHSTEIN: Okay. And at that 5 time, you've told us the vast number of autopsies were, 6 in fact, being performed by a group of fee-for-service 7 pathologists. 8 Is that right? 9 DR. DAVID CHIASSON: Correct. 10 MS. LINDA ROTHSTEIN: Dr. Hillsdon Smith 11 being the only one who was a full timer or were there 12 others? 13 DR. DAVID CHIASSON: Well, he was a -- he 14 was there full time. Dr. Noel McAuliffe was working, as 15 I understand it, certainly doing a lot of cases and could 16 be considered full time, but he was being paid on a fee- 17 for-service basis. 18 COMMISSIONER STEPHEN GOUDGE: When does 19 Dr. Hillsdon Smith retire? 20 DR. DAVID CHIASSON: 1994. 21 MS. LINDA ROTHSTEIN: April 1994, when 22 you assumed the position? 23 DR. DAVID CHIASSON: Yeah, I guess he 24 retired on March 31st, then I assumed the position on 25 April 1.


1 MS. LINDA ROTHSTEIN: Yes. So just 2 talking about that last period of his tenure as the Chief 3 Forensic Pathologist, we've heard from Dr. Young and Dr. 4 Cairns a little bit about what it was like to work for 5 him, but -- or with him -- but they didn't work for him - 6 - you did, sir. Can you help us with that? 7 DR. DAVID CHIASSON: Well, you say I 8 worked for him, and I -- I guess and in some ways I did, 9 but in other ways, I -- we were doing the autopsies for 10 the coroners; they were doing under coroner direction. 11 Dr. Hillsdon Smith rarely was in the 12 autopsy room and the -- the delegation of cases, the 13 administration, was taken care of by Barry Blenkinsop who 14 is the Chief Pathologist Assistant, and the executive 15 assistant, Jack Press, at that time. They -- they would 16 basically decide who -- who would do what cases, so the 17 day-to-day management was clearly in the hands of -- of 18 those individuals. 19 I never really felt like I was working for 20 -- for Dr. Smith, although I was working within the 21 Toronto Forensic Pathology Unit. 22 MS. LINDA ROTHSTEIN: Was there any 23 quality assurance process in place? 24 DR. DAVID CHIASSON: Not that I was aware 25 of.


1 MS. LINDA ROTHSTEIN: And what about 2 communication between the Toronto Forensic Pathology Unit 3 and the other Regional Centres where criminally 4 suspicious autopsies were being performed in significant 5 numbers? 6 DR. DAVID CHIASSON: To my knowledge, 7 there was no interaction. No, yeah, I might run into 8 somebody working in another unit at a pathology meeting, 9 but there was no formal interaction or really any good 10 informal interaction between the units. 11 MS. LINDA ROTHSTEIN: Dr. Chiasson, would 12 you tell the Commissioner how you became the Chief 13 Forensic Pathologist in April of 1994? 14 DR. DAVID CHIASSON: Well, Dr. Hillsdon 15 Smith was -- retirement was eminent. He was -- he was 16 sixty-five (65) at -- at the time. I was approached by 17 Dr. Young about applying for the position. I had a lot 18 of thought and consternation, actually, about applying 19 and eventually, accepting the position. 20 I was relatively junior scale. I'd been 21 doing forensic pathology for three (3) years if you count 22 my -- my training, and although my training was 23 excellent, it was still rather limited experience over 24 the years. 25 And assuming what was very much an


1 administrative job and a high level administrative job 2 overseeing pathology in at least a general way across the 3 province was a very daunting task. So I had 4 consternation about -- about applying and eventually 5 accepting the position, but I -- 6 MS. LINDA ROTHSTEIN: What persuaded you 7 to accept it? 8 DR. DAVID CHIASSON: Well, one of my 9 colleagues at the hospital said, Well you know, you have 10 a choice. You can either do it yourself or -- or work 11 for somebody else who you may not be very happy about 12 working for. 13 There was no -- you know, the competition 14 for the position, there -- there were two (2) -- two (2) 15 applicants as it -- as it turns out. And the other 16 applicant was of similar experience level -- was working 17 outside the Coroner's System. 18 I mean, I think I had some advantages 19 having developed within the Ontario Coroner's System. 20 So, you know, it's -- it's -- it was a question of if 21 there had been a senior person there to take on the job, 22 that would have been ideal. 23 I mean, my ideal situation would have been 24 to assume a directorship of the Toronto unit, having a 25 Chief Forensic Pathology above me that I could consult


1 with, and who would take care of the administration stuff 2 and oversee the rest of the Province. 3 That would have been ideal, but that's not 4 the reality of what was there at the time. So I 5 eventually -- I -- it was clear I wanted to forensic 6 pathology, and this was a full time job, and it was 7 actually fairly prestigious job, so I -- I eventually 8 accepted. 9 MS. LINDA ROTHSTEIN: Were there any 10 senior pathologists amongst those doing coroner's work 11 for the Toronto forensic pathology unit at that time? 12 DR. DAVID CHIASSON: There were -- there 13 were some very senior pathologists working there. Dr. 14 Hans Sepp was working there. He -- he was a big 15 influence on me actually. Over the years, I've 16 maintained informal contact with the coroner's office 17 through him, because he was also working at the Toronto 18 Western Hospital, and he would -- he would actually refer 19 hearts to me in -- in sudden death cases. 20 So -- and I would -- I would -- I got to 21 know him and I -- very -- I have a great deal of respect 22 for Dr. Sept who did over five thousand (5,000) post- 23 mortem examinations, was very experienced. 24 However, he was, I think, at that time in 25 his late '60's, maybe his early '70's. So, I mean, he


1 wasn't obviously the future of forensic pathology. 2 MS. LINDA ROTHSTEIN: He was a retired 3 Chief of Pathologist from one (1) of the community 4 hospitals, is that right? 5 DR. DAVID CHIASSON: That's correct. 6 Queen's -- St. Joseph's, I think, or Queen's Way, one (1) 7 of -- one (1) of those hospitals, yes. 8 MS. LINDA ROTHSTEIN: And was his 9 particular metier forensic pathology or not? 10 DR. DAVID CHIASSON: No. He was a 11 hospital pathologist who, like the others, had -- had had 12 an interest and had done it on the side for many years, 13 and accumulated much -- much experience. 14 MS. LINDA ROTHSTEIN: You told us a 15 little bit about Dr. McCullough who you told us did a lot 16 of the case load at -- at -- during this period. What 17 was his background? 18 DR. DAVID CHIASSON: Well, his 19 background, he -- we trained about the same time. I 20 think we -- we completed our training roughly the same 21 time. He was -- he was older. He had done general 22 medical practice before he had started pathology. 23 And he had basically started working at 24 the coroner's office. As far as I was aware, he had no 25 formal training outside of the coroner's office, no


1 formal qualifications. 2 He was doing a lot of forensic pathology, 3 a lot of cases. 4 MS. LINDA ROTHSTEIN: But he was not a 5 staff forensic pathologist, am I correct? 6 DR. DAVID CHIASSON: That's correct, no. 7 MS. LINDA ROTHSTEIN: And the same with 8 Dr. Sept? 9 DR. DAVID CHIASSON: Dr. Sept, it was all 10 a fee-for-service pathologists. 11 MS. LINDA ROTHSTEIN: Dr. Donald Reider 12 was also one (1) of the fee-for-service pathologists? 13 DR. DAVID CHIASSON: Correct, he -- he 14 worked -- Women's College Hospital was his primary 15 position. 16 COMMISSIONER STEPHEN GOUDGE: Would most 17 of them had anatomical pathology training as their 18 foundation, the way you did? 19 DR. DAVID CHIASSON: Yes, they all were 20 anatomic pathologists, with the exception of Dr. Deck who 21 actually was a board certified neuropathologist, but they 22 all had that kind of background. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 25 CONTINUED BY MS. LINDA ROTHSTEIN:


1 MS. LINDA ROTHSTEIN: Dr. Toby Rose? 2 DR. DAVID CHIASSON: Dr. Rose was a -- 3 yes, an anatomic pathologist at Women's College Hospital. 4 MS. LINDA ROTHSTEIN: Dr. Olive Williams 5 (phonetic)? 6 DR. DAVID CHIASSON: Olive Williams was a 7 staff pathologist at the Toronto East -- East General. 8 MS. LINDA ROTHSTEIN: Dr. Tim Feltis? 9 DR. DAVID CHIASSON: Tim Feltis was a 10 staff pathologist at the Credit Valley Hospital. 11 MS. LINDA ROTHSTEIN: And Dr. John 12 Doucette? 13 DR. DAVID CHIASSON: At that time he was 14 at the Etobicoke General Hospital as a staff pathologist 15 subsequently move -- he's now in York Central Hospital. 16 MS. LINDA ROTHSTEIN: Is that the list of 17 pathologists that were doing work for the Toronto 18 Forensic Pathology Unit when you first became it's Chief? 19 DR. DAVID CHIASSON: Yes, I think we've 20 got everybody in there. 21 MS. LINDA ROTHSTEIN: All right. 22 DR. DAVID CHIASSON: And Dr. Deck, you 23 didn't formally -- I -- I mentioned Dr. Deck. 24 MS. LINDA ROTHSTEIN: Yes. 25 DR. DAVID CHIASSON: But that's -- Dr.


1 Deck -- 2 COMMISSIONER STEPHEN GOUDGE: Would they 3 do the autopsies in their hospital autopsy room, or 4 would they do them at the Toronto... 5 DR. DAVID CHIASSON: This is all -- these 6 were all working doing their -- for coroner's cases at 7 the Toronto -- 8 COMMISSIONER STEPHEN GOUDGE: So they'd 9 come to the Toronto site. 10 DR. DAVID CHIASSON: They did come to the 11 unit very much as -- as needed basis. We -- back before 12 -- before I started we had a number of cases, the 13 Barrie's job. Noel did a lot of them because of his 14 availability. Dr. McAuliffe, if he wasn't available. 15 They -- they'd go look for somebody else -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID CHIASSON: -- and see who was 18 available, sometimes coming after hours in order to -- to 19 do the cases. Some of them, Dr. Feltis and I think Dr. 20 Doucette were doing cases, as well, in their local 21 hospitals, a smaller number of -- of cases -- of 22 coroner's cases. 23 24 CONTINUED BY MS. LINDA ROTHSTEIN: 25 MS. LINDA ROTHSTEIN: And so you were the


1 only full-time salaried pathologist at the Toronto of 2 Forensic Pathology Unit in 1994? 3 DR. DAVID CHIASSON: That's correct, yes. 4 MS. LINDA ROTHSTEIN: All right. There 5 were also some administrative changes that just 6 immediately precede your appointment, if I'm -- if I'm 7 correct. 8 DR. DAVID CHIASSON: That's correct. 9 MS. LINDA ROTHSTEIN: Can you tell us 10 about that. 11 DR. DAVID CHIASSON: Well, essentially 12 when Dr. Hillsdon Smith was the Chief Forensic 13 Pathologist he was at the same administrative hierarchal 14 level as Dr. Young, the Chief -- Chief Coroner, and they 15 both reported to the same Assistant Deputy Minister. So 16 -- so the Chief Forensic Pathology branch -- forensic 17 pathology branch was separate and distinct from the 18 Coroner's Office, as separate and distinct from the 19 Centre of Forensic Sciences. That was the situation 20 then. 21 So just before I came on board it changed 22 so that the Chief Forensic Pathologist would report to 23 the Chief Coroner. 24 MS. LINDA ROTHSTEIN: And how did you 25 feel about that change?


1 DR. DAVID CHIASSON: I had some 2 misgivings at first. You know, it was a change from the 3 status quo. However, having said that, I thought it was a 4 good plan. 5 I felt more comfortable reporting to a 6 chief coroner who had death investigation experience, who 7 was a medical doctor, who I think would argue much more 8 effectively than I could as a chief forensic pathologist 9 with very minimal administrative experience and none 10 within government. 11 I -- I understood Dr. Young to be someone 12 that was interested in administration and seemed to be 13 effective at getting funds and resources out of -- out of 14 the government. I mean, an example, getting money from 15 me to go -- to go train would have been the concrete 16 example of that. 17 So, I saw that a positive thing; with my 18 limited experience, report to somebody who would take 19 care, basically, of the administrative stuff and leave me 20 to deal with the more day-to-day work of the forensic 21 pathology unit. 22 MS. LINDA ROTHSTEIN: Indeed speaking of 23 Dr. Young, would it be your perception that he had, to 24 some extent, groomed you for this position -- 25 DR. DAVID CHIASSON: Well, it -- if he


1 said that, I wouldn't be surprised that -- you know, he 2 was obviously had -- had invested some government 3 resources, had -- had attracted me into the position and 4 I -- I think he was looking down the road. He knew when 5 Dr. Smith -- Hillsdon Smith was going to retire, so -- 6 MS. LINDA ROTHSTEIN: All right. 7 DR. DAVID CHIASSON: -- it makes sense. 8 MS. LINDA ROTHSTEIN: All right. So the 9 -- so we all remember where we are in this piece. At the 10 time the Toronto of Forensic Pathology Unit, which you 11 and I may call the TFP, would -- would that fit for you, 12 was not doing any pediatric cases. 13 DR. DAVID CHIASSON: Correct. 14 MS. LINDA ROTHSTEIN: The pediatric cases 15 were being done in Toronto at the Hospital for Sick 16 Children, we know that. 17 DR. DAVID CHIASSON: Correct. 18 MS. LINDA ROTHSTEIN: And where else were 19 they being done in the Province at that time? 20 DR. DAVID CHIASSON: Well, outside of the 21 unit -- the unit in Hamilton was up and running; they 22 were doing sort of the Niagara region cases, including 23 the pediatric cases. And the Ottawa unit had just come 24 on board, although that was centred at the Ottawa General 25 Hospital, but the -- the cases there would tend to go to


1 the Children's Hospital of Eastern Ontario, CHEO. 2 MS. LINDA ROTHSTEIN: Right. So -- so 3 just to be clear for the Commissioner, Dr. Chiasson, 4 because we've probably touched on this, but not 5 underlined it, there was, just before, again your 6 appointment, the creation of a regional centre in Ottawa, 7 the Ottawa General. 8 DR. DAVID CHIASSON: Correct. 9 MS. LINDA ROTHSTEIN: But it restricted 10 its mandate -- big word not really meaning a whole lot -- 11 but it restricted its scope of cases to adult cases and 12 the pediatric cases it sent to CHEO. 13 DR. DAVID CHIASSON: Which I think had 14 been the -- what was happening, the status quo, what had 15 been happening all along. So pediatric cases in Eastern 16 Ontario would tend to go to CHEO. 17 MS. LINDA ROTHSTEIN: Right. 18 DR. DAVID CHIASSON: And beyond that, as 19 longs as they weren't criminally suspicious cases, they 20 would tend to get done by the local hospital. So you 21 could -- you had situations where the local hospital 22 pathologists would end up doing SIDS-like cases, other 23 deaths of a pediatric nature. 24 MS. LINDA ROTHSTEIN: Were they doing 25 them in London?


1 DR. DAVID CHIASSON: They would -- London 2 I would imagine back then were doing the London cases. 3 But London was not a unit at that time. I don't know how 4 much referral stuff they were doing. And I -- I'm not 5 sure whether at that time they had a bonafide pediatric 6 pathologist or not. 7 MS. LINDA ROTHSTEIN: Okay. So -- 8 COMMISSIONER STEPHEN GOUDGE: So did the 9 criminally suspicious cases at that point all go to 10 Toronto or Ottawa or Hamilton? 11 DR. DAVID CHIASSON: Did they all go? 12 COMMISSIONER STEPHEN GOUDGE: Well -- 13 DR. DAVID CHIASSON: Yes. 14 COMMISSIONER STEPHEN GOUDGE: -- I'm sure 15 there were exceptions, Dr. Chiasson. 16 DR. DAVID CHIASSON: I'm sure there were 17 exceptions. And certainly in southern Ontario -- 18 COMMISSIONER STEPHEN GOUDGE: But was 19 that the design generally? 20 DR. DAVID CHIASSON: Yes. I think in 21 southern Ontario the tendency would have been they would 22 have went to a unit. Certainly the Toronto -- the Sick 23 Kid's Unit would do cases -- referred in cases from 24 outside of the GTA, yes. 25 COMMISSIONER STEPHEN GOUDGE: Right.


1 2 CONTINUED BY MS. LINDA ROTHSTEIN: 3 MS. LINDA ROTHSTEIN: Okay. You've 4 touched on this. Fair to look back as your role as the 5 Chief Forensic Pathologist as having two (2) very large 6 and quite different components: one (1), you were the 7 head of the Toronto Forensic Pathology Unit doing fifteen 8 hundred (1,500) adult autopsies a year, all of which were 9 criminally suspicious or homicide cases? 10 DR. DAVID CHIASSON: No, not all -- 11 MS. LINDA ROTHSTEIN: That would -- 12 DR. DAVID CHIASSON: -- the cases done at 13 the Toronto -- 14 MS. LINDA ROTHSTEIN: No, okay, I'm 15 sorry. 16 DR. DAVID CHIASSON: -- FPU were -- we 17 did whatever coroner -- 18 MS. LINDA ROTHSTEIN: All right. 19 DR. DAVID CHIASSON: -- cases there were. 20 So that -- 21 MS. LINDA ROTHSTEIN: What percentage 22 would they have been criminally suspicious and homicide? 23 DR. DAVID CHIASSON: We were probably 24 doing about a hundred (100) homicides a year, and then 25 criminally suspicious, it's always hard to define that,


1 but you could at least usually double, so maybe another 2 two hundred (200) cases of -- 3 MS. LINDA ROTHSTEIN: Okay. 4 DR. DAVID CHIASSON: -- some degree of 5 criminal suspicion. 6 MS. LINDA ROTHSTEIN: So perhaps a third 7 of the fifteen hundred (1,500) cases at -- at the stage 8 that you're first looking at them, are in that category? 9 DR. DAVID CHIASSON: Yes. And that's -- 10 yeah, certainly no more then that. 11 MS. LINDA ROTHSTEIN: Okay. 12 DR. DAVID CHIASSON: Maybe a quarter 13 might be more accurate. 14 MS. LINDA ROTHSTEIN: All right. And 15 then the second aspect of your -- of your role as the 16 Chief Forensic Pathologist was to be responsible for all 17 of the coroner's cases in some fashion throughout the 18 Province. 19 DR. DAVID CHIASSON: Yes, I was sort of 20 general supervision of the other forty-five hundred/five 21 thousand (4,500/5,000) autopsies that were done under 22 coroner's warrant across the Province. 23 There were -- there's clearly two (2) jobs 24 there. There is a job for a chief forensic pathologist 25 with provincial responsibility and there's clearly a


1 second job, and that's the Director of the Toronto 2 Forensic Pathology Unit. 3 MS. LINDA ROTHSTEIN: Okay. So lets -- 4 lets look at the Unit first and talk about some of the 5 changes that you implemented and were anxious to 6 implement. 7 So looking at TPFU initiatives starting in 8 1994, my understanding, Dr. Chiasson, is that you felt 9 quite strongly that you needed to do some reconfiguring 10 or consolidation to get more full time salaried 11 pathologists? 12 DR. DAVID CHIASSON: Yes. I -- I had a, 13 you know, in my mind, a five (5) year plan, although I 14 don't know that I ever formally documented this, but 15 certainly the crux of this -- my sense was that the 16 Toronto Forensic Pathology Unit was critically important 17 to the system as a whole, and that needed to be 18 crystalized into a unit that would work effectively, 19 efficiently, and -- and in my mind that meant having full 20 time forensic pathology staff. 21 So that was kind of my number 1 priority 22 for the Unit and really my number 1 priority period, 23 because I've always felt the -- the Unit was -- was, if 24 you will, the trunk of the tree, and -- and if that 25 wasn't functioning, your tree wasn't going to grow very


1 well. 2 MS. LINDA ROTHSTEIN: Okay. So we'll 3 come back to the specific things that you did in order to 4 further that number 1 priority. I understand that you 5 also wanted to take some steps to increase the level of 6 collaboration between the -- everyone who worked in that 7 Unit. 8 Fair to say there hadn't been an awful lot 9 of that prior to your appointment, is that right? 10 DR. DAVID CHIASSON: Yes. My sense was 11 that we tended to work as independent contractors. We 12 come in do an autopsy and then leave, eventually put up a 13 -- present a report. So I -- I used some of the 14 experience of what was being done in Baltimore. 15 In Baltimore at the beginning of the day 16 we would have, what we would term rounds -- I mean, it's 17 a medical term, usually associated with visiting your 18 patients; in our case it was the decedent. But all the 19 medical examiners in the office who were -- who were 20 there that day, the trainees, would go from body to body 21 and review the -- the information and make decisions 22 about who was going to do this autopsy. 23 You have to realize in -- in Baltimore we 24 were doing three thousand (3,000) autopsies a year, so 25 we're talking, you know, rounds might be anywhere from


1 eight (8) to fifteen (15) bodies that you were -- you 2 were looking at. So -- so there was kind of 3 administrative delegation of who would do the autopsies, 4 but also a discussion of what the issues were up front, 5 what had to be done, what was expected. 6 At the end of the day then you had another 7 meeting where you reviewed basically what happened during 8 the day and what -- where we were going to go from -- 9 from there. So I took that model, which -- which really 10 meant that everybody was part of a team -- and 11 transplanted that into the Toronto model, as best I 12 could. And that's basically started morning rounds. 13 So before any work was done there would be 14 a meeting where the pathologist on for that day, myself, 15 the pathologist assistants and Coroner's Office 16 representatives -- Jim Cairns was certainly attended 17 many of these meetings -- the Regional Coroner, and -- 18 and on occasion, certainly even the Chief Coroner would 19 attend these meetings. We'd review cases, make decisions 20 as to who would do the autopsy. 21 And at the same time -- actually before we 22 did that we reviewed the previous day's cases. So I 23 consolidated what was two (2) meetings in -- in the 24 Baltimore office, given that we were doing three (3) to 25 four (4) cases on average, it was certainly a smaller


1 number. We would review the previous days cases as to 2 the findings; is there more to be done about a case, is 3 the body still there, should we be looking at it again, 4 and then deciding about the new cases. 5 So that was done on a Monday to Friday 6 basis. And the pathologist who was on that day -- we 7 assigned be -- 8 COMMISSIONER STEPHEN GOUDGE: I just want 9 to ask you a question -- 10 DR. DAVID CHIASSON: Yeah. 11 COMMISSIONER STEPHEN GOUDGE: -- about 12 that, because I sort of had in my head that the fee-for- 13 service pathologists were called in by the case; that is, 14 a body arrives, and you would then call a hospital 15 pathologist who was prepared to come to do that autopsy. 16 The way you're now talking, it implicitly 17 may sound as if you actually asked pathologists to come 18 in and cover for a day? 19 DR. DAVID CHIASSON: That's -- that's it 20 exactly, Commissioner. So we went from that model of 21 calling pathologists in on a relatively ad hoc basis to 22 actually assigning a pathologist to that -- 23 COMMISSIONER STEPHEN GOUDGE: Was that 24 new with your regime? 25 DR. DAVID CHIASSON: Yes, yes.


1 COMMISSIONER STEPHEN GOUDGE: Okay. 2 3 CONTINUED BY MS. LINDA ROTHSTEIN: 4 MS. LINDA ROTHSTEIN: So you basically 5 had on call pathologists per day? 6 DR. DAVID CHIASSON: Yes. And -- 7 MS. LINDA ROTHSTEIN: A group of them? 8 DR. DAVID CHIASSON: -- and pathologists 9 were expected that -- I realize they all had hospital 10 responsibilities, but if they wanted to work at the 11 Coroner's Office, that they would have to somehow work it 12 out with their people, that on this day they would be 13 responsible for doing autopsies. 14 Once they finished their autopsies, they 15 were free to go back to the hospital and that's often 16 what would -- would happen. But that was basically the 17 -- one (1) change, which was a significant change from 18 previous -- previously. 19 MS. LINDA ROTHSTEIN: All right. And to 20 what ext -- how detailed were those daily case reviews? 21 What -- what were people actually looking at when they 22 were speaking about the issues the case arose? 23 Were they just looking at a the notes, the 24 autopsy notes; were those presented? Give us a flavour 25 for how detailed the discussions were?


1 DR. DAVID CHIASSON: The -- the 2 discussions -- as I'm sure you're aware, autopsies are 3 performed under a coroner's warrant and a coroner was -- 4 there's a section on the coroner's warrant where they 5 filled in information. 6 So that was a -- a primary focus. We 7 started generating lists and -- and that would -- the 8 history would be included in these lists of cases. So 9 that was a -- a primary focus. 10 If the regional coroner knew about the 11 case, he could provide some additional information. And 12 the other source of information was to -- to get the 13 police report in these cases. And Jack Press, as a 14 former Toronto homicide officer, was kind of the liaison 15 with police services, so he would contact them. He'd 16 either get a formal report -- at least get some sense of 17 what the background of the case was. 18 So that was basically the extent, which is 19 what you would do in a case where the police didn't 20 attend. Obviously if the police attended, you would be 21 briefed by the police before hand in more detail. But 22 that at least gave you a sense of the case. 23 Most of the time the pathologists on that 24 day would do -- would do whatever cases there was, unless 25 there were too many, in which case I might do a -- do a


1 case. Or if there was something particularly complex, I 2 might assign a case to -- to myself in that regards. 3 MS. LINDA ROTHSTEIN: I gather that in 4 addition to those daily case review sessions, you also 5 implemented a process of weekly case meetings. 6 DR. DAVID CHIASSON: That's correct. So 7 in Baltimore again they did have what you call "talks 8 rounds" or "pending rounds" where we would review cases 9 that we'd had the toxicologist come from -- well, in that 10 case it was from within the office -- and report back on 11 preliminary results in cases where we were waiting for 12 something else. And usually toxicology the most common 13 thing. 14 So before the toxicology testing was 15 completed the toxicologist would be providing preliminary 16 results. You could have a discussion as to whether 17 further tox testing was negative -- or sorry, necessary 18 whether, you know, the report needed to be expedited for 19 some reason or another. If tox is negative should we be 20 looking at other investigative issues or going back and 21 looking at more pathology samples for example. So that 22 was the -- that was the model down there. 23 So I basically again transplanted this so 24 that I would have weekly rounds on Wednesday afternoon. 25 And every second week was toxicology rounds where I had


1 the toxicologist from the Centre of Forensic Sciences 2 come over, one (1) representative at least, sometimes 3 several would come, they would have preliminary results, 4 we would discuss the case, Where do we go from here, for 5 the same -- same thing. 6 The alternative weeks we started doing 7 cases that were non-toxicological. We had -- we tried to 8 do homicide as rounds or interesting pathology cases. 9 And, this is sometime down the road, we started involving 10 the traffic police services in Toronto in reviewing some 11 of the traffic deaths, because the reconstructionists are 12 -- in the traffic units in Toronto were always attending 13 autopsies. 14 They routinely attended all fatalities and 15 were very interested in the pathology findings because 16 they would take that back and -- and work on it from a -- 17 to try to reconstruct the -- what happened in terms of 18 the -- the accident or the motor vehicle fatality. So we 19 -- we started having rounds with them. 20 MS. LINDA ROTHSTEIN: Who of your cadre 21 of pathologists were expected to attend the weekly rounds 22 you've just described? 23 DR. DAVID CHIASSON: All the -- all the 24 pathologists affiliated with the office were expected to 25 attend the weekly rounds.


1 MS. LINDA ROTHSTEIN: And if you turn up 2 Tab 4, Dr. Chiasson. It deals with a couple of the other 3 initiatives that you put in place following your 4 appointment. It's 129354. 5 "Further to our discussion this 6 morning..." 7 And that's to Dr. Cairns. 8 "...I will outline some of the major 9 changes affected since April 1, '94, 10 when I assumed the position of Chief 11 Forensic Pathologist." 12 And you're reporting to him in January of 13 '95, so about nine (9) months in. You go through the 14 daily case review sessions, the weekly rounds, and then 15 in the third paragraph you talk about the monitoring of 16 individual reports. 17 And I take it that was a brand new 18 initiative that you brought about? 19 DR. DAVID CHIASSON: Yes. As far as I 20 was aware, Dr. Hillsdon Smith was not reviewing anyone's 21 pathology reports, certainly on a -- a random or 22 otherwise basis. And I'm sure he reviewed when 23 requested. 24 But -- so this was -- was for me to review 25 the reports to ensure that what was leaving the Office


1 was -- was reasonable in terms of the conclusions that 2 were being presented; and also was a learning exercise 3 for me as to the capabilities, and especially the 4 forensic capabilities and the forensic nature or the 5 ability of the pathologist to -- to look at a case from a 6 forensic pathology point of view and to get a sense of 7 what these -- my staff pathologists were like from that 8 point of view. 9 MS. LINDA ROTHSTEIN: You and I are going 10 to spend some time, I expect, later this morning talking 11 about the strengths and weaknesses of this form of 12 oversight, but a couple of starting points: This was a 13 paper review, as I understand it, Dr. Chiasson? 14 DR. DAVID CHIASSON: In this case, yes, I 15 was reviewing their PM reports, so the reports of post- 16 mortem examination, yes. 17 MS. LINDA ROTHSTEIN: And did this put 18 you in the position of reviewing fifteen hundred (1,500) 19 reports a year? 20 DR. DAVID CHIASSON: In -- in essence, 21 yes. 22 MS. LINDA ROTHSTEIN: You weren't sharing 23 that responsibility with anyone else at that stage? 24 DR. DAVID CHIASSON: I had no one -- I 25 had no one to share the responsibility with.


1 Yeah, initially I -- I took it on. When I 2 -- when I developed and had some staff, we started to 3 share it among each other but at that time, I was 4 reviewing all the reports. 5 Now, suffice it to say, the level of 6 detail these -- these include -- we're not dealing only 7 with homicide and criminally suspicious deaths. We're 8 dealing with many -- what we would term "routine" deaths 9 -- and the amount spent -- spent looking at -- at a 10 report like that would have been relatively small so... 11 MS. LINDA ROTHSTEIN: And then the last 12 heading on that first page, "Special Case Reviews," would 13 you tell the Commissioner what that was about? 14 MR. DAVID CHIASSON: Well, this is as -- 15 as suggested here, if there was a case of particular 16 complexity, if there were particular forensic pathology 17 issues what -- and this is, if you will, a predecessor of 18 the more formalized case conferences that, subsequently, 19 developed within the Coroner's office. 20 So these were very much ad hoc meetings. 21 Police might want to -- to discuss this. A pathologist 22 would have an interesting case. I would become aware of 23 it, and I'd have said, Okay, let's -- let's have a 24 meeting of the minds. The coroner's office -- often Jim 25 Cairns -- would be involved in -- in these meetings.


1 MS. LINDA ROTHSTEIN: So if you turn the 2 page and it's 129355. In the second paragraph, you spend 3 some time setting out the importance as you said, "The 4 priority around pathology staffing" and you say: 5 "One (1) of the major factors that was 6 part of my decision to take on the 7 position of Chief Forensic Pathologist 8 was that the coroner's office agreed, 9 in principle, that the unit should be 10 staffed by full-time pathologists with 11 training and/or experience in forensic 12 pathology." 13 So stopping there for a moment, Dr. 14 Chiasson, you had in effect, discussed this with Dr. 15 Young prior to taking the position and got, I take it, 16 some assurance from him that he would endeavour to get 17 the funds you needed to employ forensic pathologists on a 18 full-time basis? 19 MR. DAVID CHIASSON: Exactly, as -- as a 20 condition of -- to my taking on the position and -- and 21 was to say, Listen, I -- I need full-time staff, and Dr. 22 Young was certainly fully supportive of that and was 23 prepared to work with me towards that goal. 24 MS. LINDA ROTHSTEIN: Do you remember how 25 many you had in mind in '94 and '95 as being the


1 appropriate complement for that unit? 2 MR. DAVID CHIASSON: I was -- I don't 3 know when I came up with the number that a full-time 4 staff pathologist should be doing between two hundred and 5 fifty (25) and three hundred (300) cases a year, post- 6 mortem. 7 And that's -- you know, there are medical 8 examiners who are doing twice that number and so, as a 9 medical examiner, you're not only doing the autopsy, 10 you're taking on the administrative; there's death 11 certification, dealing with families, et cetera. 12 So I'm -- I'm sure there are -- you know, 13 if there are medical examiners in some jurisdictions 14 looking at this, this is -- would be a cushy job but, in 15 fact, there were two (2) things. One (1) is that I 16 wanted high quality forensic pathology reports. And I 17 wanted something that, eventually, with the staff people 18 that there would be an academic focus to what's going on 19 and they would be involved in teaching residents, but 20 also teaching police officers, et cetera. 21 So I saw this as being a reasonable 22 service load for somebody who would, eventually, take on 23 other extra service responsibilities. 24 MS. LINDA ROTHSTEIN: Continuing with 25 your memo:


1 "To this end, it was agreed that the 2 first of these full-time positions 3 would be created. Indeed, this 4 occurred and has been filled by Dr. 5 John Deck who previously had worked 6 part-time in the unit." 7 He was a senior neuropathologist as you've 8 described him. Is that right? 9 MR. DAVID CHIASSON: Correct. 10 MS. LINDA ROTHSTEIN: And I take it, you 11 were quite delighted that Dr. Deck was prepared to assume 12 the position on a full-time basis? 13 MR. DAVID CHIASSON: Yes, I was quite 14 delighted, with all due respect to Dr. Deck, that anybody 15 would take on the -- the -- this position because there 16 were no obvious candidates around, but having said that, 17 Dr. Deck, as a neuropathologist and as somebody that had 18 a great deal of experience doing forensic pathology 19 albeit on a -- on a part-time basis, had an academic 20 background. 21 I knew him from my -- we were colleagues 22 at the Toronto hospital but neuropathology is an 23 important component of forensic pathology and having him 24 as a consultant on board to take on these cases and/or to 25 -- to take on the responsibility of the brains


1 examination in -- in cases was -- I was very pleased that 2 it was Dr. Deck who -- who agreed to do this. 3 He had just retired from the Toronto 4 hospital so you can see that, you know, from a long term 5 future point of view, it wasn't there, but at least, in 6 the short term, it was. I was very pleased to -- to have 7 Dr. Deck come on. 8 MS. LINDA ROTHSTEIN: But coming back to 9 the first thing that you said and is, indeed, highlighted 10 in the rest of that paragraph, Dr. Chiasson, the scarcity 11 of the resource. So it's already become quite a theme in 12 this Inquiry, but can you paint the Commissioner a 13 picture of what it was like to recruit trained forensic 14 pathologists back in 1994 and 1995? 15 DR. DAVID CHIASSON: Well, I mean, the 16 number of board certified forensic pathologists -- 17 formally trained board certified forensic pathologists in 18 Canada at that time was -- was very, very small. 19 In Ontario, the -- Dr. Mike Shkrum had -- 20 had formal training and -- and board certification from 21 the American Board of Pathology. 22 MS. LINDA ROTHSTEIN: He's at -- he was 23 at London? 24 DR. DAVID CHIASSON: He's in London. And 25 beyond that, Dr. King in -- in Hamilton had -- had


1 trained and -- and had his DMJ, Diploma of Medical 2 Jurisprudence, from -- from Britain and was working full 3 time in -- in Hamilton. 4 And I think there may have been one (1) or 5 two (2) hospital pathologists working in communities who 6 may have had their -- their board certification, but that 7 -- that was it, and they all had nice -- nice jobs where 8 they were -- I -- I -- in most cases were probably 9 getting paid more money to stay in the jobs that they 10 were, so that's Ontario. 11 And outside of Ontario, it wasn't much 12 better. Medical Examiner's Office in -- in Alberta, 13 which John Butt had -- was instrumental in developing, 14 had board certified forensic pathologists, but they were 15 working in the Medical Examiner's System and I think they 16 were quite happy, you know, in -- in terms of that model. 17 This was obviously a different model. 18 Beyond that, I'm -- I'm sure there were a 19 number of others who had a formal training and 20 certification in other provinces, but the number was very 21 small. And, you know, in terms of moving and -- there 22 wasn't -- there wasn't a pool of people that were mobile 23 from that point of view. 24 MS. LINDA ROTHSTEIN: Again, we'll come 25 back to this, but you recruited Dr. Deck in 1996 in the


1 fall, if I'm not mistaken. 2 DR. DAVID CHIASSON: 1994, Dr. Deck -- 3 MS. LINDA ROTHSTEIN: Sorry, 1994, quite 4 so. Dr. Martin Queen began in 1996 -- 5 DR. DAVID CHIASSON: Correct. 6 MS. LINDA ROTHSTEIN: -- if I have that 7 right. 8 DR. DAVID CHIASSON: Yes. 9 MS. LINDA ROTHSTEIN: He was board 10 certified? 11 DR. DAVID CHIASSON: Yes, Dr. Queen was a 12 -- had finished his pathology training in Toronto. I 13 knew him during his training. Excuse me, the job market 14 in pathology was so poor at that time, he -- he ended up 15 doing general medical practice. 16 For pathologists to go back and do general 17 medical practice is -- is really quite unusual. 18 MS. LINDA ROTHSTEIN: Well, help us with 19 that. So there was a poor job market for non-forensic 20 pathologists -- 21 DR. DAVID CHIASSON: Correct. 22 MS. LINDA ROTHSTEIN: -- but there was, 23 nevertheless, a scarce -- scarcity of forensically 24 trained pathologists at the same time, have I -- 25 DR. DAVID CHIASSON: Yes, yes.


1 MS. LINDA ROTHSTEIN: -- understood you, 2 sir? 3 DR. DAVID CHIASSON: Well, it's -- it's a 4 bit strange, but the -- at that time, you know, for 5 whatever reason, there -- there was a scarcity of -- of 6 positions in pathology that were available, and -- and 7 for that reason, Dr. Queen ended up going back to doing 8 general medical family type practice. 9 Now, he had -- he had done that before he 10 started his pathology. He had experience in that. He 11 went -- he went back to doing that. And -- and then I 12 had spoken to him, and he said he was interested in 13 forensic pathology. 14 I said, Well, that's good. We'll, I'm 15 sure, have a position for you, so he, in fact, went and 16 spent a year in Baltimore and started a -- I started a 17 bit of a trend of -- of Canadians going down to Baltimore 18 and Martin was the second. 19 And he got his training and came back and 20 we -- we had a position for him, and that's when he came 21 back in '96. 22 MS. LINDA ROTHSTEIN: Dr. Martin Bullock 23 (phonetic) started in 1997? 24 DR. DAVID CHIASSON: Yes, Martin Bullock, 25 again, was somebody I knew from the training program,


1 expressed an interest. He went from pathology training 2 directly into forensic pathology, again in Baltimore, 3 came back and we hired him in -- in '97. 4 MS. LINDA ROTHSTEIN: And Dr. Toby Rose 5 transitioned from fee-for-service pathologist to a 6 salaried forensic pathologist in '98. 7 DR. DAVID CHIASSON: Correct. Toby, in 8 fact, got her American Board exams in forensic pathology. 9 You could do it two (2) ways to get your certification; 10 you could do what I did, go off and get formal fellowship 11 training and after a year of -- of that you could write 12 the exam. 13 The other way was to sort of a 14 grandfather-type of approach where on the basis of 15 experience over a number of years the American board 16 would look at your experience and allow you to write the 17 exam, assuming that you had sufficient experience, and 18 become certified that way. And Toby became certified and 19 we hired her as the fourth forensic pathologist at that 20 time. 21 MS. LINDA ROTHSTEIN: And was that with 22 encouragement from your unit to do that? 23 MR. DAVID CHIASSON: To get the Board 24 exams, yes. In fact, you know, we're at a stage in 25 forensic pathology as I -- as far as I was concerned that


1 if you're going to work in the Toronto Forensic Pathology 2 Unit as a full-time person, you needed to have your Board 3 certification. 4 MS. LINDA ROTHSTEIN: All right. But 5 going back to your April -- or sorry, January 30th, 1995 6 memo to Dr. Cairns in the penultimate paragraph on 129355 7 you say -- because you just have Dr. Deck at that stage: 8 "In the interim there have been a 9 number of changes effected to improve 10 the provision of forensic pathology 11 services to the Coroner's Office using 12 the part-time pathologists. Changes 13 include a daily pathologist roster 14 where individual pathologists are 15 responsible for certain days." 16 That's what you've told the Commissioner 17 about is it not, Dr. Chiasson? 18 MR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: For most 20 pathologists this involves a one (1) full day per two (2) 21 week commitment to the performance of autopsies. 22 So still reasonably part-time, is that 23 fair? 24 MR. DAVID CHIASSON: Correct. 25 MS. LINDA ROTHSTEIN: It has been made


1 clear to the part-time pathologist that in no way were 2 there hospital pathology commitments to interfere with 3 the provision of these services. So they had to give you 4 a -- a fixed commitment to that as a minimum, if I 5 understand what you were telling Dr. Cairns. 6 Is that right? 7 MR. DAVID CHIASSON: Yes. 8 MS. LINDA ROTHSTEIN: 9 "Currently, in addition to my and Dr. 10 Deck's position as staff forensic 11 pathologists there are five (5) part- 12 time pathologists and Dr. McAuliffe who 13 carries a full-time load. All of these 14 autopsies are performed on a fee-for- 15 service basis. Weekend coverage is 16 supplied by the same group of 17 pathologists who perform cases during 18 the week. Every pathologist is 19 expected to attend the daily review 20 conference on their assigned days and 21 the weekly Wednesday case reviews also 22 [as you've described it to the 23 Commissioner, Dr. Chiasson]." 24 And then you say: 25 "I strongly feel that the current


1 situation is only acceptable as part of 2 a gradual evolution towards a full-time 3 staff. This changeover should be 4 carried out as soon as is practically 5 possible given the recognized shortage 6 of trained forensic pathologists in 7 this country." 8 And so let me stop there to ask you, Dr. 9 Chiasson, what stood in the way of the recruitment 10 through to Dr. Rose's full-time assumption of the 11 position? Was it dollars or was it the scarcity of human 12 resources? 13 MR. DAVID CHIASSON: Well, it was 14 primarily the scarcity of human resources. I, in working 15 with Dr. Young, you know we basically -- every year we 16 would have a new position open up. And even if I had 17 come on board and had five (5) positions I don't think 18 anything would have changed, so all the -- the money 19 being there would not have changed, you know, the 20 outcome. 21 So I -- in fact I was quite pleased. I 22 thought this was quite acceptable that over a period of 23 four (4) years we were able to recruit the full-time 24 staff pathologists that we -- we succeeded in doing. 25 MS. LINDA ROTHSTEIN: Dr. Chiasson, I


1 want to turn now to review with you some of the 2 provincial initiatives that you implemented during your 3 tenure as the Chief Forensic Pathologist, starting with 4 education. 5 What education was conducted for forensic 6 pathologists, prior to your appointment? 7 MR. DAVID CHIASSON: Dr. Hillsdon Smith 8 is -- I -- I know from having seen evid -- evidence in 9 the documents -- and I think I did attend one (1) of 10 these courses -- he -- he would put on an annual course 11 for -- for pathologists and/or senior police officers. 12 And it was an -- especially in the early days it was -- 13 it was an excellent course. 14 He -- he would have some of the major 15 leaders in forensic pathology in North America attending 16 this -- this course. They would be invited to speak. 17 And so you had people like Vince Di Maio, who's an 18 acknowledged expert in gunshot wounds, come from San 19 Antonio, where he was located, to speak on gunshot 20 wounds. This is in the 1980s. Really excellent courses 21 ran over three (3) -- three (3) days or so. 22 So he was doing that. By the time the 23 late '80s/early '90s these had sort of disappeared. I -- 24 I don't know when the last one was but certainly, there 25 seemed to be less enthusiasm to pursue that and tended to


1 be more local people as opposed to international invited 2 speakers. 3 So when I came on board, we started 4 working to try and rejuvenate this -- this endeavour 5 which I -- I thought was important, and so we would have 6 an annual course. 7 And in keeping with the now merger of the 8 forensic pathology branch with the Chief Coroner, we -- 9 we had -- courses were designed to -- to incorporate both 10 coroners and the -- and pathologists performing 11 autopsies. 12 MS. LINDA ROTHSTEIN: Would you turn to 13 Tab 50 of Volume I, 129374. Our database, being 14 hopefully reasonably exhaustive, still has the program of 15 the course that you ran for Regional Coroners and 16 pathologists back in November -- October/November of '96 17 -- you and Dr. Young apparently chairing that conference. 18 Turning to the next page which is found at 19 129375, who was invited to attend this conference? How 20 many of your pathologists were able to go? How many 21 pathologists from around the province? 22 Help us with that if you would, Dr. 23 Chiasson. 24 DR. DAVID CHIASSON: Well, the initial 25 courses were designed for any pathologist who was doing


1 medicolegal work for the coroner's office and -- and that 2 -- that numbered in excess of two hundred (200) across 3 the province, and this varied from individuals who might 4 be doing a handful of -- of cases to individuals who were 5 doing two hundred (200), three hundred (300) cases a 6 year. 7 This course is actually a little different 8 than the earlier ones because this is a Regional 9 Coroner's Pathologist course, so if you go back to the -- 10 the first page of -- under tab there, you can see it's a 11 Regional Coroner's Pathologist course. 12 So this course was specifically designed 13 for Regional Coroner's Pathologists who had been named 14 and appointed the previous -- within the previous year. 15 So this is a specific course for those pathologists whose 16 responsibilities would potentially include homicides and 17 criminally suspicious deaths. 18 So -- and you couldn't get all the 19 pathologists at the same time, otherwise there wouldn't 20 be a lot of other hospital pathology work being done, 21 because again, the vast majority of these pathologists 22 had their -- their day jobs, if you will, doing hospital 23 pathology. 24 So we -- we had two (2) courses back to 25 back. This, I think, was the first one in '96. We had a


1 similar course in '97, and we, basically -- the vast 2 majority of the Regional Coroner's Pathologists attended 3 one or the other. 4 MS. LINDA ROTHSTEIN: Right. And just 5 looking at the presenters for a moment while we're there, 6 at the bottom of that page, "Forensic Odontology", Dr. 7 Wood. What if anything does that tell us about the 8 stature of Dr. Wood in that area, as you viewed it at 9 that time? 10 DR. DAVID CHIASSON: Well, Dr. Wood, at 11 that time, was our forensic odontologist go-to guy, if 12 you will. I'm not sure -- at some point he gets, 13 actually, a formal appointment as the Chief Forensic 14 Odontologist for the coroner's office. I'm not exactly 15 sure when that occurred. It may have been subsequent to 16 this. 17 But certainly at that time, he was on his 18 way to doing that. He was the odontologist we turned to 19 with all our difficult cases, bite marks, and -- and he 20 did also wound-weapon matching for us as well. 21 MS. LINDA ROTHSTEIN: Right. I see on 22 the next page that you were presenting on "The Pathology 23 of Homicide Suspicious Death Cases, Practical 24 Considerations". 25 I won't ask you to try and summon up a


1 recollection of what the focus of your discussion was, 2 but turning to the next page, 129377, I note that Dr. 3 Charles Smith presented on "The Pathology of Child 4 Abuse/Homicide". 5 So same question, Dr. Chiasson: What does 6 that tell us about the stature of Dr. Smith, at least, in 7 the area of child homicide back in 1996? 8 DR. DAVID CHIASSON: Well, Charles was 9 the -- the go-to guy as far as child abuse and homicides. 10 He did the -- the -- had the greatest experience and 11 really, I don't know that there was anybody else in the 12 Province that -- that I would have approached, you know, 13 as a -- as an alternative. 14 I -- I take that back, Dr. Rao, Chitra 15 Rao, in Hamilton was in fact doing a fair amount of -- of 16 pediatric pathology, including child abuse cases, so she 17 would have been the -- the second choice, I think, for 18 this. But at that time certainly Charles was the 19 identified individual within the coroner's system in this 20 area of expertise. 21 MS. LINDA ROTHSTEIN: Okay. And, 22 Commissioner, you'll note, but we don't need to turn it 23 up, that there's a course the following year that has 24 sort of similar agenda and similar -- actually, many of 25 the same presenters.


1 DR. DAVID CHIASSON: There -- there may 2 have been a little bit variation as to the presenters, 3 but the idea was that it would be the same course being 4 repeated for those pathologists that had not been able to 5 attend this course. 6 MS. LINDA ROTHSTEIN: All right. As I 7 understand it, Dr. Chiasson, that your attempts to 8 provide ongoing education to pathologists, and indeed 9 coroners, about pathology issues wasn't restricted to 10 these courses. 11 In addition, you created something called 12 the Forensic Pathology Coroner, which was an article that 13 you started to write regularly for the Mortem Post. 14 DR. DAVID CHIASSON: Correct, yes. I 15 don't know if you're familiar with the Mortem Post, but 16 the Mortem Post was the Coroner's Office newsletter. 17 MS. LINDA ROTHSTEIN: So, take a look at 18 Tab 40, if you will. I believe it reflects your first 19 entry in June of 1995, if I'm not mistaken. It's 129356. 20 At least someone -- 21 COMMISSIONER STEPHEN GOUDGE: Sorry, what 22 tab? 23 MS. LINDA ROTHSTEIN: Tab 40, 24 Commissioner, of Volume I 25


1 CONTINUED BY MS. LINDA ROTHSTEIN: 2 MS. LINDA ROTHSTEIN: At least somebody 3 thinks it was June '95. Does that accord with your 4 recollection? 5 "It has been just over a year since I 6 assumed the position of Chief Forensic 7 Pathologist, and now that the dust is 8 settling a little I am taking the 9 opportunity to comment on the state of 10 forensic pathology in the Province. 11 This is the first of what I hope will 12 be a regular contribution to the Mortem 13 Post where issues relevant to forensic 14 pathology are considered." 15 You then interestingly even go on to make 16 a comment about your experience in the medical examiner's 17 system. 18 "Having directly experienced both, I 19 have been able to reflect on the 20 differences, as well as to appreciate 21 some of the inherent similarities. 22 Regardless of the system, I feel that 23 prime requisites are sincere dedicated 24 professionals and good communication 25 between the various agencies involved."


1 Dr. Chiasson, eleven (11) years later -- 2 or twelve (12) years later, how does that sentence hold 3 up in your view today? 4 DR. DAVID CHIASSON: Well, it still 5 sounds good to me. 6 MS. LINDA ROTHSTEIN: Okay. 7 "Although in Ontario the coroner has 8 the primary role in the investigation 9 of death, the pathologist, too, has a 10 very important one. It is not 11 sufficient to perform a competent 12 medicolegal autopsy; there is also a 13 need to communicate orally, and via 14 written reports, the results of the 15 autopsy and how they relate to the 16 specific circumstances surrounding 17 death. The written report should be 18 concise and clear. Should any 19 questions arise, I feel it is incumbent 20 on the coroner to address them to the 21 pathologist prior to the release of the 22 report." 23 I want to stop there just for a moment, 24 Dr. Chiasson, to acknowledge that certainly in all the 25 documentation we've seen, I think that's the first time


1 someone has actually identified that very issue; that the 2 role of the forensic pathologist does not begin and end 3 in the autopsy room and is fundamentally related to 4 communication in the entire legal process. 5 DR. DAVID CHIASSON: Yes. I -- I mean 6 that -- that stems from -- the thing about training in a 7 medical examiner's system is that as the medical 8 examiner, as a trainee, you realise that the reports are 9 necessary for -- for documentation of statistical, you 10 know, death certification, for example, but also they -- 11 they go out to families, they're important in terms of 12 communicating the information to the -- to the police. 13 You're -- since in a medical examiner 14 system, as a medical examiner, you're at the core of the 15 death investigation system. I'm trying to convey here 16 that even -- even though you're a forensic pathologist 17 and not -- not the coroner, you still -- that -- that -- 18 in order to -- for the system to work you need to have 19 excellent lines of communication open between you and the 20 death investigator, coroner. 21 MS. LINDA ROTHSTEIN: And then turning 22 the page, 129357, you talk about the need for 23 consultation and collaboration and the efforts that 24 you've described to the Commissioner already, that you 25 were making to encourage that in your unit and then go on


1 to say, in about the middle of the page, that: 2 "This system of regular meetings is not 3 practical for the majority of 4 pathologists performing medicolegal 5 autopsies." 6 So you're acknowledging there, if I 7 understand you, Dr. Chiasson, that there's still a huge 8 number of pathologists involved in medicolegal autopsies 9 who are not connected in any kind of physical, or other 10 way, with your unit, and are out there, I -- I gather, in 11 fairly isolated cultures, is that -- is that fair? 12 DR. DAVID CHIASSON: Yes, many of the 13 autopsies certainly, at this stage, were done by the 14 local hospital pathologists and -- and including up until 15 the Regional Coroner's Pathologist system was developed 16 to try and restrict the number of cases, the potential 17 was that a very complicated case could land at the 18 doorstep of a hospital pathologist working solo practice 19 in a small hospital without much resources to -- to fall 20 back on. 21 And still end up becoming involved in a -- 22 in a very difficult case. 23 MS. LINDA ROTHSTEIN: You go on to say: 24 "I would heartily encourage all 25 pathologists to regularly discuss cases


1 with their local colleagues in cases 2 which perplex. I would urge 3 pathologists to make use of the 4 services of the forensic pathology 5 units in Hamilton, Ottawa, The Hospital 6 for Sick Children, or the main office 7 in Toronto. With the heightened 8 profile of medicolegal autopsy reports, 9 I feel strongly that potentially 10 controversial forensic issues are best 11 tackled as early as possible. One (1) 12 of my primary responsibilities is to 13 provide consultative support to 14 pathologists and coroners, as well as 15 to police forces." 16 I think we'll see a lot, as we go through 17 your evidence, Dr. Chiasson, about the consultation you 18 were providing to coroners and to police forces. 19 But I do want to pause, if I can, to ask 20 you the question, to what extent did other pathologists 21 in the province take you up on your offer of consultation 22 in complex cases; looking back at the six (6) years in 23 which you performed that role as Chief Forensic 24 Pathologist? 25 DR. DAVID CHIASSON: It -- it varied. I


1 mean, there were -- there were hospital pathologists who 2 -- who had no difficulty at all and -- and would pick up 3 the phone, and if they had a complicated case would -- 4 would give me a ring. 5 My feeling, actually, was often the more 6 senior pathologists, who had been practising for a while 7 seemed to be perhaps -- I -- I wasn't getting -- I didn't 8 get as much of a response from pathologists as I, 9 perhaps, would have liked and -- and expected. 10 Many of the cases that I became involved 11 in were through the coroners side and/or the police -- 12 often the police. The police would get a report and 13 they're struggling with what's going on here, and I would 14 get -- that -- that was -- that was more common then, in 15 fact, the pathologists to recognize that the complexity 16 and say, Hey -- upfront -- we need to -- I'd -- I'd like 17 some help. 18 MS. LINDA ROTHSTEIN: Now the other 19 provincial initiative that you undertook was arguably 20 even more significant, and certainly would -- involved 21 you in -- in a lot of work. And that was the initiative 22 you undertook to review all reports of post-mortem 23 examination in homicide and suspicious cases. 24 And if you would turn up the next tab, 41. 25 You'll see that you -- at least as of September '95 --


1 129360 -- are trying to assert a new process for quality 2 control in forensic pathology. 3 It was an entirely new process, was it 4 not, Dr. Chiasson? 5 DR. DAVID CHIASSON: Yes. I was unaware 6 of any quality assurance, quality control process being 7 in place prior -- 8 MS. LINDA ROTHSTEIN: Right. 9 DR. DAVID CHIASSON: -- to this. 10 MS. LINDA ROTHSTEIN: So in the second 11 paragraph of that forensic pathology coroner you say that 12 -- that issue: 13 "Quality control has to be considered 14 with a pragmatic mind. Six (6) to 15 eight thousand (8,000) medicolegal 16 autopsies are performed annually. 17 There are neither the personnel nor the 18 resources in place which would allow 19 for each autopsy report generated to be 20 reviewed by forensic pathologists." 21 Fair enough, you're already reviewing 22 fifteen hundred (1,500) a year for your unit. You're now 23 talking about taking on an additional, if we go below, 24 perhaps two hundred and fifty (250) reports to review, is 25 that right?


1 DR. DAVID CHIASSON: In terms of the 2 number of homicides, yeah, two hundred (200), two hundred 3 and fifty (250), and the problem is always defining 4 criminally suspicious deaths. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. DAVID CHIASSON: Mostly what I 7 reviewed over the years were -- were homicides. 8 9 CONTINUED BY MS. LINDA ROTHSTEIN: 10 MS. LINDA ROTHSTEIN: Okay. So what you 11 were envisaging here, if I understand it, is that those 12 homicide autopsy reports would be sent to you by the 13 pathologist or by the coroner? 14 DR. DAVID CHIASSON: The -- the system 15 was developed that they would come through the Regional 16 Coroner, would be the most common way. And the reason 17 for that was that all the reports went to the Regional 18 Coroner regardless and from there would be disseminated - 19 - usually would be disseminated from there to the Crown 20 Attorney and wherever else it -- Head Office, et cetera. 21 So I -- I felt that the easiest thing for 22 a pathologist to do would be just to send the report as 23 they normally would and have the Regional Coroner assume 24 the administrative responsibility of forwarding it to me. 25 The option of sending it to me directly --


1 some pathologists did do that. I was open to that if 2 that's what they wanted to do -- especially if they 3 wanted a little bit of advice or hand holding about a 4 report. I might get a draft report and it varied. I had 5 no problems with that. It's just that most reports the 6 pathologist would have been satisfied with what he's done 7 and has signed it out if you will. And so I'd -- I'd 8 left the -- the avenue of -- of travel of these reports - 9 - was most commonly through the Regional Coroner. 10 COMMISSIONER STEPHEN GOUDGE: After the 11 coroner had classified the death as a homicide? 12 MR. DAVID CHIASSON: They might have 13 done that. Yeah, assuming it was straightforward, they - 14 - they may have classed -- the -- the investigating 15 coroner quite likely would have done it. Reports may be 16 modified by the Regional Coroner -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 MR. DAVID CHIASSON: -- and if -- if he 19 saw a report and thought there might be some issues he 20 might hold off on -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 MR. DAVID CHIASSON: -- on issuing a -- a 23 formal classification. 24 COMMISSIONER STEPHEN GOUDGE: And at what 25 stage would you get it after it had gone to the Crown


1 or...? 2 MR. DAVID CHIASSON: No, the -- the 3 concept was that the reports would all be reviewed before 4 they're released from outside the Coroner's System. 5 COMMISSIONER STEPHEN GOUDGE: I see. 6 7 CONTINUED BY MS. LINDA ROTHSTEIN: 8 MS. LINDA ROTHSTEIN: In fact you say: 9 "A memo outlining this policy 10 accompanies this issue". 11 I -- I believe we'll find that if you look 12 at your screen, Dr. Chiasson, at 129358 -- let's see if 13 I'm right about that -- unfortunately, don't have the 14 tab. There we go. So there's your formal memo about it, 15 September 1 '95: 16 "The purpose of the review will be to 17 identify any major forensic pathology 18 issues that may need to be addressed 19 prior to final release of the report." 20 So the -- the contemplation was this 21 really was a quality assurance mechanism that would 22 ensure that the final report met an expected standard; is 23 that right, Dr. Chiasson? 24 MR. DAVID CHIASSON: Yes. I mean the -- 25 the intent was to, as I've underlined here, to identify


1 any major forensic pathologic issue. There may be style 2 issues or things that a pathologist would do at -- you 3 know, I might want a little more description of this or 4 this is -- but the intent was that it was -- there was 5 nothing major that I thought could cause difficulty with 6 a reader down the road in terms of a criminal process. 7 MS. LINDA ROTHSTEIN: And again we will 8 come back to this in the context of individual cases but 9 just to make clear you weren't, in the ordinary course, 10 looking at photographs; is that right? 11 MR. DAVID CHIASSON: That's correct. 12 Unless I saw a problem and requested photographs, 13 photographs were not part of the review process. 14 MS. LINDA ROTHSTEIN: And the same with 15 the underlying histology? 16 MR. DAVID CHIASSON: That's correct. 17 MS. LINDA ROTHSTEIN: So to the extent 18 that the flawed analysis was only apparent in either of 19 those two (2) categories of evidence if you will, this 20 paper review would not have picked that up; is that fair? 21 MR. DAVID CHIASSON: If the issue was a 22 misinterpretation of -- of an injury or of a pathologic 23 finding under the microscope that is true. The -- the 24 report would not likely pick it up. 25 MS. LINDA ROTHSTEIN: And also as we'll


1 see, Dr. Chiasson, if the report was late, very late, and 2 made its way directly to the Crown Attorney or even into 3 the courtroom, then that wasn't a report that was part of 4 this process that gave you the opportunity to review it 5 before release; is that also fair? 6 MR. DAVID CHIASSON: Yes, I -- there are 7 reports, for whatever reason, that bypassed the -- the 8 system. I did do an audit and given that this was a 9 completely new process, I mean, we're dealing with a 10 large number of pathologists trying to -- you know, who 11 are dealing with the cases. We're not dealing with a 12 small cohort of pathologists here. We're doing homicides 13 or criminally suspicious deaths. 14 I -- I thought actually the -- the initial 15 audit -- I was pleasantly surprised. We were catching 16 the majority, but we weren't catching all of them. 17 MS. LINDA ROTHSTEIN: Can you give the 18 Commissioner a sense of what you understood to be the 19 reaction of your colleagues to this process? Was it seen 20 as a bit intrusive for a fairly young Chief Forensic 21 Pathologist with, perhaps, not so many years in the game 22 to be proposing this level of scrutiny of colleagues or - 23 - or was that not an issue? 24 DR. DAVID CHIASSON: I don't think it was 25 an -- I never got the impression that it was an issue. I


1 mean, in part, the forensic pathology coroner provided an 2 opportunity to sort of massage this so that, you know, 3 we're not trying to be too dictatorial or, you know, 4 dogmatic about what we're trying to do here. So this is 5 an opportunity to have as sort of an editorial about the 6 process and -- and give people a little more than the 7 actual memo might. 8 And I -- I didn't get the sense that there 9 was any objection to the process from the majority of 10 pathologists anyway, certainly. 11 MS. LINDA ROTHSTEIN: Did the review 12 process encompass consultation reports or second 13 opinions? 14 DR. DAVID CHIASSON: No. Not unless they 15 were sort of attached to the PM report. So if a 16 pathologist did an autopsy and got a consult, yes, that - 17 - if it's appended to the original. But if it's some 18 second opinion sought by a Crown attorney, for example, 19 that was not the -- that wouldn't have been picked up by 20 this review process. 21 MS. LINDA ROTHSTEIN: Before we turn to 22 look at any particular exam -- examples, Dr. Chiasson, 23 can you give the Commissioner sort of a paragraph 24 description of the spectrum of approaches to reporting 25 that you observed when you first implemented this process


1 in '95? 2 DR. DAVID CHIASSON: Well, the emphasis 3 is on a spectrum -- it -- it certainly went from reports 4 that were minimalistic in a homicide case and you get a 5 report that might be two and a half (2 1/2) pages of -- 6 of reporting to detailed reports that in some cases went 7 to twenty-five/thirty (25/30) pages; certainly a lot of 8 detail, sometimes they were very confusing and much more 9 difficult to review. So it was -- it was a complete 10 spectrum. 11 And pathologists would be -- some would be 12 rendering a large amount of opinion beyond the cause of 13 death; cause of death was mandated so they all had a 14 cause at that statement. Some would include history 15 about the circumstances of the death, some would not, 16 even from people that were -- and -- and I'm -- I'm even 17 -- it's -- this is -- some of the spectrum was from unit 18 to unit or within a unit you had variation. There was -- 19 certainly what there wasn't was uniformity in how reports 20 were being written. 21 MS. LINDA ROTHSTEIN: Stopping on that 22 issue of history, because as you probably know that's 23 been, again, one of the themes that at least has been 24 emphasized by some of the experts who have testified thus 25 far.


1 What was your view of the importance of 2 including a history in the post-mortem report? 3 DR. DAVID CHIASSON: Well, -- 4 MS. LINDA ROTHSTEIN: Then. Back then. 5 DR. DAVID CHIASSON: I -- I mean, I think 6 and the way I trained, our reports -- we were doing a lot 7 of, in -- in Baltimore, a lot of reports and -- and, you 8 know, efficiency was important. The -- the -- Dr. Dixon, 9 I mean, she was a -- a master of -- of conciseness and -- 10 and what I learned from her was that you could put all 11 the information that was necessary, that you needed to 12 know, that was relevant, and -- and do it in a few lines, 13 and that's -- that's the way I learnt and trained. 14 But you did put circumstantial 15 information. An example -- a straight forward example 16 that I would encounter not infrequently would be that 17 there'd be no history and there'd be a description of 18 some pulmonary edema and congestion and the cause of 19 death was drowning. 20 Well, the diagnosis of drowning 21 necessitates some kind of history because pulmonary edema 22 and congestion can come from a number of different 23 causes; it's not specific for drowning. And -- and 24 drowning is a diagnosis that needs to incorporate 25 circumstantial information, but that didn't stop some


1 pathologists from simply arriving at the conclusion. 2 Now usually the reports came with the 3 coroner's warrant, so I -- I had some information upon 4 which to assess the -- the history, but it wasn't being 5 found in the report itself. 6 MS. LINDA ROTHSTEIN: And what efforts 7 did you make to encourage your colleagues to include 8 history? 9 DR. DAVID CHIASSON: That was part of the 10 teaching process and I -- I suspect it may be a forensic 11 pathology coroner where I raise that. If not, I 12 certainly -- that was -- that was a message I was trying 13 to get across when I'm talking about homicides, 14 criminally suspicious deaths -- to -- to -- on the one 15 hand provide relevant history. 16 On the other hand, however, you had the 17 other spectrum where individuals would -- would 18 regurgitate all what -- that was on the coroner's 19 warrant, perhaps not realizing that the coroner's warrant 20 doesn't get released to the family, but in fact the 21 pathology reports under the coroner's acts are all to be 22 released to the family upon request. 23 So you would have within the report things 24 that clearly could be considered as -- as prejudicial or 25 reflecting poorly on the moral character of the decedent


1 in instances where it was irrelevant to the cause of 2 death opinion. 3 And so in some cases my comment on the 4 review would be to go back and say, listen, do we really 5 need this piece of information? Yes, I know it's in the 6 coroner's warrant. 7 And this -- this continues to this day. I 8 mean, I -- you'll see this ongoing issue. So there's a 9 problem with not enough history. There's also a problem 10 really with too much information. 11 What you need is what's relevant to the 12 forensic pathologic conclusions you're making in your 13 report. 14 MS. LINDA ROTHSTEIN: So for example, if 15 I hear what you're saying, Dr. Chiasson, we've heard 16 evidence about one of Dr. Smith's final autopsy reports - 17 - and that -- I understand that's not the same as a post- 18 mortem. But for the moment -- and this is identified in 19 Joshua's overview report 143053 at page 53, paragraph 3 - 20 - this was a sentence that's been the subject of some 21 criticism here. 22 "He lives with his twenty (20) year old 23 mother and eighteen (18) month old sib. 24 The mother is married but does not 25 officially live with her husband in


1 order that she can collect welfare." 2 If I hear what you're saying, Dr. 3 Chiasson, that kind of description in the history, that 4 kind of -- those sentences in a history were not unusual 5 in the reports that you received from other forensic 6 pathologists. 7 DR. DAVID CHIASSON: Yes, that -- that -- 8 I guess a particularly blatant example but certainly you 9 would get that kind of information which is irrelevant to 10 the issue of the cause of death. 11 In some cases the information might be of 12 -- of interest to the police in -- in what they're doing 13 but for a forensic pathology to determine the cause of 14 death, regardless of the mother's motivations for, you 15 know, collecting welfare, living on her own or whatever, 16 I mean that's clearly -- you can't make a pathology issue 17 out of that. 18 MS. LINDA ROTHSTEIN: Okay. 19 DR. DAVID CHIASSON: Clearly 20 inappropriate to be found in the PM report. 21 MS. LINDA ROTHSTEIN: All right. I want 22 to deal with a third initiative before we come back to -- 23 again -- 24 COMMISSIONER STEPHEN GOUDGE: Just before 25 you do, can I just ask a couple of questions, sorry, Ms.


1 Rothstein. 2 In terms of the numbers of reports you 3 anticipated having to review as a result of this, how 4 many on top of the two hundred (200) to two hundred and 5 fifty (250) would you have anticipated; that is how many 6 get into what -- in Dr. Young's memo or in your memo 7 announcing it, were unascertained but possibly homicide? 8 Or is the two hundred and fifty (250) to 9 encompass both homicides and the possibles? 10 DR. DAVID CHIASSON: Well the number of 11 homicides in the Province annually usually is around two 12 hundred (200), two hundred and fifty (250). 13 COMMISSIONER STEPHEN GOUDGE: Yeah, 14 that's what I thought that number was so -- 15 DR. DAVID CHIASSON: Yeah. 16 MS. LINDA ROTHSTEIN: -- you broadened it 17 somewhat. 18 DR. DAVID CHIASSON: Yes. It didn't 19 increase the number. I don't think it increased the 20 number that -- that much. It -- I mean I -- I suspect 21 there were cases that should have been reviewed that 22 weren't reviewed, that they really were criminally 23 suspicious. 24 COMMISSIONER STEPHEN GOUDGE: Right, 25 right.


1 DR. DAVID CHIASSON: And in some ways 2 they're probably even more important than reviewing the 3 straightforward homicides. 4 Now realizing that number, in the office 5 at the -- the Toronto office, I was already reviewing 6 about eighty (80) to a hundred (100) homi -- 7 COMMISSIONER STEPHEN GOUDGE: Out of your 8 fifteen hundred (1,500) anyway. 9 DR. DAVID CHIASSON: -- yeah. So that -- 10 that was -- I -- I'm looking at an additional, for the 11 sake of argument, a hundred and fifty (150), maybe two 12 hundred (200) cases -- 13 COMMISSIONER STEPHEN GOUDGE: Right, 14 okay. Fair enough. 15 DR. DAVID CHIASSON: -- for the Province- 16 wide review. 17 COMMISSIONER STEPHEN GOUDGE: Okay, 18 thanks. 19 20 CONTINUED BY MS. LINDA ROTHSTEIN: 21 MS. LINDA ROTHSTEIN: So the third 22 initiative, as I understand it, Dr. Chiasson, was 23 something that's described in our documents as the 24 creation of a regional coroner's pathologist system. 25 DR. DAVID CHIASSON: Yes.


1 MS. LINDA ROTHSTEIN: Can you tell us 2 about that. 3 DR. DAVID CHIASSON: Well it was clear as 4 I've already indicated, that the way the coroner's system 5 was set up when I came onboard, is that there was 6 certainly the theoretical possibility that a pathologist 7 working in a small community -- or even in a large 8 community, but with very little homicide experience -- 9 would be charged with -- would have a coroner's warrant 10 directed towards him or her to do a post-mortem 11 examination in what was a homicide or criminally 12 suspicious death. 13 There was -- now it varied from 14 jurisdiction to jurisdiction. Where you had a unit that 15 was quite clear -- so in Niagara region, a death in St. 16 Catherines, for example, if it was a homicide or 17 criminally suspicious death, tended to be referred to the 18 Hamilton unit. 19 But back then there was only the Hamilton 20 unit. There was the Toronto unit. There was the Sick 21 Kids unit, and Ottawa had just come on board. But 22 there's large parts of the province that that wasn't the 23 case. 24 And certainly, in these areas, it was 25 quite possible for a pathologist with virtually --


1 theoretically -- no experience in a homicide to suddenly 2 be -- have a warrant and for whatever reason, sense of 3 duty, or may have been uncomfortable about doing, but in 4 fact, would take on a case that -- that was clearly 5 beyond their -- their capabilities -- forensic 6 capabilities. 7 So the Regional Coroner's Pathologist 8 System was an attempt to, 1) ask pathologists from across 9 the province who were interested in being involved in 10 homicide and criminally suspicious that's -- and to 11 indicate in a -- in their CV -- or provide a CV and to 12 fill out a questionnaire specifically asking about 13 numbers of homicides and their experience. 14 And then restructuring or -- or creating a 15 list of Regional Coroners, pathologists, who would have - 16 - 1) be willing, and second have some credentials, some 17 experience in homicides and would, if you will, get the 18 coroner's office blessing to do that. 19 So that was done -- in fact, it ended up 20 we needed to name an associate group as well as a 21 Regional Coroners Pathologist group, because we 22 recognized back then at least, that we needed young 23 people who were interested in doing. And this, 24 particularly, applies to northern Ontario where the 25 pathologist does homic -- had been doing homicide


1 certainly, and the cost of transporting bodies was -- was 2 prohibited. 3 And -- so we wanted some sense of junior 4 people to be able to develop and do that. So we had a -- 5 a number of Regional Coroners Pathologists and Associate 6 Regional Coroner Pathologists. 7 And this number actually was greater then 8 I expected. We had two hundred/two hundred fifty 9 (200/250) pathologists doing some kind of medicolegal 10 work. At the end of the day, we ended up with, I think, 11 between ninety/ninety-five (90/95) Regional Coroners 12 and/or Associate Regional Coroner's Pathologists. 13 MS. LINDA ROTHSTEIN: Okay. After the 14 break, Commissioner, we can look at the memo that Dr. 15 Chiasson sent to all the pathologists that gives us a 16 little more detail about that initiative. 17 COMMISSIONER STEPHEN GOUDGE: Okay. So 18 we'll rise now until 11:30. 19 20 --- Upon recessing at 11:00 a.m. 21 --- Upon resuming at 11:34 a.m. 22 23 THE REGISTRAR: All rise. Please be 24 seated. 25 COMMISSIONER STEPHEN GOUDGE: Ms.


1 Rothstein...? 2 3 CONTINUED BY MS. LINDA ROTHSTEIN: 4 MS. LINDA ROTHSTEIN: Thank you, 5 Commissioner, Dr. Chiasson. If you would turn to Tab 6 6 of Volume I, 115898; it's a memorandum dated June 28th, 7 1996 that you sent to all pathologists performing 8 coroner's autopsies. 9 A couple of things to note; it would 10 appear from this that 75 percent of the homicide 11 autopsies were being performed by pathologists affiliated 12 with one (1) of the four (4) forensic pathology units at 13 that stage, do you see that? 14 DR. DAVID CHIASSON: Yes. 15 MS. LINDA ROTHSTEIN: Dr. Chiasson? So 16 that accords with your recollection, does it? 17 DR. DAVID CHIASSON: Yes. 18 MS. LINDA ROTHSTEIN: And there's that 19 two hundred (200) number for the number of pathologists 20 who are actually performing medicolegal autopsies under 21 warrant. You were hoping to widdle it down to less then 22 ninety (90) were you? What -- did you have in your mind 23 a number that seemed manageable? 24 DR. DAVID CHIASSON: Yeah, I was -- I 25 didn't really predict an outcome from doing this process.


1 I was being fairly liberal. I mean, the -- the 2 qualifications or the what I consider the cut off for 3 number of autopsies, was actually quite low. 4 And in part, it was a recognition that we 5 are dealing with a large province, and there were areas 6 where there were pathologists that we really needed to be 7 doing the cases. And I didn't want to set a too -- too 8 high a -- a level. 9 And as well, to be frank, in 1996, I'm two 10 (2) years in the job. This, I think -- unlike the review 11 process, you raise the possibility, Well, you know what 12 pathologists might have thought of that, you know, the -- 13 the -- who is this guy doing this. 14 I was more -- a little more concerned 15 about it in this case, to start telling, you know, 16 pathologists who had gone through the trouble of 17 applying, who had, you know, indicated that they're 18 willing to participate in a system which they do -- and 19 it's not quite a volunteer basis, but at this time 20 coroner's fees, certainly when you were looking at these 21 cases, was no way compensating -- nobody was doing this 22 for the money. I think they were doing it as a public 23 service. So I -- I was very leery about being too 24 aggressive about cutting it down. 25 So at least as a first go we'll have a


1 large number. I think the plan would have been -- in 2 terms of evolution, would have been the next time to 3 review -- and I think there was a five (5) year review 4 initiative going to be put in place, and -- and at that 5 time get a little more aggressive about cutting down the 6 pathologists. 7 MS. LINDA ROTHSTEIN: Right. And then 8 just looking at the qualification criteria that you set 9 out there: 10 "Prior forensic pathology training 11 and/or experience." 12 Because you were starting from the 13 proposition that hardly anyone would have the formal 14 training that you had. 15 Is that fair? 16 DR. DAVID CHIASSON: Correct. 17 MS. LINDA ROTHSTEIN: 18 "Prior experiences as an expert witness 19 in Court, the willingness and 20 interpersonal skills necessary to work 21 as part of a team." 22 I don't -- did you have in mind how you 23 were going to go about assessing that, Dr. Chiasson, 24 or...? 25 DR. DAVID CHIASSON: No, I -- I -- it


1 sounds good. I'm not sure, you know, how -- how you 2 really assess that. I -- I mean I guess it was -- if I 3 was getting information from other sources that this 4 person wasn't a team player, I would sort of, probably, 5 informally incorporate it into my decision-making 6 process. 7 MS. LINDA ROTHSTEIN: Right. And then 8 "geographic location". I take it that's because you were 9 mindful of the fact that as one got more remote there 10 might have to be some adjustment in your criteria. 11 Is that fair? 12 DR. DAVID CHIASSON: Yes, in certain 13 areas where there was a number of experienced 14 pathologists and there was somebody that wanted to do it, 15 then he -- he would have more difficulty -- you know, I'd 16 look at that more stringently than I would in an area 17 where we're dealing with a small number of pathologists. 18 MS. LINDA ROTHSTEIN: So, in general 19 terms, Dr. Chiasson, what was the reaction of your 20 colleagues to this kind of qualification process? 21 DR. DAVID CHIASSON: Again, I never got 22 personally any strong negative reaction. I mean, I -- I 23 think I got -- I think the Coroner's Office was -- 24 hierarchy was -- was pleased with the initiative. And as 25 far as the pathologist -- because I was being so liberal,


1 you know, the vast majority of pathologists that applied 2 in fact were named, and so other than the individual 3 cases where that wasn't the case, a little bit of -- of 4 dissension perhaps there. But overall I think it was a 5 positive reaction. 6 MS. LINDA ROTHSTEIN: Let's turn to the 7 subject of this Inquiry at its most specific, that is to 8 say pediatric forensic pathology. And back in 1995/1996, 9 what was your view about whether there were any pediatric 10 forensic pathologists in your province? 11 DR. DAVID CHIASSON: Well, there were -- 12 there was nobody that was formally trained and/or board 13 certified in both areas of -- of specialty. Now, in 14 Canada there was, and there still is, neither board 15 certification specialty in either pediatric or forensics. 16 But I was unaware of anybody that -- that 17 was in fact -- really had formal training and/or 18 experience in both areas, so I -- I didn't consider from 19 that point of view that there was actually, you know, a 20 clear cut pediatric forensic pathologist. 21 MS. LINDA ROTHSTEIN: You are today -- I 22 think the Commissioner knows this -- the Director of the 23 Ontario Pediatric Forensic Unit at Sick Kids. From your 24 tour, Commissioner, you'll remember that. 25 You've held that position for how long,


1 Dr. Chiasson? 2 DR. DAVID CHIASSON: I think it's about 3 two (2) years. 4 MS. LINDA ROTHSTEIN: All right. How 5 would you describe yourself today? 6 DR. DAVID CHIASSON: I'm a forensic 7 pathologist working in a pediatric environment. I have a 8 specialty interest in -- in pediatric pathology -- 9 pediatric forensic pathology, but I don't consider myself 10 a full- fledged pediatric forensic pathologist because I 11 don't consider myself a pediatric pathologist. And 12 that's in recognition that pediatric pathology is -- is 13 far more than doing autopsies. 14 I do some hospital autopsies, but in fact 15 a pediatric pathologist, the vast majority of them, you 16 know, their primary area of focus is in -- in surgical 17 pathology, of which I don't claim to have any expertise. 18 And I think it's fair to say that if it 19 wasn't for my forensic background in this specific job I 20 wouldn't have been hired as a pediatric pathologist at 21 the Hospital for Sick Children. 22 MS. LINDA ROTHSTEIN: Okay. So let's now 23 talk about the six (6) years that you were the Chief 24 Forensic Pathologist of the Province going back to that 25 period of time, between '94 and -- well, starting with


1 '94 when you assumed the position. 2 How many pediatric forensic autopsies had 3 you done when you assumed the position? 4 MR. DAVID CHIASSON: Well, the -- I had 5 in my training period as a resident performed a small 6 number of SIDS-like cases, coroner's cases, and some of 7 these under the supervision of Dr. Smith but also some 8 under the supervision of other pathologists at the 9 hospital at that time. 10 And then you have to fast forward to my 11 training experience where I perhaps did a couple of 12 dozen, maybe twenty-five/thirty (25/30) pediatric cases. 13 Now, I -- by that I'm really restricting 14 it to under age ten (10). I mean if you include 15 teenagers -- and certainly in a big city like Baltimore 16 children -- well, still children I think -- 17 sixteen/seventeen (16/17) year olds were getting shot 18 with some regularity. 19 MS. LINDA ROTHSTEIN: Right. 20 MR. DAVID CHIASSON: So I mean excluding 21 that, the real pediatrics under age five (5), under age 22 ten (10), two (2) dozen, maybe -- maybe a bit more than 23 that. 24 MS. LINDA ROTHSTEIN: And how many of 25 those became homicide cases, of that two (2) dozen?


1 MR. DAVID CHIASSON: Oh, a small 2 percentage. I mean, two (2) or three (3) maybe as I 3 recall. 4 MS. LINDA ROTHSTEIN: Did you testify in 5 any of those cases? 6 MR. DAVID CHIASSON: I don't recall 7 testifying in any pediatric case, no. 8 MS. LINDA ROTHSTEIN: So that's your 9 experience when you arrive as the Chief Forensic 10 Pathologist. During the six (6) year period that you 11 occupied that position, sir, how many pediatric forensic 12 cases did you do, other than Sharon's case; and we'll 13 talk about that -- if we exclude that one? 14 MR. DAVID CHIASSON: Yes, I think -- I 15 think I've -- we looked at this and I think there's three 16 (3) or four (4) that were under the age of -- of ten (10) 17 and they tended to be trauma cases. One (1) I recall was 18 a woman who hang -- hung herself and -- and hung her 19 child and so the adult was brought to the Coroner's 20 Office and -- and the child was brought -- it was a 21 clear-cut hanging situation so we did the both PMs in 22 that case. 23 And the only -- well, the one that really 24 sticks in my mind was a case -- the case of Farah Khan 25 who was a young girl whose body parts were found in


1 Toronto here a number of years ago. 2 So the numbers are really very small and 3 that was after -- that was towards the end of my stint as 4 the -- in the Coroner's Office. 5 MS. LINDA ROTHSTEIN: I think you told me 6 last week that you thought it was 1999? 7 MR. DAVID CHIASSON: Yes, I think so. 8 MS. LINDA ROTHSTEIN: You told me maybe a 9 couple of motor vehicle cases, right? 10 MR. DAVID CHIASSON: Yes, I did. 11 MS. LINDA ROTHSTEIN: So we've got in six 12 (6) year period Sharon's case, the Farah Khan case being 13 really the only homicide complex pediatric cases that you 14 were personally involved in doing an autopsy. 15 Is that fair? 16 MR. DAVID CHIASSON: Yes. I mean the -- 17 the hanging case I described -- 18 MS. LINDA ROTHSTEIN: Yeah. 19 MR. DAVID CHIASSON: -- it was de facto 20 a homicide, a homicide/suicide situation. So that -- 21 that was it as far as... 22 MS. LINDA ROTHSTEIN: Right. So is it 23 fair to say, Dr. Chiasson, that at no stage during your 24 tenure as the Chief Forensic Pathologist did you feel 25 that you were expert in pediatric forensic pathology?


1 Is that a fair statement? 2 MR. DAVID CHIASSON: I clear -- I clearly 3 did not feel like I had expertise in pediatric forensic 4 pathology, that's correct. 5 MS. LINDA ROTHSTEIN: Okay. Let's talk 6 then a little bit about -- well, just before we move on, 7 knowing what you know now about pediatric cases -- and 8 you've now done how many since you've been at the 9 Hospital for Sick Children, both prior to your assuming 10 the directorship and -- and to date? 11 MR. DAVID CHIASSON: I think I'm around 12 three hundred (300) cases. 13 MS. LINDA ROTHSTEIN: All right. So -- 14 COMMISSIONER STEPHEN GOUDGE: Three 15 hundred (300)...? 16 MR. DAVID CHIASSON: Three hundred (300) 17 post-mortem examinations in pediatric nature. 18 COMMISSIONER STEPHEN GOUDGE: Pediatric 19 nature 20 DR. DAVID CHIASSON: And to put that into 21 context I've done about three thousand (3,000) post- 22 mortem examinations. So 10 percent right now. 23 24 CONTINUED BY MS. LINDA ROTHSTEIN: 25 MS. LINDA ROTHSTEIN: So based on that


1 experience with pediatric cases, what's your view of the 2 optimum way to do a pediatric death investigation? 3 And particularly what -- how would you 4 rate the importance of pediatric expertise as opposed to 5 forensic expertise? 6 DR. DAVID CHIASSON: Well, it depends on 7 the nature of the case. I -- I think as the audience is 8 aware and the Commissioner is aware, the vast majority of 9 pediatric forensic pathology cases, and by that I mean 10 pediatric coroner's cases are in fact -- that's due to a 11 natural disease; that's the largest group, 70 percent 12 perhaps as a -- as a figure. 13 Now, they don't all present as natural 14 disease, a proportion of them certainly are no natural 15 disease and they die in hospital and sometimes they're -- 16 they're issues related to medical care. There's some 17 with known medical disease, for example, congenital heart 18 disease who die suddenly and unexpectedly outside the 19 hospital, and those are treated as sudden unexpected 20 deaths and undergo the -- their standard protocol, even 21 though you strongly suspect that because of the 22 underlying heart disease that that's what's going to be 23 at the end of the day. 24 And then there's the group of -- of sudden 25 unexpected deaths in infants and small children who don't


1 have any known underlying medical disease and the vast 2 majority of those turn out to be non-homicidal certainly. 3 Some of them are -- are SIDS, Sudden Infant Death 4 Syndrome. Some of them are -- are, what's been termed 5 SUD, sudden unexpected deaths, with issues of co-sleeping 6 and -- and that sort of thing; sleep environment issues. 7 And so then you're -- for al of those 8 cases a pediatric pathologist is -- is quite qualified, I 9 think, to -- to handle and competently perform autopsies, 10 assuming that that pediatric -- in -- in terms of this 11 undetermined group, they have to be, I think, trained and 12 knowledged -- have knowledge into a specific protocol 13 that looks at, as we have in place, that looks at how to 14 deal with sudden unexpected deaths in infants. 15 It's the other -- the remaining category, 16 it's my view that deaths that are criminally suspicious 17 or obvious homicides in the pediatric age group, the 18 autopsy should be performed by a forensic pathologist and 19 ideally a forensic pathologist with pediatric background, 20 pediatric experience of some sort, and with access to 21 pediatric pathology colleagues as might be -- be 22 necessary. 23 MS. LINDA ROTHSTEIN: And to what extent 24 do you think it's necessary that there be what's been 25 described here as "double-doctoring" that both a


1 pediatric pathologist and a forensic pathologist both be 2 engaged in the autopsy? 3 DR. DAVID CHIASSON: I -- I struggle with 4 the concept of double-doctoring, as I have heard it -- 5 I've heard some of the Commission's testimony by -- by 6 some of his experts and including Dr. Pollanen. I mean 7 we're -- we're in an environment where there's a severe 8 shortage of forensic pathologists and there's a severe 9 shortage of pediatric pathologists and it is -- there is 10 a significant shortage of pediatric pathologists across 11 Canada. 12 And to -- to -- I find it difficult to 13 envision a situation where you're actually, practically 14 speaking, going to be able to find two (2) such people 15 who are willing to spend the time of not only being at an 16 autopsy and -- and taking notes, et cetera, as I 17 understand the double doctoring and then to issue a 18 separate report. It's very time consuming to do any 19 pediatric autopsy regardless of whether it's criminally 20 suspicious or not. But -- so there's a lot of work, 21 thee's a -- it's very work intensive. 22 And I know there's been a notion, well you 23 could have reports that were co-signed; two (2) people 24 signing a report. I -- I think that logistically is -- 25 is full of problems and I would personally never co-sign


1 a report with another pathologist. I mean, if you're 2 going to do it I think you need to do your own -- your 3 own report. And, you know -- 4 MS. LINDA ROTHSTEIN: Stopping there, 5 what are the problems that you see? 6 DR. DAVID CHIASSON: Well, the problems 7 you see is -- I'll try to give an example; would be a 8 case of -- of smothering or alleged smothering, where the 9 forensic pathologist sees abrasions and injuries around 10 the mouth a torn frenulum -- the little piece of tissue 11 between the upper lip and the -- and the gums; and has 12 some circumstantial information that he might be taking 13 into consideration, scene information; and he might be 14 quite prepared to render a diagnosis of -- of smothering, 15 but let's say the infant also has some kind of congenital 16 heart disease, for example; he happens to have that, as 17 well. 18 So you could -- I could envision a 19 scenario where the pediatric pathologist, well, you've 20 got a little --few minor injury, I don't know about 21 smothering, but I know about congenital heart disease and 22 I know that that could actually, you know, precipitate a 23 sudden death situation and as a pediatric pathologist, 24 I'm not comfortable in rendering a diagnosis of 25 smothering.


1 So at the end of the day, whether he would 2 render it as undetermined or -- or not, or render 3 arguably potentially that, you know, the death is due to 4 heart disease. 5 The -- the forensic pathologist looking at 6 the situation saying, listen, these -- these are good 7 findings, we have some -- a few petechial hemorrhages in 8 the eyes, although that's not the commonest scenario in - 9 - in smothering, and -- but he might be quite 10 comfortable. 11 So you -- you -- I'm not sure how the 12 Courts would deal with that kind of -- of thing. In my 13 view, the forensic pathologists should trump the 14 pediatric pathologists, if you will, because that's the 15 issue at hand, is really a forensic pathology issue. 16 So, I -- I see a lot of difficulties 17 incumbent in -- in double-doctoring. If I may suggest 18 an alternative to the -- and in some ways -- the model we 19 have now at -- at Sick Kids, I'm -- I'm a major proponent 20 of this, as you might think, but in fact, in some ways we 21 -- we quadruple-doctor in -- at Sick Kids, or even more. 22 And by that, I mean we have a pediatric 23 radiologist who's a doctor, he looks at the x-rays 24 beforehand, so that's part of the investigation. We 25 have, in -- in my case, I'm very fortunate, I have a very


1 experienced pathologist assistant, and I think that's -- 2 that's a critical element to performing any autopsies; to 3 have a good pathologist assistant, but in the case of 4 pediatrics that's particularly so. And -- and the 5 training and -- and expertise of a pediatric forensic 6 pathologist assistant is -- is really very valuable. And 7 I happen to work with one who has a PhD, so he's -- he's 8 my second doctor who -- who I -- I'm very fortunate to 9 work with. 10 Then there's the for -- forensic 11 pathologist who's doing the case. 12 Then there's the neuropathologist, which 13 is critically important in --in a lot of these, I think, 14 as we're -- as you're all aware, from the nature of the 15 cases. If I have a problem, I -- I contact Dr. Halliday, 16 who happens to be down the hall; he's able to attend the 17 autopsy and render his expertise about the brain and 18 ultimately cut the brain. 19 And then, I think we're up to four (4) 20 there, but even beyond that, if there is a pediatric 21 pathology issue that I identify, then I'm very fortunate 22 because I have very experienced pediatric pathologists 23 who are also down -- down the hall. 24 Even if that wasn't the case I would argue 25 that the forensic pathologist, if this is the -- if this


1 is a forensic case -- if this is a criminally suspicious 2 death, forensic pathologists can always document what 3 needs to be documented. If congenital heart disease if 4 found, the heart could be retained and referred to a 5 pediatric pathologist. 6 MS. LINDA ROTHSTEIN: So, on your ver -- 7 your view of the optimum procedure, the potential for 8 congenal -- congenital hear failure to have been the 9 cause of death will not get missed. 10 Is that what you're telling us, Dr. 11 Chiasson? 12 DR. DAVID CHIASSON: That's right. I 13 mean you -- you'll get the opinion as to what the 14 potential significant -- con -- complex congenital heart 15 disease -- and congenital heart disease is -- is a 16 complicated area and we recognise -- an experienced 17 pediatric pathologist recognises that we see individuals 18 on a regular bases who have very complex congenital heart 19 disease who have lived for 'X' number of years, and 20 realise just because you have congenital heart disease 21 that could be very complex, and to a forensic pathologist 22 might be very intimidating; it might confuse the issue. 23 To a pediatric pathologist, I mean, that - 24 - that's where that expertise -- but you could always 25 have that expertise come in down the road. You don't --


1 don't need them there at the autopsy. 2 COMMISSIONER STEPHEN GOUDGE: I wanted to 3 ask you a little bit about that. Let me ask a first 4 question, and that is: The pathology assistant, in your 5 case what role does the pathology assistant play at the 6 autopsy? 7 DR. DAVID CHIASSON: The pathologist 8 assistant in -- in our case plays a very important role. 9 They are there to -- to take measurements, body 10 measurements. They -- they organize taking of x-rays for 11 example. They're -- they -- they have a lot of that kind 12 of administrative responsibility, accessioning issues. 13 But in terms of -- particularly the 14 technical aspects, they're the ones that will open up a 15 body, and carry out dissections. They're -- they do 16 autopsies on a -- on a daily basis. Most pathologists -- 17 you know, for every autopsy a pathologist does, the 18 pathologist assistant is usually present at three (3) -- 19 three/four (3/4) autopsies, you know, more. 20 Give you an example, Barry Blenkinsop who 21 was my assistant for many years, he -- he had, over his 22 tenure, was present and assisted at over thirty thousand 23 (30,000) autopsies. Where I -- as I, even if I continue 24 my career, you know, well into my 60's, if I do six 25 thousand/five thousand (6,000/5,000) that would be...


1 So -- so these individuals are -- are when 2 it comes to the technical dissection and -- and aspects 3 of the autopsy, the removal of the brain, specialized 4 dissection of the -- of the -- 5 COMMISSIONER STEPHEN GOUDGE: They 6 actually do the cutting? 7 DR. DAVID CHIASSON: They do the cutting. 8 And -- and in fact with -- with -- 9 COMMISSIONER STEPHEN GOUDGE: Is there a 10 varied practice in that, Dr. Chiasson; that is, we've 11 heard from one (1) or two (2) others, from our experts, 12 that they prefer to their own cutting. 13 DR. DAVID CHIASSON: Yes. No, and it's 14 not to say that I don't do any cutting. Obviously I have 15 my role and I usually dissect the -- the organ block 16 itself. But the issues of removing a brain, of -- of 17 looking at a spinal cord, taking out the spinal cord -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. DAVID CHIASSON: -- there. And 20 that's -- that's the practice and I -- I have the utmost 21 confidence. It's done under my supervision. And as I've 22 said, Dr. Perrin, for example, is -- is much more 23 technically proficient at these dissections, especially 24 with young infants then -- then I am. 25 COMMISSIONER STEPHEN GOUDGE: Right. Now


1 dealing with the other sub-specialties that you're able 2 to draw on in your present environment, how often are 3 they actually called in to the actual autopsy as opposed 4 to being called in to provide their opinion about the 5 organ or about the dissection that's under a microscope, 6 for example? 7 DR. DAVID CHIASSON: Well, I -- I think 8 in -- in the practical world -- it's not uncommon for me 9 to have the neuropathologist attend the -- the actual 10 post-mortem examination when we're removing the brain. 11 Certainly if there's anything complicated -- if there's 12 issues of a neuropathologic nature, I usually say, 13 Listen, we're going to start a PM, just to let you know. 14 You know, is there anything special in this case? 15 And regardless, often if we find anything, 16 we will call the neuropathologist in. And I -- I -- 17 COMMISSIONER STEPHEN GOUDGE: To actually 18 come down -- 19 DR. DAVID CHIASSON: Yes. 20 COMMISSIONER STEPHEN GOUDGE: -- to the 21 autopsy room? 22 DR. DAVID CHIASSON: Yes. And that's 23 done, oh I'd say, in the last ten (10) autopsies I've 24 had, I've had some -- I've had the neuropathologist in 25 three (3) or four (4) times. You know, so that's quite


1 common. 2 As far as other pediatric pathology 3 expertise -- 4 COMMISSIONER STEPHEN GOUDGE: The neuro - 5 - the radiologist -- 6 DR. DAVID CHIASSON: Well the radiologist 7 do their job -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. DAVID CHIASSON: -- they do their x- 10 rays. They don't usually attend the -- the post-mortem. 11 But a -- a -- for example, Dr. Taylor in 12 terms of -- if I found some heart disease there -- 13 COMMISSIONER STEPHEN GOUDGE: Yes, the 14 cardiopathologist. You'd -- 15 DR. DAVID CHIASSON: Cardiopatholo -- 16 COMMISSIONER STEPHEN GOUDGE: -- probably 17 show him the organ or show him a slide from -- 18 DR. DAVID CHIASSON: We would -- often if 19 there's -- if it's an issue, we'll -- we'll keep the 20 organ. We need to inform the family of that -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID CHIASSON: -- obviously, but -- 23 and we need the coroner's permission to do that. But we 24 will do that. We will photograph it. And, you know, we 25 can -- if we have the specimen we can show him down the


1 road. 2 And it's very rare that I've actually 3 called in a pediatric pathologist while I'm doing an 4 autopsy. Even -- and I do hospital medical type cases on 5 a regular basis and -- and I don't find it necessary to 6 call them in at -- at that time. 7 So I -- I can't see a real advantage to 8 having -- now this is my own situation, which obviously 9 is -- there's certainly unique aspects to it, but in 10 terms of that -- down the road, I mean, we -- we retain, 11 as I've said, other organs. More commonly what I will do 12 at a pediatric pathologist, is I'm looking at the slides 13 and I find some abnormality and then I'll walk down the 14 hall with the slide and ask -- 15 COMMISSIONER STEPHEN GOUDGE: To the 16 pediatric pathologist? 17 DR. DAVID CHIASSON: The pediatric 18 pathologist. That's -- that's the more -- practically 19 that's the more likely use of a pediatric pathologist. I 20 -- I would envision than one (1) necessarily having to be 21 at the post-mortem examination. 22 COMMISSIONER STEPHEN GOUDGE: Okay. 23 Sorry, Ms. Rothstein. Let me just ask another question 24 about -- about the lead in these cases -- the cases that 25 come to Sick Kids.


1 How many are done on under warrant each 2 year at Sick Kids? 3 DR. DAVID CHIASSON: We do about a 4 hundred and twenty (120), hundred and thirty (130) -- 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 DR. DAVID CHIASSON: -- under coroner's 7 warrant. 8 COMMISSIONER STEPHEN GOUDGE: Okay. And 9 you would take the lead as the forensic pathologist in 10 the pediatric setting in those you felt required the 11 forensic expertise to take the lead? 12 DR. DAVID CHIASSON: Yeah -- 13 COMMISSIONER STEPHEN GOUDGE: How many -- 14 how many out of the hundred and twenty (120) cases fall 15 into that category? 16 DR. DAVID CHIASSON: Well, I mean, we 17 have a schedule so -- so on any given time, there is a -- 18 an assigned pathologist -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. DAVID CHIASSON: -- and -- and just 21 to explain, the triage position -- the triage is -- is 22 done by the assigned pathologist. He gets the 23 preliminary information. 24 If there's anything that causes him 25 concern from a criminally suspicious point of view, then


1 he notifies me. We have a discussion and the decision's 2 made as to who is best person to -- to -- to proceed with 3 the post-mortem examination. 4 In a majority of those -- certainly, if 5 there's real criminal suspicious issues -- I will take 6 the lead. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. DAVID CHIASSON: If I'm not 9 available, we have Dr. Pollanen on staff to -- 10 COMMISSIONER STEPHEN GOUDGE: Right, 11 right. 12 DR. DAVID CHIASSON: -- to assist. 13 COMMISSIONER STEPHEN GOUDGE: And some -- 14 some of the cases are easy to screen. 15 DR. DAVID CHIASSON: Well, some of them 16 come with big flags on them. 17 COMMISSIONER STEPHEN GOUDGE: Exactly. 18 DR. DAVID CHIASSON: And -- and -- 19 COMMISSIONER STEPHEN GOUDGE: What about 20 the grey area cases? 21 DR. DAVID CHIASSON: The grey area cases 22 are -- our default position has been -- I -- I -- because 23 of our coverage issues and our staffing issues, I end up 24 -- I -- I work about every second week, on-call, on cases 25 anyway.


1 On the alternative weeks, it depends on 2 the pathologist. Dr. Taylor, for example, has a lot of 3 experience in -- in forensic cases including criminally 4 suspicious ones. 5 He might decide, Okay, I think I'm okay 6 with carrying this on or if -- if he decides or any of 7 his colleagues decides, No, I'm not comfortable, we'll -- 8 we'll -- either myself or Dr. Pollanen, will assume the 9 responsibility in the case. 10 COMMISSIONER STEPHEN GOUDGE: Do you have 11 something you could call a default position; that is, if 12 in doubt it goes to beyond call or if in doubt, it must 13 go to either you or Dr. Pollanen? 14 DR. DAVID CHIASSON: I -- I think -- well 15 certainly in the environment we're living in right now as 16 a result of what -- what -- I'm sitting in the middle of 17 right now, you know, our default posi -- our -- our -- 18 our cutoff for -- for having myself get involved in the 19 case is actually fairly -- fairly low. 20 And my colleagues, I can tell you -- 21 COMMISSIONER STEPHEN GOUDGE: Meaning by 22 that, that if in doubt, you would do it. 23 DR. DAVID CHIASSON: Yeah, exactly. So 24 my pediatric pathology colleagues are -- are -- are very 25 -- it's a low threshold to get to talk to me and -- and


1 usually, I'll take over the case. 2 COMMISSIONER STEPHEN GOUDGE: Okay, 3 thanks. Thanks, Ms. Rothstein. 4 5 CONTINUED BY MS. LINDA ROTHSTEIN: 6 MS. LINDA ROTHSTEIN: That's fine. So 7 let's just go back in time then and give the Commissioner 8 a picture of what the unit was, starting in 1994 when you 9 assumed your role. 10 At the time that you became the Chief 11 Forensic Pathologist, the OPFPU had been functioning for 12 about three (3) years, that was your understanding? 13 DR. DAVID CHIASSON: Correct. 14 MS. LINDA ROTHSTEIN: And Dr. Charles 15 Smith was the Director? 16 DR. DAVID CHIASSON: At the time, yes, 17 that I started. 18 MS. LINDA ROTHSTEIN: And who else was 19 part of that unit? 20 DR. DAVID CHIASSON: At that time, Dr. 21 Greg Wilson, Dr. Ernst (sic) Cutz and I think, Dr. 22 Meredith Silver was still working in the unit at that 23 time. 24 MS. LINDA ROTHSTEIN: And indeed -- in 25 passing, I'd like you to take a look at tab Number 8


1 which is 056972. Dr. Cutz applied, pursuant to your RCP 2 program -- the Regional Coroner's Pathologist Program -- 3 to be accepted as a Regional Coroner Pathologist on 4 October the 18th, '96, is that right? 5 DR. DAVID CHIASSON: Yes. 6 MS. LINDA ROTHSTEIN: As did, indeed, Dr. 7 Wilson which you'll see at tab Number 10, Commissioner 8 and Dr. Chiasson, on October 30th, '06, 056934. 9 DR. DAVID CHIASSON: Yes. 10 MS. LINDA ROTHSTEIN: And so both of 11 those doctors were anxious to be accepted in this program 12 so they could do pediatric forensic autopsies, is that 13 right? 14 DR. DAVID CHIASSON: Yes. 15 MS. LINDA ROTHSTEIN: Were they accepted? 16 DR. DAVID CHIASSON: Eventually, no. In 17 -- in fact, they were both late in applying. I think 18 they both missed the deadline and -- and there's some 19 explanation in the letters as to why that occurred. 20 But they did subsequently apply. I 21 considered their application. I looked at their 22 curriculum vitaes which are very impressive academic 23 documents. And -- and I have nothing but the highest 24 regard for Dr. Cutz and Dr. Wilson as academic pediatric 25 pathologists, and I -- I think that would be shared by --


1 on a world wide -- both have world-wide international 2 reputations and they're -- they are world leaders in 3 terms of academic pediatric pathology. 4 MS. LINDA ROTHSTEIN: So what were you 5 concerned about, Dr. Chiasson? 6 DR. DAVID CHIASSON: My concern was that 7 we were talking here about doing homicides and criminally 8 suspicious deaths in the pediatric arena. And I don't 9 know whether it was some misunderstanding in, and may or 10 may not have been -- I -- I think the sense was if they 11 weren't -- they found out that, Oh, if we're not Regional 12 Coroner's Pathologists, we're not going to be able to do 13 any -- anymore coroner's cases. 14 And that's not -- that wasn't the intent 15 of the Regional Coroner's -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID CHIASSON: -- Pathologist 18 System that we devised. It was to -- it was to -- 19 MS. LINDA ROTHSTEIN: Hive off the 20 criminally suspicious and homicide cases and have those 21 done by the RCPs, is that right? 22 DR. DAVID CHIASSON: Exactly. Exactly. 23 And -- and Dr. Smith had been so -- so appointed. And my 24 concerns were from a forensic point of view and that 25 neither -- I saw issues in terms of their forensic


1 attitude, if you will, their forensic perspective and 2 because of those concerns, I decided not to appoint 3 either of them. 4 Basically, I -- and I had said this 5 before, and I'm -- I'm just looking up at the top and Dr. 6 Taylor's name is up there, so at this time, Dr. Taylor is 7 at the Hospital for Sick Children, and my preference in - 8 - would be to have, when it came to criminally suspicious 9 deaths and homicides, that either Dr. Smith or Dr. Taylor 10 would be responsible for those types of -- of cases. 11 MS. LINDA ROTHSTEIN: And indeed, was 12 that the regime that continued from -- during the period 13 of your tenure as the Chief Forensic Pathologist that Dr. 14 Taylor and Dr. Smith were the ones that you had 15 identified as being appropriate for the criminally 16 suspicious and homicide cases, and only them? 17 DR. DAVID CHIASSON: Certainly that was 18 in -- in '97 -- the following year, I think I actually 19 formally pushed for that triage system where -- where, in 20 fact, those two (2) pathologists would be doing the 21 criminally suspicious deaths. 22 MS. LINDA ROTHSTEIN: And then just to 23 help -- 24 COMMISSIONER STEPHEN GOUDGE: Did you 25 describe your concern about Drs. Cutz and Wilson as being


1 about their experience? You used the phrase, "their 2 attitude about forensics". 3 DR. DAVID CHIASSON: Well, it -- 4 COMMISSIONER STEPHEN GOUDGE: Is that 5 really that they hadn't done many cases that would go to 6 court or was it something other than that? I was not 7 quite sure what you meant by that. 8 DR. DAVID CHIASSON: The -- the number of 9 cases they had performed and gone to -- to court were 10 small and in fact, you know, from an adult perspective 11 they were small. 12 From a pediatric pathology perspective, 13 they were not insignificant, and -- and it wasn't simply 14 the number of -- of cases as -- as much as my perception 15 that when it came to cases they -- they weren't really as 16 apprised at looking at injuries and the potential 17 significance of -- of injuries as, was my view of, Dr. 18 Smith, who was clearly interested in pediatric forensic 19 pathology and -- and, you know, whose focus was in that - 20 - that area. 21 COMMISSIONER STEPHEN GOUDGE: Thanks. 22 23 CONTINUED BY MS. LINDA ROTHSTEIN: 24 MS. LINDA ROTHSTEIN: And then just to 25 help the Commissioner with the -- the department; it was


1 -- it was a department comprised of other staff 2 pathologists who were working largely in the surgical 3 area, is that fair? 4 DR. DAVID CHIASSON: On that list of 5 staff pathologists there's Venita Jay, who is a 6 neuropathologist. Dr. Phillips, cer -- was the former 7 head of the department and -- and I think was still doing 8 surgical pathology at this point. Dr. Silver was doing 9 some medicolegal but mostly surgical pathology, and Dr. 10 Thorner was a surgical pathologist. 11 MS. LINDA ROTHSTEIN: And it was headed 12 up by Dr. Becker who was a surgical pathologist? 13 DR. DAVID CHIASSON: He was a 14 neuropathologist. 15 MS. LINDA ROTHSTEIN: Okay. I should 16 have known that. 17 So -- so tell us, Dr. Chiasson, you 18 arrived, there's a -- there is an agreement in writing 19 between the OPFPU and the OCCO, -- 20 DR. DAVID CHIASSON: Mm-hm. 21 MS. LINDA ROTHSTEIN: -- did you ever 22 have occasion to see that? 23 DR. DAVID CHIASSON: I -- I suspect at 24 some point, I saw a copy of the agreement, but I don't 25 recall when.


1 MS. LINDA ROTHSTEIN: What was your 2 understanding of the arrangement, the relationship? 3 DR. DAVID CHIASSON: It wasn't clear to 4 me, at least, in terms of what my relationship was with 5 the unit. I thought my role in the province, as I've 6 indicated earlier, as being one (1) of general 7 supervision of all the post-mortem examinations, if you 8 will. 9 The roles in terms of the units was -- was 10 not in -- clear and it -- it was unclear as to any of the 11 units -- the Ottawa or Hamilton Unit, and -- and the 12 Sick Kids Unit -- certainly nothing defined in the 13 contracts, as I -- as I understood them. 14 And, you know, accountability seemed to be 15 to the Chief Coroner, as I understood it, at least in the 16 documentation, as opposed to a Chief Forensic 17 Pathologist, so I'm unclear is I think the best way to 18 phrase it. 19 MS. LINDA ROTHSTEIN: Did you understand 20 that you, as the Chief Forensic Pathologist, was 21 exclusively responsible for the oversight and supervision 22 of that unit? 23 DR. DAVID CHIASSON: No, clearly I -- I 24 didn't see that as my exclusive responsibility. 25 MS. LINDA ROTHSTEIN: No. No, no, I


1 guess I put it badly, so my -- error in my question. Did 2 you see either the Chief Forensic Pathologist or the OCCO 3 as being the body that had the exclusive oversight role 4 of that unit; in other words, that there was no other 5 oversight to be performed by the hospital itself or the 6 Director of that unit? 7 DR. DAVID CHIASSON: Well, clearly the 8 work of the Pediatric Forensic Pathology Unit was -- was 9 entirely -- we were -- the coroner's office was the only 10 client to the PFPU and -- and I -- I accepted that the 11 coroner's office was the one that had oversight as far as 12 the -- the product, if you will; the -- the autopsy 13 reports and the work done by the -- the unit; recognizing 14 at the same time that Dr. Smith and all the other 15 pathologists were employees of the hospital. 16 And one would expect the hospital had some 17 general oversight responsibilities, but as far as the 18 activities of the unit, I -- I think -- you know, it was 19 my impression that the coroner's office had a -- had the 20 primary responsibility. 21 MS. LINDA ROTHSTEIN: Okay. So, if I put 22 it in layperson's terms, did you see yourself as 23 responsible for the supervision of the OPFPU; the work of 24 the OPFPU, and that of Dr. Smith? 25 DR. DAVID CHIASSON: Well, when I


1 answered your previous question, I mean, I said the 2 coroner's office, and I mean I -- I accept -- and I, as 3 part of the coroner's office and I, as the Chief Forensic 4 Pathologist, would certainly play a big role in that, 5 but, you know, as I've indicated, it's -- it's -- the 6 relationship between the Chief Forensic Pathologist and 7 the unit was -- was not defined in my -- in my mind. 8 I obviously had an important role to play 9 in -- in oversight, but I didn't see it as my primary -- 10 or my -- sorry, I being the only one responsible. I mean 11 I was responsible as part of the coroner's office 12 hierarchy. 13 MS. LINDA ROTHSTEIN: So, if I put it 14 this way, did you see the OCCO as having primary 15 responsibility for the supervision of the work of the 16 OPFPU, including that of Dr. Charles Smith, the answer 17 is...? 18 DR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: And what was your 20 opinion in April 1994 when you assumed the position of 21 Dr. Smith and his work? 22 DR. DAVID CHIASSON: Well, I -- I knew 23 Dr. Smith from -- from my days in training. I recognized 24 him as being a pediatric pathologist who had a 25 specialized interest in forensic -- forensic work and had


1 been doing it; that was intimately involved in -- in the 2 Paediatric Death Review Committee; had an ongoing 3 interaction with the coroner's office; and was doing a 4 large proportion of the cases, including a majority of 5 the homicides and criminally suspicious death cases. 6 That's what I came into in '94. 7 MS. LINDA ROTHSTEIN: All right. 8 COMMISSIONER STEPHEN GOUDGE: Can I just 9 ask a couple of questions, Ms. Rothstein? Did you think 10 -- was the organizational sense of responsibility back 11 then, Dr. Chiasson, that Dr. Smith had any quality 12 assurance role for the other staff pathologists in the 13 OPFPU at Sick Kids or was it a purely administrative 14 position, from your perspective? 15 DR. DAVID CHIASSON: Well, again, I -- 16 when I looked at the forensic pathology units outside of 17 Toronto, and -- and this was broached with the directors; 18 not immediately -- it wasn't first thing I did, but 19 certainly with a couple of years -- was that the 20 directors were to assume a quality control oversight of 21 their unit. 22 And that wasn't happening. And it wasn't 23 -- from what I could gather, I don't think it was 24 happening at Sick Kids at that time and it wasn't 25 happening in -- in Hamilton and it wasn't happening in


1 Ottawa. It wasn't happening anywhere, so Sick Kids 2 wasn't outside of that. 3 But I saw that the Director -- if you're 4 going to be director you should be directing, and part of 5 directing is to make sure that the -- that the product, 6 the PM reports and the work done within your unit is -- 7 is appropriate. 8 COMMISSIONER STEPHEN GOUDGE: Okay, you 9 may want to -- you may be coming back to this? 10 MS. LINDA ROTHSTEIN: I will -- I will, 11 indeed. 12 COMMISSIONER STEPHEN GOUDGE: Let me just 13 ask an unrelated question, Dr. Chiasson. In terms of 14 time spent, there were, what, four (4) of the department 15 at Sick Kids who were staff pathologists at the OPFPU? 16 Is that right? Including, Dr. Smith? 17 DR. DAVID CHIASSON: Sorry, at which time 18 period are we referring to, Commissioner? 19 COMMISSIONER STEPHEN GOUDGE: '94/'95. 20 DR. DAVID CHIASSON: Well, '94/'95, I 21 think -- 22 COMMISSIONER STEPHEN GOUDGE: '96, sorry. 23 MS. LINDA ROTHSTEIN: By '96 on this 24 letterhead. 25 COMMISSIONER STEPHEN GOUDGE: Yes.


1 DR. DAVID CHIASSON: Well, by '96 it 2 looks to be five (5): Dr. Wilson, Taylor, Smith, Silver 3 and Cutz. 4 COMMISSIONER STEPHEN GOUDGE: And Cutz? 5 DR. DAVID CHIASSON: Cutz. 6 COMMISSIONER STEPHEN GOUDGE: Yes. And 7 how much of their time would you have thought they would 8 spend doing work under warrant as opposed to surgical 9 pathology? I mean, is there normative numbers? Is sort 10 of half time? 11 DR. DAVID CHIASSON: Well, Dr. Smith, I 12 think -- again, I don't know how he split his time, but 13 in terms of coverage and looking at autopsy numbers that 14 were actually done by various pathologists -- I mean, you 15 could argue Dr. Smith was, at least, half time. 16 COMMISSIONER STEPHEN GOUDGE: He was 17 doing half the work under warrant? 18 DR. DAVID CHIASSON: Some years, half, 19 some years, a third. 20 COMMISSIONER STEPHEN GOUDGE: But was the 21 half under warrant, half of his time? 22 DR. DAVID CHIASSON: That -- well, I 23 don't think so. I think he -- I mean, he -- he had other 24 responsibilities, certainly. I don't know what -- 25 COMMISSIONER STEPHEN GOUDGE: You mean


1 at -- 2 DR. DAVID CHIASSON: -- I don't know how 3 he would have divided; I -- I had no way of knowing that. 4 COMMISSIONER STEPHEN GOUDGE: Yes, just 5 doing your raw numbers of two fifty (250) to three 6 hundred (300) autopsies a year, half of one twenty (120) 7 is sixty (60), so it's not much of his time. 8 DR. DAVID CHIASSON: Yes, but okay, you - 9 - you bring up a very important point and this is -- I'm 10 now, basically -- my responsibilities are -- are 11 pediatric forensic pathology. I'm doing -- I'll probably 12 do about fifty (50) -- fifty (50), fifty-five (55), sixty 13 (60) cases this year. 14 I consider that to be a full caseload for 15 a pediatric -- and I emphasize -- 16 COMMISSIONER STEPHEN GOUDGE: Yes, right. 17 DR. DAVID CHIASSON: -- pediatric 18 forensic pathologist. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. DAVID CHIASSON: I mean, working in 21 that academic environment, because of the extent of the 22 work, the work itself, and as well as the offshoots of 23 the work -- 24 COMMISSIONER STEPHEN GOUDGE: Okay. 25 DR. DAVID CHIASSON: -- presentations,


1 you know, meetings, case conferences, that sort of -- 2 COMMISSIONER STEPHEN GOUDGE: So, at half 3 the cases under warrant, if they were the more difficult 4 half, Dr. Smith might well have been full time at this. 5 DR. DAVID CHIASSON: I think there's a -- 6 yeah, I mean, if you look at what I'm doing; I mean -- 7 COMMISSIONER STEPHEN GOUDGE: Yes. 8 DR. DAVID CHIASSON: -- I basically 9 assumed this position. I'm -- I feel I'm doing a full- 10 time job, although it's not the only thing I -- I do -- 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. DAVID CHIASSON: -- but, certainly, 13 within the context of the -- the 9:00 to 5:00 stuff, 14 yeah, I think he was doing a full-time job while he was 15 at the Unit. 16 COMMISSIONER STEPHEN GOUDGE: As the 17 Director and -- 18 DR. DAVID CHIASSON: As the Director, and 19 looking at the number of PM reports -- 20 COMMISSIONER STEPHEN GOUDGE: -- doing 21 the cases under warrant? 22 DR. DAVID CHIASSON: I would have no 23 problem accepting that that -- what that would say -- 24 COMMISSIONER STEPHEN GOUDGE: Okay, 25 thanks. Thanks, Ms. Rothstein.


1 2 CONTINUED BY MS. LINDA ROTHSTEIN: 3 MS. LINDA ROTHSTEIN: Right. But just to 4 be clear, Dr. Chiasson, you're not saying he was actually 5 only doing coroner's cases as part of his caseload. 6 You're saying that, given the number of cases that we 7 understand him to have been doing that were medicolegal, 8 that would constitute a full-time job? 9 Is that what I hear you to be saying? 10 DR. DAVID CHIASSON: Well -- well, 11 certainly, in -- in 2007 dollars -- and I don't know that 12 -- I don't think it's changed that much, so I mean, even 13 back ten (10) years ago, it may not have been as much as 14 we're doing now. But, certainly, in some years, as I -- 15 as I recall the numbers, we're talking seventy (70) 16 cases. 17 So that's -- you know, we're pretty well 18 close to a full-time job. 19 MS. LINDA ROTHSTEIN: All right. And 20 just one (1) other technical point: When we talk about 21 "pathologists of the department," we're talking about 22 Doctors Cutz and Wilson and so on being staff 23 pathologists, not of the OPFPU, but, in fact, of the 24 Department of Pathology. 25 Is that right?


1 DR. DAVID CHIASSON: Yeah, I mean I think 2 they were all considered -- you know, they're staff 3 pathologists; that's the way they're listed there. The 4 OPFPU I don't think had their own letterhead or anything 5 like that. And the only one that I think had the formal 6 designation, was Dr. Smith as the director. 7 I -- and -- and this could have 8 theoretically been a changing, you know, case load. If a 9 pathologist decided, okay, I want to do some cases, you 10 know, and people come on. So there was nothing -- not 11 like formalized, you know, positions within the unit, it 12 was just part of their responsibilities. 13 MS. LINDA ROTHSTEIN: All right, Dr. 14 Chiasson, I want to go back to your answer to my question 15 about your opinion about Dr. Smith, and be a bit more 16 specific with you. You've certainly told me what you 17 knew about him when you began working as the Chief 18 Forensic Pathologist, but in the first years of your 19 tenure, say till '97 or so, what was your opinion of his 20 expertise in pediatric pathology? 21 DR. DAVID CHIASSON: In pediatric 22 pathology? 23 MS. LINDA ROTHSTEIN: Mm-hm. 24 DR. DAVID CHIASSON: Well, I had no 25 reason to have anything but a very high opinion. The


1 Hospital for Sick Children is a -- to use an overused 2 term, a world class institution, and you know, as -- as a 3 - all the medical departments. I mean this is a -- this 4 is a major teaching hospital within the -- the city, and 5 he's a full fledged staff pathologist. And -- 6 MS. LINDA ROTHSTEIN: And -- 7 DR. DAVID CHIASSON: -- I had no -- I had 8 no reason to doubt his competency or his abilities as a 9 pediatric pathologist. 10 MS. LINDA ROTHSTEIN: And what was your 11 opinion of his expertise as a pediatric pathologist in 12 pediatric cases? Because I -- I am assuming that in 13 adult cases you wouldn't have recognized any particular 14 expertise that he possessed. 15 Is that fair? 16 DR. DAVID CHIASSON: That's fair. 17 MS. LINDA ROTHSTEIN: All right. So, 18 tell us what your opinion was in those years, of his 19 expertise in forensic pathology in pediatric cases? 20 DR. DAVID CHIASSON: Well, I knew he 21 wasn't -- he didn't formal forensic pathology 22 certification, and I didn't think he had any formal 23 forensic pathology education, but he had been working at 24 the unit and had obviously developed this area of sub- 25 speciality interest within forensic pathology.


1 He had been doing a large number of cases, 2 had been going to court and testifying in a large number 3 of cases. Reading the newspapers is was quite clear that 4 this was somebody that -- that was developing a -- a very 5 positive at that time, reputation in -- in pediatric 6 forensic pathology. 7 MS. LINDA ROTHSTEIN: What was he like? 8 DR. DAVID CHIASSON: Well, I -- I talked 9 to a little bit about what he was alike when I was a -- a 10 resident, and -- and that personal -- I mean personality, 11 I guess doesn't -- for most people doesn't change over 12 time. 13 He was very approachable, very relaxed 14 demeanour, and always happy to engage in pathologic 15 discussions about a -- about a case; certainly would be 16 willing to provide, you know, opinions and comments. 17 MS. LINDA ROTHSTEIN: What was his level 18 of confidence? 19 DR. DAVID CHIASSON: It -- well he seemed 20 confident. He seemed self confident. 21 MS. LINDA ROTHSTEIN: Was he humble, was 22 he arrogant, was he neither? 23 24 (BRIEF PAUSE) 25


1 DR. DAVID CHIASSON: That's -- that's a 2 difficult question to answer. You know, at one level he 3 seemed quite humble. At another level, you know, it's -- 4 certainly there was a self confidence there. I -- I 5 wouldn't term it arrogance. I think that's a little too 6 strong -- strong a term. 7 But he certainly -- it wasn't a hun -- it 8 wasn't all humble. You got the sense that there was 9 perhaps an increased degree of confidence, self 10 confidence, but really a very difficult question to -- to 11 answer. 12 MS. LINDA ROTHSTEIN: Okay, fair. What 13 was your observation and understanding of the nature -- 14 closeness of his relationship with Dr. Cairns? 15 DR. DAVID CHIASSON: My sense was he had 16 a very close working, professional relationship with Dr. 17 Cairns. 18 MS. LINDA ROTHSTEIN: Okay. Dr. Cairns, 19 as you know, described him to the Commissioner -- or you 20 may know, as an icon. 21 Is that how you viewed him? 22 DR. DAVID CHIASSON: No, I don't think I 23 viewed him as an icon. And -- and that's in part that I 24 -- I knew him when he was a junior staff pathologist. 25 And so, no, I don't think I viewed him as


1 -- as an icon. I mean, I saw him very much a human. He 2 had developed this -- this area of expertise; at the same 3 time as a forensic pathologist I knew he wasn't formally 4 trained and certified there. 5 You know, so I -- I could find, if you 6 will, chinks in the -- in the image that may have been 7 projected onto other people. So I -- I don't think I 8 ever considered him to be an icon. 9 MS. LINDA ROTHSTEIN: What about his 10 relationship with Dr. Young, what was your sense of that? 11 DR. DAVID CHIASSON: My sense is that he 12 had a, again, a close working relationship, direct 13 working relationship with Dr. Young and that -- that 14 preceded my coming onboard. It was obvious that Dr. 15 Young had a lot to do with the -- the start of the unit 16 which I maintain was really very forward thinking on the 17 part of Dr. Young and Dr. Phillips to actually develop a 18 pediatric forensic pathology unit. 19 And so that had developed and I -- I think 20 that there was a close relationship, certainly working 21 relationship between Dr. Young and Dr. Smith. 22 MS. LINDA ROTHSTEIN: Did it make sense 23 to you, Dr. Chiasson -- I mean, I'm going to -- I'm going 24 to assume something here in this question -- that Dr. 25 Smith take the lead on pediatric forensic issues? I


1 mean, as opposed to you. He was on the PDRC, you were 2 not; at least not in the early years. 3 We've heard evidence that he was involved 4 in the drafting of Memorandum 631. Were you involved in 5 that in any significant way? 6 DR. DAVID CHIASSON: No. 7 MS. LINDA ROTHSTEIN: All right. So fair 8 to conclude from that, sir, that he was the lead on 9 pediatric forensic issues for the Coroner's Office? 10 DR. DAVID CHIASSON: Yes. Just to 11 clarify, I did go to some early pediatric death review 12 meetings and decided after attending a few of them that, 13 you know, I'm trying to juggle a lot of balls here, this 14 was not a ball that I needed to juggle. And -- and I 15 think it's a quite fair perception -- in my mind I'm 16 trying to move forward, you know, on a number of 17 different fronts within forensic pathology. 18 And certainly until '97, I felt pediatric 19 forensic pathology I had Dr. Smith there and, you know, a 20 lot of it he was working directly with Jim Cairns, I had 21 no -- no problem with that because I had lots of other 22 stuff to do. I was focussing on the adult stuff. 23 I think that's a fair perception of what 24 was going on. 25 MS. LINDA ROTHSTEIN: Okay. So if we


1 turn then to some of the documents we have that help us 2 explore the relationship between the Coroner's Office, 3 your initiatives, and the OPFPU, the first one that I'd 4 like you to turn to is Tab 65. 5 It's, I understand, notes of a meeting 6 that you wrote, Dr. Chiasson? It's 134495. 7 DR. DAVID CHIASSON: Yes, that's correct. 8 MS. LINDA ROTHSTEIN: All right. These 9 are, as best we can tell from the database, the first 10 handwritten notes which record a meeting between you and 11 Dr. Cairns on the one hand and Dr. Becker on the other to 12 talk about the relationship between the OCCO and the 13 OPFPU. 14 Is that likely right? 15 DR. DAVID CHIASSON: That's correct, yes. 16 MS. LINDA ROTHSTEIN: All right. And so 17 without getting you to -- to frankly read them all to us, 18 can you describe for us sort of, what the state of play 19 was as between the OPFPU on the one hand and the OCCO on 20 the other as of the summer of '94? 21 DR. DAVID CHIASSON: Well, just to set a 22 little bit of context, Dr. Becker, I think was the -- had 23 just been newly appointed as the Chief of -- Pathologist 24 and Chief of the Hospital for Sick Children, and I'm the 25 newly appointed Chief Forensic Pathologist and so we --


1 we had this meeting to talk about the Unit. And if you 2 just look at the first part of the memo, I try to 3 highlight what Dr. Becker's, sort of, priority vision of 4 the Unit, and you can see number 1 being "academic" and 5 more administrative issues. But "academic" is number 1 6 there. 7 The Unit, if you go back to the history -- 8 and I -- actually I think I just learned this relatively 9 recently from looking at some documents, it seems to have 10 been developed as a -- a venue or a unit that would look 11 at sudden infant deaths. And I think it was very much 12 driven from an academic point of view. The -- the Sudden 13 Infant Death Syndrome was and remains a mystery and is a 14 -- an area of great interest to pediatric pathologists, 15 not forensic pathology, per se, but pediatric 16 pathologists. 17 And the Hospital for Sick Children's, and 18 especially Dr. Becker and Dr. Cutz, both had major 19 research interest in this area, and I think they saw the 20 unit as some way of -- of formalizing, you know, the 21 investigation and from a -- an academic point of view, 22 and so I think this is Dr. Becker's coming back to this 23 area. 24 If you -- and -- and there was this 25 tension, should we say, because my primary area of focus


1 was one (1) of service, that the unit was there to 2 provide high quality pediatric forensic pathology to the 3 Coroner's Office, and I saw that as its raison d'ete and 4 not an academic. 5 I -- I appreciate it that there was a lot 6 to be learned and a lot of academic value and in terms of 7 having the -- the unit, but that wasn't the primary 8 focus, so there was this, if you will, tension. 9 Dr. Becker was a neuropathologist; he did 10 do, I think as -- as we're all aware, neuropathology in 11 forensic cases, but I don't think he conceived himself as 12 a forensic pathologist in any way, shape, or form. 13 So that's kind of the setting and we're 14 having a discussion, and he does have administrative 15 concerns at this point about Dr. Smith and his backlog. 16 And there's issues about how to try to -- to improve 17 that, and then we, sort of, talked about sort of 18 motherhood issues, about communication, et cetera. 19 MS. LINDA ROTHSTEIN: All right. And 20 but what -- what's the problem of communication between 21 members of the department performing medicolegals and the 22 coroner's office -- all directed through CS, Charles 23 Smith I assume -- would want more direct contact, what - 24 - what was the problem there? 25 DR. DAVID CHIASSON: It's been a long


1 time, and I'm not sure I -- I can fully answer your 2 question. The perception, I think, is that the other 3 pathologists may have had some issue with doing 4 everything through Dr. Smith. 5 And, you know, I guess as his role as 6 Director, we -- Dr. Smith was, even though he had been 7 there for a number of years now, Dr. Cutz, Dr. Silver 8 were -- were senior colleagues. Dr. Wilson is about the 9 same -- the same time period as Dr. Smith, but he -- he's 10 dealing with -- it's not like he has a bunch of junior 11 staff to deal with. He's dealing with senior people, all 12 of whom are full -- for -- sorry, full professors, you 13 know, so they're higher up in the academic ladder. So I 14 -- I don't know whether there was some difficulty from 15 that point of view. 16 We did eventually meet with the 17 pathologists there. Dr. Young and I did meet with them 18 to kind of air out their sort of issues on a -- on a one- 19 to-one basis, rather than everything through Dr. Smith. 20 MS. LINDA ROTHSTEIN: Well, the other 21 comment that you make at the bottom of the next page is: 22 "That it's obvious there is an 23 interdepartmental communication 24 problem, as well as an extra- 25 departmental ones."


1 Dealing with the first one (1), the 2 interdepartmental communication problem; to your 3 knowledge did that ever improve or does that statement 4 foreshadow an ongoing issue for that unit? 5 DR. DAVID CHIASSON: Sorry, back -- back 6 then, I mean, having worked there, my sense of -- of the 7 -- the department, there were -- there were always 8 ongoing interdepartmental communication issues; that -- 9 that's kind of like residents or -- 10 MS. LINDA ROTHSTEIN: Which means what? 11 DR. DAVID CHIASSON: That there tended to 12 be not a lot of direct talking to each other of the 13 pathologists. There were a lot of -- despite being a 14 relatively small department, there seemed to be a lot of 15 separate solitudes within the department; not to say that 16 everybody was completely an island, but that may exist in 17 a lot of departments to one (1) extent or another, but it 18 seemed to be a little bit more blatant there, so it 19 seemed to be a problem in the 1990s. 20 MS. LINDA ROTHSTEIN: Okay. And then the 21 other thing you say is that as well as an extra- 22 departmental one, what did you mean by that? That there 23 was a problem for the OCCO in getting the right level of 24 communication going with that unit? 25 Is that what you indicated?


1 You're nodding but you're not answering my 2 question, Dr. Chiasson. 3 DR. DAVID CHIASSON: I'm nodding and 4 thinking. That's just what I'm doing. 5 MS. LINDA ROTHSTEIN: Okay. 6 DR. DAVID CHIASSON: Well, I mean, if you 7 look at the -- the next line, it discussed the 8 possibility of monthly forensic pathology working 9 meetings. 10 Yeah, I think there was a sense that the 11 unit was kind of working a little bit in isolation, and I 12 thought that we -- we needed more -- there wasn't before 13 certainly, no interaction between the Chief Forensic 14 Pathologist and the unit, none at all. 15 So I -- I wanted to see a little more 16 direct communication between myself and the -- and the 17 unit. So we're talking about working meetings, proved 18 communications. 19 MS. LINDA ROTHSTEIN: All right. And, 20 Commissioner, you'll see in the next tabs, these are 21 actually in order. There's some continued correspondence 22 which flows out of that. I'm -- I don't propose to take 23 Dr. Chiasson to that. I think most of it is -- is fairly 24 self-evident. 25 But if you would turn then next to Tab 71,


1 there's a note there about -- to you actually from Dr. 2 Smith -- at 056425 and at this stage, we're in January of 3 '95; a discussion about monthly pediatric forensic 4 rounds. 5 So my question for you, Dr. Chiasson, is 6 was that a routine that developed between you and the OPP 7 -- OPFPU whereby you attended monthly pediatric rounds, 8 forensic rounds? 9 DR. DAVID CHIASSON: Yes. So -- so the 10 rounds were started, and I tried to attend them as best 11 that I could. I think I attended a number of them over 12 the next year or so. 13 MS. LINDA ROTHSTEIN: Okay. So help us 14 with that because it comes up in other correspondence and 15 documents we'll see. 16 To what extent is a case reviewed -- was a 17 case reviewed in the course of one of those rounds? Give 18 us a flavour for that. How much did you learn about the 19 diagnosis and the -- the evidence that supported that 20 diagnosis in one of those discussions at rounds? 21 DR. DAVID CHIASSON: Well, it was very 22 much directed by the person presenting the case; the 23 pathologist presenting the case as to how much it would 24 be discussed. You can see that, in fact, if you look at 25 these. There were -- there was a large number of cases


1 that were being reviewed. 2 So these were not detailed reviews. We 3 were trying to review most of the forensic -- most of the 4 coroner's cases; many of which would have been fairly 5 straightforward. But in -- included, in there, would be 6 these more complicated cases. 7 And they would get some more time but it 8 really depended on how much the pathologist, sort of, 9 what he did in terms of presenting the case and then how 10 much he might have sought some -- some input. 11 So it was driven by the presenter -- 12 presenting pathologist, if you will. 13 MS. LINDA ROTHSTEIN: Okay. 14 COMMISSIONER STEPHEN GOUDGE: Who -- who 15 went to the rounds? Anybody beyond the members of the 16 unit; that is did other members of the department go? 17 DR. DAVID CHIASSON: Well, even to this 18 day -- the forensic rounds tended to be the people doing 19 forensic pathology cases. The pathologist's assistants 20 would -- would attend. Any residents would attend -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID CHIASSON: -- and then I was 23 attending from -- from the coroner's office and sometimes 24 Dr. Cairns. 25 COMMISSIONER STEPHEN GOUDGE: Other staff


1 pathologists wouldn't attend? The ones that were only -- 2 DR. DAVID CHIASSON: No, no. I mean, you 3 know, people had their own areas of interest. For most 4 of them, they -- they st -- stuck to what they -- . The 5 -- the one thing you learn about Sick Kids is that it's a 6 place where there's -- you get rounded to death. 7 I mean, there's lots of rounds going on as 8 a pathologist or as a medical person. So you had to 9 restrict yourself or you'd spend -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. DAVID CHIASSON: -- the whole day in 12 meetings and not get anything done. 13 14 CONTINUED BY MS. LINDA ROTHSTEIN: 15 MS. LINDA ROTHSTEIN: Okay. One of the 16 other things that actually comes up because of the form 17 of reports that get used to record autopsy findings at 18 Sick Kids is this bit of a conflict that we can see in 19 some of the documents you may recall between Dr. Becker 20 and Dr. Smith and others about the form of autopsy 21 reports. 22 And because the Commissioner will know 23 from reading the overview reports that sometimes what we 24 see from Dr. Smith is a post-mortem report which we all 25 recognize. Sometimes we see an autopsy report which is a


1 hospital form. Sometimes we see a final autopsy report. 2 Can you help us shed light on what that -- 3 what those differences were, and what the debates were 4 about that? 5 DR. DAVID CHIASSON: Well, I think you -- 6 if you go back to the autopsies -- there's two (2) kinds 7 of autopsies that are performed at the Hospital for Sick 8 Children. There were the coroner's cases, and there were 9 the hospital cases, performed under next-of-kin consent. 10 And for the hospital cases, the -- the 11 procedure -- to protocol was to do the autopsy, issue a 12 provisional report to the clinician that ordered -- or 13 was responsible for the patient, so they have some sense 14 early on of what the findings are based on the gross 15 examination of the autopsy -- so no microscopic findings. 16 Ideally that should go out within forty- 17 eight/seventy-two (48/72) hours, something of that 18 nature. And then eventually, the case would be finalized 19 and they would produce what was called a final autopsy 20 report. 21 And this would be a -- basically an 22 outline or a summary of the findings, clinical history, 23 and then a clinical pathologic correlation; so an opinion 24 as to how the pathology findings relate to the clinical 25 history of the decedent.


1 So that's a hospital autopsy report, and 2 that's what -- what is used. 3 The coroner's cases would get sort of this 4 -- the coroner's office had a prescribed coroner's office 5 form, that autopsies -- back in the '80's -- you were 6 supposed to fill out this -- this particular form. 7 With advances in -- in digital word 8 processing, et cetera, people modified it sometimes to 9 varying degrees. But at least, it gave some sense of 10 what was expected of the pathologist doing a coroner's 11 case. 12 And frankly, I mean, it wasn't to the 13 degree that the pediatric pathologist would normally do 14 the autopsy. I mean, they tend to be much more detailed 15 then what might be mandated by a coroner's form; which 16 the form was for all cases, including adults as well as 17 pediatrics. 18 So -- but -- so they would fill out this - 19 - this form -- complete this form. And that's the report 20 of post-mortem examination. At the same time, however, 21 and for reasons that I'm not quite clear, but are 22 probably administrative, they would, at the same time, 23 still put out this final autopsy report format. 24 And in that case, a lot of it was cut and 25 paste from the -- it depended upon the pathologist, but a


1 lot of it could be cut and paste from the coroner's 2 report into the final autopsy report. 3 However, some pathologists would not -- 4 would include history in the final autopsy report -- the 5 Sick Kids form, if you will -- but wouldn't include it in 6 the report of post-mortem examination. 7 MS. LINDA ROTHSTEIN: Fair to say Dr. 8 Smith often fell into that category? 9 DR. DAVID CHIASSON: Exactly. Now part 10 of the use of this history information would have been to 11 provide the neuropathologist for information when he's 12 cutting the brain. 13 So there was a reason to do it and 14 document it that was, kind of, extra-curricular in some 15 ways, I guess, for the brain cutting. So that's why it 16 was done. But instead of having two (2) same reports, 17 they would -- the reports do look different -- history 18 and -- and sometimes, comment. 19 Usually the comments would be the same. 20 Cause of death, usually the same. But the big thing was 21 that there would be history in the Sick Kids format and 22 not in the coroner's office. 23 MS. LINDA ROTHSTEIN: Well, help us with 24 that. What's your understanding what the rationale for 25 that would have been? You were asking for histories in


1 your post-mortems, you've told us. 2 DR. DAVID CHIASSON: Yes. Well, the 3 rationale for not putting the history in the coroner's 4 report? Well, as -- as been suggested, I mean, the 5 incorporation of history and particularly of opinions 6 into reports of post-mortem examination, there are 7 variations in practice, and there was across the 8 province. 9 And again, Dr. Smith wasn't the only one 10 (1) that would not include a history in his report of 11 post-mortem examination. There are some that thought, 12 Well, the information would somehow bias -- bias the 13 reader. I -- I -- that's probably not the -- the best 14 way to -- to term that. 15 The information wasn't really necessary. 16 I mean, the pathologist was there to provide pathologic 17 diagnosis. We're in the coroner's system. It's the 18 coroner's job to sort of sort out the history, which they 19 would provide -- they would have and -- and, you know, 20 render their ultimate determinations of cause and manner 21 of death. 22 I -- I'm speculating. I -- I -- and there 23 was nothing in the form. I mean, if you look at the 24 coroner's form, it had "Summary of Abnormal Findings" and 25 pathologists would look at this and say, Well, all they


1 want is the abnormal findings, nobody's asking for 2 history. And to be fair to these pathologists, it wasn't 3 being specifically asked for in -- in the format. 4 So they were kind of sticking to the form 5 and -- and there was this sense that, well, you couldn't 6 do anything, you know, the form was prescribed by 7 legislation and you couldn't mess with the form and you 8 had to follow it to the 'T'. 9 MS. LINDA ROTHSTEIN: You're now -- 10 you're now giving us sort of a sense of the reaction you 11 got when you tried to ask some of the pathologists to 12 provide you with longer, more detailed reports that 13 included history among other things. 14 Is that what you're telling us? 15 DR. DAVID CHIASSON: Yes. There was -- 16 you know, that -- that was the arguments for not doing 17 it. And I -- I spent a lot of time in education courses 18 trying to convey, Listen, we want some history in these 19 cases. And up until very recently, even senior 20 pathologists -- board certified senior pathologists 21 weren't providing me with -- with history. 22 MS. LINDA ROTHSTEIN: Okay. So, 23 Commissioner, I think we're at time for the lunch, and 24 we'll try and move forward with a little more expedition 25 aft -- thereafter.


1 COMMISSIONER STEPHEN GOUDGE: Okay. Two 2 o'clock. 3 MS. LINDA ROTHSTEIN: Thank you. 4 5 --- Upon recessing at 12:46 p.m. 6 --- Upon resuming at 2:01 p.m. 7 8 THE REGISTRAR: All rise. Please be 9 seated. 10 COMMISSIONER STEPHEN GOUDGE: Ms. 11 Rothstein. 12 13 CONTINUED BY MS. LINDA ROTHSTEIN: 14 MS. LINDA ROTHSTEIN: Before the break, 15 Dr. Chiasson, you and I were talking about the 16 relationship between the OCCO and the OFPU. And we were 17 -- we were starting to talk about some of the issues that 18 saw fairly early on in that relationship and some of the 19 improvements that you were endeavouring to make. 20 I want to follow that through, but I want 21 to go back to one thing and that is Memo 631. You've 22 seen it. I've seen it. The Commissioner, I think, knows 23 it more or less by heart. 24 So the question that arises from that is 25 whether at the time you noted the language, "think


1 dirty," did you note that? 2 Did that have any particular significance 3 at the time when you read it? This goes back to '95. 4 DR. DAVID CHIASSON: Well, I read the 5 memorandum and I saw the -- I would have read the part 6 that makes reference to "think dirty." I -- I'm sure I 7 would have not thought very much of it. 8 It -- it doesn't bother -- it -- it 9 wouldn't have bothered me at that time and, I mean, I 10 think the important message that was being portrayed, as 11 I understand it, would be when you're looking at a non- 12 suspected infant death, you have to consider the 13 possibility that you may be dealing with a homicide; 14 that's -- that's always in your diagnostic possibilities. 15 And our -- our whole -- the whole memo is 16 -- is built around the notion that we're going to do the 17 things that need to be done as if that -- that is 18 potential, that that potential is -- is in fact there. 19 That's the way I would interpret that. 20 It doesn't mean you -- that you continue 21 to think dirty without the evidence to support the -- the 22 notion that something criminally suspicious is at play. 23 MS. LINDA ROTHSTEIN: And are you able to 24 assist the Commissioner with a better approach that can 25 be summarized in brief language?


1 Or are you someone who doesn't think that, 2 you know, those kinds of slogans or mottos are 3 particularly helpful? Tell us about that. 4 DR. DAVID CHIASSON: Well, I mean, I -- I 5 don't have a good alternative to -- to it and, you know, 6 I think it seems to have caused concern and distress, the 7 terminology, and therefore should be abandoned. And I 8 don't see the need for any, you know, slogan terminology. 9 MS. LINDA ROTHSTEIN: During your tenure 10 as the Chief Forensic Pathologist did it ever come to 11 your attention that any of your forensic pathologist 12 colleagues were actually being cross-examined on that 13 medo -- memo and the -- the attitude that that might have 14 conveyed? 15 DR. DAVID CHIASSON: I don't recall being 16 made aware of the problem with the memo and that 17 particular reference. 18 MS. LINDA ROTHSTEIN: Okay. All right. 19 So is it fair to summarize some of the documents that are 20 in your Volume I, Dr. Chiasson, with -- with the point 21 that there were some ongoing discussions with the 22 Hospital for Sick Children in which you and Dr. Cairns 23 were putting forward the position of the OCCO, Dr. Becker 24 and/or Dr. Smith were communicating the concerns from the 25 OPFPU's perspective?


1 DR. DAVID CHIASSON: Yes. 2 MS. LINDA ROTHSTEIN: And those 3 conversations were -- were ongoing? 4 DR. DAVID CHIASSON: Yes. 5 MS. LINDA ROTHSTEIN: And from your 6 perspective the concerns were largely three (3) in 7 number. You were concerned about who was doing the 8 forensic pathology cases at Sick Kids, yes? 9 DR. DAVID CHIASSON: Who -- who was doing 10 the criminally suspicious cases and homicide cases, yes. 11 MS. LINDA ROTHSTEIN: And as you've told 12 the Commissioner, your view at the time was that Dr. 13 Smith and Dr. Taylor ought to be doing all of those? 14 DR. DAVID CHIASSON: Yes, if at all 15 possible. 16 MS. LINDA ROTHSTEIN: You had an ongoing 17 concern, I think, is fairly reflected in the 18 documentation about the timeliness in the reports that 19 you were getting out of that unit. 20 Is that fair? 21 DR. DAVID CHIASSON: Correct. 22 MS. LINDA ROTHSTEIN: And were the 23 concerns about the timeliness of reports restricted to 24 Dr. Smith, or did they also encompass other members of 25 that unit?


1 DR. DAVID CHIASSON: I -- they -- they 2 primarily, as I recall it, related to Dr. Smith, as 3 opposed to the other pathologists, although there were 4 exceptions, where other pathologists would have reports 5 that were beyond what I thought was a reasonable length 6 of turnaround time. 7 But certainly Dr. Smith -- and in part 8 given that he was doing a -- such a significant 9 proportion of the cases, that -- he was the main concern 10 in that regards. 11 MS. LINDA ROTHSTEIN: And indeed at some 12 stage did you start to hear about that concern from 13 regional coroners, Dr. Cairns, others in the OCCO 14 community? 15 DR. DAVID CHIASSON: Yes, certainly 16 regional coroners. We had regular regional coroner 17 meetings and I was aware informally and in some cases -- 18 particularly, I recall Dr. Wilson writing memos to me 19 indicating major delays in -- in reports of Dr. Smith. 20 MS. LINDA ROTHSTEIN: And as I understand 21 it, Dr. Chiasson, you also became concerned about the 22 fact that there wasn't enough communication between Dr. 23 Smith and his unit and you and your work. 24 Is that fair? 25 DR. DAVID CHIASSON: Yes. I -- I -- in


1 this time interval, '96/'97, I'm starting to develop my 2 own forensic pathology staff, the full-time people are 3 starting to be hired. 4 And I thought it important that Dr. Smith 5 be more closely aligned with the work in the adult side 6 of things, you know, when we're dealing with forensic 7 issues as opposed to pediatric ones. He had lots of 8 support available to him from a pediatric pathology point 9 of view. 10 And given the nature to pediatric forensic 11 pathology, cases were so intensive from a pathologists 12 point of view. I mean cases, really, largely revolved 13 around pathology issue. 14 They were difficult cases, challenging 15 cases, and I wanted to build up a better rapport between 16 his unit and -- and our unit. 17 MS. LINDA ROTHSTEIN: And so that takes 18 us nicely, I think, to the next document I'd like to show 19 you, which is 117913. It's a letter that you wrote to 20 Dr. Smith on February the 17th, 1997. You'll find it at 21 Tab 14. 22 23 (BRIEF PAUSE) 24 25 MS. LINDA ROTHSTEIN: And so -- so this


1 is -- this takes place in that context, as I understand 2 it. There's a reference to triaging -- or distributing 3 the cases amongst the pathologists at Sick Kids -- a 4 reference to the expectation that Dr. Smith perform the 5 majority of the forensically complex cases, including 6 homicides and suspicious deaths with Dr. Taylor providing 7 backup. 8 And you then say: 9 "This implies that your work schedule 10 allows you the time to perform forensic 11 autopsies in a comprehensive manner, 12 generate the necessary documentation, 13 testify in court as required, and also 14 permits you to be actively involved in 15 pediatric forensic pathology 16 consultative work." 17 Stopping there for a moment, Dr. Chiasson, 18 do we read that, as suggestive of your concern, that the 19 workload demands on Dr. Smith were too great at that 20 stage? 21 DAVID CHIASSON: Yes. I mean that -- 22 that's certainly the -- the implication of -- of that. I 23 wasn't completely clear. Had the information about how 24 much service work he was doing outside of the coroner's 25 work, but I wanted to ensure that if he's going to


1 concentrate in this area, that he did have the time 2 available to do this. 3 MS. LINDA ROTHSTEIN: So speaking to the 4 issue of his workload, to what extent do you remember Dr. 5 Becker sharing with you a concern that the backlogs that 6 you were experiencing, with respect to Dr. Smith's 7 reports in particular, was also a problem on his surgical 8 cases? 9 DR. DAVID CHIASSON: In the meetings I 10 had with Dr. Becker, I don't recall any specific 11 reference to -- to problems on the pediatric side. 12 I -- and again it's -- it's hard to know 13 for sure. I don't think Dr. Becker was surprised that we 14 were having issues. And you almost got the sense that, 15 well, maybe he was having problems on the other side. 16 But it -- as I sort of recall, it was more 17 an impression rather than -- and again, nothing formally. 18 I don't document anything to that effect, and I don't 19 specifically recall that being like a -- a -- formally 20 identified issue. 21 MS. LINDA ROTHSTEIN: And at any time do 22 -- did you learn about concerns that Dr. Becker or his 23 colleagues may have had about the quality of Dr. Smith's 24 surgical pathology? 25 DR. DAVID CHIASSON: No.


1 MS. LINDA ROTHSTEIN: And to what extent, 2 if at all, would that have been relevant to you to know 3 back then in your capacity as the Chief Forensic 4 Pathologist? 5 DR. DAVID CHIASSON: Well, pediatric 6 surgical pathology, per se, is quite -- it's -- it's a 7 different art, it's a different form of work. The issues 8 are quite different than forensic pathology work. 9 I perform, I think, as a competent 10 forensic pathologist -- pediatric forensic pathologist 11 working in that unit, and I don't do any surgical 12 pathology. And neither do I feel qualified to do 13 surgical pathology. Neither do I feel disadvantaged by, 14 you know, issues in -- in the pediatric clinical side of 15 things. 16 So it -- from that point of view, I don't 17 think -- you know, looking at it specifically, I don't 18 think you need to -- to -- that the two (2) are related. 19 On the other hand, it did raise general 20 concerns as to perhaps he wasn't paying as much attention 21 to his work, because he'd certainly been doing pediatric 22 pathology for a number of years. 23 You know, is it reflective of over -- work 24 overload and a certain degree of -- of not as much 25 attention and care? And, you know, if he's not doing it


1 in -- in that sphere, you know, is the -- is the same 2 thing happening? That -- that -- that could translate 3 or, you know, relate to his functioning, his, sort of, 4 professional functioning from a -- from a forensic 5 pathology unit. 6 So it would have been of -- of interest 7 from that perspective more so than the specifics of a 8 problem in diagnostic abilities. 9 MS. LINDA ROTHSTEIN: In light of those 10 answers, or that answer, will you look at Tab 87, 137856? 11 It's a memo to Dr. Becker from Dr. Paul Thorner, dated 12 March 21, '97. 13 And just assist us, Dr. Chiasson, as to 14 whether you can offer an opinion as to the magnitude of 15 concern that these four (4) cases might demonstrate about 16 the quality of Dr. Smith's surgical pathology work. 17 DR. DAVID CHIASSON: They're -- they're 18 clearly surgical pathology type issues. The first three 19 (3) I don't see as having major clinical consequences. 20 The -- the fourth, I think, is a little different, and 21 certainly there is more clinical implication apparent in 22 that one, given the nature of the case. 23 But the specifics issues -- and I'm really 24 not the best person to address this, since I don't deal 25 with this kind of -- of work. And I think this -- this


1 is better directed to Dr. Taylor and other pediatric 2 pathologists as to the sort of surgical 3 pathology/clinical significance of these errors. 4 MS. LINDA ROTHSTEIN: Well turning to the 5 next tab then, Tab 88, 137850, a letter that may or may 6 not have been sent to Dr. Smith from Dr. Becker dated 7 April 18, 1997. 8 Without suggesting for a moment that you 9 would maintain that you ought to have been copied with 10 that letter, is the information set out in that letter 11 something that you would have thought relevant for you to 12 know in your role as the Chief Forensic Pathologist with 13 oversight responsibility for Dr. Smith and his unit? 14 DR. DAVID CHIASSON: Well first let me 15 say -- I mean, to me this is a very significant letter 16 that, you know, I've worked in pathology departments, and 17 if I was to receive such a letter, I -- I would consider 18 this to be a very serious matter, that the Chief is 19 writing and making this -- these -- these indications and 20 -- and especially issues of docking salary. 21 I mean, that's -- that's a very serious 22 degree of -- of problem here. And, yeah, I wouldn't 23 expect to be copied this, but to perhaps be given some 24 indication that yes, we're having problems with Dr. 25 Smith.


1 When I'm speaking to Dr. Becker and 2 suggesting that, you know, we're having problems on our 3 side, I think it would have -- it would have certainly 4 been of interest to me to know this, at least in a 5 general way, that -- that there were problems on the 6 clinical side. 7 COMMISSIONER STEPHEN GOUDGE: I mean the 8 timeliness problem is shared? 9 DR. DAVID CHIASSON: Well, and the 10 timeliness problem, yes, Commissioner, is -- is very much 11 shared, so -- and that, like I said, that might have 12 been alluded to in our conversations. 13 I don't specifically recall that, but 14 certainly there was at no point any allu -- allusion this 15 issue of -- of actual casework, diagnostic problems. 16 17 CONTINUED BY MS. LINDA ROTHSTEIN: 18 MS. LINDA ROTHSTEIN: Now, Dr. Chiasson, 19 I understand that indeed in this year or -- or shortly 20 thereafter you actually took the step of doing some kind 21 of a random audit of files at the OPFPU. 22 Is that right? 23 DR. DAVID CHIASSON: Yes. 24 MS. LINDA ROTHSTEIN: Can you turn it to 25 Tab 19, please, 134371?


1 Am I correct in understanding this is one 2 of the -- some of the working notes that you made in the 3 course of that audit? 4 DR. DAVID CHIASSON: Yes. 5 MS. LINDA ROTHSTEIN: And can you assist 6 the Commissioner with what the nature and process was for 7 your audit, nature of that process, please? 8 DR. DAVID CHIASSON: Well, basically I 9 looked at the -- if you go to the top it says "Twenty 10 (20) files, pediatric cases by pathologists at the -- at 11 the unit." 12 If you go down about three quarters (3/4s) 13 of the way down, it says "pathologists," and you can see 14 "CS" is Dr. Smith, "EC" is Dr. Cutz, "JW" is Dr. Wilson, 15 and a list in brackets there is whether they -- what the 16 nature of the deaths were. 17 And if you go back to "death type," which 18 is just before that, there is a focus on accidental 19 homicide, there's suicide. The S is suicide. So I'm 20 looking at the more forensic-type cases as opposed to the 21 more pediatric or medical ones. 22 MS. LINDA ROTHSTEIN: But so we're clear, 23 in this set of twenty (20) files there's actually only 24 one (1) that in the end is identified as a homicide. 25 Is that right? Is that how I read that?


1 DR. DAVID CHIASSON: That's correct, yes. 2 MS. LINDA ROTHSTEIN: All right. And it 3 -- and this audit that you did comprised not only Dr. 4 Smith's cases but also those of the other members of his 5 unit? 6 DR. DAVID CHIASSON: Yes. 7 MS. LINDA ROTHSTEIN: And in the end are 8 we correct in reading this as -- as being a conclusion 9 that you saw some minor concerns in four (4) of the 10 cases, no major concerns? 11 Is that right? 12 DR. DAVID CHIASSON: Yes. 13 MS. LINDA ROTHSTEIN: And that the minor 14 concerns comprised limited description of injuries, 15 especially external injuries not described in continuity, 16 is that? 17 DR. DAVID CHIASSON: Yes, which means 18 that, for example, you're -- you're describing a gunshot 19 wound. You -- you describe the entrance wound, the 20 external features. 21 Then you move inside, you dri -- describe 22 the wound track through whatever organ. And if there's 23 an exit wound, you describe that in -- in that kind of 24 continuity. 25 MS. LINDA ROTHSTEIN: So what was your


1 conclusion at the end of this audit? What level of 2 comfort did it give you about the quality of the post- 3 mortem reports that were being done by the OPFPU? 4 DR. DAVID CHIASSON: Well, as suggested, 5 I mean, I -- I think they were relatively minor issues. 6 Now, having said that, I mean most of these are -- are 7 non-homicidal cases. 8 And therefore, you know, if you have an 9 accidental death and you're not quite describing the 10 injuries right, they -- the down-the-road implications of 11 that are usually limited. I mean it doesn't usually end 12 up in a courtroom type of setting. 13 It did confirm my sense that there were -- 14 the -- the descriptions and -- and stuff were things that 15 we're taught as forensic pathologists that are important. 16 Now, having said that, it wasn't these 17 issues of limited descriptions of injuries -- and 18 especially external ones and -- and not described in 19 continuity -- were issues that I was having with 20 pathologists, adult pathologists, performing 21 medicolegals, as well. So they weren't restricted to the 22 Sick Kids pathologists. 23 And neither was the last one (1), no 24 correlative comment, no opinion. That, again, was 25 something that I was seeing pretty well across the -- the


1 board. 2 The biggest concern is turnaround time 3 issues where, you know, there's a range there up to eight 4 (8) plus months and the turnaround time in the four (4) 5 to five (5) month range. 6 I -- I thought that was greater than I was 7 wanting to see coming out of the unit, especially in 8 light that around this time we're starting to get 9 complaints about turnaround time. It did con -- confirm 10 that there are indeed -- these aren't isolated issues. 11 There is a trend towards extended turnaround times. 12 MS. LINDA ROTHSTEIN: So again, just to 13 summarize a little bit, Dr. Chiasson, if we can move 14 forward a little more quickly with that, by 1998, am I 15 right in reading the documents as suggesting you started 16 to take some more formal steps to try and create some 17 improvements in that unit? 18 DR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: But before we turn 20 to those, I -- I do want to touch on at least what you've 21 just raised, which is the oversight issues that you 22 confronted, apart from those that arose at Sick Kids. 23 I'm quite right, am I, Dr. Chiasson, that the Hospital 24 for Sick Children was not the only forensic unit that you 25 viewed as needing some improvement?


1 DR. DAVID CHIASSON: That's correct. 2 MS. LINDA ROTHSTEIN: And in particular, 3 am I right that you -- during this same period of time 4 were confronting some fairly significant problems in the 5 Eastern Ontario Regional Forensic Unit? 6 DR. DAVID CHIASSON: I was. 7 MS. LINDA ROTHSTEIN: All right. Am I 8 right that that is a unit that started in January of 9 1994, again, just shortly before you assumed the position 10 as the Chief Forensic Pathologist? 11 DR. DAVID CHIASSON: Yes. And so I had 12 nothing to do with creation of the unit -- of that unit. 13 MS. LINDA ROTHSTEIN: And am I right that 14 that was a unit that restricted its cases to adult cases? 15 DR. DAVID CHIASSON: Yes. 16 MS. LINDA ROTHSTEIN: And the children's 17 cases had historically, I think you and I talked about 18 this this morning, been routed to CHEO, the Children's 19 Hospital in Eastern Ontario? 20 DR. DAVID CHIASSON: Yes. 21 MS. LINDA ROTHSTEIN: Who headed up the 22 Eastern Ontario Regional Forensic Unit which in the 23 documents is referred to, Commissioner, as the EORFPU? 24 DR. DAVID CHIASSON: Dr. Brian Johnston. 25 MS. LINDA ROTHSTEIN: Okay. What was his


1 background, Dr. Chiasson? 2 DR. DAVID CHIASSON: As I understand 3 around the time in the Unit, he was a hospital 4 pathologist working, I think it was at the Riverside 5 Hospital. He was doing a -- a large number of forensic 6 cases, coroner's cases, in the -- as part of his role 7 although he was a hospital pathologist and doing other -- 8 other things. 9 His background, as I understood it was 10 that he had done some form of training, I think in 11 Winnipeg. This wouldn't have been, I don't think, a 12 formal training program in the extent of that of -- as 13 I'm unclear. I do not believe at that time that he had 14 any formal certification in forensic pathology. 15 COMMISSIONER STEPHEN GOUDGE: But the 16 training was forensic that he had in Winnipeg, or do you 17 know? 18 DR. DAVID CHIASSON: Well, and I don't 19 know when I learned this as opposed to what I knew at the 20 time. I -- I think there was some indication of some 21 additional training in Winnipeg doing -- doing forensic 22 cases, but I don't think it was a formal training 23 program. I could be wrong about that. 24 25 CONTINUED BY MS. LINDA ROTHSTEIN:


1 MS. LINDA ROTHSTEIN: Now can you tell 2 the Commissioner, very briefly, but by way of overview, 3 Dr. Chiasson, whether you had some concerns about Dr. 4 Johnston's unit, and indeed about his own forensic 5 pathology work in this period; '95, '96, '97? 6 DR. DAVID CHIASSON: Yes. I -- I had 7 significant concerns about the work that was coming out 8 of this unit, and specifically the work of Dr. Johnston. 9 I'd reviewed a number of his cases as part of the quality 10 control review process that I had instigated and I was 11 identifying, what I thought were significant forensic 12 pathology issues. Most notably was a case where he 13 concluded that an individual had been strangled. 14 In reviewing his pm report, it was clear 15 that there were other potential explanations for the 16 death including significant coronary artery disease, 17 including a significant level of methadone in -- in the 18 blood. 19 I therefore carried out a formal review. 20 And I -- I should say that Dr. Johnston had given a 21 preliminary opinion at the time of autopsy that the cause 22 of death was strangulation, which in itself was in my 23 view, problematic. 24 COMMISSIONER STEPHEN GOUDGE: What? The 25 preliminary part?


1 DR. DAVID CHIASSON: Yes, the preliminary 2 part of the diagnosis of manual strangulation in the 3 setting of other significant pathology findings and in 4 the setting of -- you don't know what the toxicology 5 report is yet to -- to find. 6 So an individual, as I understand, was 7 arrested, was in custody at the time. I performed a 8 detailed review, including review of the histologic 9 slides, reviewing of the hyoid bone which was an issue as 10 to whether it was fractured or not, and all the 11 photographs. I met with the Ottawa police investigator 12 involved in the case and eventually issued my own report 13 indicating that I did not think that the diagnosis of 14 strangulation could be substantiated as being certainly 15 the most likely cause of death. 16 I thought that there was significant -- or 17 there were other very real possibilities. I think 18 ultimately we concluded, I think was, most likely he died 19 of a combination of drug intoxication and a significant 20 coronary heart disease. 21 MS. LINDA ROTHSTEIN: And indeed, the 22 result down the line was that there were some civil 23 litigation that arose out of that case. Am I right about 24 that? 25 DR. DAVID CHIASSON: Well, the initial


1 result was that the accused in this matter was released 2 from custody and -- and charges were dropped. 3 Subsequently, a civil lawsuit against Dr. 4 Johnston -- and I think the Ottawa police and some other 5 parties was -- was instigated, yes. 6 MS. LINDA ROTHSTEIN: Indeed, 7 Commissioner, we have a copy of that in your Volume III, 8 the Decision from the Superior Court of Justice in that 9 case at 141947, that's Tab 17. 10 The name of the deceased in that case, am 11 I correct, Dr. Chiasson, was Marcel Vaness (phonetic)? 12 DR. DAVID CHIASSON: Yes. 13 MS. LINDA ROTHSTEIN: And you, somehow, 14 escaped involvement in the civil litigation. You may 15 want to postulate as to why that happened. But I don't 16 see you mentioned. Were you a witness, Dr. Chiasson? 17 DR. DAVID CHIASSON: I was not a witness 18 in the civil litigation. I don't know why. I mean, it's 19 obviously, it's -- it's not my job to subpoena myself in 20 such circumstances. 21 MS. LINDA ROTHSTEIN: You -- you may be 22 interested to note though, Commissioner, that Dr. John 23 Butt at paragraph 12 was the expert forensic pathologist 24 testifying on behalf of the plaintiff and Dr. Peter 25 Marcustein (phonetic) was the expert forensic pathologist


1 testifying on behalf of Dr. Johnston. 2 Let's look at one other example arising 3 from that unit, by no means exhaustive of your concerns, 4 but as a way of perhaps illustrating what kind of 5 comments you were occasionally -- or when necessary -- 6 making on the post-mortem reports that you actually 7 received. And that's the case that we now have on the 8 screen involving, I understand, a deceased by the name of 9 Dan Jones. 10 Is that right? 11 DR. DAVID CHIASSON: Yes. I don't see 12 the name there but I think that's the -- the reference -- 13 MS. LINDA ROTHSTEIN: So if we look at 14 that and, Commissioner, with that, you may also want to 15 turn up Tab 4 of Volume III which is 141753. 16 But, Registrar, if you could just leave 17 this so Dr. Chiasson has both the two (2) page autopsy 18 report prepared by Dr. Johnston and his notes of it. 19 And, Dr. Chiasson, if you would take us 20 through your note which you'll find at Tab 4 of Volume 21 III and assist the Commissioner with the sorts of 22 concerns that you were attempting to address as part of 23 your review of -- of provincial post-mortem reports. 24 DR. DAVID CHIASSON: Well, there's a 25 number of issues here that -- that caused me concern. As


1 a pathologist working in a coroner's system, the 2 determination of manner is not part of his responsibility 3 and there's clearly references to the manner of death 4 here in -- in the -- in the report. I'm not arguing that 5 that isn't the right manner of death in this case. I'm 6 saying that a pathologist working in a coroner's system 7 should avoid references to the manner of death, and he's 8 making clearly a reference to homicidal in -- in the 9 title. 10 The issue of close range which is made 11 there; in fact, if you look in the report, it's not 12 really well-defined what he means by -- by close range 13 firing. And certainly, that is a significant forensic 14 pathology issue when one's dealing with a gunshot wound. 15 And especially if one is opining that it's 16 homicidal; if it's, in fact, it's close range there's, 17 you know, the alternative that it is suicidal is always, 18 you know, needs to be considered. 19 The reference to 12 gauge shotgun which is 20 not in the title -- the title you could argue is -- is 21 kind of trying to describe the case in some kind of 22 summary fashion. 23 But, in fact, the reference in the summary 24 of findings that this is a single 12 gauge shotgun blast 25 is clearly something that can't be established by a


1 pathologist examining a body. You can't tell what kind 2 of -- you can say it's a shotgun blast or -- but not 12 3 gauge or -- or whatever unless you're a firearms expert 4 concurrently and have examined the weapon, in my view. 5 And then in the summary part of this 6 report, there's reference to death occurring within three 7 (3) to four (4) minutes. And this is a comment that -- 8 it goes back to the opinions and how much opinion you 9 should put into a report. 10 It's an opinion in this case that, yes, 11 it's on page 2 and it's at the end there. It's an 12 opinion that in all likelihood how long somebody survived 13 is not -- is in all likelihood not -- not that critical 14 one and is one that I don't think you can substantiate. 15 The degree of accuracy with which you can 16 determine how long somebody survives and injury is -- is 17 not an exact science. It's a difficult thing, and -- and 18 to opine such a thing in a report, to me is -- is 19 misleading and suggests the degree of accuracy which I 20 don't think can be supported. 21 There's reference in the history to the 22 decedent; possible cocaine dealer and being treated for 23 psychotic psychiatric illness. It's arguable as to how - 24 - how relevant that is to the establishment that he's a 25 homicide victim and whether that could be somehow deemed


1 to be unnecessary prejudicial information. 2 There's also reference to a history of hay 3 fever and being treated would react -- and I mean there - 4 - there's too much information here that is 5 inconsequential as far as the forensic pathology side of 6 things. 7 So there are -- there is this issue about 8 history and what you put in. I think one tries to be 9 concise and try to restrict your history to that part 10 that is relevant to your forensic pathology work. 11 And then when you're rendering forensic 12 pathology opinions -- the thing here, he doesn't really 13 expand on his close-range firing which is an important 14 forensic pathology issue, but yet, he gives a time of 15 survival post-injury which I don't think is -- is 16 forensically accurate and is really probably of limited 17 importance. 18 So there's all sorts of, what I consider, 19 forensic pathology issues in this report. 20 MS. LINDA ROTHSTEIN: So turning to the 21 next tab if you would, Dr. Chiasson, Mr. Commissioner as 22 well, Tab 5 of Volume III, 141787. There you've 23 documented in some reform some of the concerns as of 24 February 13th; I'm not sure if it's '96, '97, '98. 25 Can you assist us?


1 DR. DAVID CHIASSON: I think it's '96. 2 MS. LINDA ROTHSTEIN: Okay. So you 3 record: 4 "Isolationist attitude. Has never 5 requested assistance with any cases. 6 Was offered opportunity to visit, came 7 for a few days, no changes. Reports 8 confusing; poorly organized, 9 repetitious, makes unwarranted 10 conclusions, administrative apparently 11 not reviewing any cases from the 12 unit..." 13 And so on. 14 Help us. How serious was that level of 15 concern? 16 DR. DAVID CHIASSON: Well, it -- it was 17 of concern, I mean, in -- we've already talked about the 18 Vaness case. The Vaness case caused me extreme concern. 19 This -- this is -- this case is of less concern, I think. 20 I don't think it had any criminal court proceeding impact 21 issue, but it -- it suggests a background of forensic 22 pathology approach that -- that I have difficulty 23 reconciling. 24 And then the administrative stuff is, you 25 know, again it's -- it's relatively minor considering


1 what I thought to be the important -- the very important 2 issue as to the actual nature of the reports that were 3 being produced and the -- and the PMs that were being 4 performed. 5 MS. LINDA ROTHSTEIN: Did you engage in 6 discussions with the Regional Supervising Coroner and Dr. 7 Johnston's superior, Dr. Micheau (phonetic) and indeed 8 Dr. Young, in attempt to try and improve the situation in 9 Ottawa? 10 DR. DAVID CHIASSON: Yes, I did. 11 MS. LINDA ROTHSTEIN: And what did you 12 try to do? 13 DR. DAVID CHIASSON: Well, I had a number 14 of meetings over a time period with Dr. Bechard who -- we 15 worked together as -- he was Regional Coroner situated in 16 Kingston. We met with Dr. Johnston. We suggested 17 certain remedial activities. We invited them to come to 18 Toronto for several months in order to work within the 19 unit; get a sense of what we were doing, get a sense of 20 what my expectations were, the way we approach things. 21 So it was -- it was a remedial form of 22 activity. 23 MS. LINDA ROTHSTEIN: And was Dr. 24 Johnston amenable to those suggestions? 25 DR. DAVID CHIASSON: No.


1 MS. LINDA ROTHSTEIN: So what happened? 2 DR. DAVID CHIASSON: I wrote a member -- 3 memo to Dr. Young indicating basically a summary of -- of 4 the events and what was going on in -- in Ottawa. I 5 suggested that he be removed as the Director of the 6 Ottawa Unit. And he could continue to work as a forensic 7 pathologist, but that we needed to seek out a new 8 director and hopefully have him continue to work but 9 under -- under somebody else's direction. 10 MS. LINDA ROTHSTEIN: And is that your 11 memo that we find at Tab 13, dated February 3, 1998? 12 DR. DAVID CHIASSON: Yes, it is. 13 MS. LINDA ROTHSTEIN: And can -- 14 Registrar, that's 141866. 15 So the bottom line for you then was that a 16 new director needed to be recruited? 17 DR. DAVID CHIASSON: Yes. And for the 18 benefit of those present, this is the draft memorandum. 19 There's actually, just before it -- 20 MS. LINDA ROTHSTEIN: Oh, sorry. Thank 21 you. 22 DR. DAVID CHIASSON: -- in the book there 23 is the actual memorandum. 24 MS. LINDA ROTHSTEIN: 130640. Thank you 25 for that.


1 DR. DAVID CHIASSON: I think they're both 2 very similar, but that's -- a formal memo was issued to 3 Dr. Young. 4 MS. LINDA ROTHSTEIN: What was Dr. 5 Young's view? 6 DR. DAVID CHIASSON: I -- I don't have a 7 specific recall of -- of his view. I mean, what I'm 8 proposing here is that we need to find somebody to try 9 and -- to find somebody to take over the Unit. And we 10 did work towards doing that. 11 We tried to recruit a Dr. Irvine who was 12 just finishing up her training. And we saw that there 13 were issues obviously with having a junior take over a 14 unit where there's a fairly seriou -- sig -- sorry, 15 senior person involved. But we needed somebody that we 16 could work with who -- who sort of followed more standard 17 forensic pathology approaches, could oversee the work of 18 Dr. Johnston. 19 So Dr. Young -- I never did get a formal 20 reply from Dr. Young to my memorandum. We talked about 21 it, we're trying to do what we could in terms of 22 recruiting. In the meantime, however, Dr. Johnston 23 remained the director. 24 MS. LINDA ROTHSTEIN: And indeed remained 25 the director until the time that you left your position


1 as the Chief Forensic Pathologist, am I right? 2 DR. DAVID CHIASSON: That's correct, yes. 3 MS. LINDA ROTHSTEIN: And, Commissioner, 4 you will find in the rest of that volume, some of the 5 documents that chronicle the story after Dr. Chiasson's 6 involvement, and indeed the issue again became of some 7 concern, I think you'll see, for doctors Pollanen and 8 McLellan. And you can read through the documents which 9 will bring that to light. 10 I take it, Dr. Chiasson, you can't really 11 shed a lot of light from personal knowledge on what 12 happened after your resignation as the Chief Forensic 13 Pathologist, or -- or do you know in fact? 14 DR. DAVID CHIASSON: Well, I -- I know 15 that Dr. McLellan did contact me to find out, you know, 16 what information that I had that could be helpful to him 17 in terms of the past while I was there, and I provided a 18 copy of this memo and some other documents related to 19 that. 20 COMMISSIONER STEPHEN GOUDGE: Is Dr. 21 Johnston still there? 22 DR. DAVID CHIASSON: Dr. Johnston is 23 still working at the Unit as -- as far as I know, yes. 24 COMMISSIONER STEPHEN GOUDGE: Is he the 25 Director? Or do you know?


1 DR. DAVID CHIASSON: I don't know whether 2 he's still the Director or not. 3 MS. LINDA ROTHSTEIN: He's about to 4 retire, Commissioner. But it's -- when you read through 5 the documents, Commissioner, you -- the story I think is 6 more or less told in those documents that you have, in 7 the rest of that binder. 8 COMMISSIONER STEPHEN GOUDGE: Okay. 9 Thanks. 10 11 CONTINUED BY MS. LINDA ROTHSTEIN: 12 MS. LINDA ROTHSTEIN: So lets go back 13 then to the unit at the Hospital for Sick Children and -- 14 and sort of take up the story where I left it in -- in 15 the earlier part of 1998. 16 You had some concerns, you've told us 17 about that, and I gather that your -- your views as to 18 how to deal with them at that time were to try and triage 19 the cases; that is to say, get Dr. Smith to ensure that 20 the criminally suspicious and homicide cases were done by 21 him or Dr. Taylor, yes? 22 DR. DAVID CHIASSON: Yes. 23 MS. LINDA ROTHSTEIN: To try to improve 24 the communication between that unit and yours by 25 encouraging Dr. Smith to participate in the -- the -- the


1 weekly and daily sessions that you had commenced at the 2 Toronto Forensic Unit. 3 Is that right? 4 DR. DAVID CHIASSON: Yes, I invited him 5 to -- when he -- when there were cases at Sick Kids, to 6 come to our morning meeting and -- and present, so -- so 7 I had a feeling as far as what was going on there and the 8 kinds of cases that were being performed. 9 MS. LINDA ROTHSTEIN: And -- and did Dr. 10 Smith take you up on that? 11 DR. DAVID CHIASSON: He came to some of 12 the meetings early on, but that after awhile dwindled 13 away. 14 MS. LINDA ROTHSTEIN: And the concern 15 about delayed reports, did you have an approach as to how 16 you were going to encourage the earlier completion of the 17 post-mortem reports in '98? 18 DR. DAVID CHIASSON: In the early part of 19 '98, no, other than to monitor the situation, you know, 20 make him aware of the issue or keep him apprised of the 21 issue, but no, nothing beyond that at that time. 22 MS. LINDA ROTHSTEIN: And indeed in this 23 period of time we have a couple of documents that shed a 24 little bit more light on those issues, Commissioner, at 25 Tab 21, 096 --


1 COMMISSIONER STEPHEN GOUDGE: Are we back 2 in Volume I or...? 3 4 CONTINUED BY MS. LINDA ROTHSTEIN: 5 MS. LINDA ROTHSTEIN: Sorry, Volume I. 6 Thank you. 096526, Tab 21, there's the result of your 7 audit that you've told us about and the proposals for 8 trying to improve turnaround times. 9 You had a goal of 90 percent of the cases 10 within ninety (90) days. 11 DR. DAVID CHIASSON: Yes, a somewhat 12 optimistic goal, but that sounded -- I -- I try to avoid 13 buzzwords, but that sounds good. 14 MS. LINDA ROTHSTEIN: That one actually 15 didn't come to light ever, did it? It didn't succeed 16 ever, did it? 17 DR. DAVID CHIASSON: I -- I don't think 18 so and I -- I'll confess it doesn't succeed to this day. 19 MS. LINDA ROTHSTEIN: Yeah. And all 20 pediatric coroner's cases to be presented at morning 21 rounds, you've told us about that, that's -- there was an 22 early sort of attempt at that, but it didn't really hold. 23 Do I have your evidence correctly? 24 DR. DAVID CHIASSON: That's correct. 25 MS. LINDA ROTHSTEIN: Okay. And then we


1 have a letter here to you from Dr. Smith the following 2 tab, 22, 132345, which appears to be a response to that 3 meeting. 4 And can I just ask you -- turning the page 5 to the second page of that, 132345/2, Dr. Smith appears 6 to be contending that there was a need for a dedicated 7 individual to provide secretarial and support serviced. 8 Can you assist the Commissioner as to what 9 extent, if at all, Dr. Smith's explanation for delays was 10 that he lacked the clerical support he needed to get the 11 reports out? 12 DR. DAVID CHIASSON: Well, that was 13 certainly an argument that he made. It was my 14 understanding that in fact he did a lot of his own 15 reports. Now, if you had more clerical help would he 16 have, you know, had -- had that involved, I'm -- I'm not 17 sure; that was certainly, like I said, his -- his 18 suggestion. 19 MS. LINDA ROTHSTEIN: Part of our issue, 20 what I thought would be important would be to have a 21 delegated person for the Unit who could respond to 22 inquiries; because one (1) of the issues was you were 23 always often contacting him directly rath -- for 24 administrative matters, which really could easily have 25 been handled by an administrative assistant and it wasn't


1 clear exactly that -- there was no defined individual 2 within the -- within the ho -- within the department at 3 that time for this purpose. 4 MS. LINDA ROTHSTEIN: Dr. Chiasson, by 5 the end of 1998 had things been proved to your 6 satisfaction at that unit? 7 DR. DAVID CHIASSON: No. 8 MS. LINDA ROTHSTEIN: All right. So, 9 before we deal with what you did about that, because I 10 gather, sir, that you actually put pen to paper and came 11 up with a restructuring model, if you will. 12 Is that fair? 13 DR. DAVID CHIASSON: Yes. 14 MS. LINDA ROTHSTEIN: I -- I think it 15 would be useful if we put sort of that proposal in some 16 chronological context and -- and hearken back to some of 17 the other issues that you were dealing with by then. And 18 I want to for this purpose, Dr. Chiasson, get you to turn 19 up the overview reports, and particularly the Nicholas 20 case, which you will find in Volume II of your overview 21 reports at Tab number 12. 22 We haven't talked about this case thus 23 far, but you do remember some involvement in that? Is 24 that fair? 25 DR. DAVID CHIASSON: Yes.


1 MS. LINDA ROTHSTEIN: All right. And so 2 let's see if we can plot when it was that you first 3 became involved in this case. Dr. Cairns told us that he 4 first became involved in this case. Dr. Cairns told us 5 that he first became involved in the decision to disinter 6 Nicholas which was in 1997. 7 To what extent were you involved in that 8 decision? 9 DR. DAVID CHIASSON: I don't recall 10 having any involvement in that decision. 11 MS. LINDA ROTHSTEIN: So looking back, is 12 that surprising? You're the Chief Forensic Pathologist. 13 There's a disinterment of a child. I take it that's a 14 fairly unusual event. 15 What are we to make of the fact that Dr. 16 Cairns and Dr. Smith were dealing with that issue and you 17 weren't involved? 18 DR. DAVID CHIASSON: Well again, I mean, 19 I think it's a reflection of the -- a bit of a divide 20 between pediatric work -- pediatric forensic pathology 21 and -- and the rest of forensic pathology that Charles 22 was -- was really taking the ball -- working in concert 23 with Dr. Cairns in order to -- to deal with pediatric 24 forensic pathology issues. 25 MS. LINDA ROTHSTEIN: We know that -- and


1 if you look at -- starting at page 58. Well, it's 2 actually a little bit earlier than that. We know that 3 Dr. Smith's post-mortem report was prepared August 6th, 4 '97. 5 Did you do a paper review of that case? 6 DR. DAVID CHIASSON: I don't believe so, 7 no. 8 MS. LINDA ROTHSTEIN: And do you know why 9 that was? 10 DR. DAVID CHIASSON: No. 11 MS. LINDA ROTHSTEIN: Okay. We know that 12 by the summer of '98, June of '98, the defence in the -- 13 in the CAS proceedings have identified an expert, Dr. 14 Halliday. 15 So stopping there for a moment, Dr. 16 Chiasson, by the time the case has become active because 17 there are Children's Aid Society proceedings commenced, 18 are you involved? 19 DR. DAVID CHIASSON: Yes. It's somewhere 20 around that time that Dr. Cairns has me -- talks to me 21 about the case. I -- I have the opportunity to review 22 Dr. Halliday's report. 23 MS. LINDA ROTHSTEIN: And were you 24 familiar with Dr. Halliday? 25 DR. DAVID CHIASSON: Dr. Halliday was at


1 the Hospital for Sick Children around the time that I was 2 finishing up my training. I -- I think we did overlap 3 there for a year or two (2). 4 Then, as I understood it, he -- he moved 5 to Winnipeg, and I hadn't had any contact with him or 6 knew what exactly he was doing in Winnipeg over a period 7 of time. 8 He then came back to Toronto, I think in 9 the early part of 2000, maybe in the late '90's, and -- 10 and since is -- is working in the office next to mine at 11 the Hospital for Sick Children. 12 MS. LINDA ROTHSTEIN: He's the 13 neuropathologist that you rely on when you need some 14 neuropath advice? 15 DR. DAVID CHIASSON: Yes, and I rely very 16 heavily, and I respect Dr. Halliday as a pediatric 17 neuropathologist greatly. 18 MS. LINDA ROTHSTEIN: But for the moment, 19 if you would be good enough to cast your mind back to the 20 summer of '98, paragraph 91, Commissioner, picks up this 21 part of the narrative. 22 You receive, at some point after its 23 creation, a copy of Dr. Halliday's report and do you 24 remember why it was that Dr. Cairns was showing it to 25 you? Was he asking your opinion of it? What -- what was


1 the nature and extent of your involvement? 2 DR. DAVID CHIASSON: Well, as I recall, 3 yes, he was getting now these differences of -- of 4 opinions and, yes, he was asking me for my input as to 5 how to proceed. 6 MS. LINDA ROTHSTEIN: And do you remember 7 what your input was at that stage? 8 DR. DAVID CHIASSON: Well, basically, 9 reviewed the report, we talked about it. Subsequently, 10 we -- I think we obtained another affidavit from -- from 11 Dr. Halliday, and I -- I was basically apprised of what 12 was going on. And this is over a period of some -- some 13 months, I would believe. 14 MS. LINDA ROTHSTEIN: Well, were you 15 apprised of the events enough to know that Dr. Cairns 16 authored an affidavit that was filed in the CAS 17 proceedings? 18 DR. DAVID CHIASSON: I suspect -- at this 19 stage, I -- I -- my independent recall is -- is somewhat 20 foggy. I suspect that he would have, at least, told me 21 that that was happening. 22 MS. LINDA ROTHSTEIN: Take a look at 23 paragraph 101 of the overview report. It's at page 36 of 24 the PFP number, and I know you've seen this since so it's 25 a tough question to answer.


1 But do you remember seeing this affidavit 2 at the time? 3 DR. DAVID CHIASSON: I may well have, but 4 I don't recall having seen it at the time. 5 MS. LINDA ROTHSTEIN: So let's start with 6 this question, Dr. Chiasson: Did it strike you as 7 appropriate that Dr. Cairns would be filing an affidavit 8 such as this? Well, no, actually, let me ask you this 9 question first. 10 Would you have been prepared to author an 11 affidavit for submission in this Children's Aid 12 proceedings at that time? 13 DR. DAVID CHIASSON: No. 14 MS. LINDA ROTHSTEIN: Why not? 15 DR. DAVID CHIASSON: This -- the issues 16 here are of a pediatric forensic neuropathology nature. 17 I'm neither a neuropathologist, nor am I a pediatric 18 pathologist and you -- though I -- so I only -- I only 19 fit into one (1) -- one third (1/3) of that degree of 20 sub-specialization, but this was clearly an area outside 21 of my comfort level as far as offering an opinion. 22 MS. LINDA ROTHSTEIN: Do you remember 23 being asked whether or not you would prepare an affidavit 24 for these proceedings? 25 DR. DAVID CHIASSON: I don't recall being


1 asked by anyone to prepare an affidavit. 2 MS. LINDA ROTHSTEIN: All right. So, do 3 you remember having a view as to the propriety of Dr. 4 Cairns preparing such an affidavit? 5 DR. DAVID CHIASSON: Well, I think 6 clearly, in retrospect, that it was not appropriate for 7 Dr. Cairns to provide an affidavit of this nature. 8 MS. LINDA ROTHSTEIN: But at the time, 9 sir? 10 11 (BRIEF PAUSE) 12 13 DR. DAVID CHIASSON: I think -- I think I 14 -- even at the time that it was really not appropriate 15 for Dr. Cairns, given what his expertise was, and then as 16 a -- as a coroner. Even though he had a lot of 17 experience in dealing with pediatric cases over the years 18 and had a lot of experience with pediatric death 19 investigation, the issues here are really one (1) of a 20 forensic pathology nature, and as I said, a pediatric 21 neuroforensic pathology nature. And I -- I think he 22 would agree, he's not really qualified to opine 23 independently on -- on the findings. 24 MS. LINDA ROTHSTEIN: Did you express 25 that view to anyone?


1 DR. DAVID CHIASSON: I don't think so, 2 until now. 3 MS. LINDA ROTHSTEIN: Why is that? 4 DR. DAVID CHIASSON: Again, I'm not sure, 5 you know, whether I saw this -- I -- I suspect Dr. Cairns 6 would have apprised me of he's going to send off an 7 affidavit. I didn't inquire specifically as to the 8 nature of his affidavit. 9 As you're well aware you have -- 10 affidavits could -- could say anything. And at no point 11 was I presented with a document and asked for an opinion 12 as to whether it was appropriate to send off or not. 13 MS. LINDA ROTHSTEIN: Did you talk to Dr. 14 Smith about this case at that time? 15 DR. DAVID CHIASSON: I don't recall 16 speaking to Dr. Smith directly about this case at that 17 time. 18 MS. LINDA ROTHSTEIN: Why was that? 19 DR. DAVID CHIASSON: Well, again, I 20 didn't feel comfortable in this particular area. There 21 was an ongoing procedure, and Dr. Smith was expressing 22 his opinions fairly clearly in his affidavit, as I -- as 23 I recall it. 24 And I'm -- I'm -- I guess, in some ways, 25 leaving Dr. Cairns to carry the ball, perhaps


1 inappropriately, but that's -- that's what is -- that's 2 what was happening, and again, feeling certainly a 3 certain level of discomfort on -- on this area of 4 forensic neuropathology. 5 MS. LINDA ROTHSTEIN: And we know, as 6 you've mentioned, that, in fact, there was a second 7 affidavit from Dr. Halliday. You'll see that at 8 paragraph 127. Paragraph 144 moves us ahead in time 9 quite a lot to January of '99 and makes reference to the 10 concern that the defence, in this case, had getting 11 disclosure of some of the underlying physical exhibits 12 that they needed in order to have them reviewed by their 13 expert. 14 Do you remember being involved in that 15 issue? 16 DR. DAVID CHIASSON: No, I don't recall 17 issues about having exhibits provided to defence counsel 18 experts. 19 MS. LINDA ROTHSTEIN: And is -- is -- are 20 we to gather from that again, Dr. Chiasson, that's 21 because Dr. Cairns and Dr. Smith were dealing with this 22 for the most part and your involvement was rather 23 peripheral? 24 DR. DAVID CHIASSON: Yes. I mean the 25 issue of trying to get exhibits; Dr. Cairns is as -- as


1 able, capable to facilitate that or to try and -- and set 2 that into motion as I am, and he was the one that had the 3 ongoing relationship with Dr. Smith in regards to this 4 case and in general. So I don't have any issue with Dr. 5 Cairns in fact being the one approached and ultimately 6 dealing with this -- what is essentially a management 7 issue. 8 It's not a forensic pathology issue. 9 MS. LINDA ROTHSTEIN: Okay. And then in 10 December '98, paragraph 149, the overview recor -- report 11 records that counsel for the CAS, Mr. Parise, expressed 12 concerns to the OCCO and Dr. Smith about the conflicting 13 expert opinions in the case. He suggested that another 14 expert opinion, rather then just that of Dr. Cairns, 15 would help support Dr. Smith. 16 Until that point, Dr. Chiasson, do you 17 remember it occurring to you that that's what the OCCO 18 ought to be doing in the face of a report from Dr. Smith 19 that was being refuted by Dr. Halliday? 20 DR. DAVID CHIASSON: I'm not sure I 21 understand your question. If -- if it's to say that 22 should the OCCO be involved in facilitating a third 23 opinion? 24 MS. LINDA ROTHSTEIN: More then that. My 25 question is, until December of '98, when that's raised by


1 Mr. Parise, do you remember any conversation with Dr. 2 Cairns that was along the lines of saying, You know, we 3 should get another opinion? 4 DR. DAVID CHIASSON: I don't specifically 5 recall any conversation to that effect, no. 6 MS. LINDA ROTHSTEIN: Okay. So as best 7 you know, that didn't really arise until the issue was 8 squarely addressed by Mr. Parise? 9 DR. DAVID CHIASSON: That's right, 10 correct. 11 MS. LINDA ROTHSTEIN: All right. And 12 then I understand that indeed you were involved in 13 identifying the person who would be most appropriate to 14 provide that independent third opinion? 15 DR. DAVID CHIASSON: Yes. 16 MS. LINDA ROTHSTEIN: And that was Dr. 17 Mary Case? 18 DR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: And how did you 20 come to identify Dr. Case? 21 DR. DAVID CHIASSON: Well Dr. Case I -- I 22 knew to be an experienced forensic pathologist, worked 23 out of St. Louis, and that she had, from -- from her 24 writings, had an interest in the area of -- well she was 25 a neuropathologist as -- as I recall, and she also had


1 interest in pediatric head trauma. 2 I didn't -- I didn't know her personally, 3 but I knew of her area of expertise. 4 MS. LINDA ROTHSTEIN: Okay. And so we 5 know that by March 6th of '99 -- just to refresh your 6 memory, Dr. Chiasson, that's paragraph 157 -- she in fact 7 provides her opinion. 8 And at that stage are you involved enough 9 that you're reviewing it and coming to some conclusions 10 about its fairness and reasonableness? 11 DR. DAVID CHIASSON: Yes, I certainly 12 reviewed her opinion when it was produced. 13 MS. LINDA ROTHSTEIN: And what 14 conclusions did you come to after reading her opinion and 15 considering it? 16 DR. DAVID CHIASSON: Well I thought her 17 opinion made -- made sense to me. Again, this is not an 18 area of my -- that I feel I have particular expertise in. 19 But certainly, she seemed to be fairly balanced or strong 20 in -- in her view, which -- which did make, I think, 21 forensic pathological sense to me that -- in -- and -- 22 arriving at her undetermined conclusion. 23 MS. LINDA ROTHSTEIN: Okay. So what, if 24 any, conclusions did you come to, having read Dr. Case's 25 opinion, about the expertise or limits of the expertise


1 or other concerns about Dr. Smith? 2 DR. DAVID CHIASSON: Well I -- I think 3 that this was a difficult case, a difficult issue. I -- 4 I thought that Dr. Smith had rendered an opinion that 5 went beyond what the evidence really allowed him to go. 6 And I guess that's basically it. I -- I - 7 - you know, I supported Dr. Case's opinion and -- and 8 felt that Dr. Smith had -- had really gone beyond the 9 evidence in this case. 10 MS. LINDA ROTHSTEIN: Okay. 11 COMMISSIONER STEPHEN GOUDGE: Had he gone 12 beyond his own expertise? 13 DR. DAVID CHIASSON: I think -- I wasn't 14 clear as to how much neuropathology he may have been 15 doing and what his level of comfort in the area of 16 neuropathology -- I knew he wasn't a neuropathologist. 17 And frankly, certainly, I work very 18 closely with neuropathologists, and I -- I don't do my 19 own neuropathology. I -- I spend -- I -- I utilize the 20 resources I have at the hospital. 21 Having said that, I do spend a fair amount 22 of time discussing cases with the neuropathologist. And 23 I have, over the years, developed a certain sense of 24 forensic neuropathology, even though I'm not -- that's 25 not my area.


1 I mean a certain comfort level in terms of 2 the issues and what to look for in -- in various cases. 3 So I -- I wasn't clear on, you know, where 4 Charles was in -- into that, whether he had evolved some 5 special expertise in the area of neuropathology. 6 It certainly wouldn't be an area, as I've 7 said, I wouldn't be comfortable back then. Now after -- 8 in my current position I would not have done my own 9 neuropathology in -- in this setting. 10 11 CONTINUED BY MS. LINDA ROTHSTEIN: 12 MS. LINDA ROTHSTEIN: Did you sit down 13 and talk to Dr. Smith about this case? 14 DR. DAVID CHIASSON: No. 15 MS. LINDA ROTHSTEIN: Help us with that, 16 Dr. Chiasson. You've shown us already that you were very 17 diligent and very minded to provide a meaningful 18 oversight role for your colleagues. 19 So -- so why was it that you didn't at any 20 stage sit down and talk to Dr. Smith about this case? 21 DR. DAVID CHIASSON: Well, there's a 22 couple reasons. I've already indicated, pediatric 23 pathology was not my area of expertise, and certainly a 24 case like this was beyond what I felt comfortable 25 discussing.


1 I was comfortable in running a unit where 2 some of my colleagues were -- were quite senior to me. 3 Dr. Deck (phonetic) was senior to me when I hired him, 4 and yet I felt comfortable enough in the adult world, and 5 even in the adult forensic neuropathology world, to -- to 6 work with him. 7 And -- and he was somebody that was really 8 open to -- to my involvement. He would seek out my 9 opinions on -- on issues, we would discuss cases, we had 10 a good rapport. And he was my employee, so I was his 11 boss. 12 Dr. Smith, I wasn't his boss. My role -- 13 MS. LINDA ROTHSTEIN: Stopping there, 14 just stop there for a moment. Is that a -- is that big 15 issue? 16 DR. DAVID CHIASSON: Well, I think it's - 17 - it's a potentially a big issue. 18 MS. LINDA ROTHSTEIN: Mm-hm. 19 DR. DAVID CHIASSON: I wasn't his boss. 20 And my role in terms of overseeing the forensic pathology 21 units, and especially the Sick Kids Forensic -- Pediatric 22 Forensic Pathology Unit, was unclear. 23 I also was aware -- I mean, and then -- 24 and then we're talking about an area which I'm not 25 comfortable in. We're talking about an area which, you


1 know, I've allowed him to develop his relationship with 2 Dr. Cairns, in particular, in terms of -- of taking care 3 of that need. 4 So I -- I'm guilty in -- in -- of -- of 5 perhaps allowing a certain isolation of pediatric from -- 6 from my umbrella of -- of responsibilities. 7 And I think the other thing is is that Dr. 8 Smith was not someone that I felt comfortable, really, in 9 sitting down with and -- and challenging. 10 And it's interesting, I just thought about 11 this as we're -- we're talking about it. Dr. Deck, who I 12 said I was -- was more senior than Dr. Smith even. But 13 he was very open to -- to my, you know, involvement. He 14 -- he sought my opinions, and we were able to develop a 15 very -- a good collegial relationship. That was not the 16 case with Dr. Smith. 17 And it went beyond, I think, 18 employee/employer setting. Dr. Smith tended, I think, to 19 -- to feel that I was junior to him, which I was. And 20 then I was -- this wasn't even my area of -- I -- I did 21 not feel comfortable in -- in really sitting down with 22 him over an issue such as this. 23 MS. LINDA ROTHSTEIN: Mm-hm. If I hear 24 what you're saying in part, Dr. Chiasson, it is that 25 pediatrics was really seen as a fairly separate


1 subspecialty in forensics? 2 DR. DAVID CHIASSON: Yes. 3 MS. LINDA ROTHSTEIN: In which you hadn't 4 had the experience, as you've been very candid with the 5 Commissioner in -- in describing? 6 DR. DAVID CHIASSON: Correct. 7 MS. LINDA ROTHSTEIN: And Dr. Smith had 8 lots of experience? 9 DR. DAVID CHIASSON: Correct. 10 MS. LINDA ROTHSTEIN: And was he around? 11 Was he at the OCCO? Were you having those kinds of 12 informal chats about cases? 13 Or as of the end of '98, was that mostly 14 fleeting? 15 DR. DAVID CHIASSON: Well he certainly, 16 after coming to a few morning meetings, he stopped coming 17 to morning meetings. I -- to be honest, I didn't -- I 18 didn't push him. I didn't seek him out. 19 He, again, you know, if he's -- if he's 20 your employee, then you can be strong. If he's not, I 21 think I felt it's a little dif -- different. 22 COMMISSIONER STEPHEN GOUDGE: I get the 23 sense, Dr. Chiasson, that he would not have taken it very 24 well, at least that is what you thought? 25 DR. DAVID CHIASSON: I -- I think he


1 might have -- I don't think he would have told me to my 2 face that, you know, Butt out, or, you know, Back off, or 3 -- I think -- but I mean the sense, the undercurrent may 4 well have been that that he -- he would not have been 5 very happy with -- with me trying to assume a degree of - 6 - of control if you will. 7 COMMISSIONER STEPHEN GOUDGE: Or 8 oversight, or -- 9 DR. DAVID CHIASSON: Oversight. 10 COMMISSIONER STEPHEN GOUDGE: -- quality 11 assurance, or even discussion? 12 DR. DAVID CHIASSON: Yes. Discussions 13 with Dr. Smith for me were mostly him educating me about 14 pediatric forensic issues, as opposed to him seeking out 15 my views or -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID CHIASSON: -- anything of that 18 nature. 19 20 CONTINUED BY MS. LINDA ROTHSTEIN: 21 MS. LINDA ROTHSTEIN: And at that stage, 22 Dr. Chiasson, did you have a sense of how active Dr. 23 Smith was in leading discussions, presentations, lectures 24 on pediatric forensic pathology, and specifically, did 25 you know that he and Dr. Young were involved in some form


1 of research and presenting papers together? 2 Did you know about that? 3 DR. DAVID CHIASSON: I -- I mean, I 4 didn't follow everything he did, but I have some sense, 5 certainly, that he was talking to various -- various 6 groups about pediatric forensic pathology, yes. 7 MS. LINDA ROTHSTEIN: Did -- did you know 8 for example -- we can see this on his CV -- that he was 9 fairly regularly a presenter at meetings of Crowns 10 attorney -- Crown attorneys, police officers, that sort 11 of thing? 12 DR. DAVID CHIASSON: I think in a general 13 way I was aware that certainly he was giving talks to -- 14 MS. LINDA ROTHSTEIN: Yeah. 15 DR. DAVID CHIASSON: -- to those 16 audiences, yes. 17 MS. LINDA ROTHSTEIN: Would you have been 18 giving talks to those audiences at the same time? Is 19 that sort of the standard fare for the forensic 20 pathologist at the OCCO? 21 DR. DAVID CHIASSON: I certainly was 22 asked to speak to Crown attorney meetings and the police 23 -- a lot -- a fair amount of work at the police college, 24 and occasionally homicide courses, yes. 25 MS. LINDA ROTHSTEIN: Well, having told


1 us a little bit about what you did not feel comfortable 2 doing, which was sitting down with Dr. Smith one-to-one. 3 Lets look at what you -- you did attempt to do. 4 I'd ask you to turn up Tab 27 of Volume I, 5 056292. 6 And this is a memo you wrote to Dr. Young 7 December 10, 1998: "Revisioning the Pediatric Forensic 8 Pathology Unit." 9 Am I right, Dr. Chiasson, in 10 characterising this as a pretty dramatic proposal for 11 change in the structuring of pediatric forensic 12 pathologic services for Ontario? 13 MR. DAVID CHIASSON: Yes. 14 MS. LINDA ROTHSTEIN: Yeah. And you 15 refer back to the March 31 meeting that you and I have 16 chatted about: 17 "In a meeting with Drs. Becker and 18 Smith, Dr. Cairns and I put forward the 19 following four (4) specific objectives 20 aimed at improving the service provided 21 to the Coroner's office by the PFPU: 22 A triage system to ensure that 23 autopsies in all homicide and 24 criminally suspicious cases would be 25 performed by either Dr. Smith or Dr.


1 Taylor. 2 2. That Dr. Smith regularly 3 participate in daily case rounds at the 4 Coroner's office. 5 3. That the hospital provide Dr. Smith 6 with an administrative assistant. 7 4. That there will be a significant 8 underlined improvement in the 9 turnaround time for completion of 10 reports of post-mortem examination. 11 I consider that these proposals were 12 only the first steps along the road to 13 improving the performance of this 14 forensic unit. I left the meeting with 15 the understanding that these measures 16 were to be implemented quickly and it 17 was agreed that the situation would be 18 reassessed in six (6) months time." 19 You say then: 20 "It is now over six (6) months since 21 that meeting. In my opinion there has 22 been very little real progress made in 23 improving the service provided to the 24 Coroner's office by this unit. In 25 particular, no admin. assistant has


1 been hired for Dr. Smith (very recently 2 some additional temporary secretarial 3 help was provided) and most importantly 4 the turnaround time for reports has 5 apparently increased, not decreased 6 since the Spring." 7 You go on to talk about that. You go on 8 to talk about: 9 "The Pediatric Forensic Pathology Unit 10 is not fulfilling its mandate to 11 provide a high-quality forensic 12 pathology service to the Coroner's 13 office, despite our office's attempts 14 to provide guidance and direction [and 15 so on]." 16 Just to make sure that we have it, the -- 17 the idea that Dr. Smith regularly participate in daily 18 case rounds, that was not improving based on what you've 19 told us either? 20 MR. DAVID CHIASSON: Correct. 21 MS. LINDA ROTHSTEIN: And then, 22 Commissioner, skip the second page for the moment and go 23 to the conclusion, page 3, which is 056294: 24 "I am convinced that the restructuring 25 of the PFPU along these lines will


1 result in a unit which is responsive to 2 our need as a provincial agency 3 accountable to the system of justice 4 and the public at large for a service 5 which is timely and efficient in the 6 production of its reports. At the same 7 time I see no reason why our office and 8 the hospital cannot continue to 9 mutually benefit from a close 10 collaborative relationship within the 11 proposed framework." 12 So that takes us back to number 2, which 13 is 056293. 14 And tell us what exactly was it that you 15 were proposing would happen, Dr. Chiasson? 16 DR. DAVID CHIASSON: Well, what I was 17 proposing was that there would be a redistribution of 18 cases, and, in essence so that the cases of a 19 forensic/homicidal criminally suspicious cases, all of 20 those would be performed at the Office of the Chief 21 Coroner, as well as all the sudden unexpected death out- 22 of-hospital cases would be referred to the OCC. Where -- 23 MS. LINDA ROTHSTEIN: So stopping there. 24 DR. DAVID CHIASSON: Yeah. 25 MS. LINDA ROTHSTEIN: Would that be all


1 medicolegal? All coroner's cases would be done at the 2 Office of the Chief Coroner? 3 DR. DAVID CHIASSON: No, no. 4 MS. LINDA ROTHSTEIN: No, okay. 5 DR. DAVID CHIASSON: Deaths that occurred 6 in hospital -- in -- at the Hospital for Sick Children -- 7 MS. LINDA ROTHSTEIN: Okay. 8 DR. DAVID CHIASSON: -- unless they were 9 criminally suspicious, would be done at the hospital. 10 MS. LINDA ROTHSTEIN: Right. 11 DR. DAVID CHIASSON: And at this stage, 12 everything that occurs outside the hospital refer -- gets 13 referred to the Coroner's Office. 14 In retrospect, and I -- I think that that 15 -- if this had come to some sort of fruition we may have 16 ended up -- certain patients dying outside of the 17 hospital would -- that were hospital patients, we may 18 well have redirected back to Sick Kids, but the majority 19 of the outside of hospital deaths would be done at the 20 OCC. 21 COMMISSIONER STEPHEN GOUDGE: You would 22 have had the SIDS cases mostly. 23 DR. DAVID CHIASSON: Exactly, that -- 24 that would have been the -- the biggest group of cases. 25 All of those would have gone to the OCC, where with Dr.


1 Smith working with us at the Coroner's Office, taking an 2 ongoing significant number of these cases himself and 3 assisting my staff pathologist, who at that time had 4 grown to a four (4) in doing their cases, so starting to 5 redistribute the cases and starting to incorporate 6 pediatric cases in the work of the OCC's Unit, PFPU. 7 8 CONTINUED BY MS. LINDA ROTHSTEIN: 9 MS. LINDA ROTHSTEIN: Who were you 10 contemplating would be Dr. Smith's employer in this 11 proposal, or had you thought about that? 12 DR. DAVID CHIASSON: That was a 13 administrative issue that I really hadn't worked out 14 completely. My sense was that he would remain a hospital 15 employee, that he would commit 50 percent of his time to 16 the unit. 17 I mean, in fact that's what he was doing, 18 it was just a question of where he was doing the autopsy. 19 If that had -- if there had been an objection in whether 20 we'd have to pay the hospital to recount -- compensate 21 them for a part of the salary, I mean all of that was to 22 be discussed. 23 MS. LINDA ROTHSTEIN: Right. So the 24 notion would be that the PFP would be physically 25 relocated to the Office of the Chief Coroner, yes?


1 DR. DAVID CHIASSON: Basically. Most of 2 it would be relocated, yes. 3 MS. LINDA ROTHSTEIN: That Dr. Smith 4 would continue as the Director of the PFPU, but he would 5 report directly to you in that capacity? 6 DR. DAVID CHIASSON: Yes. 7 MS. LINDA ROTHSTEIN: That he would make 8 a minimum 50 percent time commitment to your unit? 9 DR. DAVID CHIASSON: Yes. 10 MS. LINDA ROTHSTEIN: And that HSC would 11 still be very much needed on some collaborative and 12 partnership basis because you were still looking to them 13 to provide the laboratory medicine, the radiology, the 14 histology and the other laboratory support for the unit. 15 DR. DAVID CHIASSON: Yes. That's an 16 optimistic proposal, perhaps, but that's where we were 17 starting from, yes. 18 COMMISSIONER STEPHEN GOUDGE: Why 19 optimistic? 20 DR. DAVID CHIASSON: Well, I mean the -- 21 the issue would be whether the hospital would be willing 22 to provide all this backup at the same time we're pulling 23 out -- 24 COMMISSIONER STEPHEN GOUDGE: What, they 25 got their nose out of joint and wouldn't do the backup?


1 DR. DAVID CHIASSON: Well, that's -- I 2 mean that was certainly -- 3 COMMISSIONER STEPHEN GOUDGE: That's not 4 a nice way to put it, but is that really the idea? 5 DR. DAVID CHIASSON: Well, that -- that 6 was certainly I think a real possibility, yes. 7 8 CONTINUED BY MS. LINDA ROTHSTEIN: 9 MS. LINDA ROTHSTEIN: And may I ask you 10 this, Dr. Chiasson, to what extent was your vision, as 11 annunciated in this memo, dependent on the staffing model 12 that you had successfully brought about with four (4) 13 full time forensic pathologists located and working for 14 the Toronto Forensic Pathology Unit? 15 DR. DAVID CHIASSON: Critically depended 16 upon that. 17 MS. LINDA ROTHSTEIN: All right. 18 Commissioner, it's a good time for our afternoon break. 19 COMMISSIONER STEPHEN GOUDGE: Sure. 20 3:30. 21 22 --- Upon recessing at 3:15 p.m. 23 --- Upon resuming at 3:31 p.m. 24 25 THE REGISTRAR: All rise. Please be


1 seated. 2 COMMISSIONER STEPHEN GOUDGE: Ms. 3 Rothstein...? 4 MS. LINDA ROTHSTEIN: Can we turn to 5 Tab 28 please, Dr. Chiasson, 056321? We're into 1999, 6 just after you first authored your December '98 memo. 7 You have a handwritten note: 8 "Charles Smith, JY, JC; Re. Pediatric 9 FP revisioning." 10 Is this a meeting with Dr. Smith, Dr. 11 Young, Dr. Cairns about it? 12 DR. DAVID CHIASSON: Yes. 13 MS. LINDA ROTHSTEIN: And some discussion 14 about a job description for Dr. Smith? 15 DR. DAVID CHIASSON: Yes. 16 MS. LINDA ROTHSTEIN: And salary and 17 benefits and so on? 18 DR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: And at that stage 20 did you believe that you had the support of Dr. Young and 21 Dr. Cairns in this revisioning proposal? 22 DR. DAVID CHIASSON: I did. 23 MS. LINDA ROTHSTEIN: Can you assist us 24 with your last two (2) words and the question marks 25 beside them?


1 "External review," you'll understand those 2 words have a particular significance in 2007, but can you 3 assist us as to what they did mean back in 1999? 4 DR. DAVID CHIASSON: No. I -- you -- you 5 showed me this recently, and I -- I really don't know 6 what that is making reference to. 7 MS. LINDA ROTHSTEIN: We know that you'll 8 recall this, I believe, that in February of 1999, 9 probably later, Doctors Young and Cairns attended a 10 meeting of the Academy of Forensic Sciences, when it was 11 first suggested that there was a serious potential 12 miscarriage of justice arising in the Sharon XXXX 13 case. 14 Is there any relationship at all between 15 those words and that event? 16 DR. DAVID CHIASSON: No, I think they 17 would have attended the meeting after this meeting -- 18 MS. LINDA ROTHSTEIN: Right. 19 DR. DAVID CHIASSON: -- so I -- I don't 20 think that that played a role in the -- in that 21 reference. 22 MS. LINDA ROTHSTEIN: Right. Let's turn 23 to the next tab then, please, Dr. Chiasson, which is a 24 March 12th, '99 meeting, now at 056317. 25 My understanding, sir, is that you first


1 presented the proposal, which you took the Commissioner 2 and I through just before the afternoon break, at a 3 meeting with Dr. Becker and Cairns on March the 12th, 4 1999. 5 That was the first formal propo -- formal 6 presentation to Dr. Becker as opposed to Dr. Smith? 7 DR. DAVID CHIASSON: Yes. 8 MS. LINDA ROTHSTEIN: And can you tell us 9 about that based on whatever this note does to refresh 10 your memory about that meeting? 11 DR. DAVID CHIASSON: Well, in essence 12 we've seen the revisioning proposal. And -- and this was 13 a -- a meeting to -- to alert Dr. Becker as to what our 14 proposal was. 15 It was done in the context of reviewing 16 ongoing issues with Dr. Smith. Dr. Smith wasn't at this 17 meeting. And it basically outlines, I think, what I've 18 already addressed as far as how the cases would be 19 distributed. 20 MS. LINDA ROTHSTEIN: Okay. And am I 21 right in discerning from your note that Dr. Smith was not 22 in attendance at this meeting? 23 DR. DAVID CHIASSON: That's correct. 24 MS. LINDA ROTHSTEIN: And what, if any, 25 significance should we attach to that?


1 DR. DAVID CHIASSON: Well we had broached 2 the issue with Dr. Smith. Obviously if Dr. Smith had 3 expressed objection, major reservations in regards to the 4 proposal, you know, would have stopped it in its tracks, 5 at least as it was framed. So he was aware of what was 6 going on. 7 I think we -- we wanted to speak to Dr. 8 Becker without Dr. Smith, because some of the issues -- 9 some of our arguments in dealing with Dr. Becker as to 10 why we were doing this really had to do with Dr. Smith. 11 And I think we just felt it would be a -- a better way of 12 broaching it with Dr. Becker. 13 MS. LINDA ROTHSTEIN: So to that -- so to 14 the extent that your notes record that you reviewed the 15 issues with respect to Charles Smith, there was indeed 16 some specific discussion of the concerns that you had 17 about Dr. Smith's timeliness at a bare minimum? 18 DR. DAVID CHIASSON: Well I think yes, 19 and as I'm looking at this, I -- I suspect what we -- we 20 were starting to broach the issues beyond simply 21 administrative turnaround issues, such as the Gagnon 22 matter. 23 And by this time the issue about Sharon 24 was also a -- beginning to -- to gel, if you will, in 25 terms of -- this is after the meeting, the forensic


1 meeting, forensic sciences meeting. 2 MS. LINDA ROTHSTEIN: So are you saying 3 that you yourself, Dr. Chiasson, had a heightened level 4 of concern about Dr. Smith by that point? 5 DR. DAVID CHIASSON: Well, I think we 6 were starting to -- to insert these other issues into the 7 mix, and -- and therefore in -- in making our argument 8 about the proposal that -- in -- with Dr. Becker, that we 9 wanted to do that, including these issues with regards to 10 Dr. Smith. 11 And I think our preference was to not have 12 Dr. Smith present, you know. 13 COMMISSIONER STEPHEN GOUDGE: I take it 14 these concerns that were starting to emerge, Dr. 15 Chiasson, were about his lack of forensic ability. And 16 so putting him in a forum, the OCCO, where he would be 17 working in a more collaborative way with forensic 18 pathologists, would be an improvement? 19 DR. DAVID CHIASSON: Yes, I mean clearly 20 the Sharon case was issues of -- of forensic pathology 21 and -- and as was the -- the Nicholas matter. So -- and 22 they were -- they were forensic, as opposed to pediatric 23 pathology. 24 And -- and you're absolutely correct that 25 it was a way to -- to stre -- remediate, if you will, the


1 -- his forensic view. 2 It's -- it's not unlike what had proposed 3 with Dr. Johnstone earlier on. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 6 CONTINUED BY MS. LINDA ROTHSTEIN: 7 MS. LINDA ROTHSTEIN: And indeed, just 8 following up on what you've said, Dr. Chiasson, am I 9 right that shortly after this meeting in March, on April 10 the 12th of 1999 you authored a memo on forensic 11 pathology pitfalls -- you'll find that at Tab 52 -- that 12 arose, we're told by Dr. Young, very much as a reaction 13 to the concerns that had been raised in the Nicholas 14 case? 15 Is that your recollection as well? 16 DR. DAVID CHIASSON: Yes. Certainly 17 limits of expertise was -- consultations, formal versus 18 informal, were -- were both issues arising out of the 19 Nicholas matter. 20 MS. LINDA ROTHSTEIN: That's 07950 -- 21 wait, 007950, sorry. 22 DR. DAVID CHIASSON: The first issue, a 23 preliminary cause of death opinion, is actually more 24 related to the matter with Dr. Johnstone. I mean that 25 was kind of the index case for -- for that as opposed to


1 anything to do with Dr. Smith. 2 MS. LINDA ROTHSTEIN: But the limits of 3 expertise portion on the next page, page 2, you believe 4 was very much a response to an objective view of what 5 had, perhaps, led to the outcome of the Nicholas case. 6 Is that what I understand you to say, sir? 7 DR. DAVID CHIASSON: Yes. 8 MS. LINDA ROTHSTEIN: Okay. And Dr. 9 Young says that he never told Dr. Smith that this memo 10 was indeed a reaction to Dr. Charle -- Dr. Smith's work. 11 Did you ever tell Dr. Smith that? 12 DR. DAVID CHIASSON: No. 13 MS. LINDA ROTHSTEIN: Do you think he 14 knew that? 15 16 (BRIEF PAUSE) 17 18 DR. DAVID CHIASSON: I -- I -- looking at 19 it and given what was going on, I would have hoped that 20 he would have realized that, you know, what was going on 21 with the Nicholas case certainly applied to this. But I 22 -- I can't say whether in fact he did. 23 COMMISSIONER STEPHEN GOUDGE: He did not 24 take criticism very well? 25 DR. DAVID CHIASSON: That -- that would


1 have been my impression. I mean I -- I never sat down to 2 criticize him and, you know, see his reaction to it. So 3 I -- I can't -- from my own experience, I really can't, I 4 think, answer that question very... 5 6 CONTINUED BY MS. LINDA ROTHSTEIN: 7 MS. LINDA ROTHSTEIN: Whose idea was this 8 memo? 9 DR. DAVID CHIASSON: This was my memo. 10 This was my -- I -- I basically wrote this memo. I think 11 Dr. Young had some part in, perhaps, editing a thing here 12 or there. Well, actua -- sorry. 13 To be fair, the -- the idea was probably a 14 joint venture, in terms of putting out something that 15 addresses the problems that we're having. I -- I think 16 that's -- that's fair. But I -- it's basically my -- my 17 memo, as far as drafting it and wor -- wording it. 18 MS. LINDA ROTHSTEIN: And you may not 19 know anymore, so forgive me if it's hairsplitting from 20 your perspective, but do you remember, did you go to Dr. 21 Young and say, We ought to write a memo? 22 Or did Dr. Young come to you and suggest 23 it? 24 25 (BRIEF PAUSE)


1 2 DR. DAVID CHIASSON: I don't -- I don't 3 recall. And it may well have been Dr. Young that -- that 4 suggested putting out a memo. It could well have been, 5 I... 6 MS. LINDA ROTHSTEIN: Can we go back to 7 Tab 30 then, because as I understand it, 045476, this is 8 the follow-up meeting that you had to the March 12th 9 meeting with Dr. Becker. 10 And yet at this meeting Dr. Smith is in 11 attendance. Is that right? 12 DR. DAVID CHIASSON: Yes. 13 MS. LINDA ROTHSTEIN: So you're following 14 up the discussions which you had initiated on, again, 15 your proposal for revisioning? 16 DR. DAVID CHIASSON: Yes. 17 MS. LINDA ROTHSTEIN: And it starts out a 18 little strangely, you note: 19 "Didn't expect us, not on his calendar, 20 did meet for thirty (30) minutes." 21 What was the problem? Do you remember? 22 DR. DAVID CHIASSON: Well I don't -- I 23 mean, the problem was, I think, what's expressed there. 24 We -- we attended his office. We had a meeting on our 25 calendars, and that had been set up, you know, in follow-


1 up to the previous meeting in March. 2 And his secretary told us, well, that we 3 weren't on his calendar and -- but he did agree to meet 4 with us. We had a short meeting. 5 COMMISSIONER STEPHEN GOUDGE: That is Dr. 6 Becker? 7 DR. DAVID CHIASSON: That's Dr. Becker, 8 yes. 9 MS. LINDA ROTHSTEIN: And then further 10 down the page, Dr. Chiasson, it reads: 11 "Attached items presented, response 12 muted, question mark, question mark, 13 very negative." 14 Tell us what that indicates as you best 15 recall it. 16 DR. DAVID CHIASSON: Well, the -- the 17 very negative was the impression, and the sort of verbal 18 response was -- was muted. I -- you know, it's a -- 19 there's body language or -- or whatever. I certainly 20 left with the impression that -- that Dr. Becker was -- 21 was not happy about the plans. 22 I -- I left the previous meeting feeling 23 that he understood where we were coming for -- from and 24 that was prepared to work with us to arrive at some kind 25 of solution, within the context of what we were


1 proposing, that the -- that the -- there may be logistic 2 issues, et cetera. 3 But the -- the basic proposal was -- was 4 satisfactory to him. 5 MS. LINDA ROTHSTEIN: What about Dr. 6 Smith? Do you remember what his reaction was by April of 7 '99? 8 DR. DAVID CHIASSON: Well, I -- I don't - 9 - I mean, we -- we had basically told him back in -- in 10 January. And he didn't express any objections at that 11 time. And -- and really, I was unaware of anything 12 developing in -- in the interim. 13 MS. LINDA ROTHSTEIN: Okay. And so at 14 that stage did you think you had Dr. Cairns' support for 15 this proposal? 16 DR. DAVID CHIASSON: Yes, I think I 17 continued to have Dr. Cairns' support, yes. 18 MS. LINDA ROTHSTEIN: And as at that 19 stage in April did you think you had Dr. Young's support 20 for this proposal? 21 DR. DAVID CHIASSON: I did. 22 MS. LINDA ROTHSTEIN: We know Dr. Cairns 23 actually went on a leave of absence starting in about 24 April of 1999 and wasn't back until July, if memory 25 serves.


1 And then it looks to us from the 2 documents, at least, that for the most part nothing much 3 happens until June. And there's a memo from you, Tab 20 4 -- or excuse me, 35, 045494, June 17, '99. 5 DR. DAVID CHIASSON: Sorry, which tab is 6 that? 7 MS. LINDA ROTHSTEIN: Tab 35, the same 8 volume. And this appears to be preparation for a meeting 9 which was to take place in June of 1999. 10 DR. DAVID CHIASSON: Yes. 11 MS. LINDA ROTHSTEIN: And you say: 12 "Please find attached the pediatric 13 medicolegal case distribution proposal 14 presented to Drs. Becker and Smith when 15 Jim Cairns and I met them on April the 16 16th. You will recall that our 17 original proposals, going back to your 18 '98 memorandum, was to have all the 19 pediatric medicolegal autopsies 20 performed at the coroner's office. 21 The proposal now on the table is that 22 pediatric forensic post-mortem 23 examinations will be performed at both 24 the Office of the Chief Coroner and the 25 Hospital for Sick Children according to


1 the attached revised case distribution 2 protocol." 3 And there's indeed quite a detailed 4 schematic drawing which accompanies this memo at 056312. 5 So can you help us, Dr. Chiasson, as to 6 what revisions in your thinking had occurred and what was 7 different about what you were now attempting to put 8 forward? 9 10 (BRIEF PAUSE) 11 12 DR. DAVID CHIASSON: I'm just looking at 13 the -- the sort of triage sheets here. Yes, death 14 outside of Sick Kids, if it appeared to be natural or 15 medical in nature, previously in the -- in the previous 16 model they would have been -- everything outside of Sick 17 Kids would have been sent to the Coroner's Office. 18 In this scheme we have natural deaths 19 could go to the Coroner's Office, or it might go to Sick 20 Kids. They would be triaged by Dr. Smith. If -- if they 21 were felt to be innocuous, no -- no forensic issues, they 22 might well be done -- continued to be done at Sick Kids. 23 MS. LINDA ROTHSTEIN: Okay. 24 DR. DAVID CHIASSON: The nonnatural ones, 25 these would have been the accidental trauma deaths, would


1 be done at -- at the Coroner's Office, as would the 2 homicide and suspicious cases from -- from outside, and 3 as would -- so -- so basically it's just a question of if 4 -- if it appeared to be a natural death outside the 5 hospital, they might well go to -- 6 COMMISSIONER STEPHEN GOUDGE: So the SIDS 7 cases go to Sick Kids as opposed to the OCCO? 8 DR. DAVID CHIASSON: The -- it's 9 possible. If -- if they looked innocuous, they could go 10 to Sick Kids. Certainly the ones, as I indicated, if 11 somebody had congenital heart disease and was -- that 12 sort of thing and died outside and it was a coroner's 13 case, that would go to -- likely go to Sick Kids. So 14 there was a little more flexibility in terms of the 15 natural deaths. 16 17 CONTINUED BY MS. LINDA ROTHSTEIN: 18 MS. LINDA ROTHSTEIN: It's not clear on 19 this diagram to answer the Commissioner's question 20 exactly where the SIDS kids -- SIDS cases fit in this 21 scheme. 22 They have to be triage beyond their 23 identification as SIDS cases, I take it? 24 DR. DAVID CHIASSON: Yes, I -- I think if 25 you look at the triage, the natural and medical, the


1 SIDS-like cases would probably fall in there, unless 2 there was something about the sudden, unexpected death 3 that caused concerns. 4 So you'd have to determine whether the 5 death was suspicious or not. If it wasn't suspicious, 6 even though it was unexplained at this time, it -- as it 7 says, it could go to either Sick Kids or -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. DAVID CHIASSON: -- to the Coroner's 10 Office. Before, they would have all gone to the 11 Coroner's Office. 12 13 CONTINUED BY MS. LINDA ROTHSTEIN: 14 MS. LINDA ROTHSTEIN: And then on the 15 second page of your memorandum to Dr. Young, 045495, you 16 say: 17 "Dr. Becker's response to this proposal 18 at our last meeting was clearly 19 negative. He stated that he needed 20 more time to consider the implications, 21 ramifications, of these proposed 22 changes. 23 I was very much surprised by his 24 response, given that Jim Cairns and I 25 had already outlined this approach to


1 him at a March 12th meeting. At that 2 time I was left with the impression 3 that he understood our position that 4 was -- that there was a need for 5 significant change from the status 6 quo." 7 And you go on to make your case. So, 8 again, at this stage did you believe that you had the 9 support of Dr. Young, as least, in continuing to advance 10 this revision? 11 DR. DAVID CHIASSON: I had no reason not 12 to believe that I had Dr. Young's support at this time. 13 MS. LINDA ROTHSTEIN: All right. 14 COMMISSIONER STEPHEN GOUDGE: And I am 15 still not clear, where did you think Dr. Smith was on the 16 proposal? 17 DR. DAVID CHIASSON: Dr. Smith was still 18 working, doing any homicide, criminally suspicious -- 19 COMMISSIONER STEPHEN GOUDGE: No, but was 20 the for or against the -- 21 DR. DAVID CHIASSON: Oh, where -- again, 22 he wasn't -- I wasn't getting any revised or updated 23 information as to how he was feeling about it. I mean, 24 we were going along and he's -- he seemed to be going 25 along with it.


1 I wasn't getting any objection from him 2 and no voiced objection. 3 MS. LINDA ROTHSTEIN: Yeah. 4 COMMISSIONER STEPHEN GOUDGE: Were you 5 surprised by that? 6 DR. DAVID CHIASSON: Yeah, perhaps a 7 little. I -- frankly, I thought, you know, he would have 8 been more comfortable to continue the status quo, doing 9 cases where he was doing. 10 I wasn't, you know, asking him for his, 11 you know, input. I -- I made a decision that this is the 12 route we were going to go and -- and laying it on the 13 table for him. So I mean, I guess his choice may have 14 been to say, Well, I -- I'm not interested and stop doing 15 pediatric forensic pathology. 16 I mean that would have been his fallback 17 position, I guess, if he really objected to what I was 18 saying. 19 COMMISSIONER STEPHEN GOUDGE: All right. 20 21 CONTINUED BY MS. LINDA ROTHSTEIN: 22 MS. LINDA ROTHSTEIN: Dr. Chiasson, I 23 believe you know that when Dr. Young testified here -- I 24 wish I had the date at my fingertips, Commissioner -- but 25 at page 85 of the transcript he was asked about whether


1 in fact he supported this proposal of yours, and he said: 2 "To my mind I was not in favour at this 3 point in time of simply abandoning and 4 moving the unit from Sick Kids over to 5 the Office of the Chief Coroner for a 6 number of reasons. Part of the 7 visioning initially in the whole unit 8 was that it be -- it be there to 9 produce quality pathology reports, that 10 it be there to allow residents to go 11 through and teach, and that it be there 12 to provide research, as well. 13 What we needed from Sick Kids was we 14 needed their lab, we needed their 15 pathologists, but we also need their 16 laboratories, the access to all the 17 testing that we had. We needed their 18 specialized x-ray equipment, which we 19 didn't have at the Office of the Chief 20 Coroner. In fact we had broken down, 21 thirty (30) year old x-ray machine then 22 at the time and not the money to buy a 23 new one. 24 We needed the radiology consultations, 25 the neuropath consultations, all the


1 things that were available at Sick 2 Kids." 3 And he -- he goes on to identify a number 4 of the other logistical issues and says: 5 "So the unit was an important part of 6 what we were doing, and the funding of 7 it had taken a great deal of work. And 8 I believed it needed fixing, but I 9 didn't want to abandon the unit." 10 And did Dr. Young ever share that view of 11 the world with you at the time, Dr. Chiasson? 12 DR. DAVID CHIASSON: No. 13 MS. LINDA ROTHSTEIN: Were you aware, 14 indeed, of the logistical issues? 15 DR. DAVID CHIASSON: Yes, and they're 16 addressed in the revisioning memo. And certainly they're 17 not addressed in a -- in a solution manner, but they're 18 certainly identified. 19 And -- and I agree with Dr. Young. There 20 were many logistical hurdles that had to be dealt with. 21 MS. LINDA ROTHSTEIN: Dr. Chiasson, you 22 and I have also had the ability to look at some of Dr. 23 Becker's musings on this issue, which, as I understand 24 it, he never shared with you. So you were seeing them 25 for the first time in preparing your evidence, in


1 particular at Tab 33, PFP117786. 2 3 (BRIEF PAUSE) 4 5 MS. LINDA ROTHSTEIN: I realize the 6 hazards of asking any witness to try and put themselves 7 in the position of someone else who's no longer with us 8 and who wrote something that they weren't privy to at the 9 time. 10 But can you assist us at all, Dr. 11 Chiasson, as to how, looking at this, you believe Dr. 12 Becker was approaching this issue that you had raised, if 13 you can? 14 DR. DAVID CHIASSON: Well, I mean I -- I 15 think reading the document, I mean, Dr. Becker is really 16 proposing an alternative to my -- to my proposal. I have 17 never seen this document before. 18 It's -- in a lot of ways I -- I can see 19 where this is coming from. I think the -- Dr. Becker is 20 looking to continue to do pediatric pathololo -- the 21 coroner's cases that are medical that are pediatric in 22 nature would continue to be done at the -- at the 23 hospital. 24 Certainly those individuals who die at the 25 hospital would be autopsied at the hospital under a


1 coroner's warrant, and that they were prepared for -- for 2 a price to continue to provide pediatric autopsy services 3 to the Coroner's Office for cases outside. But this 4 would be basically restricted to medical and pediatric 5 medical deaths. 6 It's not clear, at least as I recall, 7 exactly where the -- the SIDS, sudden unexpected deaths 8 would fall in this -- in this proposal. 9 The other thing that's obvious is that he 10 is proposing, basically, the dissolution of the pediatric 11 forensic pathology unit as it's been defined. 12 And the other thing that I -- I noted was 13 the fact that pathologists employed by the Hospital for 14 Sick Children -- and this is on page 7 of the document -- 15 would not be performing autopsies at the Coroner's 16 Office, which obviously would be a serious issue as to 17 Charles and where -- where he would work and how he would 18 work in the context of -- of this proposal. 19 MS. LINDA ROTHSTEIN: In other words, it 20 would suggest that the hospital wouldn't have been 21 prepared to continue his employment if he was indeed 22 committing 50 percent of his time to work at your office. 23 Is that the inference you draw from that? 24 DR. DAVID CHIASSON: I think that's 25 clearly the inference to be drawn.


1 MS. LINDA ROTHSTEIN: All right. There 2 was a meeting on June the 23rd, '99, thanks to your 3 careful note taking, at Tab 37. Dr. Young was in 4 attendance, Dr. Becker, Dr. McGibney (phonetic). 5 DR. DAVID CHIASSON: It -- it's actually 6 Mr. McGibney. 7 MS. LINDA ROTHSTEIN: Okay. 8 DR. DAVID CHIASSON: He's the -- he's the 9 -- the VP who was responsible -- at the hospital that was 10 responsible for laboratory services as well as some other 11 portfolios. But he was basically Dr. Becker's 12 administrative boss. 13 MS. LINDA ROTHSTEIN: So that's 044187. 14 And what, if any, resolution was reached at that meeting? 15 DR. DAVID CHIASSON: Well, as indicated 16 here, cases where death occurs outside of Sick Kids, non- 17 natural ones would go to OCC, natural would go to -- it's 18 kind of along the models that I proposed in -- in April 19 as I'm reading this document. 20 The natural ones would tend to go -- well 21 it could go either direction but it could go to Sick 22 Kids. 23 MS. LINDA ROTHSTEIN: Dr. Chiasson, 24 you'll note that in the tab before that, there's a 25 proposal which Dr. Becker authored, dated that very same


1 day, June 23, '99. It's 117889, entitled "Pediatric 2 Forensic Pathology". 3 I'm wondering if you can tell us whether 4 that was presented at that meeting, as you recall it? 5 DR. DAVID CHIASSON: No. The document 6 wasn't presented at the meeting. Some of the -- some of 7 the concepts are -- are arguably related to what we 8 discussed. 9 And -- and I should say that as I 10 understand -- at this meeting there's no sense of dis -- 11 dissolution of the Pediatric Forensic Pathology Unit. 12 That wasn't on -- broached as a area of discussion. 13 MS. LINDA ROTHSTEIN: So what happened to 14 your idea? 15 DR. DAVID CHIASSON: Basically in 1999 it 16 was my horrible year. I think the Queen had one of those 17 while she was -- a few years ago. That was my horrible 18 year. I -- I lost three (3) of my staff pathologists 19 within a six (6) to nine (9) month period and -- and 20 therefore we were back to almost square-one. 21 I -- I still had Dr. Rose working as a 22 salaried staff pathologist. I was turning -- had to go 23 back to -- with cap in hand to my fee-for-service 24 pathologist who I had gradually let go over a number of 25 years. And I'm very thankful to all those individuals


1 who actually didn't kick me out the door when I came 2 knocking to -- to have them come back and -- and help out 3 the -- the Unit, in order to get the work -- the basic 4 they -- they worked on. 5 MS. LINDA ROTHSTEIN: Commissioner, I had 6 sort of promised many around, including Dr. Chiasson that 7 it's been a long week and that I would be able to 8 complete my examination even if we ended early today. 9 So I'm going to live up to that 10 undertaking if it's all right with you -- 11 COMMISSIONER STEPHEN GOUDGE: Sure. 12 MS. LINDA ROTHSTEIN: -- and with Dr. 13 Chiasson and we'll continue this story about the 14 challenges of staffing your Unit and take you, 15 Commissioner, to some of the memorandum that fall out 16 from what Dr. Chiasson has just, said on Monday when we 17 reconvene. 18 COMMISSIONER STEPHEN GOUDGE: That's fine 19 then. We'll rise until 9:30 Monday. Have a good weekend 20 and come back recharged. 21 22 (WITNESS RETIRES) 23 24 --- Upon adjourning at 4:00 p.m. 25


1 2 3 Certified correct, 4 5 6 7 _________________ 8 Rolanda Lokey, Ms. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25