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 10th, 2007 25

2
  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           )
 12  
 13  Jane Langford        (np) )     Dr. Charles Smith
 14  Niels Ortved         (np) )
 15  Erica Baron          (np) )
 16  Grant Hoole               )
 17   
 18  William Carter       (np) )     Hospital for Sick Children
 19  Barbara Walker-Renshaw(np) )
 20  Kate Crawford        (np) )
 21  
 22  Paul Cavalluzzo      (np) )     Ontario Crown Attorneys'
 23                                   Association
 24  
 25

3
  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              )     Sherry Sherret-Robinson and
 10  Phil Campbell             )     seven unnamed persons
 11  
 12  Peter Wardle              )     Affected Families Group
 13  Julie Kirkpatrick     (np) )
 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      (np) )     of Toronto and Nishnawbe
 23  Sheila Cuthbertson    (np) )      Aski-Nation
 24  Julian Falconer      (np) )
 25

4
  1                 APPEARANCES (cont'd)
  2  
  3  Suzan Fraser       (np)   )     Defence for Children 
  4                             )     International - Canada
  5  
  6  William Manuel            )     Ministry of the Attorney
  7  Heather Mackay     (np)   )     General for Ontario
  8  Erin Rizok          (np)   )
  9  Kim Twohig          (np)   )
 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, Resumed 4 5 Continued Examination-In-Chief by Ms. Linda Rothstein 6 6 Cross-Examination by Ms. Luisa Ritacca 162 7 Cross-Examination by Mr. Phillip Campbell 220 8 9 10 11 12 13 Certificate of transcript 272 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: Good 6 morning. 7 Ms. Rothstein...? 8 MS. LINDA ROTHSTEIN: Commissioner. 9 10 DAVID ALEXANDER CHIASSON, Resumed 11 12 CONTINUED EXAMINATION-IN-CHIEF BY MS. LINDA ROTHSTEIN: 13 MS. LINDA ROTHSTEIN: Dr. Chiasson. 14 COMMISSIONER STEPHEN GOUDGE: Good 15 morning, Ms. Rothstein. 16 MS. LINDA ROTHSTEIN: Commissioner, Dr. 17 Chiasson, you'll remember that when we left off on Friday 18 Dr. Chiasson had told us about the revisioning proposal 19 that he had put forward in the Spring of 1999, the 20 discussions which he'd had with Dr. Becker about that 21 proposal and others, and had begun to explain, 22 Commissioner, that in the end that proposal did move 23 forward, at least in part, because of the staffing issues 24 which had arisen at the Toronto Pathology Unit. 25 And I think we stopped at that point, if I

1 recall correctly, is that right, Dr. Chiasson? 2 DR. DAVID CHIASSON: It sounds right, 3 yes. 4 MS. LINDA ROTHSTEIN: All right. So if 5 you would good enough, sir, to pick up Volume I, Tab 58, 6 129428. This is a memo which you wrote to Dr. Young on 7 June the 16th, 1999. 8 Is that right? 9 DR. DAVID CHIASSON: Correct. 10 MS. LINDA ROTHSTEIN: And in it you say: 11 "Please find attached Dr. Martin 12 Bullock's letter of resignation that 13 indicates he will be leaving the 14 Forensic Pathology Unit on August the 15 6th, '99." 16 He had came in 1997, as I recall it. Is 17 that right -- 18 DR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: -- Dr. Chiasson? 20 This resignation follows closely Dr. Queen's resignation 21 in the spring. And again, Dr. Queen had arrived in 1996? 22 DR. DAVID CHIASSON: Correct. 23 MS. LINDA ROTHSTEIN: 24 "At the same time Dr. Deck will be on 25 an extended medical leave of absence

1 beginning in mid-July, although efforts 2 are underway to replace both Dr. Queen 3 and Dr. Bullock. I believe we will be 4 fortunate if we can fill one (1) of 5 these positions by this Fall. In order 6 to deal with this staffing shortage it 7 will be necessary to again turn to part 8 time fee-for-service pathologists to 9 perform the autopsies. I will need to 10 dedicate an increased percentage of my 11 time in the autopsy room performing 12 and/or supervising cases." 13 Stopping there for a moment, Dr. Chiasson, 14 how much of the work of the Unit was being done by fee- 15 for-service pathologists as of June 1999? 16 DR. DAVID CHIASSON: Well, Dr. Queen had 17 -- so we're -- we're in a stage of transition at this 18 point. When I had the full -- the four (4) staff 19 pathologists, virtually all of the cases -- I think there 20 may have been still one (1) part time pathologist having 21 some work to do -- but -- and certainly the majority of 22 the cases were being done by staff pathologists. 23 So as Dr. Queen leaves, I -- I have to go 24 back and start re-recruiting my fee-for-service 25 pathologists into the caseload in order to get the

1 caseload done. 2 MS. LINDA ROTHSTEIN: And do you recall, 3 when you had the full compliment of staff pathologists, 4 what percentage of your time you were devoting to the 5 autopsy room performing autopsies? 6 DR. DAVID CHIASSON: I -- I tended to do 7 plus or minor a hundred (100) cases a year, personally; a 8 fair amount of those were done on weekends, but some 9 during the -- the weekdays. This is an order to maintain 10 my own sense of comfort and -- and expertise, I felt I 11 needed to do that, as well. But about a hundred (100) 12 cases a year I was doing. 13 What percentage of my time that was taking 14 up, it's hard to calculate. Maybe a quarter of my time. 15 MS. LINDA ROTHSTEIN: Right. But I take 16 it anything much more than a quarter of your time would 17 indeed start to impinge on your ability to do the 18 management, administration and supervision that was 19 attendant on your position? 20 DR. DAVID CHIASSON: Well, I think I 21 could argue that even doing the quarter time was -- was 22 cause -- cause -- was an impingement on my other 23 responsibilities, but I felt I had to -- I had to 24 maintain my hand in doing cases. That was -- that was 25 important especially given that when I started I wasn't -

1 - it's not like I had thirty (30) years experience under 2 my belt, at that time. 3 MS. LINDA ROTHSTEIN: You continue: 4 "This will no doubt impact on my other 5 responsibilities, some of which will 6 have to be curtailed in order to ensure 7 that the unit continues to function in 8 an effective and efficient manage -- 9 manner." 10 What were you envisioning you would have 11 to stop doing in order to deal with the need to actually 12 perform more autopsies? 13 DR. DAVID CHIASSON: I'm not sure exactly 14 what I was thinking of back then. A lot of my respons -- 15 I mean, I had educational responsibilities; they -- they 16 might of had to be cun -- curtailed; lectures to police, 17 colleges; arguably, perhaps some of the administrative 18 meetings. I attended regularly all the regional coroner 19 meetings, for example. 20 I -- I would have been hesitant to -- to 21 stop that. And probably the last -- I mean, the most 22 important, the ongoing quality assurance review of PM 23 reports. That would have been something that I would 24 have kept in place regardless. 25 So it probably would have been some of the

1 softer -- arguably softer things such as education, pure 2 administrative stuff outside of forensic pathology. 3 MS. LINDA ROTHSTEIN: Right. And then 4 you continue in the third paragraph: 5 "As troubling as the acute staffing 6 shortage is, I'm even more concerned 7 about the long-term future of this 8 forensic pathology unit. Why Doctors 9 Queen and Bullock have resigned after 10 such short periods of employment with 11 the Coroner's Office needs to be very 12 seriously addressed. I have carried 13 out exit interviews with both of them, 14 certainly personnel issue -- personal 15 issues [excuse me] played a role in 16 their decisions. It is, however, 17 apparent that both felt that their 18 specialized expertise in forensic 19 pathology and death investigation was 20 not fully appreciated and/or utilized 21 within the office. Having trained to 22 be medical examiners, I believe that it 23 was frustrating for them to be 24 relegated to be simply an autopsy 25 technician as one of them termed it."

1 Now, help us with that, Dr. Chiasson. 2 What was the concern of Dr.'s Bullock and Queen about the 3 work that they had been asked to do with your unit? 4 DR. DAVID CHIASSON: Well, both had 5 trained in medical examiner's office; it happ -- happened 6 to be Baltimore in both cases, where, I think as we've 7 explained, a medical examiner is in charge of the death 8 investigation and certification of death and clearly is 9 the -- is the top of the pecking order, if you will. 10 In the case of coming into a coroner 11 system the coroner, by definition, is the one who's 12 charged with much of the primary oversight of -- of the 13 death investigation decisions regarding autopsies, for 14 example, being one (1) area. 15 And I think that it's important to put 16 this in a perspective in a way that, in fact, this was 17 the way it was back in the '80s and '90s, was the 18 pathologist was there, they were fee-for-service, part- 19 time; they were there to do the autopsies. 20 They were in some ways autopsy 21 technicians. They certainly provided a report and often 22 did very good work in doing that and did attend court as 23 necessary. But -- but clearly the -- their function was 24 within the autopsy room, and they did not generally play 25 any bigger role. And, in fact, they're part-time; this

1 is something they're trying to do on top of everything 2 else they do. It's not their primary responsibility. 3 So now we have individuals who are -- this 4 is their career choice, this is their career plan -- and 5 so I think there was a -- a difficulty for the Coroner's 6 Office and the coroner's system, if you will, to adjust 7 to having individuals like this. And although there were 8 similar individuals in some of the units, this was, in 9 fact, the -- you know, they were part and parcel of the 10 Coroner's Office as employees. 11 So it was a very different structure, if 12 you will and -- and the -- the role they played. And I - 13 - I think there was a difficulty in -- in adjusting -- 14 for the Coroner's Office as an organization, to adjust to 15 what -- how to deal with these particular well trained 16 pathologists who had expertise beyond the autopsy room. 17 MS. LINDA ROTHSTEIN: Dr. Chiasson, 18 you've been using the past tense in answering that 19 question. 20 Do I infer from what you've said that you 21 in the last eight (8) years have seen some changes with 22 respect to how full-time forensic pathologists are 23 engaged by the coroner's system, or not? 24 DR. DAVID CHIASSON: Well I think in 25 part, I mean, my role, I didn't feel for my part this was

1 as -- as a major issue. I did feel I was part of the 2 team of death investigation. I was not in every case 3 obviously, but on many cases consulted as to how to 4 approach it. 5 And my role obviously was a little 6 different being the Chief Forensic Pathologist; I had 7 attended the administrative meetings of the Coroner's 8 Office on a regular basis. So I -- this was more of any 9 issue for my -- my staff pathologists then for me 10 personally. 11 Secondly, has it changed? I've always -- 12 even when I stopped doing -- stopped -- resigned from the 13 Coroner's Office subsequently, I -- I think I always 14 maintained a good working relationship with the coroners. 15 I think I was treated in a way that extended beyond my 16 services in the autopsy room. Now in part I'm -- I'm the 17 exception, because I was the -- formally the Chief 18 Forensic Pathologist. 19 Has it changed with the individuals who 20 are in there now? Dr. Pollanen is probably a better 21 person to -- to answer that question. I mean still, a 22 large proportion of the autopsies at the Coroner's Office 23 are performed by fee-for-service pathologists on a part- 24 time basis. They all have their own jobs. 25 So there is -- there is this sort of --

1 there are differences in regards to that. 2 MS. LINDA ROTHSTEIN: Okay. 3 DR. DAVID CHIASSON: I suspect that -- 4 that there are changes, there have been improvements, but 5 as I said, Dr. Pollanen is a better person to address 6 that specifically. 7 COMMISSIONER STEPHEN GOUDGE: Can I ask 8 you, Dr. Chiasson, was the concern or was a part of the 9 concern of doctors Queen and Bullock, that they wanted to 10 be more involved in the death investigation team in the 11 cases where they had done the autopsies? 12 DR. DAVID CHIASSON: Yes, yes. 13 COMMISSIONER STEPHEN GOUDGE: And is that 14 feasible in a coronial system? 15 DR. DAVID CHIASSON: I think it is. 16 COMMISSIONER STEPHEN GOUDGE: Elaborate 17 that a little bit. 18 DR. DAVID CHIASSON: Well, I mean, partly 19 and subsequently, a forensic pathology -- I think it was 20 Issues Committee was created, where I was trying to -- to 21 expand the role of the forensic pathologist within the 22 coroner's system. 23 So in that time we were looking at things 24 such as scene attendance. It was not part of the usual 25 mandate of a --

1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID CHIASSON: -- pathologist to 3 attend a scene. 4 COMMISSIONER STEPHEN GOUDGE: So scene 5 attendance is an obvious example? 6 DR. DAVID CHIASSON: That's an obvious 7 example of where -- and -- and the individuals were 8 talking about that are -- my forensic pathologists were 9 very well equipped to attend scenes, in selected cases; 10 I'm not suggesting every case. 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. DAVID CHIASSON: So that would be one 13 (1) example. And then the other thing I looked at in 14 this Committee was the issue of whether in fact the 15 forensic pathologists -- the select individuals who are 16 trained in forensic pathology -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID CHIASSON: -- this is their 19 career path, not part-time people, et cetera, but that 20 they would have an opportunity to in fact render a 21 opinion as to manner of death, which is not part of the 22 general responsibilities of a pathologists in the coroner 23 system; and that they would -- there would be a form, and 24 in addition to rendering an opinion as to cause of death, 25 they would render an opinion as to manner of death.

1 And if there was some discrepancy between 2 their opinion and the Coroner's Office -- coroner's 3 opinion, that could be looked at, you know, by the 4 hierarchy as to what issues are here and -- and resolve. 5 But at least it gave them a sense that 6 they're doing more then simply doing an autopsy and 7 rendering a cause of death opinion. 8 COMMISSIONER STEPHEN GOUDGE: And would 9 the opinion about manner of death be derived from the 10 evidence they learned in the autopsy room or would their 11 information basic stand as it does for the coroner to 12 circumstantial evidence around -- 13 DR. DAVID CHIASSON: Well, clearly it's 14 important for anyone rendering a manner of death opinion 15 to have the full range of investigative information, so 16 it -- certainly the pathologist is provided with often 17 much of that in order to render an opinion. And manner 18 of death is -- is in most cases not a problematic issue. 19 You don't need a large volume of information plus your 20 autopsy findings. 21 But in those cases where it did extend, it 22 -- it would -- I would expect that the pathologist, the 23 forensic pathologist in that case would be -- would be 24 made available to them, the whole range of information, 25 especially if there was something complex, controversial.

1 COMMISSIONER STEPHEN GOUDGE: They 2 wouldn't gather it, they'd just be given it? 3 DR. DAVID CHIASSON: They would -- they 4 would be given it. They'd have the same information that 5 the coroner would have. 6 COMMISSIONER STEPHEN GOUDGE: Does that 7 duplicate the coroner's function, at least to the extent 8 of manner of death? 9 DR. DAVID CHIASSON: It does duplicate 10 the function, yes. As I said, most of the time, you 11 know, the issue would be very straightforward. What it 12 would -- and -- and perhaps you could argue it's 13 redundant, but at the same time, I'm trying to make my 14 pathologists -- my forensic pathologists, who are trained 15 in both cause and manner of death determinations, to -- 16 to make it -- make them able to function across the -- 17 this -- this entire spectrum. 18 So, this is -- I -- I thought that was an 19 important thing for -- for them to do, regardless of a 20 bit of redundancy. But where it would be particularly 21 important are in those difficult cases where you have the 22 path -- the coroner may -- may be -- limited experience 23 in -- in terms of this. In many of the difficult cases, 24 the decision making really went from the investigative 25 coroner to a regional coroner level and some cases, up to

1 the Deputy Coroner, where these cases were -- were 2 difficult. 3 So I'm -- I'm just saying, give the 4 forensic pa -- an opportunity to be part of that -- that 5 team. And that's -- that's where I think it would have 6 been valuable to -- for the forensic pa -- are those 7 difficult cases. 8 COMMISSIONER STEPHEN GOUDGE: Okay. Just 9 switching gears for a minute: Was income part of the 10 reason for these two (2) leaving? 11 DR. DAVID CHIASSON: Yes. Dr. -- Dr. -- 12 COMMISSIONER STEPHEN GOUDGE: Sorry, are 13 we getting into that, Ms. Rothstein? 14 MS. LINDA ROTHSTEIN: Yeah, you will see 15 some -- some discussion of that in some -- 16 COMMISSIONER STEPHEN GOUDGE: Okay, well, 17 let me leave that then -- 18 MS. LINDA ROTHSTEIN: -- subsequent 19 memos. 20 COMMISSIONER STEPHEN GOUDGE: -- and you 21 can come to it when -- 22 MS. LINDA ROTHSTEIN: Yes, all right. 23 24 CONTINUED BY MS. LINDA ROTHSTEIN: 25 MS. LINDA ROTHSTEIN: So turning, then,

1 to your last paragraph on that page, you say: 2 "For the past year or so, I, too, have 3 been feeling increasingly frustrated 4 with aspects of my position. I have 5 now just completed my fifth year of 6 service and, therefore, would very much 7 appreciate the opportunity to formally 8 reevaluate with you my role as Chief 9 Forensic Pathologist." 10 What -- what were the frustrations you 11 were referring to there, Dr. Chiasson? 12 DR. DAVID CHIASSON: Well, certainly, 13 this staffing issue was a major frustration and I think a 14 theme of what I'd like to try to convey to the Commission 15 is that -- and maintain -- that the Toronto Forensic 16 Pathology Unit, to me, is a core. It's -- it's the trunk 17 of the pathology service within the Province and if the 18 trunk isn't -- isn't intact, if -- if there's 19 deficiencies there, it's going to be hard to -- to 20 blossom out as -- as a -- as a full-grown system. 21 So, this -- this was a major, major 22 concern in my mind. We're -- we're taking several steps 23 forward over a number of years and now we're going 24 backwards to where we were before. 25 So, this was -- you know, this was my

1 number 1 frustration. I think there were other 2 frustrations in dealing with the -- the other units, as 3 we've talked about, to some extent. That would -- that 4 would have been another level of frustration in terms of 5 the relationships there. 6 MS. LINDA ROTHSTEIN: All right. And, 7 indeed, you asked to meet with Dr. Young. As I 8 understand it, you did, on June 23rd as -- or rather -- 9 yes, on June 23rd. If we look at your memo dated June 10 30th, 1999 at Tab 24. It's 129431. 11 DR. DAVID CHIASSON: Yes. 12 MS. LINDA ROTHSTEIN: You say: 13 "Thank you for meeting with me. I hope 14 that you found it as productive as I 15 did. To ensure that we are both on the 16 same wavelength, allow me to briefly 17 review the salient elements of our 18 discussion, as I understood them. 19 You appreciate the level of my 20 frustration as it relates to my current 21 administrative status with the Office 22 and are willing to effect changes to 23 address my concerns. Most importantly, 24 you are willing to support coroners 25 appointments for both myself, as the

1 Deputy Chief level and the Office's 2 salaried staff forensic pathologists. 3 Concurrently, you are agreeable to my 4 assuming a greater hands-on 5 administrative budgetary role as it 6 relates to medicolegal autopsy services 7 across the Province." 8 So, what were your concerns about the 9 limits on your role at that time, Dr. Chiasson? 10 DR. DAVID CHIASSON: Well, there's two 11 (2) things I -- I refer to here. 12 One (1) is in terms of getting coroners 13 appointments for myself and for my salaried staff 14 pathologists. And this -- again, we're dealing with a -- 15 I'm not talking about part-time pathologists and I'm not 16 talking about pathologists outside of the -- the 17 Government, if you will. 18 But these individuals, I thought if you 19 could get them appointed them as coroner -- and there's 20 no de facto reason not to have them appointed as coroner 21 -- that that would again bring together -- bring them 22 into the family, if you will -- the coroners' family, in 23 a more concrete manner. I thought that was -- that was 24 important. 25 The budgetary responsibility. It's --

1 it's kind of strange because I'm reading this in 2 retrospect, I -- I think there's a -- with a little more 3 experience under my belt, yeah, I'm -- I'm struck with 4 the idealism that -- at the same time I'm having these 5 major problems, but we're going to push ahead regardless. 6 And that, I think it was partly a sense that I -- this -- 7 this is the way I was planning that things might evolve 8 and I'm going to push forward, regardless of the fact 9 that I'm kind of being pulled back by -- by the realities 10 of the situation. 11 So the -- the issue about administrative 12 budget, I -- I saw that the Chief Forensic Pathologist 13 should have a -- a responsibility for overseeing forensic 14 pathology at the -- across the Province. And at some 15 level -- and I'm not saying that I would spend all my 16 time with -- with budgets, obviously, and dealing with 17 things on the line-to-line basis -- but that I would some 18 sense of where the money for forensic pathology is being 19 spent, how it's being spent, and -- and have more of role 20 in that, and I -- at this time I had no sense of -- of 21 that at all. 22 MS. LINDA ROTHSTEIN: And what did you 23 hope to achieve by it -- being appointed as a coroner? 24 DR. DAVID CHIASSON: Well, as I said, it 25 was partly to -- we were basically hiring individuals

1 trained as medical examiners who were not given any kind 2 of statutory responsibility; as we've heard many times, 3 pathologist is not even mentioned in the Coroner's Act. 4 I did not see them going out and functioning as coroners 5 in terms of investigation; we had coroners to do that. 6 The primary responsibility still would be within the 7 autopsy room. 8 So it was more of a philosophical sense 9 that they're -- they're tied in together. I -- I could 10 see in cases where they might go to a scene and might 11 assume responsibility for a case from -- from an 12 investigation point of view; that -- that might be 13 something down the road -- maybe yes, maybe no. But it 14 was more, again, a bringing together of the pathologist 15 into the coronial system in -- in a concrete manner. 16 And as far as myself, again, I think it 17 was important that -- that the Chief Forensic Pathologist 18 again be seen as part in parcel of -- of the Coroner's 19 Office, and that the notion that in fact a forensic 20 pathologist could become the Chief Coroner was kind of 21 implicit in this. 22 I had no designs on Dr. Young's job at 23 this time -- Dr. Young was still quite -- quite young; 24 he's only a few years older than I am -- and that wasn't 25 my intent here. But it at least gave the impression

1 whoever came behind me and whoever I hired that at least 2 there's the sense that, you know, a forensic pathologist 3 could move on and become Chief Coroner. 4 MS. LINDA ROTHSTEIN: In terms of the 5 actual work that you were doing on individual cases, were 6 you contemplating that this would allow you to render 7 manner of death determinations, as well as cause of death 8 determinations? 9 DR. DAVID CHIASSON: Well, it would have 10 been part of that. I mean it logistically might have 11 created a little bit of a problem with two (2), you know, 12 appointed coroners rendering different opinions, but to 13 me that was a quality control sort of function. The -- 14 it was very common that a investigating coroner would 15 render an opinion and the regional coroner would overrule 16 him based on his experience and his knowledge of the 17 case. 18 So the idea that an investigating coroner 19 made a determination of manner of death wasn't something 20 that was carved in stone. So, in fact, if you did have 21 different opinions that ultimately you're trying to -- to 22 do the best job you can, and if you have two (2) people 23 rendering an opinion and they happen to be different, so 24 let's have -- let's look at this case in some detail; 25 let's get the regional coroner involved, which he would

1 normally be anyway; and in some cases maybe get Deputy 2 Chief Coroner, get the Chief Forensic Pathologist 3 involved so that ultimately you have the best possible 4 answer to the -- to a given case. 5 I -- so it was another form of quality 6 control, not only from the pathologist's point of view, 7 but also from the coroner's point of view. 8 COMMISSIONER STEPHEN GOUDGE: Can I just 9 ask a couple of question, Ms. Rothstein? 10 First of all, I take it your contemplation 11 wasn't that the staff pathologists, once appointed 12 coroners, would be the investigating coroner on a 13 specific death investigation? 14 DR. DAVID CHIASSON: No, that -- that 15 wasn't my intent, no. 16 COMMISSIONER STEPHEN GOUDGE: So that 17 there would be on those cases two (2) coroners; 1) the 18 investigating coroner and 2), the staff pathologist who 19 would be also classified as a coroner and could therefore 20 render a manner of death opinion. 21 DR. DAVID CHIASSON: No, I didn't see as 22 two (2) coron -- I mean clearly the investigating coroner 23 has his responsibility. The forensic pathologist would 24 still -- you know, primary responsibility was to perform 25 the post-mortem examination, render an opinion as to --

1 to cause of death, but as well, render an opinion based 2 on the information he as to manner of -- of death. 3 The -- you know, I was appointed 4 eventually a -- a coroner. I still have my badge, I 5 still am a coroner, although I'm inactive in -- in that 6 sense and that's -- that's fine. I -- I didn't see them 7 as taking over the coroner's responsibility. 8 It wasn't -- that wasn't my intent in 9 doing that. And it was as much a symbolic effort on my 10 part as a, you know, practical one of, you know, we're 11 going to take over the -- the coroner system. That -- 12 that wasn't the intent and I think that's -- that's -- 13 COMMISSIONER STEPHEN GOUDGE: It would of 14 sort of legally legitimize the forensic pathologist 15 providing an opinion on manner of death, in a sense? 16 DR. DAVID CHIASSON: In a sense, yes. 17 COMMISSIONER STEPHEN GOUDGE: Yes. And 18 was your sort of initiative in that direction -- I mean, 19 I take it, it was partly driven by finding ways to 20 increase the job satisfaction for these positions that 21 you viewed as being very important? 22 DR. DAVID CHIASSON: Yes. 23 COMMISSIONER STEPHEN GOUDGE: But was it 24 also -- I mean, I get the sense, in part, that it was 25 your view that in some way this provides a better quality

1 of ultimate determination of manner of death, to add to 2 the input, in effect, that the ultimate decision will 3 receive? 4 DR. DAVID CHIASSON: I think so -- 5 COMMISSIONER STEPHEN GOUDGE: Is that a 6 fair...? 7 DR. DAVID CHIASSON: I think that's very 8 fair, Mr. Commissioner. It's -- if you think about it 9 and some -- I mean, the -- the theoretical possibilities 10 that the investigating coroner, who could have very 11 limited experience in a case be rendering the manner of 12 death, and the forensic pathologist with much more formal 13 training and experience, having a different notion about 14 the manner of death but somehow not be able to -- to 15 express that in any formal -- formal way. 16 And as I said to Ms. Rothstein, I mean, to 17 me ultimately the -- we're trying to -- to have the best 18 result and the best result is input from whoever can 19 provide the -- the information. 20 COMMISSIONER STEPHEN GOUDGE: Implicit in 21 that is -- let me ask it as a question -- is it your view 22 that it is often difficult to draw a bright line between 23 an opinion about cause of death and an opinion about 24 manner of death, that those often shade into each other? 25 Does that reflect a view that you hold for

1 certain cases? 2 DR. DAVID CHIASSON: Certainly, for -- 3 for a group of cases and we're often -- you know, is it 4 undetermined, is it accidental, is it suicidal, or in 5 some cases, is it a homicidal death? I mean, there -- 6 there can be shades of -- of gray, certainly and -- and 7 those are the cases I think that are -- they're most 8 challenging within any death investigation system. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 Thanks, Ms. Rothstein. 11 12 CONTINUED BY MS. LINDA ROTHSTEIN: 13 MS. LINDA ROTHSTEIN: Commissioner. Dr. 14 Chiasson, would you look at Tab 59 and 60, because they 15 appear to be similar memos written to Dr. Young by you. 16 One (1) dated July 16, '99, the other August 30th, '99. 17 And tell me whether the memo at Tab 59 is 18 a draft of what became the memo at Tab 60 or whether they 19 were both sent? Can you help us with that? 20 DR. DAVID CHIASSON: They seem to be very 21 similar memos. So one (1) does seem -- I -- I suspect 22 the one -- the latter dated one, August 30th, is actually 23 the one that was forwarded. It looks like I've -- I've - 24 - I was going to add some information about the Public 25 Sector Salary Disclosure Act -- Act as it related to how

1 much pathologists were getting paid. 2 MS. LINDA ROTHSTEIN: Right. 3 DR. DAVID CHIASSON: So there's probably 4 a little more additional information that was plugged in, 5 but the rest of it looks very -- very similar. 6 MS. LINDA ROTHSTEIN: Okay. So let's 7 turn to Tab 60 then and it's 129435. August 30th, '99 to 8 Dr. Young, you say: 9 "Further to our recent discussion, I 10 wish to draw your attention to the 11 following information, which I've 12 gleaned through Ministry of Finance's 13 1998 Public Sector Salary Disclosure 14 Act. The process of recruiting two (2) 15 forensic pathologists for the unit here 16 at the Coroner's Office is not going 17 well. And I'm becoming increasingly 18 pessimistic that we will be able to 19 attract even one (1) appropriate 20 candidate. In order to understand why 21 this is so, the following factors have 22 to be considered. 23 A) There is clearly a shortage of 24 suitably trained and/or experienced 25 forensic pathologists in this country.

1 The initiation of our forensic 2 pathology fellowship program here in 3 Toronto begins to address this issue in 4 the long-term, but is not the answer to 5 our current staffing crisis." 6 In what stage was the Forensic Pathology 7 Fellowship Program back in August 1999? 8 DR. DAVID CHIASSON: Well I think we had 9 hired, about this time, probably in July, our first 10 forensic pathology fellow and in fact our first and only, 11 at least Canadian trained forensic pathology fellow. 12 MS. LINDA ROTHSTEIN: And who was that? 13 DR. DAVID CHIASSON: Michelle -- this is 14 awful... 15 MS. LINDA ROTHSTEIN: We'll find out, and 16 you'll let us know -- 17 DR. DAVID CHIASSON: Yes. She's -- she's 18 now a pathologist in -- in Oshawa -- Sapp, Dr. Sapp, yes. 19 MS. LINDA ROTHSTEIN: All right. 20 DR. DAVID CHIASSON: S-A-P-P. 21 MS. LINDA ROTHSTEIN: And then you say: 22 "...the job market for both general and 23 anatomic pathologists has recently 24 opened up with the retirement of many 25 older laboratory physicians."

32
  1                 So that hearkens back to what you told us
  2  on Friday which was there had actually been a very small
  3  market for pathologists in Toronto and it looks like that
  4  had changed since you had initially come on as the Chief
  5  Forensic Pathologist.
  6                 Am I reading that correctly?
  7                 DR. DAVID CHIASSON:   Yes.  Pathology --
  8  and it had been forewarned for a while, was -- it was --
  9  had gone from gray to white to pathologists actually
 10  dying out.  Pathologists would not retire, was -- and --
 11  and that's partly because the -- the -- a lot of
 12  different reasons, but they would continue on, and so
 13  they were actually keeping positions tied up, if you
 14  will.  
 15                 And they were able to function -- because
 16  of all their experience they were able to function at a
 17  much more efficient level than a junior person.  But
 18  eventually they did retire, so it did open up some
 19  positions.
 20                 MS. LINDA ROTHSTEIN:   
 21                   "At the same time the number of
 22                   residents entering training programs in
 23                   pathology laboratory medicine has
 24                   decreased.  The supply of pathologists
 25                   will, therefore, not be able to meet

1 the demand in the near future. See 2 Appendix A." 3 And I can tell both you, Commissioner and 4 Dr. Chiasson, that we don't seem to be able to locate 5 that in our database. Maybe someone will, but presumably 6 you had there some kind of chart, Dr. Chiasson, that 7 actually mapped out what you foresaw as the supply/demand 8 curve for pathologists in the upcoming future. 9 Is that -- 10 DR. DAVID CHIASSON: Yes. And I suspect 11 this is something that I obtained through the -- either 12 the Ontario Association of Pathologists or the Canadian 13 Association of Pathologists who are actually having an 14 ongoing monitoring of the pathologist staffing situation 15 across the country, I think was, you know... 16 MS. LINDA ROTHSTEIN: And then in C) you 17 deal with the issue that the Commissioner had raised with 18 you just minutes ago, the issue of salary, and you 19 mention the fact that: 20 "According to the 1999 Canadian 21 Association of Pathologists 22 Professional income survey of 23 laboratory physicians, the average 24 total professional income for a 25 pathologist in Ontario is over two

1 hundred and five thousand dollars 2 ($205,000); this representing an 3 increase of 10 percent over the 4 previous year. This upward trend will 5 likely escalate even more steeply over 6 the next few years given the projected 7 shortage of laboratory physicians in 8 this country." 9 So what's been happening to pathologists 10 salary, in general, over the five (5) years that you'd 11 been in the chair at that stage? Can you tell the 12 Commissioner about that. 13 DR. DAVID CHIASSON: Yes. So salaries 14 for pathologists working hospitals were -- were gradually 15 increasing. There was a supply and demand situation that 16 was clearly developing and it was increasingly at a -- at 17 a steady rate and fairly steeply. So we were behind at 18 this time in terms of the sal -- the salaries that the 19 forensic pathologists were being paid. And the curve -- 20 the -- the line for pathologists was clearly going up 21 and, in fact, it bore out that salaries continued to 22 raise outside of the government environment. 23 MS. LINDA ROTHSTEIN: Do you remember, 24 Dr. Chiasson, what the starting salary was you were able 25 to offer the pathologists you were in the -- in need of

1 at this stage? 2 I make note that over the page, on page 2, 3 that you bemoan the fact that the one (1) pathology 4 candidate that you had hoped to -- to recruit, was 5 expecting to earn a hundred and seventy thousand 6 (170,000) annually at a hospital. 7 Does that help you remember what it was 8 that your comparison salary was? 9 DR. DAVID CHIASSON: Yes, well clearly it 10 wasn't that good. 11 MS. LINDA ROTHSTEIN: Yeah, but how much 12 less was it, do you remember? 13 DR. DAVID CHIASSON: Well, I -- I 14 remember that when I started my salary was about a 15 hundred and fifty-six thousand (156,000), and I don't 16 know that it had increased in -- in any significant -- 17 and I was at the top level of salaries for -- for 18 forensic pathologists. 19 COMMISSIONER STEPHEN GOUDGE: When you 20 started as...? 21 DR. DAVID CHIASSON: As the Chief 22 Forensic Pathologist. So I moved from the -- the 23 hospital to the Chief Forensic Pathologist without any -- 24 my salary basically stayed the same, even though I had 25 more administrative responsibilities, et cetera.

1 So I didn't take -- quite take a cut in 2 pay to become the Chief Forensic Pathologist, but I did 3 not -- 4 5 CONTINUED BY MS. LINDA ROTHSTEIN: 6 MS. LINDA ROTHSTEIN: But you took on 7 more responsibility for effectively the same pay. 8 DR. DAVID CHIASSON: Yes. And then my 9 colleagues who would have similar administrative 10 responsibilities within the hospital would have been paid 11 more, certainly, than I was getting paid as the Chief 12 Forensic Pathologist. 13 COMMISSIONER STEPHEN GOUDGE: What would 14 the counterpart figure be to the two hundred and five 15 thousand dollar ($205,000) figure, if one were to look 16 for an average forensic pathologist's salary in the Chief 17 Coroner's Office? 18 DR. DAVID CHIASSON: About this time 19 we're probably in the hundred and fifty/hundred and sixty 20 (150/160) range. 21 The -- the thing about the salaries within 22 the Government, and certainly within forensic 23 pathologists, is that it -- they were tightly clustered. 24 So I was making only five thousand dollars ($5,000) more 25 than the people I was -- the junior people I was hiring -

1 - five (5), maybe ten thousand dollars ($10,000) more. 2 So it's -- everything was closely clustered around this 3 fif -- one fifty/one sixty (150/160) ballpark. 4 5 CONTINUED BY MS. LINDA ROTHSTEIN: 6 MS. LINDA ROTHSTEIN: And then the other 7 thing you note in the first full paragraph on that page 8 is that one (1) of the two (2) pathologists that you had 9 lost had been offered a guaranteed minimum salary 50 10 percent greater than he had been earning while at the 11 Toronto Forensic Unit. 12 DR. DAVID CHIASSON: Yes, I had some 13 regret that I hadn't been approached about the job, but 14 he -- and he's still happily ensconced in this position 15 and I suspect he's still making more money than -- than I 16 am. 17 MS. LINDA ROTHSTEIN: So you say: 18 "In conclusion I feel strongly that 19 without a significant improvement in 20 our current salary structure we will be 21 unable to attract any suitable 22 candidates to fill our current 23 vacancies. The credentials and 24 qualifications of pathologists 25 performing medicolegal autopsies are

1 being challenged with increasing 2 frequency and with greater vigour than 3 ever before." 4 Let's stop there for a moment, Dr. 5 Chiasson. 6 What were you referring to? Had you, 7 yourself, gone to Court and found that defence lawyers 8 were more likely to probe vigorously your own 9 qualifications? Are you referring to the experience of 10 your colleagues. 11 Just help us with that comment, if you 12 would, please. 13 DR. DAVID CHIASSON: Well, I think, I 14 mean, I -- I felt like I was appropriately credentialed, 15 certainly within the context of forensic pathology in the 16 Province of Ontario and given the nature of my work had 17 appropriate experience. 18 But certainly no, the -- the feeling is, 19 and -- and this is from having worked in -- in the United 20 States where things were much more established, I mean I 21 -- I don't think I was being particularly radical in my 22 view of what was going on, in that, hey, you know, 23 forensic pathology is becoming recognised as a 24 specialised area and that individuals would be challenged 25 as to their qualifications with time; that the -- the

1 days of the hospital pathologist who did one (1) or two 2 (2) homicides, perhaps in their lifetime, appearing in a 3 courtroom to convey opinions were -- were going to 4 disappear; hopefully disappear. 5 MS. LINDA ROTHSTEIN: So, am I right, Dr. 6 Chiasson, that by the end of '99 Dr. Toby Rose was the 7 only salaried forensic pathologist other than you at the 8 Toronto Forensic Pathology Unit? 9 DR. DAVID CHIASSON: Yes, Dr. Deck 10 eventually retired. He -- he had come -- he was -- he 11 had retired from the hospital and now he retired from the 12 Coroner's Office -- 13 MS. LINDA ROTHSTEIN: And -- 14 DR. DAVID CHIASSON: -- so that left Dr. 15 Rose. 16 MS. LINDA ROTHSTEIN: And so you had to 17 revert back to using part time pathologists to deal with 18 the autopsies that needed to be done by your unit? 19 DR. DAVID CHIASSON: Yes. 20 MS. LINDA ROTHSTEIN: In two (2) -- 21 COMMISSIONER STEPHEN GOUDGE: Sorry, Mr. 22 Rothstein. 23 MS. LINDA ROTHSTEIN: Yeah. 24 COMMISSIONER STEPHEN GOUDGE: Before you 25 move away from salaries, Dr. Chiasson, what was the

1 remuneration level of those in the units around the 2 Province? Because they're hospital employees. 3 DR. DAVID CHIASSON: That's correct. 4 COMMISSIONER STEPHEN GOUDGE: What are 5 they paid? 6 DR. DAVID CHIASSON: It -- it varied from 7 -- from hospital -- 8 COMMISSIONER STEPHEN GOUDGE: Were they 9 paid at the hospital pathologist rate, is -- 10 DR. DAVID CHIASSON: Oh -- oh, yes, they 11 were paid as their colleagues would have been paid. They 12 were paid more than -- than the Government forensic 13 pathologists. 14 COMMISSIONER STEPHEN GOUDGE: So you 15 would have had a regional forensic pathologist in a unit 16 who was making significantly more than a staff 17 pathologist at the Toronto Forensic Pathology Unit. 18 DR. DAVID CHIASSON: Yes, a signif -- I - 19 - I would think significantly more. The -- the 20 Government would publish the basic salaries, but -- but I 21 knew that some of these pathologists were in fact making 22 more money -- making money beyond their actual salaries, 23 so... 24 But it was clear, even looking at their 25 salaries, they were doing better than my forensic

1 pathologists. 2 MS. LINDA ROTHSTEIN: Right. 3 COMMISSIONER STEPHEN GOUDGE: Right. And 4 at least the regional pathologist would have doing 5 forensic pathology, more or less, full-time in the 6 regional units. 7 DR. DAVID CHIASSON: They -- they were 8 and they getting paid -- they were getting paid like 9 their colleagues in the hospital and so, therefore, much 10 more competitive within the general pathology 11 environment. 12 13 CONTINUED BY MS. LINDA ROTHSTEIN: 14 MS. LINDA ROTHSTEIN: And am I right, Dr. 15 Chiasson, that in addition to the higher hosper -- 16 hospital salary they were also getting fee-for-service 17 for all their coroner's cases? 18 DR. DAVID CHIASSON: It -- it varied as 19 to what -- they would bill for the fee-for-service work - 20 - that's -- 21 MS. LINDA ROTHSTEIN: Mm-hm. 22 DR. DAVID CHIASSON: -- and it varied 23 from unit to unit, as I understood, as to what happened 24 to that money. Some of the -- some of the money went 25 back to the hospital --

1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID CHIASSON: -- and -- and they 3 did not see it, or in some cases they would get paid for 4 their weekend work, wouldn't get paid for their weekday 5 work. In some cases, some of this money -- more of this 6 money seemed to be going into pathology partnerships and 7 finding its way back to the forensic pathologist that did 8 the work. 9 10 CONTINUED BY MS. LINDA ROTHSTEIN: 11 MS. LINDA ROTHSTEIN: It was hospital 12 specific, is what you're telling us? 13 DR. DAVID CHIASSON: Yes. Unit specific, 14 yes. 15 MS. LINDA ROTHSTEIN: Okay. But in most 16 cases, those that were doing a significant number of 17 forensic pathology cases had income beyond their hospital 18 pathology salaries, did they not? 19 DR. DAVID CHIASSON: I think most of them 20 did, yes. 21 MS. LINDA ROTHSTEIN: Yeah. 22 Commissioner, we will hear more about that and the salary 23 structure when we hear from the regional pathologist in 24 January and hopefully we'll be able to shed some more 25 light on the specifics --

1 COMMISSIONER STEPHEN GOUDGE: Right. 2 MS. LINDA ROTHSTEIN: -- of all of that. 3 4 CONTINUED BY MS. LINDA ROTHSTEIN: 5 MS. LINDA ROTHSTEIN: All right. Dr. 6 Chiasson, I want to turn your involvement in some our 7 cases. You and I talked about Nicholas' case on Friday. 8 You will know, I think if you didn't remember then, that 9 one (1) of the things that occurred during the 10 correspondence between Dr. Cairns and Mr. Parise in that 11 case, is that Mr. Parise sent Dr. Cairns a copy of the 12 decision of Justice Dunn in Amber's case. 13 My question for you, sir, is: Were you 14 aware of that at that time, that that written decision of 15 a -- of a Provincial Court judge was forwarded to the 16 Coroner's Office in order to shed some light on previous 17 testimony and conclusions that Dr. Smith has reached? 18 DR. DAVID CHIASSON: Yes. I -- Dr. 19 Cairns told me that he -- he had become aware of this 20 case, an older case. I had no prior knowledge about the 21 case until 1998. 22 MS. LINDA ROTHSTEIN: Did -- did you read 23 it? 24 DR. DAVID CHIASSON: No, not at that 25 time. I sub -- subsequently read it.

1 MS. LINDA ROTHSTEIN: Okay. Can you help 2 us understand why you weren't curious about reading it 3 then? 4 DR. DAVID CHIASSON: As I recall this -- 5 and I -- I stand to be corrected, it's -- it's obviously 6 been a passage of time -- Dr. Cairns told me about it, 7 gave me an overview of what was -- what was in the 8 decision there, and I think may of -- some point said, 9 you know, I'll pass it onto you, but he -- but it never 10 did get passed on to me or else I would have -- I would 11 have read it. 12 So I -- it never did cross my desk, 13 formally. 14 MS. LINDA ROTHSTEIN: Having read it 15 since, what do you think of it? 16 DR. DAVID CHIASSON: Well, it's certainly 17 a decision that's critical of Dr. Smith, in terms of his 18 opinions. It's not only his opinions. On the one hand, 19 apparently, as I read it, it's -- colleagues or the 20 clinical colleagues at the hospital were of the same sort 21 of opinion. 22 And it's because that it -- that there are 23 numerous very experienced experts in neuropathology and - 24 - and I think in forensic engineering of biomechanics. I 25 mean, there's -- there's a whole range of -- of experts

1 on the other side who are rendering a contrary opinion to 2 -- to Dr. Smith's. 3 MS. LINDA ROTHSTEIN: When Dr. Pollanen 4 testified last week, I believe he used the words, 5 "masterful discussion of the issues". 6 To what extent, if at all, do you agree 7 with that characterization of the case? 8 DR. DAVID CHIASSON: Well, it's certainly 9 a very detailed judge's verdict. I -- I'm not that 10 familiar with reviewing judgments; we don't usually get 11 them except in ordinary -- in extraordinary -- sorry, 12 extraordinary circumstances. It certainly seems very 13 thoughtful, in-depth discussion of the -- of the issues. 14 MS. LINDA ROTHSTEIN: Okay. Let's turn 15 to Sharon's case, if we can, Dr. Chiasson. And you'll 16 find our overview report, which I will use as a bit of 17 touchstone as we go through this, in Volume II, Tab 13 of 18 your overview report binders. 19 And you'll recall, Dr. Chiasson, that you 20 certainly spoke a little about this on Friday in terms of 21 your awareness sometime after -- sometime during or after 22 February 1999 when Dr. Cairns and Dr. Young returned from 23 the American Academy of Forensic Sciences Conference with 24 concerns that they had had explained to them, during that 25 meeting, and your involvement subsequent to then. But I

1 want to -- I want to talk about, if I can with you, the 2 nature and extent of your involvement prior to February 3 1999, before we move forward. 4 We know that the autopsy was actually 5 conducted on June the 13th and 15th of 1997 at the OCCO. 6 You were the Chief Forensic Pathologist. 7 It was unusual for a child to be autopsied 8 at your Unit, is that true? 9 DR. DAVID CHIASSON: Yes. 10 MS. LINDA ROTHSTEIN: Did you know about 11 it at the time, sir? 12 DR. DAVID CHIASSON: I did not know about 13 the case coming in. I wasn't contacted or -- or informed 14 that -- that a case was coming in from -- from Kingston 15 of this nature. I did happen -- and I think this was 16 later on in the afternoon, I -- I have this image of I 17 was on my way home. I dropped in to the autopsy room to 18 find the examination being, at least, started at that 19 time. 20 MS. LINDA ROTHSTEIN: Okay. And were you 21 surprised that this had happened without any discussion 22 with you? Or is that what one would have expected given 23 the -- the way that coroners referred cases to individual 24 pathologists at that time? 25 DR. DAVID CHIASSON: I was -- I was

1 surprised that this autopsy -- because Dr. Smith would 2 not normally do autopsies. Although he had done some 3 over the years -- some exhumations -- that -- that was 4 usually something that I would have been apprised of. 5 So to not be apprised of Dr. Smith, if you 6 will, as a -- as a visiting pathologist doing an autopsy, 7 that was unusual and I was surprised. 8 MS. LINDA ROTHSTEIN: Just pausing on 9 that point for the moment. If you were sculpting the 10 future for the Commissioner and looking at what the 11 proper roles and responsibilities of the Chief Forensic 12 Pathologist of the Province should be, is it your view 13 that, in that position, one should be consulted about who 14 would do an autopsy in a highly charged and arguably 15 complex case like that? 16 DR. DAVID CHIASSON: Yes. Clearly, I 17 think this is part of the Chief Forensic Pathologist's 18 role. And -- and in his dual role of being the Director 19 of the Forensic Pathology Unit, if in fact the 20 examination's going to be carried out in your Unit, it 21 would have obviously lend to -- have -- being informed 22 that, you know, this is going -- this is going on. 23 But -- but, no, in cases like this, I 24 think the Chief Forensic Pathologist obviously should be 25 part of the decision-making as to who and where the

1 autopsy is done; who does it and where he does it. 2 MS. LINDA ROTHSTEIN: And apart from 3 appreciating that this autopsy was being conducted in 4 your Unit, did you have any role at all in the autopsy 5 itself? 6 DR. DAVID CHIASSON: No. I think I -- I 7 dropped in, I -- I suspect I -- I spoke briefly to -- to 8 my assistant, Barry Blenkinsop, who was in attendance at 9 the time. I don't recall specifically speaking to Dr. 10 Smith. Dr. Smith certainly did not ask me for any 11 opinion about the case or -- or direct any information to 12 me directly. I may have spoken to the police officers 13 briefly. 14 And my encounter was -- was quite short. 15 I -- that -- that I recall. 16 MS. LINDA ROTHSTEIN: And as of the 17 summer of 1997, what was the extent of your own 18 experience with animal wounds, dog bites, something of 19 that kind? 20 DR. DAVID CHIASSON: It was very -- very 21 limited. I think I'd personally performed, perhaps, one 22 (1) case that -- there is one (1) that I recall in an 23 adult being attacked by a dog that resulted in a 24 fatality. 25 We did have a case of a young -- young

1 woman -- adult woman being attacked by wolves, as well. 2 That case I recall, although I don't think I actually 3 performed the post-mortem examination in that case. I 4 had some -- 5 COMMISSIONER STEPHEN GOUDGE: Did you 6 ever form an understanding of why the autopsy was being 7 done at the OCCO, as opposed to the hospital? 8 DR. DAVID CHIASSON: Certainly, not at 9 that time. I think, you know, in retrospect, the sense 10 was that, given the nature of the case, that perhaps -- 11 and with the availability of Mr. Blenkinsop to assist -- 12 there was a relationship between Dr. Smith and -- and my 13 Chief Pathologist Assistant because they had worked 14 together on -- on exhumations -- and given the nature of 15 the case, I think they felt that it was best done at the 16 Coroner's Office. And that, I think, was a reasonable 17 decision. 18 MS. LINDA ROTHSTEIN: All right. We know 19 from the overview report at paragraph 61, that Dr. Smith 20 delivered his post-mortem -- or -- or that Dr. Smith -- I 21 should say this carefully -- post-mortem examination 22 report is dated March the 8th, 1998. I'm not sure we 23 know exactly on what date it was completed. But 24 considerably after the autopsy itself. 25 Now by 1998 you had imposed your rule that

1 post-mortem reports were to go through your review 2 process, prior to being finalized. 3 Did this one (1) go through that process, 4 Dr. Chiasson? 5 DR. DAVID CHIASSON: No. 6 MS. LINDA ROTHSTEIN: Why is that? 7 DR. DAVID CHIASSON: As I understand the 8 sequence of events, the report basically was presented at 9 the time that he was testifying at the preliminary 10 hearing, that it wasn't formally signed out before then, 11 and certainly hadn't been forwarded to the -- to the 12 Regional Coroner for review, prior to his testimony. 13 MS. LINDA ROTHSTEIN: Now, indeed there 14 were some issues that arose in terms of getting that 15 report completed in what the defence at least, viewed as 16 a timely way, and some correspondence that appears to 17 copy you with respect to that. 18 So would you be good enough, Dr. Chiasson, 19 to look at Volume II of the documents. And I want to 20 take you through some of the documentation which appears 21 to involve you with that issue and get your best 22 recollection as to the nature and extent of your 23 involvement in it, starting with Tab 17, which is 056554. 24 It's a copy of the Kingston Whig Standard from February 25 5th of that year, faxed to you from Dr. Bechard, who I

1 understand was the Regional Supervising Coroner. 2 Is that right? 3 DR. DAVID CHIASSON: For eastern Ontario, 4 that's correct, yes. 5 MS. LINDA ROTHSTEIN: And it recounts, as 6 you can see, that there's some concern that -- that the 7 Court is going to convene for the purpose of determining 8 whether Dr. Charles Smith can tell the Court if he has an 9 autopsy report available. 10 Do you remember whether or not this was 11 the first time, in your capacity as Chief Forensic 12 Pathologist, or indeed otherwise, that you became aware 13 that there had been some concerns expressed about the 14 timeliness of Dr. Smith's preparation of this report? 15 DR. DAVID CHIASSON: Yes, about the issue 16 of preparation, I think so. It's possible that Dr. 17 Bechard and I may have had a conversation prior to this 18 time, but I don't have any documented evidence of that. 19 I had -- I had a good working relationship with Dr. 20 Bechard. We would discuss cases and issues. 21 So maybe sometime before this, but this is 22 the first documented certainly in my -- in my files as to 23 this information. 24 MS. LINDA ROTHSTEIN: All right. And did 25 you get involved in assisting with that?

1 DR. DAVID CHIASSON: Not -- not secondary 2 to this particular item in the paper, no. 3 MS. LINDA ROTHSTEIN: All right. There's 4 also a -- a kind of confusing documentation which is at 5 the previous tab; it's hard to know how this routed its 6 way to you, at least from my fumbling through it. We're 7 at 056540, and we've got a fax cover sheet dated May 8 20th, '98 addressed to you, accompanying a letter dated 9 January 12th, '98, so considerably earlier, which at 10 least on its face appeared to have been copied to you. 11 Can you shed any light on that and assist 12 us as to whether Mr. Rumble who was forwarding this 13 documentation, engaged you directly in trying to assist 14 him in getting Dr. Smith to respond to his inquiries 15 about the report? 16 DR. DAVID CHIASSON: Yeah, I can't help 17 you as to when I actually received this. That is the 18 Forensic Pathology Unit fax number in front of my name, 19 which is misspelled, but -- and I see that it is cc'd to 20 me at the bottom. I don't know when I actually -- well 21 if -- if you look up at the top in -- on this copy, it 22 looks -- this is the -- the actual letter. It does -- 23 it's dated May 20th, so whether -- I -- I don't recall 24 any document that indicates I had this when it's actually 25 dated or --

1 MS. LINDA ROTHSTEIN: All right. There's 2 also a document which, arguably, comes a little earlier, 3 which is at Tab 18. It's dated May the 5th, 1997 and 4 does appear to have been faxed on that date, if we look 5 at 056536 at the top of the page. This one is directed 6 to the Office of the Chief Forensic Pathologist, not -- 7 you're not named, but presumably that would find its way 8 to you. 9 Is that right? 10 DR. DAVID CHIASSON: Yes. And I -- it's 11 date stamped, for some reason, May 15th, but it's -- it's 12 -- that's my date stamp there and so it did find its way 13 to me. 14 MS. LINDA ROTHSTEIN: All right. And 15 this is a request for more than help in getting Dr. Smith 16 to prepare his report. This asks a number of questions 17 about the manner in which the autopsy was conducted, 18 asking about X-rays on page 2, procedural guidelines, who 19 assisted Dr. Smith, whether the -- the autopsy, itself, 20 was tape recorded, videotaped and so on. 21 Did you get involved at that stage in 22 trying to answer Mr. Rumble's questions? 23 DR. DAVID CHIASSON: I did, yes. 24 MS. LINDA ROTHSTEIN: And, in fact, if we 25 look at the next tab, Tab 19, 056533, there is a draft

1 letter non -- not proofed, not sent, which you appear to 2 have written. 3 Is that right? 4 DR. DAVID CHIASSON: Correct. 5 MS. LINDA ROTHSTEIN: Can you assist us 6 again as to whether -- what -- what happened, why you 7 prepared this in draft but didn't send it? Can you shed 8 any light on that at all, Dr. Chiasson? 9 DR. DAVID CHIASSON: Well, it is directed 10 to Mr. McKenna who was the Crown attorney involved in the 11 case -- the senior Crown, at least, overseeing the case 12 and it was directed to him. I had spoken to Dr. Young. 13 It's unusual for me, at that time and, really, 14 subsequently, to get a letter from a -- from a defence 15 lawyer in regards to an ongoing case; or any letter from 16 a defence lawyer, for that matter. 17 So I -- I broached it with him as to the 18 best way to -- to deal with this. And for reasons of 19 disclosure to make sure that the Crown is aware of what 20 I'm answering, I addressed it to him for -- to be 21 disclosed as he saw fit. And I -- 22 MS. LINDA ROTHSTEIN: But -- sorry. 23 DR. DAVID CHIASSON: Well, I was just 24 going to say, I don't know why I didn't actually send the 25 letter. I don't -- I don't recall why it never got sent.

1 MS. LINDA ROTHSTEIN: Right. Let's look 2 at this systemically, if we can, just for a moment, and 3 talk a little bit about the way, in your view, 4 communications with defence and the Crown worked best 5 with all the years of additional experience you have. 6 You -- you certainly, I am sure, 7 acknowledge that there will be many occasions where the 8 Defence will have questions, maybe not these precise 9 questions, but questions about the way an autopsy has 10 been conducted and more detail that they need. 11 Do you see that as being best obtained by 12 the defence writing directly to the individual 13 pathologist? What role should the Chief have? What role 14 should the Crown have? Can you give the Commissioner any 15 help with how you think those communications are best 16 structured? 17 DR. DAVID CHIASSON: Well, as I've 18 indicated, in my experience it's very unusual -- this is 19 unusual in the sense I'm being contacted as an 20 administrator, if you will, as opposed to I had nothing 21 directly to do with the case. So I think that's a little 22 bit different issue than a defence pathologist -- sorry, 23 defence lawyer wanting some information from the Crown 24 pathologist that hasn't been -- that hasn't been 25 supplied.

1 In my experience, what usually happens is 2 the Crown attorney is approached by the defence lawyer 3 and that -- whatever requests for information for 4 disclosure is -- I get -- I get contacted by the Crown 5 attorney, I respond to the Crown attorney's request. And 6 usually this is done phone, email; t's -- it's unusual 7 that it has to be formally -- in formal letters, if you 8 will. And the material is just forwarded or the 9 questions are -- are answered and that is conveyed back 10 to the defence lawyer. 11 I -- I personally have had no -- no 12 problems that I can recall of -- that that system didn't 13 -- didn't really address what needed to be addressed. I 14 mean, obviously, it isn't -- it's important for the 15 pathologist to respond in a timely fashion to these -- 16 these requests. 17 So that -- that, to me, has -- has worked 18 in the cases. Issues as to, perhaps, elaboration of an 19 opinion, I -- I always say to the Crown attorney when I 20 meet with them, the defence pathologist wants to talk me 21 about this case, and certainly if there's a possibility 22 that by talking to me I won't have to show up in Court, I 23 encourage that. 24 It doesn't often happen, but the -- the 25 opportunity is certainly given to the defence pathologist

57
  1  to contact me directly if there's something that I can
  2  assist them with.
  3                 But I think -- in my view, I think the
  4  Crown needs to be apprised of -- of what's -- what's
  5  going on, or at least -- obviously I'm -- I'm not
  6  rendering any opinion to a defence lawyer in confidence,
  7  as far as I'm concerned, and whatever I tell them, if the
  8  Crown attorney approaches me and asks what, you know,
  9  what you talked about, I mean I think that I -- I need to
 10  -- to convey that information.
 11                 MS. LINDA ROTHSTEIN:   How often in your
 12  experience does a defence lawyer call you up and ask to
 13  meet with you to understand your opinion; not the defence
 14  pathologist, but the defence attorney herself?
 15                 DR. DAVID CHIASSON:   It's unusual, but it
 16  -- it has occurred on occasion.
 17                 MS. LINDA ROTHSTEIN:   All right.  And is
 18  that something you feel you have to let the Crown know? 
 19  Do you ever have any hesitation about doing it?
 20                 DR. DAVID CHIASSON:   I -- I have -- I
 21  alert the Crown that in fact defence pathologist -- I'm
 22  sorry, a defence lawyer would like to meet with me.  I --
 23  I let them know that.  I've never had an objection from
 24  the Crown attorney as far as doing that, and I've never
 25  had any problem with -- with meeting with a defence

1 lawyer. I -- I think it -- it's a good thing. 2 I mean, I'd rather get asked the questions 3 upfront in a one-on-one meeting, rather than on the 4 stand. 5 MS. LINDA ROTHSTEIN: All right. 6 COMMISSIONER STEPHEN GOUDGE: Sorry. So 7 I take it you really don't have any concern with the 8 contact coming from the defence to you directly, as long 9 as there's transparency, as to the Crown knowing about 10 that happening and your response. 11 DR. DAVID CHIASSON: Exactly, Mr. 12 Commissioner. Transparency is exactly what I'm trying to 13 convey, less effectively. 14 15 CONTINUED BY MS. LINDA ROTHSTEIN: 16 MS. LINDA ROTHSTEIN: One of the other 17 things that has arisen in our -- in the testimony we've 18 heard about this case, Dr. Chiasson, comes from Dr. 19 Cairns. When he testified on November the 26th of this 20 year he recalled a meeting in which you, Dr. Wood, Dr. 21 Queen, and Dr. Smith were all present. You were 22 reviewing the post-mortem. I'm not sure it was the 23 report, but certainly you reviewing photographs. 24 And his recollection was that meeting took 25 place fairly early on in the genesis of this case, that

1 is to say, fairly soon after the autopsy. We have a copy 2 of Dr. Cairns' testimony at Tab 38 of this volume. 3 Do you recall being at such a meeting, Dr. 4 Chiasson? 5 DR. DAVID CHIASSON: Yes, I recall being 6 at a meeting where this case was reviewed, yes. 7 MS. LINDA ROTHSTEIN: And to the best of 8 your recollection, when did that meeting occur? 9 DR. DAVID CHIASSON: Well, it's -- it's 10 only through reviewing documents that were provided to me 11 in preparation that I -- I didn't -- I didn't have any 12 formal documentation of -- in my record, that I'm aware 13 of, but it's clear that Dr. Cairns makes reference to it 14 in a memo to file he dated in 2000. I'm not sure the 15 date. And he makes reference to attending the American 16 Academy meeting in February, and that would have been 17 1999. 18 And in that memo he then makes reference - 19 - he came back and -- and he -- he set up this meeting. 20 And I think that's the -- in fact what happened and -- 21 and it -- it makes sense to me chronologically. I think 22 once the -- Dr. Young and Dr. Cairns went to the meeting 23 -- this is obviously now an international issue, if you 24 will -- and so he came back and we sat down and reviewed 25 the case.

1 So I -- I think it is in 1999 and not 2 shortly after the post-mortem examination. It was -- it 3 was an extraordinary meeting, it wasn't a routine, you 4 know, Wednesday afternoon meeting like we would have. 5 Dr. Queen was -- was invited, that -- that 6 part of it I do recall, as much as I don't seem to have 7 much of a recall of the actual meeting. But, Dr. Queen, 8 I recall inviting him in. He hadn't originally been 9 invited, but I brought him in: Interesting case, let's 10 see what you think, I was trying to include in -- in the 11 discussion, if you will. 12 MS. LINDA ROTHSTEIN: Thank you. 13 Specifically, at page 221, Commissioner and Dr. Chiasson, 14 what Dr. Cairns said was, about the timing, when I asked 15 him was: 16 "It certainly was the time when at 17 least the issue -- it was some -- it 18 was a reasonable period of time after 19 the autopsy. By reasonable, it was at 20 least probably a month, two (2) months, 21 three (3) months. Unfortunately I 22 can't help you any further." 23 And so if I understand what you're saying, 24 Dr. Chiasson, you do not think that any such meeting 25 occurred in that timeframe?

1 DR. DAVID CHIASSON: No. 2 MS. LINDA ROTHSTEIN: All right. You 3 agree with what I just said? 4 DR. DAVID CHIASSON: Yeah, I don't think 5 it occurred in that timeframe. And, in -- in fact, if 6 you look at what subsequently happened, I think this was 7 -- the meeting that we did have in -- in 1999 really was 8 the beginning of the process leading to the exhumation of 9 Sharon. 10 MS. LINDA ROTHSTEIN: Okay. All right. 11 Leaving aside the issue of when it took place, Dr. Cairns 12 went on to say at page 222: 13 "And the discussion came up that there 14 had been some information been brought 15 to people's attention that there may 16 not be stab wounds, that they may be 17 dog bites, and it was discussed. And 18 primarily, the opinion of Dr. Wood was 19 no, these were dog bites. Barry 20 Blenkinsop, who had been there for 21 years and year and had seen probably 22 more dog bites, more wolf bites, et 23 cetera, than anyone else was emphatic 24 that these were -- were not. Dr. 25 Chiasson did not feel that they were

1 dog bites and I wouldn't have had the 2 expertise, but I was going along with 3 them. And to be fair, Dr. Martin Queen 4 was the only one who wasn't sure that 5 these may not be dog bites." 6 So can you assist us, Dr. Chiasson. 7 Leaving aside the timing of the meeting, does that 8 description of the various opinions that were put forward 9 during that meeting accord with your recollection? 10 DR. DAVID CHIASSON: Well, yes. I mean, 11 I -- my impression was that Dr. Wood, Dr. Smith, and Mr. 12 Blenkinsop, again somebody who -- who did have, in fact, 13 the most experience, practical experience, with dog 14 bites, we're all of the opinion that it wasn't. 15 I don't know how strong an opinion I -- I 16 rendered one way or the other. I -- I saw myself as 17 somewhat of a mediator, if you will, to what -- to what 18 was going on, and was concerned in terms of where to go 19 from -- from there. I certainly didn't strongly object to 20 the notion that these were stab wounds as opposed to dog 21 bites, at this time. And I don't recall Dr. Queen's 22 comments, but he may have raised the issue that they 23 weren't -- that they might have been dog bites. 24 MS. LINDA ROTHSTEIN: Why did you see 25 yourself as a mediator, Dr. Chiasson?

1 DR. DAVID CHIASSON: Well, I mean, I 2 think to put it into context, Dr. Smith was -- was 3 somebody that I did have, at this time, a lot of respect 4 for as a -- as a pathologist. He seemed to be very 5 clear. And he was -- he was at the post-mortem 6 examination. 7 You know, the -- some of the injuries, you 8 look at them, in my view, certainly could have been stab 9 wounds. And part of the issue as terms of trying to 10 render the opinion -- this is a case where the person who 11 would be in best, I think, equipped to make a -- an 12 opinion was -- would be at the autopsy, because we're not 13 looking at only at surface pattern injuries, we're 14 looking at what's happening to the wound tracks beyond 15 the skin. And so that -- that's always been -- we're 16 talking three-dimensionals; it's always best conveyed by 17 -- by actually being there ad it's always -- it's not 18 always best conveyed by photographs. 19 Dr. Wood -- again to put into context, Dr. 20 Wood was our forensic odontologist. He had -- somebody 21 that I had basically -- I was responsible for bringing 22 him onboard -- he may have started doing some work 23 beforehand -- but really nurtured his work in forensic 24 dentistry. And he was doing some very -- very innovative 25 work with wound weapon matching, as well as bite issues.

1 I had a great deal of respect for -- for 2 Dr. Wood and so his opinion was -- was, as well, strong. 3 And I had a great deal of respect for Mr. Blenkinsop. So 4 I -- so that's why, I guess -- I mean, even -- given my 5 limited experience in terms of dog bites, I did not feel 6 I -- I had the background or expertise, really, to 7 challenge these -- these three (3) -- three (3) 8 individuals. 9 Even if I did think they were dog bites, I 10 really wasn't -- wasn't sure, at this time. 11 MS. LINDA ROTHSTEIN: Okay. Would you 12 turn to page 99, paragraph 216 of the overview report. I 13 just want to confirm with you that that is the memo that 14 you referred to just earlier that Dr. Cairns prepared 15 that you say assisted you in recalling the date of the 16 meeting you've just described; that is to say Dr. Cairns 17 February 8th, 2000 memo to file, footnoted 338. The PFP 18 number for that memo being 055743. 19 Is that -- is that what refreshed your 20 memory as to what you think the appropriate timing of 21 that meeting was? 22 DR. DAVID CHIASSON: I -- I think I'm 23 lost as far as what you're referring to -- 24 MS. LINDA ROTHSTEIN: Okay. Look at 25 paragraph 216.

1 DR. DAVID CHIASSON: Which -- which -- 2 MS. LINDA ROTHSTEIN: Of the overview 3 report. 4 DR. DAVID CHIASSON: Overview reports, 5 Tab 13? 6 MS. LINDA ROTHSTEIN: Tab 13. 7 DR. DAVID CHIASSON: Page -- paragraph -- 8 MS. LINDA ROTHSTEIN: Paragraph 216. 9 DR. DAVID CHIASSON: Oh, paragraph 216. 10 Okay. Yes, I'm -- I'm with you now. 11 MS. LINDA ROTHSTEIN: Great. Is that the 12 memo that refreshed your memory as to what you think is 13 the time of that meeting? 14 DR. DAVID CHIASSON: Yes. In fact if -- 15 I think if one reads this, I indicated in February of 16 1999, that's when he went to the American Academy. On 17 return from that meeting I arranged to have a meeting 18 with Dr. Smith, Dr. Woods, and Dr. Chiasson. 19 So I -- I think this -- I -- there wasn't 20 more then one (1) meeting of this nature. I think this 21 is the meeting being referred to and it's in 1999. 22 MS. LINDA ROTHSTEIN: Okay. All right. 23 As we know, you were then part of a meeting that was held 24 in Kingston with the police and Crown and others 25 recommending the exhumation of Sharon's body.

66
  1                 Am I right about that?
  2                 DR. DAVID CHIASSON:   Yes.
  3                 MS. LINDA ROTHSTEIN:   And that indeed
  4  resulted in the second autopsy which you attended and
  5  were -- can I put it this way, the lead pathologist on in
  6  the Summer of -- let me make sure I've got that right --
  7  Summer of 1999. 
  8                 Is that right?
  9                 DR. DAVID CHIASSON:   Yes.  I -- I was the
 10  pathologist of record, if you will, yes.
 11                 MS. LINDA ROTHSTEIN:   Okay.  So if we
 12  look at your report of second post-mortem examination --
 13  that can be found at Tab 23 of Volume II, and it's
 14  PFP012038 -- I just want to walk through with you, if I
 15  can, Dr. Chiasson.
 16                 Who was in attendance and why.
 17                 DR. DAVID CHIASSON:   So Mr. Blenkinsop,
 18  my Chief Pathologist Assistant, and who -- who had been
 19  present at the original autopsy; C. Baird and A. Bird
 20  were Kingston police department officers; Dr. Smith; Dr.
 21  Wood; a private investigator who was working for the
 22  defence in this case, a Mr. Davis; Dr. Ferris, and Dr.
 23  Dorion; Dr. Ferris being a forensic pathologist, Dr.
 24  Dorian being a odontologist/forensic odontologist.
 25                 MS. LINDA ROTHSTEIN:   Registrar, 012038.

1 Okay. 2 DR. DAVID CHIASSON: Sufficed to say, Dr. 3 Ferris, Dr. Dorion, and Mr. Davis were all there to 4 represent the defence counsel. 5 MS. LINDA ROTHSTEIN: And why was Dr. 6 Smith in attendance? 7 DR. DAVID CHIASSON: I asked Dr. Smith to 8 -- I invited him to -- to attend. We were having a 9 second look at his -- at a case and I would have done 10 this with -- in -- in any such situation; have an 11 opportunity for him to personally re-examine the remains. 12 MS. LINDA ROTHSTEIN: And we can read 13 through your post-mortem report, but it doesn't give us a 14 real sense for -- for -- or a real sense of the 15 challenges that this second autopsy may or may not have 16 created. 17 Can you tell the Commissioner how helpful 18 was the second autopsy to reaching, from your 19 perspective, a firm conclusion on what had happened in 20 this case? 21 DR. DAVID CHIASSON: Well I think it -- 22 it was -- it's important to realize the -- the obj -- the 23 object of this second post-mortem examination was in fact 24 to procure samples and -- in essence, bone samples that 25 might have evidence of damage to it which could support

1 or -- support one contention or another as to whether 2 these were all bite injuries, as to whether they were 3 stab wounds caused by scissors or some other sharp force 4 -- sharp force object. 5 So we -- we went in -- or I went in not 6 expecting the information from the skin, for example, to 7 be of -- of great -- great use, or, for that matter, much 8 of the soft tissue. So we're -- we're looking at 9 primarily bone. 10 And, in fact, there was an advanced state 11 of decomposition which, as I indicate on page 2 of my 12 report, precluded optimal assessment, certainly, of any 13 skin or soft tissue injuries. 14 But we did take various samples of bone 15 including the skull; retained those for detailed 16 examination. The bones, in fact -- and this was a bit of 17 a surprise, and -- and disappointing -- were, in fact, 18 deteriorating as well, and perhaps more so than I was 19 perhaps expecting. And that may reflect that we're 20 dealing with a child where the bone calcium isn't quite 21 that what we see in an adult situation. 22 So -- but we did procure the samples that 23 we were looking for. 24 MS. LINDA ROTHSTEIN: And what about your 25 conclusions, Dr. Chiasson? Can you -- we can read them,

1 of course; they look to us, I think, as being fairly 2 conservative. 3 Is that a fair characterization? 4 DR. DAVID CHIASSON: Yes, they're -- 5 they're based -- the findings here are based on the 6 findings at the second post-mortem examination. I'm not 7 rendering an opinion here based on review of the original 8 material. 9 So this is a report detailing what 10 happened at the second post-mortem examination. 11 MS. LINDA ROTHSTEIN: So, stopping there 12 for a moment. Do I hear you to be suggesting that this - 13 - this post-mortem report does not encompass your views 14 of what, for example, the photographs might tell you in 15 combination with the findings following the second post- 16 mortem? 17 DR. DAVID CHIASSON: That's correct, yes. 18 MS. LINDA ROTHSTEIN: Okay. So this 19 wouldn't necessarily reflect your entire opinion on the 20 case. 21 Have I fairly characterized that? 22 DR. DAVID CHIASSON: That's correct. I - 23 - I decided that I was going to keep this report separate 24 and distinct from any more global reexamination of the 25 case.

1 MS. LINDA ROTHSTEIN: And why was that? 2 DR. DAVID CHIASSON: Again, this was -- 3 this was not an area that I was comfortable in in terms 4 of the -- the injuries -- limited experience in dog 5 bites. And it was not an area that I think 6 administratively I felt comfortable in. 7 So I -- so, if you can envision a level of 8 discomfort from my own personal experience with this kind 9 of case, and then the added discomfort of having some of 10 my colleagues rendering significantly stronger opinions. 11 So, if you will, there's a -- there's a -- 12 a bit of a -- a conflict. That's not to say -- and there 13 are certainly matters where I've -- if I feel comfortable 14 and strong about my own opinion that I will, you know, go 15 ahead and -- and render that opinion. I think we've 16 talked about some of the Ottawa issues, for example. 17 This was not one (1) of those cases where 18 I -- I felt per -- particularly strong from a -- from a - 19 - an experience point of view. 20 MS. LINDA ROTHSTEIN: Dr. Chiasson, tell 21 us; you've got quite a group of people there who come to 22 it with at least different premises, if nothing else. 23 Was there a discussion amongst you? 24 DR. DAVID CHIASSON: There is some 25 discussion but, clearly -- you know, I've heard reference

1 to, you know, defence pathologists and -- and 2 pathologists doing the primary autopsy sort of sitting 3 around and having very amicable discussions. 4 There is a tension. I mean, I -- I knew 5 of Dr. Ferris, I knew of Dr. Dorion. I -- I had met Dr. 6 Ferris, certainly, before on occasion, but I certainly 7 didn't feel we had a close working relationship. 8 Most of the work he's done in Ontario -- 9 well, all of the work he's done in Ontario over the last 10 number of years has been for the defence as opposed to -- 11 to that. 12 So, I mean, this is not a group of people 13 who are -- have some pre-existing, you know, history. 14 So, it's basically the defence experts were allowed to 15 opine as to what, you know, samples might want to be 16 taken. Certainly they took -- in the case of Dr. Dorion, 17 at least, took his own photographs. And, subsequently, 18 Dr. Dorion was provided with the same samples that Dr. 19 Wood looked at. 20 But it's not -- you know, it's not a free- 21 flowing discussion here. It's -- I don't think anybody's 22 particularly comfortable about that -- the -- the 23 dynamics in regards -- in that regards. 24 MS. LINDA ROTHSTEIN: What about 25 afterwards? Did you candidly discuss the case with any

1 of Mr. Blenkinsop, Dr. Wood or Dr. Smith? 2 DR. DAVID CHIASSON: I had -- not -- no, 3 nothing that would -- could be described as a candid, 4 frank, formal discussion of the case, no. 5 MS. LINDA ROTHSTEIN: Why not? And 6 that's not to suggest you were supposed to lead it, but 7 to really say to us on the outside, it would seem that 8 would be the normal human response to this case. 9 Why didn't that happen? 10 DR. DAVID CHIASSON: Well I -- I think in 11 part, this is an ongoing process. We do the post-mortem 12 examination, in fact, you know, Dr. Wood's then looking 13 at -- and -- and I think this was, to be fair to Dr. 14 Wood, he was rendering his original opinion without 15 benefit of actually seeing the body and -- and -- so he 16 had a lot more material from which to work with. 17 By the time -- he -- he was doing this in 18 an independent fashion, as clearly his -- his role in 19 this. So he's doing this and eventually his report comes 20 out. And then from that I issue my report. 21 It's before the courts, the defence has 22 obviously their experts. You know, if -- I suspect if at 23 the end of the road perhaps there would be an opportunity 24 for a -- a more candid discussion, but -- but this is a 25 process that's ongoing.

1 I -- I never thought that, at the time 2 certainly, that -- I never really thought about having a 3 candid discussion of something that's -- that's moving in 4 this direction. 5 MS. LINDA ROTHSTEIN: So -- 6 COMMISSIONER STEPHEN GOUDGE: It wasn't, 7 I take it, from your perspective, a collaborative 8 exercise of scientists attempting to collectively reach 9 the truth as best they could? 10 DR. DAVID CHIASSON: I wouldn't call this 11 -- I mean there's -- well no. I don't think it was a 12 collaborative process in the sense of everybody getting 13 together and free form exchange of opinions. 14 You know, we have Dr. Wood's part; I'm 15 looking at Dr. Wood's report in order to issue my own 16 report. Dr. Smith ultimately looks at my report, Dr. 17 Wood's report, and -- and issues his own report. 18 It's -- it's -- no, it wasn't anything -- 19 COMMISSIONER STEPHEN GOUDGE: Why was 20 that, Dr. Chiasson? Or was that that people were dug in 21 by this stage? 22 DR. DAVID CHIASSON: Well again, from my 23 perspective, I'm -- I'm not feeling particularly 24 comfortable about the case in terms of where -- where my 25 own position is. As I've indicated, Dr. Smith is --

1 COMMISSIONER STEPHEN GOUDGE: Did you 2 feel like you were refereeing a trial between Dr. Smith 3 and Dr. Ferris? 4 DR. DAVID CHIASSON: I -- I think that's 5 part of it, yes. I mean -- and -- and, you know, as 6 Chief Forensic Pathologist, I've got to try to maintain - 7 - I think quite rightfully so, a degree of objectiveness 8 that if you're the individual on a case, you should be 9 objective regardless, I'm -- I'm not suggesting that. 10 But certainly I'm feeling like I am in the 11 middle of -- of this -- you know, on one (1) hand you 12 have one (1) credible experts, on the other hand you have 13 credible experts. And I'm in the middle without -- I'm - 14 - I'm not the -- I'm not the answer. 15 I don't have the answer in my own mind as 16 to what's going on here. 17 COMMISSIONER STEPHEN GOUDGE: You've got 18 to come to the best answer you can? 19 DR. DAVID CHIASSON: Yes, and -- and to 20 try to maintain a -- a course that is, for me, ultimately 21 defensible. 22 COMMISSIONER STEPHEN GOUDGE: I guess 23 what I'm getting at, Dr. Chiasson, and just let me spell 24 it right out. We've heard a number of descriptions of 25 how the scientific process might work best in this kind

1 of circumstance, described as a collaborative exercise -- 2 DR. DAVID CHIASSON: Yes. 3 COMMISSIONER STEPHEN GOUDGE: -- where 4 scientists attempt, collectively, to reach the best 5 possible truth they can. 6 This paradigm suggests there are human 7 difficulties with doing that sometimes? 8 DR. DAVID CHIASSON: Exactly, Mr. 9 Commissioner. I think that's a bit of an idealistic 10 approach to -- I mean, in part, the criminal justice 11 system is an adversarial system. 12 COMMISSIONER STEPHEN GOUDGE: Yes, the 13 criminal justice system doesn't encourage this kind of 14 thing, but at this point you have two (2) pretty dug-in 15 views that are opposite and getting a collective 16 enterprise going is pretty tough. 17 DR. DAVID CHIASSON: Yes, and -- and at 18 the same time I'm -- you know, two (2) of these 19 individuals are certainly people that I have an ongoing 20 professional relationship with. 21 COMMISSIONER STEPHEN GOUDGE: That's just 22 another dimension to the human difficulty in the 23 collaborative model. 24 DR. DAVID CHIASSON: Exactly. I -- I 25 think --

1 COMMISSIONER STEPHEN GOUDGE: It's too 2 bad. 3 DR. DAVID CHIASSON: It is too bad. And 4 there may be situations where -- and in fact at some 5 level, I mean, we -- we, for example, often present 6 rounds if it's at an early stage. 7 I think that's -- part of the problem here 8 is that this process has been allowed to develop to an 9 advanced stage, and so that, you know, once you've put 10 pen to paper and rendered on opinion, to -- to change 11 that opinion is -- is a major -- there's a major issue 12 there, as opposed to early on having a discussion if -- 13 if in fact, you know, two (2) days after the autopsy the 14 issue of the dog was raised, I think that dynamic is very 15 much different. 16 People are still in the process of -- of 17 thinking and are much more likely to be flexible than 18 they are, I think, almost two (2) years down the road by 19 the time, you know, the exhumation is -- is done; that -- 20 that's a more difficult scenario and certainly from a 21 collaborative point of view, I think that's -- that's 22 problematic. 23 COMMISSIONER STEPHEN GOUDGE: All right, 24 Ms. Rothstein. 25

1 CONTINUED BY MS. LINDA ROTHSTEIN: 2 MS. LINDA ROTHSTEIN: So, am I right in - 3 - in suggesting, Dr. Chiasson, that between the second 4 autopsy and the withdrawal of the charges against Ms. 5 Reynolds you did not ever speak to Dr. Smith one to one 6 about this case? 7 DR. DAVID CHIASSON: No. 8 MS. LINDA ROTHSTEIN: All right. Would 9 you take a look at Tab 37? This is an email which Dr. 10 Smith wrote to Dr. Goldbloom, I believe, in the absence 11 of Dr. Becker sometime later, certainly after the charges 12 were actually withdrawn against Ms. Reynolds, so we know 13 that that would be, or just before, in -- in 2001. 14 And you, of course, wouldn't have seen 15 this, that's apparent, is it not, Dr. Chiasson? 16 DR. DAVID CHIASSON: I -- I hadn't seen 17 it until recently -- 18 MS. LINDA ROTHSTEIN: All right. 19 DR. DAVID CHIASSON: -- in preparation 20 for this. 21 MS. LINDA ROTHSTEIN: So we're looking at 22 132419. I just wanted to ask you about certain of the 23 statements that Dr. Smith made there, halfway down the 24 page: 25 "I (reluctantly) performed the post-

1 mortem examination at the coroner's 2 building." 3 Do you know anything about that? Why 4 there would have been any reluctance or any particular 5 necessity for Dr. Smith to have conducted that particular 6 autopsy? 7 DR. DAVID CHIASSON: No, I don't -- don't 8 understand the reluctance. Dr. Queen was -- happened to 9 be on that weekend and certainly there was no staffing 10 issue at -- 11 MS. LINDA ROTHSTEIN: Right. 12 DR. DAVID CHIASSON: -- that time, from a 13 -- from a Coroner's Office point of view. 14 MS. LINDA ROTHSTEIN: 15 "Sometime later the question arose as 16 to whether the puncture wound could 17 have been caused by a dog; because I 18 have no expertise in bite marks, Dr. 19 Roberts, who serves a forensic 20 odontologist for the Chief Coroner was 21 consulted." 22 At any stage did you hear from Dr. Smith 23 himself that he was acknowledging his lack of expertise 24 in bite marks? 25 DR. DAVID CHIASSON: No.

1 MS. LINDA ROTHSTEIN: 2 "He reviewed the materials and wrote a 3 report dismissing this possibility. I 4 subsequently wrote an autopsy report 5 attributing death to multiple stab 6 wounds. I testified at the preliminary 7 hearing in April '98. Subsequently 8 defence experts continued to postulate 9 that the injuries were due to a dog 10 attack. The body was exhumed and a 11 second autopsy was performed by Dr. 12 David Chiasson, the Chief Forensic 13 Pathologist of Ontario, and Dr. Woods 14 in July '99. Dr. Woods examined the 15 bony injuries and wrote a report 16 attributing some of the bar -- marks to 17 dog bites, and some were inconsistent 18 with dog bites. Dr. Chiasson concurred 19 with this opinion." 20 Did you in fact concur with that opinion, 21 that some of the -- and the specific point being that 22 some of the boney injuries were inconsistent with dog 23 bits, because that looks a little bit different than the 24 language of your report itself? 25 DR. DAVID CHIASSON: Well, if you see my

1 report at the bottom, I'm -- I'm obviously making 2 reference to Dr. Wood and I'm accepting what he is saying 3 in his report. I'm, if you will, deferring to his 4 expertise as to the evaluation of the bone. 5 Boney injuries of this nature is not 6 something that I consider to be part of my area of 7 expertise. 8 MS. LINDA ROTHSTEIN: And then he goes on 9 about the bones were sent to Dr. Steven Symes, and so on, 10 and we'll deal with that with other witnesses. 11 You were involved, though, were you not, 12 in identifying Dr. Stevens Symes as an appropriate person 13 to assist in this case? 14 DR. DAVID CHIASSON: Yes. 15 MS. LINDA ROTHSTEIN: And can you just 16 tell the Commissioner about that? 17 DR. DAVID CHIASSON: Well, we had these 18 different injuries to the bone that Dr. Wood was opining 19 that -- that were not attributable to dog bite. So I 20 felt what we needed was a forensic anthropologist, who 21 has expertise in looking at bones and looking at injuries 22 on bones. This is in the -- in the United States a 23 recognized area of subspeciality within forensic science. 24 And Dr. Symes just from reading the 25 literature was the person that seemed to be the most

1 appropriate one to look at that. I did not know him 2 personally or anything of that nature, but knew -- knew 3 of him. 4 MS. LINDA ROTHSTEIN: All right. Dr. 5 Chiasson, in the interest of time I'm going to move on to 6 another case, the Baby F case. And I want to use it, if 7 we can, to help illustrate the -- the strength and limits 8 of the review process that you put in place, being a 9 paper review of post-mortem reports. 10 At Tab 1 of Volume II, we have the form of 11 those reports. 12 DR. DAVID CHIASSON: Sor -- sorry, Ms. 13 Rothstein -- 14 MS. LINDA ROTHSTEIN: So Volume II of 15 your -- 16 DR. DAVID CHIASSON: Of my documents. 17 MS. LINDA ROTHSTEIN: -- of your 18 documents. And I'm at 009850. February 6th, '97 19 memorandum to you from Dr. Karen Acheson, who was the 20 regional supervising coroner in this case, is that right? 21 DR. DAVID CHIASSON: Yes. 22 MS. LINDA ROTHSTEIN: And she's saying: 23 "Please review the enclosed post-mortem 24 examination report for the above- 25 mentioned deceased and then return it."

1 2 The following tab, Tab 2, 057168 3 indicates, if I understand it correctly, that you indeed 4 reviewed this case. 5 DR. DAVID CHIASSON: Yes. 6 MS. LINDA ROTHSTEIN: You have a 7 checkmark. 8 DR. DAVID CHIASSON: Yes. 9 MS. LINDA ROTHSTEIN: And we can take it, 10 can we, that because there are no comments that you had 11 no significant concerns based on your paper review of 12 this case, is that right? 13 DR. DAVID CHIASSON: That's correct. 14 MS. LINDA ROTHSTEIN: All right. So 15 let's take a look at the actual post-mortem report that 16 you would have seen and see what you can tell us looking 17 back about the kinds of cases that raised concerns and 18 the kinds of cases which don't. 19 If you could go to Volume I of the 20 overview reports. Tab 2 is the Baby F overview report at 21 142804. And we can see that this was a case, 22 Commissioner, just to remind you where Baby F was born on 23 November the 28th of '96. And there were, indeed, 24 criminal proceedings against Baby F's mother that 25 ultimately resulted in a pardon. This is a case in which

1 we can tell that the original autopsy was done by Dr. 2 Walsh. 3 Do you remember that, Dr. Chiasson, at 4 least having refreshed your memory about this case 5 recently? 6 DR. DAVID CHIASSON: Yes. 7 MS. LINDA ROTHSTEIN: And Dr. Smith did a 8 consultation report on January the 20th of '97. And an 9 excerpt or the -- the mat -- the -- the actual post- 10 mortem report is excerpted in our overview report. And 11 it is found starting at the bottom paragraph 38. 12 So it's page 14 of the overview report. 13 We can see that Dr. Smith noted the following anatomical 14 diagnoses: 15 "1) infanticide (1.1 full term 16 gestation, 1.2 live born female). 17 Number 2) Asphyxia with [and then] 18 petechial haemorrhages of the thoracic 19 viscera, congestion of the lungs, 20 cyanosis of the nailbeds [and so 21 on]..." 22 Dr. Chiasson, in preparation for your 23 testimony, I gather that you had occasion to review, at 24 least briefly, Dr. Butt's criticisms of that report, did 25 you not?

1 DR. DAVID CHIASSON: Yes. 2 MS. LINDA ROTHSTEIN: And you will 3 recall, therefore, that one (1) of the things that Dr. 4 Butt criticized was the use of the word "infanticide" and 5 the parenthesis around that. He gave that evidence, 6 Commissioner, on November the 20th of this year at page 7 111. 8 Can you assist us, back in 1997, when you 9 reviewed this, what your views of the propriety of that 10 language was? 11 DR. DAVID CHIASSON: If -- if I may -- 12 MS. LINDA ROTHSTEIN: Were? 13 DR. DAVID CHIASSON: -- just back -- back 14 track to indicate -- 15 MS. LINDA ROTHSTEIN: Sure. 16 DR. DAVID CHIASSON: -- that Dr. Walsh in 17 fact did contact me about the case. And the reason Dr. 18 Smith became involved was because I referred Dr. Walsh to 19 Dr. Smith for a second opinion, because this was an area 20 that was outside my usual practice. And I though Dr. 21 Smith would be more appropriate to render a consult 22 letter. 23 So I did have some prior knowledge about 24 the case, and the circumstances about the case before 25 getting these materials.

1 MS. LINDA ROTHSTEIN: And just stopping 2 there for a moment, Dr. Chiasson, I take it that wouldn't 3 always be the case. In fact, you might just get, as you 4 told us on Friday, the post-mortem report itself together 5 with the coroner's statement and -- and no other verbal 6 briefing if you will. 7 Is that right? 8 DR. DAVID CHIASSON: That's correct. 9 MS. LINDA ROTHSTEIN: Okay. 10 DR. DAVID CHIASSON: In many cases there 11 was no other additional information. 12 So to get back to infanticide issue, t's - 13 - certainly in retrospect, it's not an appropriate 14 designation in a -- in a report prepared for the 15 Coroner's Office. It's a determination of manner of 16 death, not cause of death. And therefore is outside the 17 usual purview of a pathologist performing an autopsy. 18 (Infanticide), in brackets, and this is a 19 practice that I was aware of, and -- is meant to -- to 20 indicate something that is of a circumstantial or 21 clinical nature. So, it's not uncommon, and I -- I do it 22 myself on occasion, if somebody, for example, has 23 diabetes mellitus, I might include it as a summary of 24 abnormal finding as being a significant medical finding, 25 but it's not something I have pathological confirmation

1 of. You can have diabetes mellitus and have a completely 2 normal autopsy. 3 So the brackets are meant to indicate, in 4 my practice, and I imagine in Dr. Smith's as well, that 5 this is something that is circumstantial. 6 It's not a -- an anatomic diagnosis. In 7 this case it's -- implies a certain, again, obvious 8 judgment as to the manner of death. 9 COMMISSIONER STEPHEN GOUDGE: 10 Circumstantial in the sense of something he had been 11 told, as opposed to something he found when he did the 12 autopsy? 13 DR. DAVID CHIASSON: Yes, yes. It wasn't 14 something specifically -- well, it's something he's been 15 told or something he's -- in this case, something he's 16 concluded, I -- I expect. 17 Certainly, again, in retrospect, not -- 18 not an appropriate -- 19 COMMISSIONER STEPHEN GOUDGE: This 20 doesn't fit your bracketed use, does it? Because you -- 21 DR. DAVID CHIASSON: No. 22 COMMISSIONER STEPHEN GOUDGE: -- wouldn't 23 conclude diabetes from the pathology; you would put it in 24 as something you'd been told? 25 DR. DAVID CHIASSON: Yes. Now having --

1 you know -- it's -- it's complicated. I -- I sometimes 2 will put Sudden Unexpected Infant Death in brackets, and 3 then list the -- the minor findings. So it's kind of -- 4 it's a historical thing. 5 But infanticide obviously has all sorts of 6 issues attached to it that Sudden Infant -- or Sudden 7 Unexpected Infant Death wouldn't. I mean, that -- that 8 would be a pretty non-controversial issue in most cases. 9 You have an infant that died suddenly. 10 In this case, this is -- this is going 11 beyond that, so not -- not an appropriate designation. 12 13 CONTINUED BY MS. LINDA ROTHSTEIN: 14 MS. LINDA ROTHSTEIN: Then dealing with 15 asphyxia, Dr. Chiasson -- 16 DR. DAVID CHIASSON: Mm-hm. 17 MS. LINDA ROTHSTEIN: You'll -- you'll 18 rem -- recall that Dr. Butt, and indeed other -- others 19 of those who've testified, Dr. Crane and Dr. Milroy, I 20 think were all unanimous on the point that that's an 21 ambiguous term. 22 And that in combination with the language, 23 petechial hemorrhages of the thoracic viscera, congestion 24 of the lungs, cyanosis of the nail beds, is singularly 25 unhelpful, because those three (3) quote, "anatomical

1 diagnosis" closed quote, are so universal as to be of 2 little worth. Or at least the last two (2) are, and even 3 the petechial hemorrhages in the thoracic area are quite 4 non-specific. 5 What do you say about that, sir? 6 DR. DAVID CHIASSON: Well number 1, I 7 agree that use of the term asphyxia is -- is quite 8 ambiguous. I would say -- and I've -- I've read some of 9 the comments of -- of the -- the consultants in regards 10 to the term -- asphyxia from a forensic point of view 11 does imply something -- apply something mechanical, imply 12 smothering, strangulation, some -- some form of non- 13 natural activity. 14 However, if you look at it from a 15 pediatric pathology point of view -- from a pediatric 16 pathology point of view asphyxia is used not uncommonly 17 in situations that are not meant to imply something non- 18 natural. For example, intrauterine asphyxia is -- is 19 something that is quite commonly used, and up until, you 20 know -- up until now continues to be used to describe 21 situations where a stillbirth, for example, might show 22 evidence of fetal distress. And the implication is, is 23 that it's interfering with respiration. In this case, 24 the supplying of oxygen to the -- to the fetus. 25 And -- so it -- it is -- from a pediatric

1 point of view really has a broader con -- context. 2 Perinatal asphyxia, asphyxial issues after birth, again 3 is a term that's quite commonly used. I agree it's -- 4 it's a mechanism of death not a cause of a death in and 5 of itself. But in its -- part of its ambiguity it really 6 stretches out if you're looking at it from more a 7 pediatric pathology point of view than a forensic point 8 of view. So this was not uncommon to see in reports, and 9 it's not restricted to Dr. Smith, when you're dealing 10 with pediatric cases. 11 I agree that the findings there are 12 nonspecific. And actually to -- to stretch out the 13 asphyxia comment, just a little bit more is that some 14 people argue that, in fact, Sudden Infant Death Syndrome 15 is an asphyxial -- there is an asphyxial mechanism of 16 death occurring there. There's some problem with 17 respiration, there is a problem -- because of the 18 positioning there may be issues, of some degree, of -- of 19 airway obstruction, but everybody terms that natural. 20 Nobody -- nobody implies that. At least the 21 straightforward SIDS cases are, in fact, natural. 22 So again, I think it's important to put 23 asphyxia in a broader can -- context than simply one from 24 a forensic point of view. 25 MS. LINDA ROTHSTEIN: Now, if we look

1 under the heading at paragraph -- under the heading 2 discussion, which is excerpted in paragraph 39. To be 3 fair to Dr. Smith, he can be seen to be making the point 4 you have about the ambiguity when he says: 5 "The exact means by which the asphyxia 6 was induced could not be determined on 7 review of these materials." 8 But in the last sentence he concludes: 9 "In the absence of an alternative 10 explanation, the death of this baby 11 girl is attributed to infanticide." 12 And Dr. Butt was -- I think I fairly 13 summarized his evidence, in saying very critical of that 14 logic, if you will. 15 What do you say about that, Dr. Chiasson? 16 DR. DAVID CHIASSON: Well, somebody that 17 now has to deal with this kind of issue in a day-to-day 18 point of view, it -- it's a difficult situation. And the 19 way I would deal with it now is different than the way 20 Dr. Smith has -- had dealt with it. 21 But, you know, I -- I see the basis for 22 his -- his reasoning. We have someone, an infant -- and 23 the -- the important point here is that the evidence does 24 support that the infant was live born. The evidence 25 doesn't support any sign of intrauterine distress and,

1 therefore, most infants that are born and -- and are live 2 born, you'd expect to survive. And if they're not -- 3 MS. LINDA ROTHSTEIN: Well, actually I 4 think Dr. -- to be fair, we don't have photos and so when 5 I was going to ask you about that -- and you may not 6 recall the details of this case, but Dr. Butt was pretty 7 clear that there was an issue of a clot in the photos 8 that wasn't fully developed, and there was an issue with 9 respect to the placenta encircling the neck of the fetus. 10 So I'm not sure that Dr. Butt was 11 satisfied, as I understand his evidence, that one could 12 exclude some potential issue for the fetus. 13 DR. DAVID CHIASSON: Yes. No, I -- and I 14 -- I do recall that; you made a point. Cord around the 15 neck is a very common situation -- 16 MS. LINDA ROTHSTEIN: Okay. 17 DR. DAVID CHIASSON: -- and it's -- the 18 vast majority of times is not an explanation for a -- a 19 infant death. The issue of a clot in -- in abruptio 20 placenta does raise issues, but, in fact, again you go 21 back to the pathology in the infant, there is nothing. 22 So I mean, we're -- we're in a gray area 23 here, and I respect Dr. Butt, and he's looking at as the 24 -- from -- from his perspective. And I think there is a 25 debate that could be engendered regarding live birth

1 versus stillborn. On the preponderance of the evidence I 2 read -- read it, I think it -- that Dr. Smith's 3 conclusion as to live birth is a reasonable one. 4 MS. LINDA ROTHSTEIN: Okay. 5 DR. DAVID CHIASSON: And assuming that, 6 then you have an infant who's obviously become deceased 7 and then the issue of -- of how that happened, it does 8 open up a number of possibilities. Having said that, I 9 agree, you know, to -- to suggest that it's infanticide 10 because you don't have anything else is really going 11 beyond what the evidence really allows you to do. 12 MS. LINDA ROTHSTEIN: And, Dr. Chiasson, 13 to be fair, I think you were careful in saying you would 14 deal differently with it today. 15 How would you deal with it today? 16 DR. DAVID CHIASSON: Well, there's -- 17 there's -- these are difficult case and -- and suffice it 18 to say that Dr. Smith was really -- had the -- the -- his 19 -- his professional practice dealt with a lot of 20 difficult cases and I'm -- I'm very much appreciative of 21 how difficult they are when you have to deal with them 22 yourself. 23 So, how I would deal with a case like 24 this, I mean the big number 1 issues is, is this infant 25 live born or not? Because obviously if it's a stillborn,

1 that -- that's a major impact on any kind of criminal 2 process. 3 So once you determine -- make a 4 determination of that -- and it's not black and white 5 science as to -- to that determination; you've got to 6 look at a number of factors. So I think, you know, if in 7 fact I think it's live born, I make that -- that clear; 8 live born. 9 The fact that it's a full term infant is 10 important, because if it's a twenty-seven (27) weeks 11 premature infant, the chances that it's going to die 12 related to the birthing process is -- is greater than a 13 full term infant. So that's another important finding. 14 And then I wouldn't use the term 15 "asphyxia", but I would make reference to the findings, 16 as nonspecific as they are, they are findings, and then 17 it would be a question of discussion. The discussion 18 would revolve around, 1), I think this infant was live 19 born, and 2), I don't have an anatomic cause of death to 20 explain why. 21 Now, this is where, you know, how much 22 opinion do you put in your report, as opposed to what you 23 might tell the police investigator or a Crown attorney, 24 but the -- the possibility certainly include some form of 25 activity which could be termed as infanticide, homicidal

1 in nature. 2 But the ultimate conclusion would be, in 3 my mind, an undetermined cause of death, but in an infant 4 that is live born. 5 MS. LINDA ROTHSTEIN: Commissioner, is it 6 time for our morning break? 7 COMMISSIONER STEPHEN GOUDGE: Thank you. 8 We'll rise now until 11:30. 9 10 --- Upon recessing at 11:17 a.m. 11 --- Upon resuming at 11:31 a.m. 12 13 THE REGISTRAR: All rise. Please be 14 seated. 15 COMMISSIONER STEPHEN GOUDGE: Ms. 16 Rothstein...? 17 18 CONTINUED BY MS. LINDA ROTHSTEIN: 19 MS. LINDA ROTHSTEIN: Thank you, 20 Commissioner. 21 Dr. Chiasson, I want to touch briefly on 22 Jenna's case for the purpose of illustrating some of the 23 systemic issues it raises with respect to the oversight 24 and case management problems in pediatric forensic 25 pathology.

1 This was another case where we have a 2 document which indicates you did a paper review of the 3 actual post-mortem report that was prepared by Dr. Smith. 4 Is that right? 5 DR. DAVID CHIASSON: Yes. 6 MS. LINDA ROTHSTEIN: But we know from 7 our understanding of that case that the most contentious 8 and critical issue in that case is the one with respect 9 to the timing of the injuries. 10 And am I right in understanding that that 11 issue would not have revealed itself upon a paper review 12 of the post-mortem report? 13 DR. DAVID CHIASSON: Or -- or even upon 14 reviewing the slides and the photographs. 15 MS. LINDA ROTHSTEIN: Right. 16 DR. DAVID CHIASSON: Yes. 17 MS. LINDA ROTHSTEIN: So, if that is the 18 issue I a particular case -- well, let me start with 19 this, if that was indeed the issue, what was your 20 expectation back in 1997, when Dr. Smith prepared his 21 report, as to how he would document his opinion with 22 respect to the timing of the injuries? 23 DR. DAVID CHIASSON: Well, there is no, 24 you know, black and white approach to that issue. My own 25 practice -- if there is an issue that -- that arises,

1 certainly, after the post-mortem examination report's 2 been completed, in most times you -- you -- it gets 3 conveyed in a preliminary hearing setting; have a 4 discussion with Crown attorney; preliminary hearing. 5 If there's something critical in terms of 6 -- of charging an individual -- which I guess is really 7 what we're dealing with in this situation -- and it isn't 8 in the PM report, the usual practice would be simply to 9 have, you know, the police officer would approach you or 10 the Crown would approach you and ask you the question. 11 And in -- in my experience, it's often acted upon based 12 on verbal opinions. 13 If the Crown wants a formal opinion, then 14 my -- my approach is you want an opinion, you -- you 15 write me a letter addressing or -- or laying out what the 16 opinion is you want, specifically; lay out the questions. 17 And -- and I will answer that. And then -- so -- there's 18 a number of different possible approaches. 19 Putting it into the post-mortem 20 examination report -- and this goes back to how much 21 opinion you put into a report -- it's often the issues 22 aren't clear. So at the time that, you know, relevance 23 of how acute an injury is or how long the interval may 24 be. And because it's an inexact science at the best of 25 times, trying to date injuries, I -- my -- my practice is

1 not to render opinions on such things in the context of a 2 post-mortem examination report, because I like to keep my 3 post-mortem examination report sort of as a separate 4 distinct document that addresses the questions that the 5 Coroners Act -- that the coroner is -- is primarily 6 asking about, and that's the opinion as to the cause of 7 death. 8 There may be some opinion -- if I'm 9 sufficiently comfortable and it's sufficiently clear to 10 me that this is not going to change down the road, based 11 on some additional or new circumstantial information. 12 So, you know, there is no clear-cut 13 practice; it varies. And to me the ideal thing is if 14 it's something that's going to lead to criminal charges 15 that's outside the general nature of what you have in 16 your PM report, is -- is to contact the pathologist, get 17 -- get an opinion in writing and then proceed. 18 That -- that would be the safest thing to 19 do. 20 MS. LINDA ROTHSTEIN: Did I understand 21 you to say, however, Dr. Chiasson, that back in '97 when 22 this case arose, it would not have been uncommon for the 23 pathologist to testify about the timing of the injuries 24 at the preliminary inquiry without having put the essence 25 of that testimony in writing beforehand?

1 DR. DAVID CHIASSON: That's absolutely 2 correct. And -- and I, to this day, go to preliminary 3 hearings, render all sorts of opinions that are not in my 4 post-mortem examination report. 5 MS. LINDA ROTHSTEIN: Do you see the 6 pitfalls in that practice; the potential concerns that 7 raises that the defence cannot be fairly put forward; 8 that they don't have enough time to consider your opinion 9 and, perhaps, get defence pathologists? Or are you more 10 agnostic about that practice? 11 DR. DAVID CHIASSON: Well, "agnostic" is 12 an interesting choice of term there. I guess, in fact, I 13 mean, the preliminary hearing I see, and -- and -- where 14 -- where I trained in Baltimore, as I've indicated, 15 preliminary hearings were -- were uncommon. And I think 16 the preliminary hearing in my mind does provide the 17 opportunity for the pathologist to render opinions on 18 issues that are beyond what would normally be enclosed, 19 encapsulated into a report. 20 I would suggest that at the preliminary 21 hearing stage, if a pathologist renders an opinion that - 22 - that is something that -- that the defence wants to 23 challenge, they certainly have the opportunity to then go 24 forth and -- and seek a defence pathologist opinion. 25 And I -- I see a very important role for

1 the use of more defence pathologists, you know, in that 2 kind of -- of setting, whether -- whether it may not be 3 identified, I agree, prior to the preliminary hearing. 4 But my sense of preliminary hearings is that it's not -- 5 you know if the pathologist testifies and that's it, you 6 know, it's -- it's all over and done with, I would expect 7 there'll be the opportunity, if it's raised, for the 8 defence to in fact try. And I appreciate there are major 9 issues relating to defining defence pathologists, but at 10 least we'd have the opportunity to challenge at that 11 particular stage. 12 COMMISSIONER STEPHEN GOUDGE: In a case 13 like this, why wouldn't time of injury be something you 14 would put in your report? 15 DR. DAVID CHIASSON: Well, because, you 16 know, you -- you may well not be aware of it as -- as an 17 -- as an issue -- in the vast majority of -- of cases, 18 you know, we see blunt trauma. You know, the pediatric 19 circumstances is different I -- I admit, but where 20 there's injuries and -- you know, you could potentially 21 render an opinion on any death as to the interval between 22 injury and death; gunshot wounds, stab wounds. In the 23 vast majority of those cases it's -- it's not an issue. 24 And I would suggest that, you know, if it 25 is an issue -- it's hard to know, so I mean to -- to

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1 prescribe, okay, in every report you're now going to 2 render an opinion as to the interval between -- 3 COMMISSIONER STEPHEN GOUDGE: A case like 4 this where it's obviously critical, at least with 5 hindsight? 6 DR. DAVID CHIASSON: Well, with 7 hindsight, yes, it's -- it's obviously critical. And I 8 would suggest that still my -- my feeling is, and -- and 9 we're dealing with -- it's -- it may be one thing for an 10 experienced forensic pathologist to be looking at this, 11 but to -- to suggest that this is some kind of global 12 policy -- because I think we've already made reference to 13 issues where pathologists have rendered opinions which 14 are really not substance -- able -- where it doesn't 15 appear that they even need to render them, and that's 16 creating all sorts of problems. 17 You know, if -- if you have a uniform high 18 level of forensic pathologists who know what they're -- 19 they're doing on an ongoing basis and -- it might be a 20 different situation. I don't think there should be 21 anything to stop a pathologist from rendering that 22 opinion, but if in fact he doesn't have all the 23 information -- may not feel he has all the information. 24 If I may digress very shortly, I -- I 25 learned -- when I was a junior pathologist in Baltimore I

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1 went to Court one time where I rendered an opinion in a 2 PM report -- and back there we didn't usually render very 3 much opinion -- suggesting that one (1) gunshot wound 4 occurred before another gunshot wound. 5 I was actually called by the defence in to 6 show my experience. I didn't even realise I had been 7 called by the defence, which is, again, an unusual 8 situation in a trial. 9 And I was literally hammered with the same 10 question over and over again as to the ordering of the 11 gunshot wounds, until finally the Judge looked down on me 12 and said, Dr. Chiasson, you know, we appreciate your 13 opinion, but are you sure about this, because in fact 14 there's really good circumstantial evidence that you're 15 wrong. And I never was -- you know, I never was 16 informed of the circumstantial information. 17 Now, that's -- that's a dramatic example 18 of the problems you can run into by rendering opinions, 19 but unless you have all the information, if you render an 20 opinion you may find yourself, you know, causing yourself 21 a lot of grief and -- and potentially causing problems 22 from a justice point of view in another direction. 23 24 CONTINUED BY MS. LINDA ROTHSTEIN: 25 MS. LINDA ROTHSTEIN: One of the other

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1 systemic issues this case raises is about who at that 2 Coroner's Office should get involved, having regard for 3 how controversial the case became. We know that Dr. 4 Cairns was involved very early, as early as February '97. 5 We know that Dr. Porter became involved when Dr. Cairns 6 went on a leave and she stayed involved, if we look at 7 the documentation, fairly closely. I mean, even going so 8 far as to be involved in providing her own assistance to 9 the Crown and summarising the controversial opinions that 10 had been received thus far on the timing of the injuries. 11 So, why not you, Dr. Chiasson? Why 12 weren't you involved to that degree? 13 DR. DAVID CHIASSON: Well, that's a very 14 good question and certainly this -- although this is a 15 pediatric case, the issue is one of timing of injuries -- 16 it's a histopathological issue -- and I would have been 17 quite inclined to at least crea -- do a review and -- and 18 address the issue at a certain degree or certain level of 19 -- of certainty. 20 And suffice it to say, realising the 21 problems with trying to time injuries, you know, if 22 somebody is trying to -- to narrow down this window into 23 something that is -- that is perhaps more dogmatic, I 24 think I would have been prepared to say, hey, that's -- 25 you're going a little farther than the evidence here.

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1 Even though it's a pediatric pathology 2 problem, even though it's Dr. Smith, you know, it's -- 3 it's timing of injuries is -- is a sort of general 4 forensic pathology. 5 MS. LINDA ROTHSTEIN: So I hear you to be 6 making the case that you ought to have been involved? 7 DR. DAVID CHIASSON: Yes. But in fact, I 8 mean, I realize I had some involvement in -- in the case. 9 MS. LINDA ROTHSTEIN: Let me rephrase 10 that. You ought to have been more involved? 11 DR. DAVID CHIASSON: I ought to have been 12 more involved, yes. 13 DR. DAVID CHIASSON: So why weren't you? 14 MS. LINDA ROTHSTEIN: Well, you know, I 15 guess I -- I wasn't asked to be more involved than I was. 16 MS. LINDA ROTHSTEIN: And looked at 17 systemically, what is the optimal way to deal with those 18 developing issues; that is to say, what is the role of 19 the Deputy Coroner versus the Chief Forensic Pathologist 20 in helping the police, and the Crown, and indeed the 21 defence make their way through those developing issues? 22 DR. DAVID CHIASSON: Well, I thank that 23 the -- the issue is to certainly have the Chief forensic 24 Pathologist involved, whether he carries out a review or 25 whether he recommends somebody to carry out a review. I

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1 think that that will vary with the nature of the -- the 2 process. 3 But certainly having him involved in the - 4 - the decision making process is the big thing. 5 MS. LINDA ROTHSTEIN: All right. In the 6 time remaining, Dr. Chiasson, I'd like to review with you 7 the events that continued to involve you in your position 8 as the Chief Forensic Pathologist following on the summer 9 of '99 which was that -- as you described it in the 10 realign, a bit of crisis time in terms of your staffing. 11 By November of '99, we know that there is 12 at least some other public concern raised with respect to 13 the quality of work that was being performed by Dr. Smith 14 by means of the Fifth Estate broadcast in November of 15 that year. 16 Did you hear about that? 17 DR. DAVID CHIASSON: Yes. 18 MS. LINDA ROTHSTEIN: Did you see it? 19 DR. DAVID CHIASSON: Yes. 20 MS. LINDA ROTHSTEIN: What did you think? 21 DR. DAVID CHIASSON: Well, it's -- it's 22 a -- 23 MS. LINDA ROTHSTEIN: At the time, past 24 tense, please, sir. 25 DR. DAVID CHIASSON: Past -- past tense.

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1 It's -- it was obviously a very critical piece of 2 journalism that was aimed at Dr. -- Dr. Smith. 3 You know, to my mind, it was -- we were 4 aware of the issues that were being raised. I mean, they 5 -- they weren't surprises from that point of view, but 6 certainly it was very critical journalism. 7 MS. LINDA ROTHSTEIN: Did you think that 8 something more had to be done with respect to Dr. Smith? 9 At that stage, nothing in particular had changed in terms 10 of the -- the way his cases were being handled. And he 11 wasn't being restricted in any way. 12 Did you have any views about that then? 13 DR. DAVID CHIASSON: Well, I think, you 14 know, my view back then was that we were dealing with the 15 -- we were aware of the issues, we were dealing with them 16 as best, I think, as we could at the time. The fact that 17 the media's now gotten a hold of the story and -- and is 18 -- I mean, that -- that creates, obviously, a -- a 19 different level. 20 But I mean, in terms of driving us to do 21 anything different, I -- I'm not sure that -- you know, 22 we're -- we're not going to be driven by the -- the media 23 in terms of our management of a senior pathologist in our 24 office or affiliated with our office. 25 MS. LINDA ROTHSTEIN: Okay. Would you

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1 turn to Tab 61, of Volume I, please, of your documents, 2 PFP129468. 3 DR. DAVID CHIASSON: Sorry, Ms. 4 Rothstein, again. 5 MS. LINDA ROTHSTEIN: Volume I, Tab 61. 6 Dr. Chiasson, I understand that you created a committee 7 to try and assist you in -- in getting more teamwork 8 going in your office in dealing with some of the 9 sensitive forensic pathology issues that you had 10 encountered, is that right? 11 DR. DAVID CHIASSON: Correct, yes. 12 MS. LINDA ROTHSTEIN: And it was known as 13 the Forensic Pathology Issues Committee? 14 DR. DAVID CHIASSON: Yes. 15 MS. LINDA ROTHSTEIN: And indeed its 16 inaugural meeting was on February the 29th of 2000, is 17 that right? 18 DR. DAVID CHIASSON: Yes. 19 MS. LINDA ROTHSTEIN: All right. Can you 20 give the Commissioner a little bit more in the way of 21 background as to what lead to the inception of this 22 committee. Why you thought it was important and 23 necessary. 24 DR. DAVID CHIASSON: Well, I -- I thought 25 there was a crisis in forensic pathology at the Coroner's

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1 Office, in large part precipitated by the loss of -- of 2 three (3) staff pathologists in a -- in a space of -- of 3 a very short period of -- of time. 4 And I thought that the -- and -- and as I 5 indicated in this -- these minutes, the impending 6 retirement of Mr. Blenkinsop, who was really an 7 invaluable asset to the office and to me, in -- in 8 particular, and so difficulties recruiting staff. 9 I was feeling somewhat isolated with 10 having to deal with a lot of problems here, so I created 11 this committee to -- to sort of assist me in trying to 12 deal with forensic pathology issues, as -- as the name 13 implies. 14 MS. LINDA ROTHSTEIN: And the members of 15 the committee were those listed on this document? 16 DR. DAVID CHIASSON: Correct, yes. 17 MS. LINDA ROTHSTEIN: D. Eden is who, 18 sir? 19 DR. DAVID CHIASSON: Dr. Eden is the -- I 20 think at that time was the Regional Coroner in the 21 Niagara region. 22 MS. LINDA ROTHSTEIN: Okay. 23 DR. DAVID CHIASSON: He was a Regional 24 Supervising Coroner. His -- his position has changed a 25 bit over the years, but I think at that time he was the

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1 one for the Niagara region. 2 MS. LINDA ROTHSTEIN: Did the committee 3 continue to meet after this inaugural meeting? 4 DR. DAVID CHIASSON: It did. 5 MS. LINDA ROTHSTEIN: Okay. How 6 frequently did it meet? 7 DR. DAVID CHIASSON: I'd have to check 8 the actual minutes; maybe every couple of months or so. 9 MS. LINDA ROTHSTEIN: And to what extent 10 did it explore what you describe in this minutes as 11 "alternative models" for the provision of Forensic 12 Pathology Services? 13 DR. DAVID CHIASSON: Well, as I -- as I 14 have suggested, I mean, I -- I was feeling somewhat 15 beleaguered and embattled trying to maintain the current 16 model. A major issue in my mind was -- was trying to 17 recruit people and, you know, part of that process of 18 trying to deal with that is, is -- is there a better 19 alternative model, is there one that we're going to -- 20 that would work better in -- in trying to recruit and 21 retain forensic pathologists. 22 MS. LINDA ROTHSTEIN: But how far did 23 those conversations go? Did you get very for -- far in 24 fashioning an alternative model, or do you recall? 25 DR. DAVID CHIASSON: There was

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1 discussion. I mean, some of the models involved the 2 Forensic Pathology Unit forensic pathology, separating 3 from the Coroner's Office. And if you look up at that 4 top there, I'm -- I'm the lone pathology voice in a -- in 5 a forest of coroners. So there wasn't a lot of support 6 for models that -- that really saw a re-visioning of 7 forensic pathology outside of the Coroner's Office at 8 that time. 9 MS. LINDA ROTHSTEIN: Dr. Chiasson, could 10 I ask you to turn to Volume II? 11 COMMISSIONER STEPHEN GOUDGE: Just before 12 you do -- 13 MS. LINDA ROTHSTEIN: Sorry. 14 COMMISSIONER STEPHEN GOUDGE: -- can I 15 ask you one (1) question, Dr. Chiasson? What's the 16 notion you had in mind about functioning under the aegis 17 of the University? I mean... 18 DR. DAVID CHIASSON: Well, this would 19 have -- and again, this -- this never got formulated. 20 COMMISSIONER STEPHEN GOUDGE: Yes, that 21 would have been, at this point, a relatively -- 22 DR. DAVID CHIASSON: No, no. 23 COMMISSIONER STEPHEN GOUDGE: -- 24 undefined concept, but... 25 DR. DAVID CHIASSON: But the -- the

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1 concept was one similar to what was happening in the 2 other forensic pathology units, which were located in 3 hospitals with university academic involvement. So are 4 we, in fact, going to create a Toronto Forensic Pathology 5 Unit that is like the Hamilton Forensic Pathology Unit; 6 it's outside of the -- the Coroner's Office, it's under - 7 - it's in a hospital -- 8 COMMISSIONER STEPHEN GOUDGE: Staffed by 9 forensic pathologists who would be hospital employees. 10 DR. DAVID CHIASSON: Exactly. That -- 11 that was the basic model. 12 COMMISSIONER STEPHEN GOUDGE: And, I take 13 it, your concept would have been that would have been at 14 the Toronto Hospital. 15 DR. DAVID CHIASSON: Well, I mean, that's 16 -- that would have been a certainly obvious -- 17 COMMISSIONER STEPHEN GOUDGE: That's the 18 obvious candidate as -- 19 DR. DAVID CHIASSON: -- candidate, but I 20 mean, you know, obviously -- 21 COMMISSIONER STEPHEN GOUDGE: You could 22 have used St. Mikes or any of the other teaching 23 hospitals -- Sunnybrook. 24 DR. DAVID CHIASSON: Could have been, and 25 certainly I had no discussions about any hospitals about

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1 that -- that notion actually ever taking place. But that 2 -- or if you -- 3 COMMISSIONER STEPHEN GOUDGE: Did you 4 have sense -- sorry, did you have any sense in your own 5 head as to how receptive any of the teaching hospitals 6 would be to that? 7 DR. DAVID CHIASSON: Well, I mean, there 8 was the -- the precedent in the City of the Toronto -- 9 the Hospital for Sick Children -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. DAVID CHIASSON: -- having the 12 pediatric units. So what we're doing is basically having 13 an adult unit. I think that the hospitals probably had 14 raised eyebrows -- would have been the first reaction, 15 and then, you know, money would have probably been a 16 driving factor, if there was some sort of -- felt to be 17 some financial, you know, benefit to the hospital and 18 some academic benefit to the hospital. 19 COMMISSIONER STEPHEN GOUDGE: Thanks. 20 21 CONTINUED BY MS. LINDA ROTHSTEIN: 22 MS. LINDA ROTHSTEIN: Sorry. Volume II - 23 - I am moving a little briskly, Commissioner -- Tab 41, 24 PFP026847. It's a letter from Rita Zaied, Crown Attorney 25 -- Assistant Crown Attorney to Dr. Smith, copied to you

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1 in the Kporwodu matter, explaining to him that he needs 2 to complete an addendum report in light of the defence 3 having threatened to bring a motion to stay the charges 4 unless it was provided. 5 And were you involved in dealing with Dr. 6 Smith and attempting to get him to provide the necessary 7 information, or not? 8 DR. DAVID CHIASSON: I think I was 9 involved. I -- I've had some involvement with this case, 10 obviously, subsequent to this. But I think at this 11 stage, Ms. Zaied and I had some correspondence to try and 12 get Charles to -- Dr. Smith to do what was being 13 requested here. 14 MS. LINDA ROTHSTEIN: And how seriously 15 did you view the matter at that time? 16 DR. DAVID CHIASSON: That's -- I mean, to 17 actually -- well, a stay a proceeding because of a lack 18 of a report is obviously a significant issue. And to 19 have a subpoena issued to attend court to explain why 20 you're not doing that; I mean, this is completely 21 extraordinary and it's difficult to understand actually. 22 MS. LINDA ROTHSTEIN: Tab 32 of Volume I 23 -- sorry to make you flip around. 24 DR. DAVID CHIASSON: It's okay. 25 MS. LINDA ROTHSTEIN: But it is

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1 chronological. This is a draft letter that you wrote 2 that I understand, Dr. Chiasson, you never sent. 3 DR. DAVID CHIASSON: I'm sorry. Are we 4 Volume I or Volume II? 5 MS. LINDA ROTHSTEIN: Back to Volume I, 6 Tab 32 -- whoops, that's not it. Okay, one of my tabs is 7 off -- sorry everybody -- 132, there we go. Thank you. 8 And it's PFP129447. 9 We're quite clear, are we not, Dr. 10 Chiasson, that you never sent this letter to Dr. Young? 11 DR. DAVID CHIASSON: That's -- that's 12 correct, yes. 13 MS. LINDA ROTHSTEIN: All right. And -- 14 and fair enough, but can you just give us some insight, 15 if you will, as to what it was that provoked you to even 16 prepare a draft in which you were contemplating 17 resignation in March of that year? 18 DR. DAVID CHIASSON: Well, I -- I think I 19 -- I made reference in -- into the letter, it's not only 20 the loss of the staff pathologist and -- and Mr. 21 Blenkinsop; that was a particularly major loss. 22 Barry was a wonderful person to work with 23 and took on a lot of the administrative responsibilities, 24 vis-a-vis, the functioning of the Unit. He was 25 invaluable, and the loss of him would have just added

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1 more administrative stuff -- administrative matters on my 2 shoulders that I clearly didn't feel I needed. 3 And the -- the -- in about the -- one (1), 4 two (2), three (3), four (4), five (5) -- fifth 5 paragraph, I felt that I could no longer effectively 6 carry out my responsibilities. 7 MS. LINDA ROTHSTEIN: Did the issues 8 involving Dr. Smith play any role, whatsoever, in that 9 moment where you were contemplating your resignation? 10 DR. DAVID CHIASSON: You know, it was a - 11 - it was part of my management headache, if you will; a 12 management issue that I had to deal with. It -- it was a 13 reflection of the difficulties I was having with managing 14 the forensic pathologists who worked in the Forensic 15 Pathology Unit. 16 So it -- it certainly was a -- a factor, 17 but it was a minor factor in my decision or my thinking 18 at this time. 19 MS. LINDA ROTHSTEIN: Now, in October of 20 2000 you had actually been appointed Deputy Chief 21 Coroner, Pathology, at the OCCO. 22 Am I right about that? 23 DR. DAVID CHIASSON: Yes. 24 MS. LINDA ROTHSTEIN: So what was the 25 importance, if any, of that appointment? What change did

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1 it make to your responsibilities? What was the purpose 2 of that change in your title? 3 DR. DAVID CHIASSON: Well, as I've 4 indicated, the reasons for going that route was to try 5 and reinforce the teamwork between pathologists and -- 6 and coroners to make pathologists feel part of the 7 office. 8 At the same time, Dr. Toby Rose was named 9 a coroner. And, for me, again sort of opened up the 10 avenue that -- well, for anybody -- again, not 11 necessarily me, but the opportunity of becoming a Chief 12 Coroner and being in charge of death investigation was -- 13 was opened up. 14 It -- as far as my responsibilities, they 15 were essentially the same. They did not change in any 16 significant way. I did get to move upstairs and have an 17 office with a window. That was the other. 18 MS. LINDA ROTHSTEIN: Was there any 19 change in your salary? 20 DR. DAVID CHIASSON: No. 21 MS. LINDA ROTHSTEIN: Dr. Chiasson, same 22 volume, Tab 104, Tab 105, are some email exchanges 23 between you and Dr. Smith in the Fall of that year, 2000. 24 And my question for you before we look at the detail of 25 them is this.

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1 We don't have a lot in our database. We 2 don't have a lot of email exchanges between you and Dr. 3 Smith, and it's difficult for us to know whether that's 4 merely reflective of what was still available in 5 everybody's email in the database of the hospital or the 6 OCCO, or whether that was reflective of the extent to 7 which you engaged in that kind of contact and 8 communication with Dr. Smith. 9 Can you help us with that, please? 10 DR. DAVID CHIASSON: Well, email actually 11 was a way that Dr. Smith and I would communicate with 12 some regularity. In fact, more likely to do that than we 13 were to talk on the phone, for example. 14 So, you know, is there a lot more emails? 15 I -- I don't think -- I'd suspect you've got -- most of 16 the emails have been dug -- dug up. 17 MS. LINDA ROTHSTEIN: All right. So 18 looking at 104 and 105, they, to my eye, appear to 19 record, you know, some considerable follow-up by you 20 about the timeliness of certain reports. And they also 21 seem to reflect some discussion of Wednesday meetings. 22 And I'm wondering if you can assist us as 23 to whether they're indicative of some more hands-on 24 supervision by you at this stage, or if they are a 25 continuation of what had been the status quo?

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1 DR. DAVID CHIASSON: Well, certainly the 2 email at Tab 104, PFP129217; that really relates to the 3 activities of the SIDS/SUDS Committee, which subsequently 4 became the Sudden Unexpected Death Under Two, 5 subsequently Under Five Committee. 6 So, this is related to cases that we're 7 asking him to review. A large part of this is -- is 8 related to that. So we are having more communications on 9 that level. I think that's mostly what is being referred 10 there. Jeff Mainland was the EA to Dr. Cairns, who was 11 facilitating this. 12 So -- and if you see under Tab 105, again 13 it's re: Death Under Two Committee cases related to -- to 14 that. 15 MS. LINDA ROTHSTEIN: But to the extent 16 that you're urging Dr. Smith to attend homicide rounds on 17 Wednesday, was that a new development or a continuation 18 of -- of something that had gone on for some period of 19 time. 20 Can you assist us with that? 21 DR. DAVID CHIASSON: Well, I think back 22 in '98, we were encouraging him to become more a part of 23 what we were doing. And we had started -- I think it's 24 '99 -- a series of pediatric pathology rounds at the 25 Coroner's Office as opposed to at Sick Kids before.

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1 So I was sort of taking charge of having 2 cases, and this was the opportunity for Dr. Smith to 3 present source of cases, have my staff get used to the 4 idea of reviewing and -- and being -- getting exposure to 5 pediatric pathology cases. So that's -- they were 6 Wednesday afternoon rounds. 7 MS. LINDA ROTHSTEIN: And did they occur 8 with regularity, or not? 9 DR. DAVID CHIASSON: They did, I think, 10 through '99 into 2000 with -- they were fairly regular, 11 yes. 12 MS. LINDA ROTHSTEIN: What does that 13 mean? How frequent were they? 14 DR. DAVID CHIASSON: I'd have to go back 15 and check exactly, but I think pediatric rounds, maybe 16 every couple of months. 17 MS. LINDA ROTHSTEIN: Okay. Now, as you 18 know, Dr. Chiasson, in January of 2001 there were two (2) 19 cases where charges were withdrawn within days of each 20 other; Sharon's case and the case involving Tyrell. 21 And did you know about that before it 22 actually happened? Was that something that you were 23 given the heads up on? Were you at all involved in any 24 decisions with the Crown or others about whether they 25 ought to do that?

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1 DR. DAVID CHIASSON: No. 2 MS. LINDA ROTHSTEIN: We also know that 3 on January the 26th Dr. Smith submitted a letter to Dr. 4 Young in which he withdrew himself from coroner's cases 5 for a period of time and asked for an independent review. 6 7 You know about that, do you? 8 DR. DAVID CHIASSON: Yes. 9 MS. LINDA ROTHSTEIN: Again, did you know 10 anything about that before it happened? Were you 11 consulted? Were you involved in the discussions with 12 either Dr. Young or Dr. Smith about that before it 13 occurred? 14 DR. DAVID CHIASSON: There was a meeting 15 that I recall -- excuse me, Dr. Cairns, Dr. Young and -- 16 and myself met in regards of how to manage and deal with 17 the -- this latest crisis involving Dr. Smith. 18 And the decision was that Dr. Young would 19 speak to him nd, as I understood it, would -- would ask 20 him to stop doing cases or -- or have him stop doing 21 cases. Exactly how that was going to be massaged, I 22 didn't know but that was -- that was going to be the end 23 result. 24 MS. LINDA ROTHSTEIN: And was that a 25 consensus that the three (3) of you reached? In other

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1 words, did you favour that approach? 2 DR. DAVID CHIASSON: I certainly thought 3 that was a very reasonable approach given the 4 circumstances, yes. 5 MS. LINDA ROTHSTEIN: And at that stage 6 in your discussions with Dr. Cairns and Young, did you 7 also discuss the necessity for any kind of independent 8 review of Dr. Smith's work, or did that -- those 9 discussions occur later on? 10 DR. DAVID CHIASSON: There were 11 discussions about a review process and, certainly, I 12 think when Dr. Smith was looking for one as part of the 13 agreement to step down, I mean, that -- where exactly it 14 -- the discussions took place relative to the meeting 15 with Dr. Smith, I don't have any specific recall. 16 But it certainly was a -- an item that was 17 discussed. 18 COMMISSIONER STEPHEN GOUDGE: By that 19 time had you developed concerns about Dr. Smith's 20 competence? 21 DR. DAVID CHIASSON: Well, it was a lot 22 of smoke, Mr. Commissioner, obviously, and I -- I was 23 starting to have concerns that where there's a lot of 24 smoke, there was some -- some fire going on here, yes. 25

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1 CONTINUED BY MS. LINDA ROTHSTEIN: 2 MS. LINDA ROTHSTEIN: And we know, as 3 well, that you attended, or at least it appears you 4 attended a meeting on January the 26th of 2001. If you 5 turn to Tab 122 of Volume I, 139736. 6 Do you remember that meeting, Dr. 7 Chiasson? A meeting at which you, Mr. Blenkinsop, Dr. 8 McLellan, Al O'Marra, Jeff Mainland and others were in 9 attendance? 10 DR. DAVID CHIASSON: I -- I don't 11 specifically recall the meeting. I mean, I certainly 12 accept that I was there, as documented here. 13 MS. LINDA ROTHSTEIN: Well, there seems 14 to be some conversation at that meeting, as we've heard 15 it from other witnesses, about doing some form of review 16 of Dr. Smith's cases. 17 Can you give us your best recollection as 18 to what your understanding was of the nature and scope of 19 any review that was to be conducted? 20 DR. DAVID CHIASSON: Well, there was, you 21 know, I mean, as I've said, we certainly had discussions 22 about -- about reviewing. We thought -- I thought that 23 was important. Obviously there was enough issues here 24 that we did need to do that. 25 And I certainly felt that this was going

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1 to be a difficult process to do, given the nature of Dr. 2 Smith's work. I really struggled -- there was no 3 apparent people, you know, that jumped out to do this 4 review work. So there was that difficulty that was 5 inherent in -- in all of this. 6 MS. LINDA ROTHSTEIN: You also attended, 7 we understand, Dr. Chiasson, a meeting with Mr. McMahon, 8 who was then the head of the Toronto Crown Attorneys, Dr. 9 Cairns, and you'll forgive me, one of the senior police 10 officers whose name I'm forgetting as I stand here, on 11 January the 31st of 2001. 12 DR. DAVID CHIASSON: Yes, I recall a 13 meeting with Mr. McMahon. 14 MS. LINDA ROTHSTEIN: And, again, can you 15 give us your best recollection of what was discussed and 16 ultimately decided, if anything, during that meeting, 17 please? 18 DR. DAVID CHIASSON: Well, I think the 19 intent of the meeting was to convey to a senior Crown 20 attorney -- somebody with supervisory responsibilities 21 for Crown attorneys -- the -- what the status was in 22 regards to Dr. Smith, and to offer our assistance to the 23 Ministry in terms of how to deal with cases that were in 24 the court system. 25 I think it was general feeling that there

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1 were -- there were going to be issues and problems raised 2 in any, now that Dr. Smith was involved in within the 3 criminal justice system. And that we were prepared to 4 assist, certainly, on an individual case-to-case basis, 5 with finding some suitable expertise to review the cases. 6 MS. LINDA ROTHSTEIN: Okay. And then 7 finally, it would appear that in that same very tight 8 timeframe in late January/early February you met, as 9 well, with Dr. Goldbloom at the Hospital for Sick 10 Children to discuss the go-forward plan with Dr. Smith at 11 the hospital. If you look at Tab 123, Dr. Chiasson -- 12 DR. DAVID CHIASSON: Yes. 13 MS. LINDA ROTHSTEIN: -- PFP056703 makes 14 reference to a lunch meeting that you, Dr. Cairns, and 15 Dr. Mainland had with Dr. Goldbloom. 16 Is that right? 17 DR. DAVID CHIASSON: Yes. 18 MS. LINDA ROTHSTEIN: And it would appear 19 -- I'm assu -- I'm assuming what you've recorded here 20 fairly summarizes the discussions that you had and the -- 21 and the agreement that you reached in that meeting. 22 Is that right? 23 DR. DAVID CHIASSON: Yes. 24 MS. LINDA ROTHSTEIN: And so you say: 25 "Post-mortem examinations in pediatric

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1 coroner's cases will continue to be 2 performed at HSC utilizing its 3 facilities as before." 4 And stopping there for a moment, Dr. 5 Chiasson, I take it that at that stage you really didn't 6 have the ability to start doing the medicolegal cases at 7 26 Greville for all the reasons you've told us about? 8 DR. DAVID CHIASSON: Yes. By this time 9 we'd actually hired a couple of forensic pathologists, 10 but they were both junior. They were just out of their 11 training. And we still had a fair amount of part-time 12 people working, and we -- we just were not able to assume 13 the responsibility at the Coroner's Office to do 14 pediatric pathology cases. 15 MS. LINDA ROTHSTEIN: Number 2: 16 "The Coroner's Office will be 17 responsible for the triage of cases in 18 which an autopsy has been ordered by 19 the investigating coroner." 20 So what was contemplated there, Dr. 21 Chiasson; that you would speak to the local coroner and 22 make a determination as to who should be doing the 23 autopsy at Sick Kids? 24 DR. DAVID CHIASSON: Yes. Normally, the 25 director of the unit would have been charged with this,

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1 you know, responsibility, but clearly, under the 2 circumstances, we couldn't have that happening. So we 3 were assuming the responsibility for -- for triaging the 4 cases, and in part -- as part of it was -- would involve 5 our staff pathologists in -- in selected cases. 6 So, obviously, the triage is not simply 7 within the Hospital for Sick Children. It's a triage, 8 okay, do we need a forensic pathologist from the 9 Coroner's Office to, in fact, be involved in the case. 10 MS. LINDA ROTHSTEIN: You go on: 11 "Autopsies of a primary medical nature 12 in cases of sudden and unexpected death 13 with no suspicion of foul play will be 14 directed to the HSC pathologists Greg 15 Wilson or Ernest Cutz, who is on call 16 for coroner's cases. Autopsies in 17 primary forensic traumatic cases or in 18 those deemed to be suspicious, will be 19 performed by one (1) of the Coroner's 20 Office staff forensic pathologist; 21 either myself, Dr. Rose, Dr. Lee, or 22 Jacqueline Parai." 23 Now, couple of questions arising out that. 24 And it's very much one (1) of the Commissioner's 25 interests. How easy is it to that bifurcation between

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1 the cases that should go to those with more of a 2 pediatric focus -- if I can put it that way -- and the 3 pediatric forensic cases that should go to those with 4 more of a forensic background? 5 Is that something that's actually more or 6 less easy to do? 7 DR. DAVID CHIASSON: It's not easy to do. 8 It's a -- if -- if you look at it as a -- an evolving 9 process so that, okay, you get the initial information, 10 some cases are ser -- are going to quickly branch off, 11 this is criminally suspicious. 12 So you can -- then you go a little further 13 on. You may get information in a police briefing, for 14 example, that's -- indicates suspicion. Or you may get 15 your x-rays done and you've got fractures, so that 16 clearly deviates it into suspicious cases. 17 To do it upfront from a coroner's, you 18 know, warrant point of view, based on that kind of level 19 or that stage of the investigation is -- is difficult. 20 And -- but as -- as you go along, you need somebody to be 21 able to step in really at -- at almost any stage, 22 including doing the post-mortem examination and finding a 23 problem at that time. 24 MS. LINDA ROTHSTEIN: Now, we know that 25 you actually left the Coroner's Office by June, or the

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1 end of June of 2001. How did it work in practice? How - 2 - what do you remember about how difficult it was to 3 perform this level of triage during that period? 4 DR. DAVID CHIASSON: Well, to be -- to be 5 honest, I'm not sure how much triaging actually took 6 place. I mean, what happened was is that Dr. Wilson and 7 Dr. Cutz did the vast majority of cases -- 8 MS. LINDA ROTHSTEIN: Okay. 9 DR. DAVID CHIASSON: -- in this time 10 interval. I did not -- I don't recall attending Sick 11 Kids during this time period to do a post-mortem, and I 12 don't think any of my colleagues there actually did 13 attend Sick Kids during this time period. 14 Dr. Rose may have attended for one (1), 15 but -- so whether that's simply good luck that we didn't 16 have any suspicious cases, or whether it was Dr. Wilson 17 and Dr. Cutz were able to -- felt comfortable enough to 18 handle what was -- what was being directed to them, I'm - 19 - I'm not sure. I haven't gone back and looked at the 20 cases in that time interval. But -- 21 COMMISSIONER STEPHEN GOUDGE: But your 22 sense of the time was this would be your function, as the 23 Chief Forensic Pathologist, to triage and that it didn't 24 pose any difficulty in this time frame? 25 DR. DAVID CHIASSON: Well, if -- if you

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1 look at the memo, it's -- it makes actually a reference 2 to the Coroner's Office, as opposed to me, specifically. 3 COMMISSIONER STEPHEN GOUDGE: I assumed 4 that's what that -- 5 DR. DAVID CHIASSON: I would -- I would 6 expect that I would have been involved in the triage 7 process, but there may have times where Dr. Cairns, for 8 example, might have done the triaging. 9 COMMISSIONER STEPHEN GOUDGE: The best, I 10 take it, would have been for you to do it or be involved 11 with it? 12 DR. DAVID CHIASSON: Yes. No, I think 13 that's -- that was preferred. 14 COMMISSIONER STEPHEN GOUDGE: And one (1) 15 of those two (2) -- you or Dr. Cairns, or some 16 combination -- as opposed to simply the bodies arriving 17 at Sick Kids and a determination being made by Drs. 18 Wilson or Cutz that they could do it. 19 DR. DAVID CHIASSON: Yes, as I've 20 indicated -- 21 COMMISSIONER STEPHEN GOUDGE: That would 22 be a third best. 23 DR. DAVID CHIASSON: Well, yes. But I 24 think the idea was that in fact the Coroner's Office 25 would be contacted and notified we're sending a case

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1 down, where, you know, we're -- we're alerting that. 2 COMMISSIONER STEPHEN GOUDGE: The 3 investigating coroner would say, I'm sending a case down, 4 where do you want it to go? Well, it would go to Sick 5 Kids, but who do you want to do it? 6 DR. DAVID CHIASSON: Yeah, through the 7 Regional Coroner, yes, that would be the -- 8 COMMISSIONER STEPHEN GOUDGE: That was 9 the system. 10 DR. DAVID CHIASSON: That was what was 11 designed to happen, yes. That's the way -- 12 COMMISSIONER STEPHEN GOUDGE: And during 13 this period of time, you don't recall that providing 14 problems for you. 15 DR. DAVID CHIASSON: Well, it -- it 16 really, during this time period, didn't create any 17 problems that I'm aware of. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 Thanks. 20 21 CONTINUED BY MS. LINDA ROTHSTEIN: 22 MS. LINDA ROTHSTEIN: Dr. Chiasson, am I 23 right, though, there was some reluctance on the part of 24 your staff, that is to say Drs. Rose and Lee and Parai, 25 about taking on these cases given their lack of

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1 experience in that area? 2 DR. DAVID CHIASSON: There was major 3 concerns expressed about taking on these cases by my 4 staff. Certainly, Dr. Lee and Dr. Parai were quite 5 junior at the time; did not feel comfortable about doing 6 pediatric cases, especially in the environment where the 7 senior pediatric forensic pathologist was under a lot of 8 scrutiny. 9 MS. LINDA ROTHSTEIN: And are their 10 concerns fairly reflected in the next document at Tab 11 124, their memo to you dated February the 2nd of 2001, 12 that's 136262? 13 DR. DAVID CHIASSON: Yes. 14 MS. LINDA ROTHSTEIN: All right. And so 15 in the result they did very few of these cases. Is -- 16 does -- was that partly because of their reluctance; is 17 that what I'm hearing you say? 18 DR. DAVID CHIASSON: Well, as -- as I've 19 indicated, I don't think any of us ended up doing any 20 cases, and I -- I shouldn't be completely 100 percent 21 there. But very few cases, if any, were done in that 22 time period, and neither Dr. Parai nor Dr. Lee -- neither 23 of them did any. I know that. 24 Dr. Rose may have done one (1), and 25 frankly, I don't recall doing any at this time either.

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1 MS. LINDA ROTHSTEIN: Were you reluctant 2 to do them then? 3 DR. DAVID CHIASSON: Was I reluctant? 4 Well, I -- hesitant -- 5 MS. LINDA ROTHSTEIN: Okay. 6 DR. DAVID CHIASSON: -- as opposed to re 7 -- reluctant. 8 MS. LINDA ROTHSTEIN: Okay. 9 DR. DAVID CHIASSON: You know, I saw this 10 as being a -- a major area of obviously high profileness 11 because of what was going on and -- and I had lots of 12 other things on my plate. And to start getting involved 13 in this, at that time, was creating me some concern, yes. 14 But the buck had to stop somewhere. 15 MS. LINDA ROTHSTEIN: Dr. Young and Dr. 16 Cairns have testified that by the end of February or 17 March, Dr. Young had determined that it wasn't 18 appropriate to go forward with the -- with an external 19 review, if you will, of Dr. Smith's cases, other than in 20 those cases where the Crown specifically asked for one. 21 Did he tell you about that? 22 DR. DAVID CHIASSON: I found out about 23 it. I don't recall this being broached with me prior to 24 finding out about it in sort of a round-about way. 25 MS. LINDA ROTHSTEIN: Okay. How did you

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1 find out about it in a round-about way, sir? 2 DR. DAVID CHIASSON: I'm not sure if it 3 was through Dr. Cairns or whether I actually -- through 4 media reporting. I -- I don't recall. 5 MS. LINDA ROTHSTEIN: So, certainly, it 6 wasn't something that Dr. Young sought your views about 7 before he made the decision. 8 Is that fair? 9 DR. DAVID CHIASSON: That's fair. 10 MS. LINDA ROTHSTEIN: Okay. We know as 11 well, Dr. Chiasson, that on June the 29th, 2001 you did 12 tender your resignation. 13 DR. DAVID CHIASSON: I did, yes. 14 MS. LINDA ROTHSTEIN: Okay. Can you tell 15 us what the catalysts were that lead to that final 16 decision, sir? 17 DR. DAVID CHIASSON: Well, I think there 18 were a number of ongoing frustrations. Obviously it 19 wasn't a decision, you know, a split-second decision. 20 I'd been thinking back in -- in about a year -- over a 21 year before. 22 The frustrations were continuing. Dr. 23 Lee, who I had hired in August/September of the previous 24 year, had decided to resign for a position in Vancouver, 25 again, for a significant increase in -- in money,

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1 although I'm not sure that was completely his decision. 2 I think he's actually got some connections back on -- on 3 the West Coast, so... 4 But, regardless, I had lost another 5 forensic pathologist within nine (9) months of hiring 6 him. I -- I -- my sense of the writing on the wall was 7 that recruiting was going to continue to be a major 8 problem. And we were also, just to make things worse -- 9 I -- I guess I had two (2) bad years -- but we had a 10 strike among pathologist in the community over 11 remuneration for doing fee-for-service autopsies. 12 And, so, in the first part of 2001, we 13 were getting more and more referred cases from 14 jurisdictions where the pathologists were refusing to do 15 the cases. So, I'm losing my staff pathologist, the 16 number of cases that are being directed to the office is 17 increasing, and that not only creates problems in terms 18 of doing the case, but also the potential for down the 19 road for testifying in -- in other jurisdictions where 20 you normally wouldn't have to. 21 Scheduling was -- was problematic, and I 22 felt that I really, at this stage, could not carry out my 23 responsibilities as the Deputy Chief Coroner of 24 Pathology. And somebody had to do the work in terms of 25 the day-to-day stuff, and I decided to step down and --

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1 and start going back into the autopsy room and doing -- 2 doing cases for the Coroners Office; in that case, on a 3 fee-for-service basis. 4 MS. LINDA ROTHSTEIN: And indeed, Dr. 5 Chiasson, if we look at Tab 133 of same volume, 129449, 6 were you also troubled by the way that the issues with 7 the pathologists had been dealt with in the sense that 8 you had - if I quote you here - "been relegated to the 9 sidelines" in handling that situation. 10 Is that also, again, an example of a 11 situation where you thought you should have had more 12 direct involvement than you did? 13 DR. DAVID CHIASSON: Well, clearly, I 14 did. And in -- in retrospect, this was kind of the straw 15 that broke the camel's back but in fact, you know, this 16 is a rather minor thing. 17 Dr. Cairns and I had an excellent working 18 relationship while we were at the Coroners Office. And 19 this is a -- a blip in our working relationship. 20 Clearly, I was the one responsible for 21 scheduling pathologists in -- in this, and I think, you 22 know, what he did was completely inappropriate. 23 But, at the same time, this is -- as I 24 said, it's a blip in a -- in a working relationship that 25 -- that was very good for a number of years and may be,

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1 in part, a reflection of the stress and strain that he 2 was under trying to -- as we're aware, he had a lot to do 3 with the carriage of pediatric forensic pathology issues 4 through Dr. Smith. 5 And I suspect this is, in part, related, 6 to -- to what happened here. 7 MS. LINDA ROTHSTEIN: So your evidence is 8 clear, Dr. Chiasson, I actually asked you about being 9 relegated to the sidelines in handling the work action by 10 the pathologist and if I understand what you've just told 11 us -- 12 DR. DAVID CHIASSON: No. 13 MS. LINDA ROTHSTEIN: -- you've responded 14 to what you fairly have characterized as a blip, which is 15 the fact that Dr. Cairns was involved in scheduling 16 pathologists in your unit on a -- on an occasion. 17 Is that right, that you and I were a 18 little bit at cross purposes there? 19 DR. DAVID CHIASSON: Obvi -- Obviously we 20 were and yes, I've -- I've answered what may or may not 21 have been your next question, I don't know. But to get 22 back to the question you did ask in the first part of the 23 paragraph, yes, I -- there was a feeling, I was involved 24 in deciding what to do with individual cases during the 25 strike situation.

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1 But I did not feel I was as involved as I 2 should have been. And it's a bit -- you know, given 3 everything that was going on and it -- it goes back to 4 what I -- I perhaps was an idealistic viewpoint. I kept 5 trying to move forward, despite the realities of what was 6 happening, and was it really reasonable that I would take 7 on a big role in directing cases where the Coroners had 8 done it over the years and were very, for the most part, 9 very, you know, adept at doing that and used to doing 10 that. 11 At the same time, I'm having all these 12 basic forensic pathology issues. 13 COMMISSIONER STEPHEN GOUDGE: Looking at 14 this memo, Dr. Chiasson, one could easily conclude that 15 you felt you weren't being properly supported by Dr. 16 Young. 17 DR. DAVID CHIASSON: Well, you could look 18 at it that way, Mr. Commissioner. You know, I go back to 19 the basic issue of not having the -- the staff within the 20 forensic pathology unit and ultimately somebody to direct 21 those people, so that part of the job could be taken off 22 my plate. 23 And to try to do all of that -- so I 24 didn't have the pathologist -- and it's not to say, as 25 I've indicated, Dr. Young was -- was very successful in

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1 getting the actual positions created. 2 The recruiting and retention and the 3 amount of money we were offering, I think remained a 4 problem; that I did put on to Dr. Cor -- Dr. Young's 5 plate, if you will, and that was not responded to. 6 Whether it's his fault or the hierarchy 7 within the government, I mean that's -- that's debatable 8 I guess. I don't think -- I don't think it was Dr. Young 9 per se that was -- you know, he was sympathetic to what I 10 was doing. 11 So until, you know, all of that got 12 resolved, it was difficult for me to see anything to try 13 -- I mean I'm trying to take a bigger administrative 14 role, and be what I think a Chief Forensic Pathologist 15 should be, and should be doing. And clearly, I didn't 16 feel I could do that. 17 18 CONTINUED BY MS. LINDA ROTHSTEIN: 19 MS. LINDA ROTHSTEIN: One of the things I 20 understand you did before you resigned, Dr. Chiasson, was 21 organize the Carpenter Review of Dr. Smith's work? 22 DR. DAVID CHIASSON: Yes. 23 MS. LINDA ROTHSTEIN: And that was, as 24 we've heard, because there was a concern that the 25 Hospital for Sick Children couldn't do all of the

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1 coroner's cases with the complement they had. Is that 2 right? 3 DR. DAVID CHIASSON: Yes. 4 MS. LINDA ROTHSTEIN: And they wanted Dr. 5 Smith to come back and be at least able to do the non- 6 criminally suspicious and homicide cases. Is that fair? 7 DR. DAVID CHIASSON: Yes. 8 MS. LINDA ROTHSTEIN: And were you the 9 one who selected the cases for Dr. Carpenter's review? 10 DR. DAVID CHIASSON: Yes. 11 MS. LINDA ROTHSTEIN: Am I right in 12 understanding you did that on some kind of randomized 13 basis; looking for cases however, that were not criminal 14 -- neither criminally suspicious nor homicide cases. 15 Is that fair? 16 DR. DAVID CHIASSON: Correct. 17 MS. LINDA ROTHSTEIN: All right, and did 18 you personally have any concerns about Dr. Smith being 19 put back on the roster, provided he wasn't engaged in 20 criminally suspicious and homicide cases? 21 DR. DAVID CHIASSON: That's correct. We 22 had no reason to suspect that there were issue -- the 23 issues that seemed to be problematic were forensic 24 criminally suspicious cases. We had no indication that 25 there were any problems with pediatric pathology medical

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1 type cases. 2 MS. LINDA ROTHSTEIN: All right. Now 3 finally, just before we close up, Dr. Chiasson, you 4 became a witness in the Kporwodu matter, we know that. I 5 don't want to take you through your evidence so much as I 6 want to direct you to some aspects of Dr. Smith's 7 testimony in that matter and get your comments. 8 So would you turn to Tab 43 please, of 9 Volume 2, in which we have some of the transcripts of Dr. 10 Smith's testimony which took place in the fall of 2001. 11 So after you had left the coroner's office. 12 And as I understand it, you were working, 13 at that stage, fee for service for the coroner, yes? 14 DR. DAVID CHIASSON: My -- my 15 responsibilities included fee-for-service autopsy work at 16 the Coroner's Office. I'd started also doing some work 17 at the Hospital for Sick Children in pedia -- forensic 18 cases and had a contract with the Coroner's Office to 19 carry out some of the administrative functions that I had 20 beforehand; the primary one (1) being the review of post- 21 mortem examinations and homicides in criminally- 22 suspicious deaths. 23 MS. LINDA ROTHSTEIN: All right. I just 24 want to turn then to some of the evidence, starting again 25 at Tab 43, it's PFP020949. So I'm at page 49. And there

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1 are questions from Ms. Wasser, one (1) of the defence 2 counsel in this case. She's cross-examining Dr. Smith on 3 the sorts of reviews that had been done of Athena's case 4 and starting in the middle of the page she says: 5 "Now your work on Athena's case was 6 subject to review by another 7 pathologist, correct?" 8 DR. DAVID CHIASSON: I'm sorry -- 9 MS. LINDA ROTHSTEIN: Page 49. 10 DR. DAVID CHIASSON: -- Ms. Rothstein. 11 Oh, I'm okay. 12 MS. LINDA ROTHSTEIN: Sorry. 13 DR. DAVID CHIASSON: Yes, okay, I'm with 14 you. Thank you. 15 MS. LINDA ROTHSTEIN: 16 "A: I'm not aware it was. It could be 17 that it was, I don't know. 18 Q: Were you ever asked by the police 19 or the Crown attorney to provide your 20 work for it to be reviewed for the 21 purposes of a review? 22 A: Well, you may be asking a 23 different question. Every homicide 24 report before it is released in Ontario 25 is reviewed by Dr. David Chiasson in

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1 his role as Chief Forensic Pathologist 2 so Dr. Chiasson has reviewed this 3 case." 4 And is that a fair characterization of the 5 state of affairs? 6 DR. DAVID CHIASSON: I mean, I think what 7 he's referring to there is the review of the 8 documentation, termed the paper review process. I think 9 that's what's being referred. 10 There was no independent full case review 11 by me that I can recall. 12 MS. LINDA ROTHSTEIN: All right. And 13 then over the page at page -- 14 COMMISSIONER STEPHEN GOUDGE: Just a 15 second, we'll get the document on the screen. It's 16 020900 and we're at page 49 of the transcript, 17 Christopher. 18 MS. LINDA ROTHSTEIN: Yeah. My PFP 19 number, Commissioner, is actually PFP020949. 20 COMMISSIONER STEPHEN GOUDGE: Okay. 21 MS. LINDA ROTHSTEIN: See if that works. 22 There we go. So it's page 49, Registrar, 23 please. There we go. 24 COMMISSIONER STEPHEN GOUDGE: We are 25 actually at the next page.

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1 MS. LINDA ROTHSTEIN: Next page. 2 COMMISSIONER STEPHEN GOUDGE: One (1) 3 more page. 4 MS. LINDA ROTHSTEIN: Yeah. There we go. 5 Thank you. 6 7 CONTINUED BY MS. LINDA ROTHSTEIN: 8 MS. LINDA ROTHSTEIN: And then over the 9 page, he answers: 10 "Dr. Chiasson reviews all of these as a 11 routine. I can't recall that there was 12 anything more than the standard review 13 but I honestly don't know. 14 Q: Okay. And as far as you know is 15 Dr. Chiasson the only person who has 16 reviewed your report or your work in 17 Athena's case? 18 A: It could be, I don't know." 19 Stopping there for a moment. Do you know 20 of any other reviews that could have been done of this 21 particular case being a criminally suspicious and 22 homicide case, other than the one (1) that you did? 23 DR. DAVID CHIASSON: No, I don't recall 24 any other review having been performed in this case. 25 MS. LINDA ROTHSTEIN: Was there any other

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1 process that would have kicked out that kind of a review, 2 other than the one (1) that you did, the paper reviews 3 we've talked about? 4 DR. DAVID CHIASSON: Well, there's no 5 other routine process there because this was a criminal 6 case ongoing; whether there was some sort of individual 7 case review because of the environment that -- that was 8 ongoing at this time. 9 MS. LINDA ROTHSTEIN: 10 Q: Have you provided samples from 11 your work or any other reports to 12 anyone other than Dr. Chiasson and the 13 police and the Crown for the purposes 14 of disclosure? 15 A: I can't think that I have. 16 Q: Has your work apart from this 17 case, Doctor, ever been the subject of 18 an investigation or review apart from 19 Dr. Chiasson's normal review? 20 A: Now help me here. What do you 21 mean by my work? 22 Q: Your work as a pathologist and the 23 autopsies you conducted forensically. 24 A: Okay, yes. 25 Q: And by whom was your work

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1 investigated? 2 A: Reviewed? 3 Q: Yes. 4 A: Dr. Blair Carpenter who's a 5 pathologist and Chief at the Children's 6 Hospital of Eastern Ontario. 7 Q: And when did that review take 8 place? 9 A: May-June of this year, I believe 10 it was. 11 Q: Is it an ongoing investigation? 12 A: No. 13 Q: When did it conclude? 14 A: I believe he wrote a report in 15 early June. 16 Q: Have you seen that report?" 17 And then there's a discussion about 18 whether that can be produced and so on. 19 But I take it, Dr. Chiasson, that's a fair 20 characterization of the -- of the extent to which Dr. 21 Carpenter was involved in reviewing Dr. Smith's work as 22 far as it goes. 23 Is that right? 24 DR. DAVID CHIASSON: Yes. 25 MS. LINDA ROTHSTEIN: All right. And

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1 then if you turn to the bottom of page 53 -- 52 on my 2 copy -- you'll see that there's been discussion between 3 the judge and counsel about whether or not that report 4 can be produced. And then an answer at the bottom of the 5 page, line 25, as follows: 6 "I don't know if there is or not..." -- 7 that's with respect to a privacy concern -- 8 DR. DAVID CHIASSON: Sor -- sorry, Ms. 9 Rothstein, I'm -- I'm lost here. 10 MS. LINDA ROTHSTEIN: I'm at the bottom 11 of page 52. Is that the same for you? 12 DR. DAVID CHIASSON: "I don -- I don't 13 know if there is..." Yes. 14 MS. LINDA ROTHSTEIN: Yes. 15 DR. DAVID CHIASSON: Okay. 16 MS. LINDA ROTHSTEIN: 17 "Let me explain what's gone on here. 18 I'm sure you know by virtue of the 19 nature of your questions whether or not 20 the judge knows and, so, sir, maybe I 21 should explain to you because you may 22 need to tell me what to do here. 23 Earlier this year in response to come 24 incredible frustration and some 25 misinformation that was propagated by

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1 Crown attorneys, I withdrew services 2 from the Office of the Chief Coroner 3 and refused to perform post-mortem 4 examination for the Office of the Chief 5 Coroner. And, at the same time, I 6 asked the Chief Coroner to perform or 7 to arrange for an independent peer 8 review of my work, and so Dr. Young did 9 that." 10 Now, stopping there for a moment; in your 11 discussions with Dr. Young and Cairns, did you understand 12 that there was some misinformation that had been part of 13 the events that had precipitated Dr. Smith's withdrawal 14 of services for forensic autopsies? 15 DR. DAVID CHIASSON: No, I don't -- I 16 don't understand what he's referring to as 17 "misinformation." 18 MS. LINDA ROTHSTEIN: All right. And 19 would you have characterized what Dr. Young had done, as 20 of the fall of 2001, as an independent peer review of his 21 work? 22 DR. DAVID CHIASSON: No. 23 MS. LINDA ROTHSTEIN: All right. 24 DR. DAVID CHIASSON: When we were talking 25 about it in January, we were talking about looking at his

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1 as criminally suspicious case, which clearly is not what 2 the Blair Carpenter Report Review process looked at. 3 MS. LINDA ROTHSTEIN: Okay. And then if 4 you would turn to page 72, and I believe, Registrar, 5 it'll be 73 for you. There's a very long answer about 6 some of the other pathologists who we've heard of in this 7 case; Dr. Ferris and others, and what Dr. Smith's opinion 8 is of all of the them. 9 At the bottom of page 72, you should see 10 your name. Do you see it, Dr. Chiasson? 11 DR. DAVID CHIASSON: I do, yes. 12 MS. LINDA ROTHSTEIN: That's where I'm 13 starting at line 25. Ms. Wasser, question: 14 "Now, Dr. David Chiasson is the doctor 15 that reviews your work. Do you respect 16 his opinions and his work? 17 "A: Yes, in adult stuff. Understand 18 that when it comes to pediatric 19 forensic work, such as he will doing 20 next week at the Hospital for Sick 21 Children, I supervise him." 22 Now, stopping there for a moment. Dr. 23 Smith was, indeed, still the Director of the Ontario 24 Pedriatr -- Pediatric Forensic Pathology Unit in the 25 fall of 2001, was he not?

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1 DR. DAVID CHIASSON: Yes. 2 MS. LINDA ROTHSTEIN: Did you see him as 3 continuing to provide a supervisory role with respect to 4 the autopsies that were done by that unit? 5 DR. DAVID CHIASSON: That wasn't my 6 impression, no. 7 MS. LINDA ROTHSTEIN: Did you have the 8 impression or, indeed, did he, to your knowledge, ever 9 supervise the work that you did in that fall? 10 DR. DAVID CHIASSON: There -- there was 11 an agreement that if I was involved in a case and I 12 needed some pediatric pathology assistance, that he was - 13 - he would be available to -- to provide that. And he 14 did, in fact -- was present at a number of autopsies that 15 I did perform, certainly in the latter part of 2001 when 16 I was just starting and probably into 2002, as well. 17 COMMISSIONER STEPHEN GOUDGE: They were 18 done at the OCCO? 19 DR. DAVID CHIASSON: No, they were done 20 at the Hospital for Sick Children. 21 COMMISSIONER STEPHEN GOUDGE: Okay. 22 23 CONTINUED BY MS. LINDA ROTHSTEIN: 24 MS. LINDA ROTHSTEIN: And did you 25 perceive his role in attending those autopsies as

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1 supervising you? 2 DR. DAVID CHIASSON: No, I -- I didn't 3 perceive them that way. I -- I was clearly cognizant 4 that these were often suspicious cases, and the -- my 5 view was that I -- I was taking carriage of the case. He 6 was there to provide some assistance, if I needed it, in 7 terms of pediatric pathology issues, not -- not the 8 forensic issues, per se. 9 MS. LINDA ROTHSTEIN: All right. Could I 10 ask you to turn to Tab 45 which is a continuation of the 11 evidence that Dr. Smith gave during the preliminary 12 inquiry before Justice Harris, this time on December the 13 17th, 2001. And it's PFP021477. 14 And if you would turn to page 10 of the 15 transcript, page 11 of the PFP document, starting a 16 quarter of the way down the page at approximately 17 question 7: 18 "Q: And one (1) other area I'd like to 19 clarify [this is, again, Ms. Wasser] 20 from your previous testimony that had 21 indicated, I believe, that Dr. David 22 Chiasson reviews your work. 23 A: Mm-hm. 24 Q: The autopsies? 25 A: That's right.

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1 Q: And just the autopsies, correct? 2 A: Just the forensic autopsies, yeah. 3 Is that right? 4 Yeah." 5 And I take it that 'forensic' there is 6 potentially ambiguous, referring both to medicolegal and 7 criminally suspicious, but certainly all you did indeed 8 review, as we understand it, are the subset of criminally 9 suspicious and homicide cases. 10 Is that right? 11 DR. DAVID CHIASSON: That's correct, yes. 12 MS. LINDA ROTHSTEIN: And continuing 13 along he goes on and says that indeed at the answer at 14 page -- at line 20: 15 "While he reviews all homicide 16 autopsies in Ontario, he does a paper 17 review, he may or may not do a slide 18 review. Now, let me explain what the 19 nature is of that review process of a 20 case like this because in fact that's 21 only one (1) minor component of it." 22 And so stopping there for a moment, Dr. 23 Chiasson, how often, as a result of the paper reviews 24 that you initiated for post-mortem reports and homicide 25 and criminally suspicious cases, did you actually look at

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1 slides? 2 DR. DAVID CHIASSON: It was uncommon. 3 Histological slide -- more -- more commonly would be 4 reviewing photographs. To review histologic slides was - 5 - was uncommon. 6 MS. LINDA ROTHSTEIN: Line 25, I'm going 7 to continue to read: 8 "This case is reviewed in a multi- 9 disciplinary setting at the Hospital 10 for Sick Children. Every autopsy, 11 every death in that hospital is, and so 12 that involves the pathologists and 13 experts in clinical medicine that deal 14 with acute care medicine and that sort 15 of thing, so this case would have been 16 presented and discussed amongst a group 17 of pathologists, including 18 neuropathologists, pediatric 19 pathologists; they all are, as well as 20 people from the two (2) intensive care 21 units." 22 Stopping there. So he's referring to the 23 Athena case, and he's saying that it would have gone 24 through that kind of process. 25 Is that a fair characterisation of your

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1 understanding of what would have happened with that case 2 at the Hospital for Sick Children, at that time? 3 DR. DAVID CHIASSON: If the decedent was 4 a hospital patient, that -- that would -- I'd expect this 5 kind of multi-disciplinary. Every Friday morning there's 6 -- there's what we call "autopsy rounds," "CPC rounds," 7 and they would review all hospital cases, so individuals 8 dying in hospital that become coroner's cases. 9 Outside referral cases, back then, I think 10 it's a little less clear as to whether they would have 11 been reviewed or not. 12 MS. LINDA ROTHSTEIN: So, this is a '98 13 case, Dr. Chiasson. He continues: 14 "In addition to that, the cases are, 15 after a report or before a report is 16 completed, the case is also presented 17 at this time. Now things have changed 18 since, but at this time the case was 19 then presented to a group of forensic 20 pathologists who work at the Coroners 21 Building in Toronto, and so the 22 photographs would have been shown and 23 everything discussed at that point." 24 Is that what happened in 1998; Dr. Smith's 25 cases?

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1 DR. DAVID CHIASSON: There is a point 2 where we did start reviewing pediatric pathology cases at 3 the Coroner's Office. I'm not sure whether it was in 4 fact in '98 or subsequently in '99; I -- I'd have to 5 check on the timing. 6 So, initially, why -- we did have some 7 cases reviewed at the hospital, and that's '94/'95, I 8 think into '96, and then '98 or '99; I'm not sure when we 9 started reviewing them at the Coroner's Office. 10 MS. LINDA ROTHSTEIN: Okay. He 11 continues: 12 "After the report has been finalised, 13 it is then reviewed by the Regional 14 Coroner, usually the Deputy Chief 15 Coroner, although that depends just on 16 exactly when in the history it 17 occurred. So, in this case, I can't 18 tell you when it did. The case would 19 be sent to Dr. Chiasson, who, at that 20 time, was the Chief Forensic 21 Pathologist for Ontario, and he would 22 review the case, and then after that 23 review, the case would then be 24 released." 25 And stopping there, you've told us, Dr.

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1 Chiasson, that if the post-mortem was long delayed and 2 wasn't released for some time, it would, in fact, have 3 not gone to you. 4 Is -- have I fairly summarised the 5 evidence you've given us? 6 DR. DAVID CHIASSON: Well, the intent was 7 that all reports should be, no matter how long they're 8 delayed, reviewed prior to the pathologist releasing it 9 outside the coroner's system. 10 The exception would be the kind of thing 11 that happened with the Sharon case where he, in fact, 12 does not appear to have completed it until he's ready to, 13 in fact, testify. 14 MS. LINDA ROTHSTEIN: And this -- 15 DR. DAVID CHIASSON: But the majority of 16 cases, regardless of the delay, should have been 17 reviewed. 18 MS. LINDA ROTHSTEIN: And what about the 19 addendum in this case, in Athena's case, that we know was 20 the result of a letter in -- the press by the Crown and 21 the defence to get it to court before there was a motion 22 to stay the proceedings. 23 DR. DAVID CHIASSON: There is no process 24 in place -- there was no process in place at that time 25 that addendums or supplementary reports would be

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1 reviewed. 2 MS. LINDA ROTHSTEIN: Dropping down to 3 line 20: 4 "The in-hospital review of autopsies 5 has been going on -- we began that I 6 think in 1982, so that's been going on 7 since then. The review of them by the 8 Chief Forensic Pathologist -- prior to 9 Dr. Chiasson, Dr. Hillsdon Smith 10 reviewed them. So that would have been 11 going on as long as I've been 12 practising." 13 Does that accord with your understanding 14 of what occurred during Dr. Hillsdon Smith's tenure, sir? 15 DR. DAVID CHIASSON: No, I didn't -- I 16 was unaware that Dr. Smith was reviewing, certainly on a 17 regular basis, any PM report. 18 MS. LINDA ROTHSTEIN: 19 "The process of reviewing the cases by 20 the other forensic pathologist is one 21 which began -- it could be ten (10) 22 years ago. I don't know how long ago 23 that began." 24 Does that accord with your understanding 25 of when cases were reviewed by other forensic

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1 pathologists? 2 DR. DAVID CHIASSON: Well, as I've 3 indicated, in '94, '95, '96, I started going -- attending 4 rounds. I don't know that any of my colleagues, at that 5 time, were actually regularly attending the rounds at the 6 Sick Kids; the forensic pathology rounds. 7 It certainly was taking place in -- 8 whenever -- '98-99 -- whenever we started having them at 9 the Coroner's Office. 10 MS. LINDA ROTHSTEIN: 11 "I don't know how long ago that began, 12 and we've, in fact, changed it since 13 then as well, and so we have yet 14 another review process and the 15 possibility of yet a second review 16 process on top of that one, and that 17 began two (2) or three (3) years ago." 18 Do you know to what Dr. Smith is referring 19 there? 20 DR. DAVID CHIASSON: He may be referring 21 to the Death Under Two/Death Under Five Committee which 22 would review the deaths as long as it falls into that age 23 category. 24 MS. LINDA ROTHSTEIN: Okay. And over the 25 page to page 12.

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1 "Q: All right. So let me just 2 clarify this team [undescribed; hard to 3 tell you what that means in this 4 context] 5 will review the report that you 6 generate or that the pathologist 7 generates and in Athena's case your 8 report was reviewed by this team and 9 sometimes they will review the slides; 10 other times they may not? 11 A: No, not the team; Dr. Chiasson 12 independently of anyone reviews it. 13 And sometimes Dr. Chiasson then will 14 review the slides and sometimes he 15 won't? 16 Yeah. 17 He can do so if he wants to? 18 Yeah. 19 And are these reviews documented at 20 all? 21 A: I think he writes a very brief 22 review which indicates that the report 23 is acceptable to be distributed, I 24 think. He writes a very brief 25 statement which goes to the Regional

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1 Coroner before the report is released." 2 And how much does that accord with your 3 understanding of your process, Dr. Chiasson? 4 DR. DAVID CHIASSON: I mean, I think 5 that's fair. In the majority of cases, if there's no 6 issues a memo is sent to the Regional Coroner saying the 7 review has been completed. 8 If there is an issue, it's often pointed 9 out in an email correspondence, or if there's deemed to 10 be more review necessary, then there's a request for more 11 materials. But that -- that's, I think, a fair... 12 MS. LINDA ROTHSTEIN: And then at the 13 bottom at line 30, Dr. Smith says: 14 "A: Let me make a statement here. My 15 autopsy reports, and I've been a major 16 author in creating the review process - 17 - my autopsy reports are more 18 thoroughly reviewed than any pediatric 19 forensic autopsy report in Canada, and 20 I do that, not at one (1) level but at 21 multiple levels, purely for quality 22 assurance purposes." 23 What do you say about that, Dr. Chiasson? 24 DR. DAVID CHIASSON: Well, I -- I don't 25 have no direct knowledge as to what the rest of the

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1 country is doing in terms of pediatric forensic autopsy 2 reports. 3 There are -- he makes reference, and I -- 4 I think quite accurately, that there are a number of -- 5 of reviews. 6 Having said that, the reviews in the 7 hospital -- multi-disciplinary reviews -- it's -- it's a 8 question of a -- the pathologist presenting his findings 9 and getting feedback. You know; which issues might the 10 feedback be would very much depend on the pathologist and 11 what he's seeking -- where he's seeking assistance, for 12 example. 13 And there is variation as opposed to 14 simply presenting a case and saying, This is what I 15 found, this is what I think, thank you very much. And -- 16 and oftentimes there's -- there's -- in the rounds we 17 were having at the Coroner's Office, there were many 18 cases being reviewed, so how much time we're talking 19 about. 20 So it is a form of -- of review, 21 certainly, but perhaps not as detailed and -- and formal 22 as some might think. But -- 23 MS. LINDA ROTHSTEIN: Because, Dr. 24 Chiasson, the question for us systemically is this, if: 25 In fact, Dr. Smith is correct that there was all this

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1 review going on, what -- in the time remaining -- can you 2 tell us, sir, what happened? 3 DR. DAVID CHIASSON: Well, -- 4 MS. LINDA ROTHSTEIN: I mean, it's an if, 5 so you don't have to accept it, but help us understand 6 what could -- what could explain why there's still many 7 concerns about Dr. Smith's work that weren't detected by 8 these processes? 9 DR. DAVID CHIASSON: Well, I think -- I 10 think the part that really is critical in understanding 11 what happened with Dr. Smith and -- and these cases 12 actually revolves around what was said in the courtroom. 13 As I -- as I read these reports, many of them revolve 14 around opinions that aren't expressed in -- in reports in 15 a formal way and that are expressed either to police, 16 Crown, and/or in preliminary or -- or finally trial 17 opinions. 18 And that -- currently there is no way that 19 -- that we have in place really to address, you know, 20 quality assurance as to what a pathologist says about -- 21 you know, renders his opinion in a courtroom setting. 22 The defence pathologist is -- is a way and a certainly 23 plays a role in a number of -- of the cases and plays a 24 very important role, I think, in -- in addressing how -- 25 how to deal with that.

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1 So I think it's at that level that a lot 2 of the issues really -- really erupted or came out of. 3 That's not to say that there weren't issues in select 4 cases, such as the Sharon case, which underwent basically 5 a detailed process and -- and certainly involved more 6 than -- than Dr. Smith. 7 But if -- if the -- it just goes to show 8 you that even if you have a lot of processes in place in 9 terms of reports and presenting it at -- that that in 10 itself is not the answer. It's very valuable -- having 11 said that, I -- I -- certainly from my experience at -- 12 at the Hospital for Sick Children, rounds, for example, 13 are very valuable. 14 It -- it -- and with me it's often the 15 case because I'm not a pediatric pathologist. I'll put 16 out issues, I'll ask questions, I look for feedback and 17 subsequently then the report is, in my case, formally 18 reviewed by my -- my -- the head of pathology, Dr. 19 Taylor, who is -- again has this -- this really 20 impressive clinical pediatric pathology experience. 21 So it -- it's -- there's a lot of value, 22 and I think these things need to be kept in place. But 23 it isn't the be end and end all to matters which 24 ultimately are often played out in courtrooms of law. 25 MS. LINDA ROTHSTEIN: Commissioner, I've

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1 -- I've overstayed my welcome by five (5) minutes. I 2 hope you'll forgive me. There's much more we'd like to 3 explore with Dr. Chiasson, but I'm confident My Friends 4 will do -- will advance things this afternoon. 5 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 6 Rothstein. We will rise now until five (5) past 2:00. 7 8 --- Upon recessing at 1:50 p.m. 9 --- Upon resuming at 2:05 p.m. 10 11 THE REGISTRAR: All rise. Please be 12 seated. 13 COMMISSIONER STEPHEN GOUDGE: Good 14 afternoon. Well, you're first, Ms. Ritacca. And then I 15 think Mr. Centa has handed out the schedule that I've 16 allotted and basically, everybody is getting the time 17 they asked for, so we'll move along that way. Ms. 18 Ritacca...? 19 MS. LUISA RITACCA: Thank you, 20 Commissioner. 21 22 CROSS-EXAMINATION BY MS. LUISA RITACCA: 23 MS. LUISA RITACCA: Dr. Chiasson. Doctor, 24 I'd like to start from where Ms. Rothstein left off and 25 ask you if you could comment on how the quality assurance

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1 process that you can get out of participating in rounds, 2 compares to the quality assurance processes that are at 3 work during a peer review, or paper review of a post- 4 mortem report, like the ones you conducted, and during 5 the process of quality assurance that takes place in the 6 Death Under Five Committee. 7 DR. DAVID CHIASSON: Well, in the case of 8 -- of rounds and presentations at multi disciplinary -- 9 with multiple disciplines present at a meeting are -- 10 are, I think they constitute a form of quality assurance, 11 but it's certainly not the same level and the same degree 12 of formality as a PM report review process or what 13 happens at a Death Under Five meeting as we now have 14 them. 15 In a sense that the rounds are meant as 16 opportunities for the pathologists with a case to present 17 his findings and -- and for other people to comment it -- 18 on it. But as I indicated this morning, these -- it's 19 very much driven by the pathologist as to how much -- 20 what issues he might want to canvass from the audience. 21 And if he's comfortable in what's going 22 on, it may well turn out to be simply a -- more of a show 23 and tell. This is what I found, this is what I think and 24 not extend much beyond that. 25 Whereas with a PM report review, clearly

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1 I'm -- I'm signing off on something in a formal way. So 2 I have a responsibility there. And again, what a multi 3 disciplinary session, individuals are there 4 participating, but nobody is actually, that I'm aware of, 5 taking any specific minutes as to what the discussion was 6 about, and sort of conveying any ownership of what 7 conclusions might have been gathered as a result of the 8 session. 9 So it's very, very different in terms of 10 that. And the Death Under Five Committees are structured 11 so that there is a multi disciplinary discussion with 12 police officers who investigate the police report, or who 13 review police and investigative findings, the Coroner, 14 the Pathologist, all presenting their -- their -- 15 reviewing their pieces of it but, ultimately, a 16 conclusion being reached and being formalized in -- in 17 minute form for -- for the future. 18 MS. LUISA RITACCA: And so, I take from 19 what you're saying then, there's no con -- conclusion 20 reached by a multi disciplinary team during rounds, in 21 the same way that there would be at a Death Under Five 22 Committee. 23 Is that right? 24 DR. DAVID CHIASSON: That -- that's 25 correct. There's no formalized consensus that is sought.

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1 MS. LUISA RITACCA: And earlier today, 2 you also spoke about the need to include forensic 3 pathologists as, you know, team players in the death 4 investigation beyond really being autopsy technicians 5 which is, I believe, a term you said one of your former 6 forensic pathologists used. 7 Are you able to comment on the role of the 8 forensic pathologist, and perhaps you in specific -- the 9 role that you play on the committees, and particularly 10 the Death Under Five Committee and in case conferences, 11 and how that role helps the forensic pathologist to be a 12 part of the team? 13 DR. DAVID CHIASSON: Well to -- to 14 address the case conference issue first, it is a format 15 for the forensic pathologist to actually render opinions 16 beyond simply the post-mortem findings. To listen to 17 information, to distill it and to provide opinions as to 18 both cause and manner of death. 19 So the case conference concept is 20 actually, I think, a very good one to -- to draw in a 21 forensic pathologist into the larger death investigation 22 process. In terms of Deaths Under Five Committees and 23 Committees, that's the one I have the most experience 24 with. 25 That sort of Committee, again, we have on

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1 that Committee pathologists, in that case, pediatric 2 pathologists who are -- review cases and do partake in 3 discussions as to the significance of findings, and 4 ultimately part of consensus -- a consensus opinion being 5 -- being issued. 6 So again, another format which I think is 7 -- as part of its -- the consequences of it as part of 8 what the sequella is really the side benefit to -- to 9 incorporate pathologists -- forensic pathologists more 10 into the death investigation process. 11 MS. LUISA RITACCA: And -- and 12 historically, were any of the forensic pathologists you 13 had on staff participating in any of the committees that 14 are -- were in place at the OCCO? 15 DR. DAVID CHIASSON: Well, Dr. Toby Rose 16 -- I'm not exactly when she started, and I think she's 17 still on the Obstetric Death Review -- Perinatal 18 Obstetric Death Review Committee. 19 She's a -- she's certainly participated in 20 that. The other pathologists I don't think had gotten 21 involved into that, although they did participate in Case 22 Conferences. 23 MS. LUISA RITACCA: Dr. Chiasson, I 24 understand that in addition to your role as Director of 25 the OPFPU, you work as a fee-for-service pathologist at

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1 the Toronto FPU? 2 DR. DAVID CHIASSON: Correct. 3 MS. LUISA RITACCA: And could you explain 4 why you continue to do that work at the Toronto Unit? 5 DR. DAVID CHIASSON: Well there's mult -- 6 it's multiple reasons, but I think from a professional 7 point of view, the one (1) that is most important is that 8 I'm maintai -- well there's two (2) -- two (2) offshoots. 9 One (1) is that I maintain an exposure to 10 adult cases, including adult homicide cases. So I -- I 11 keep abreast of issues related to that, I'm keeping my 12 hand in that. With adult cases you go to court -- 13 because there's more adult homicides than pediatric 14 homicides, your opportunity to go to court is -- is 15 increased. 16 And your opportunity to go to court in 17 cases that aren't -- often aren't that controversial. So 18 it's -- it's cases -- it gives you exposure to the 19 courtroom, maintains your comfort level. 20 So that when you do have to present 21 evidence in a pediatric case where almost now, without 22 exception, there is going to be some contentious issue 23 revolving around the forensic pathology aspects of it. 24 At least you're -- you're not going into a 25 -- a minefield situation every time you go to court. So

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1 it sort of acts as a bit of a buffer against that -- that 2 situation. The other thing is that ped -- pedia -- the 3 adult world, you -- I'm -- I'm losing the train of my 4 thought here. Maybe it'll come back. 5 MS. LUISA RITACCA: Well I'll ask you 6 this next question which is related. 7 As a systemic issue, do you think it's 8 important for someone practising pediatric forensic 9 pathology to dabble in or continue to do some adult 10 forensic cases? 11 DR. DAVID CHIASSON: I think -- I think 12 somebody practising -- I think -- you're going to get two 13 (2) kinds of -- of pathologists doing pediatric forensic 14 cases in the broad spectrum. So you have the -- and as 15 we're aware of, most of the cases are non-criminally 16 suspicious. 17 I think those pathologists who are 18 involved in the criminally suspicious and homicide cases 19 should maintain an adult component to their -- to their 20 practice for the reasons that I've illustrated. 21 The pediatric pathologist who would be 22 doing mostly the medical type cases that -- that, I mean, 23 I think they should maintain, their pediatric pathology 24 in which, you know, it's -- it's -- there's no pediatric 25 pathologist that I'm aware of that devote all their time

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1 to medicolegal or coroner's cases, so they would, by 2 definition, maintain a pediatric pathology experience. 3 COMMISSIONER STEPHEN GOUDGE: With your 4 fee-for-service at the OCCO, are they mostly criminally 5 suspicious cases? 6 DR. DAVID CHIASSON: No, the OCCO is -- 7 there's a spectrum, I mean we do -- 8 COMMISSIONER STEPHEN GOUDGE: Oh, you do 9 whatever they ask you to do. 10 DR. DAVID CHIASSON: I -- I do -- I'm 11 assigned a day and it's whatever happens to come in on 12 that day, so I do the full spectrum of cases, but that 13 does include criminally suspicious -- 14 COMMISSIONER STEPHEN GOUDGE: Yes. 15 DR. DAVID CHIASSON: -- and homicide 16 cases. 17 COMMISSIONER STEPHEN GOUDGE: Asking Ms. 18 Ritacca's question another way: Is it useful for your 19 forensic skills to have that day where you are rubbing 20 shoulders with full time forensic pathologists? 21 DR. DAVID CHIASSON: Thank you, Mr. 22 Commissioner, you've -- you've triggered what -- what 23 escaped my mind before. The other thing, obviously, is 24 that I am by -- by virtue of being in attendance there, 25 over there there's rounds in the morning; I would attend

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1 on the round -- the morning rounds on that day. 2 I would maintain my con -- contact with my 3 adult forensic pathology colleagues. I mean I -- it wou 4 -- in my case I've had that background and -- and it 5 would have been maintained anyway, but I think certainly 6 if you -- if you were trying to recruit somebody in, that 7 way this person could, you know, maintain and -- and 8 continue a -- an adult contact would be very important. 9 COMMISSIONER STEPHEN GOUDGE: How much 10 time do you spend at OCCO? 11 DR. DAVID CHIASSON: I've been doing a 12 weekend a month and usually one (1) weekday, sometimes 13 two (2) weekdays a month, so three (3) to four (4) days a 14 month. And the bottom line, I -- I do a hundred (100) 15 cases, maybe a hundred and ten (110) cases -- adult cases 16 a year in addition to my pediatric -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID CHIASSON: -- practice. 19 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 20 Ritacca. 21 22 CONTINUED BY MS. LUISA RITACCA: 23 MS. LUISA RITACCA: Are -- are you able 24 to say how many of the hundred (100) or a hundred and ten 25 (110) are criminally suspicious cases?

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1 DR. DAVID CHIASSON: As a -- as a general 2 ballpark we -- we would say 10 percent of the cases you 3 would do at the adult unit would fall into that category. 4 MS. LUISA RITACCA: And, Dr. Chiasson, we 5 -- we heard of some of the steps that you took or tried 6 to take in response to the difficulties you encountered 7 with the Director of what I call the Ottawa Unit, which 8 is Dr. Johnston, in 1997/1998. 9 Can you explain why you took such sig -- 10 significant steps and just to remind the Commissioner 11 that you were calling for his removal of -- as Director 12 of the unit, with regard to Dr. Johnston, but you didn't 13 take similar steps with regard to Dr. Smith in 1998/1999? 14 DR. DAVID CHIASSON: Well, I think in 15 regards to Dr. Johnston in Ottawa it was -- it's a 16 question of both quantity and quality of -- of issues, 17 forensic pathology issues. 18 There was a -- really a series of cases 19 where I had forensic pathology concerns and there was a 20 smaller number of cases where those concerns were very 21 significant and we've talked about the -- the Venoss 22 (phonetic) case where clearly had a very different 23 opinion and I thought his conclusions, really I -- I 24 couldn't support them, and they were obviously very 25 forensically significant.

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1 On the other hand, with Dr. Smith, even 2 into 1998/1999, at that stage we weren't talking about a 3 large number of -- of problematic cases and, you know, in 4 part it might be relate -- related to my inexperience 5 with pediatric forensic pathology issues, which is where 6 Dr. Smith fell within, as opposed to adult issues where I 7 felt more comfortable. 8 But also I saw the issues with Dr. Smith 9 as being ones where they were more obviously in areas of 10 -- of evolving pathology involving pediatric forensic -- 11 evolving pediatric forensic pathology issues that were 12 more gray than what I construed to be more black and 13 white issues in the Ottawa situation. 14 MS. LUISA RITACCA: And -- and prior to 15 January 2001, did you ever consider removing Dr. Smith or 16 recommending to Dr. Young that he remove Dr. Smith as the 17 Director of the Unit? 18 DR. DAVID CHIASSON: No. I think we 19 talked about my plans and hopes to have revisioning and 20 bringing him over and -- and having a situation where I 21 would have more direct supervision over the work of Dr. 22 Smith, you know, we talked about that. But at no point 23 up until January 2001 were we really seriously 24 considering stopping him from doing cases. 25 MS. LUISA RITACCA: And other than what

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1 you've just described as your -- your hopes and plans to 2 revision the Unit, were there any other reasons why you 3 just didn't consider removing Dr. Smith? 4 DR. DAVID CHIASSON: Well, I mean, even 5 if the problems were greater than, you know, what we 6 construed them to be, and I'm not trying to minimalize 7 the issues and problems that have since become apparent, 8 the issues with Dr. Smith, the -- the big -- the big 9 alternative issue is what to do with this coterie of 10 cases that, you know, that are very specific. 11 With Dr. Johnson, our hope was in fact -- 12 it wasn't to stop him from doing cases, it was to have 13 him work under direction. So even there, to be -- to be 14 accurate, we're not trying -- we're not talking about 15 cutting Dr. -- sorry, Dr. Johnson completely off the 16 cases, we were talking about having him work under -- 17 under supervision. 18 But certainly with the pediatric 19 situation, this left a big vacuum and there was nobody at 20 the hospital who could step in. I mean, we still had the 21 same problems in January of 2001: Who are going to do 22 these cases? And that was -- that was a major concern of 23 mine. It's easier to do it in the adult side than it is 24 on the pediatric side. 25 COMMISSIONER STEPHEN GOUDGE: In Ottawa,

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1 had you contemplated - I think I remember reading this - 2 moving some of the cases? 3 DR. DAVID CHIASSON: I don't know that we 4 were really contemplating that; our hope was to have 5 hired somebody to go in there and -- and direct -- you 6 know, act as a supervisor, a director on top. 7 I don't think we really, at that stage, 8 looked at taking cases out of -- there was no unit in 9 Kingston at the time, it would have meant coming to 10 Toronto to do the cases. 11 COMMISSIONER STEPHEN GOUDGE: Right. And 12 that would have been difficult? 13 DR. DAVID CHIASSON: Well, you know, in 14 the -- in the '98, that's -- that would have been okay in 15 '98; '99 we would have problems because that's when a lot 16 of pathologist -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID CHIASSON: -- staff left. 19 COMMISSIONER STEPHEN GOUDGE: Would you 20 ever have considered moving the pediatric cases the other 21 way; to the Children's Hospital of Eastern Ontario? 22 DR. DAVID CHIASSON: No. 23 COMMISSIONER STEPHEN GOUDGE: Why not? 24 DR. DAVID CHIASSON: From Sick Kids to 25 the Children's --

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1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 DR. DAVID CHIASSON: -- Hospital? 3 Because the -- although we were unaware of any specific 4 problem issues, the number of cases they were doing from 5 a forensic true criminally suspicious point of view were 6 small. They were pediatric pathologists, they weren't 7 forensic pathologists and I saw the issues here as being 8 ones of forensic pathology issues. 9 And even though there were no identified 10 problems, we were still having -- it would have meant 11 having pediatric pathologists doing forensic criminally 12 suspicious cases. I didn't -- 13 COMMISSIONER STEPHEN GOUDGE: But you 14 really needed was to introduce more forensic pathology 15 into those cases? 16 DR. DAVID CHIASSON: Exactly. And -- and 17 as I said the re-visioning forensic pathologists from our 18 unit, the adult one, getting involved in the case. I 19 didn't see it as a question of finding some other 20 pediatric pathologist to try and deal with the issue. 21 COMMISSIONER STEPHEN GOUDGE: That's 22 helpful. Thanks. 23 24 CONTINUED BY MS. LUISA RITACCA: 25 MS. LUISA RITACCA: And, Dr. Chiasson, we

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1 heard that in 1997 you conducted an audit of some of the 2 cases at -- at the OPFPU. 3 Did you conduct a similar audit for either 4 of the other units that were up and running at the time, 5 which I guess would have been Ottawa or Hamilton? 6 DR. DAVID CHIASSON: No, nothing of that 7 degree of formality. 8 MS. LUISA RITACCA: Why not? 9 DR. DAVID CHIASSON: Well, Hamilton -- I 10 mean, there were -- there was some degree of auditing as 11 far as turnaround times. I mean, there were issues 12 related to -- to that. But Hamilton, in terms of cases, 13 it was -- not to say that there weren't cases that were 14 potentially problematic, but the -- there was no real 15 identified, I thought, sort of systemic problem within 16 the Hamilton unit. 17 The Ottawa unit. I think we identified 18 the problem just by picking up the cases through the 19 review process and there were enough problems there that 20 I felt I could -- I needed to act based on what I knew 21 and without having to go back and doing a more extensive 22 audit of the situation. 23 Whereas, with Sick Kids, I was having a 24 sense that there were issues related to the way reports 25 were being reported, the -- the written. And the issue

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1 of turnaround time, you know, again I had the sense there 2 was a problem. 3 This was to try and -- and actually 4 provide -- find the evidence for that sense that I had. 5 MS. LUISA RITACCA: Now, I -- I may, in 6 fact, be going back one (1) question, but do you have a 7 sense of how many cases Dr. Johnson would have been doing 8 in a given year in 1997/1998 as compared to how many 9 cases Dr. Smith was doing? 10 And I appreciate we might be comparing 11 apples and oranges a little bit because they're pediatric 12 versus adult. 13 DR. DAVID CHIASSON: We're clearly 14 comparing apples and oranges. I would guess, at that 15 time, that Dr. Johnson was probably doing in the vicinity 16 of two hundred and fifty (250), maybe three hundred (300) 17 cases. He was -- he was the only full-time forensic 18 pathologist in the Unit, at that time. 19 I think the Unit was doing -- well, it's 20 evolving, I mean, the numbers are increasing over the 21 years, but probably four hundred fifty/five hundred/five 22 hundred and fifty (450/500/550) cases. He was doing a -- 23 a large chunk of those. 24 Dr. Smith, I think the numbers were 25 probably more --

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1 MS. LUISA RITACCA: Right. 2 DR. DAVID CHIASSON: -- in the sixty (60) 3 plus or minus range. But clearly, we are comparing 4 apples and oranges -- 5 MS. LUISA RITACCA: Right. 6 DR. DAVID CHIASSON: -- because of the 7 degree of complexity inherent in virtually all pediatric 8 cases. 9 MS. LUISA RITACCA: And can we assume 10 that of the two hundred/two hundred and fifty (200/250) 11 that Dr. Johnson was doing 10 percent of those are 12 criminally suspicious, like -- 13 DR. DAVID CHIASSON: I think, again, -- 14 MS. LUISA RITACCA: -- it's the -- it's 15 the same -- 16 DR. DAVID CHIASSON: -- that's a fair 17 ballpark. 18 MS. LUISA RITACCA: Right. 19 DR. DAVID CHIASSON: I mean, criminally 20 suspicious and/or homicide, the homicide numbers were 21 probably, you know, 5 percent. 22 MS. LUISA RITACCA: Okay. 23 DR. DAVID CHIASSON: And then criminally 24 suspicious on top of that. 25 MS. LUISA RITACCA: Dr. Chiasson, did Dr.

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1 Smith ever tell you while you were the Chief Forensic 2 Pathologist that he did not want to take on any more 3 cases for the Coroner's Office either because he was 4 feeling overwhelmed, or too busy, or behind? 5 DR. DAVID CHIASSON: No, he never 6 conveyed that to me. 7 MS. LUISA RITACCA: And, sir, someone 8 who's now essentially in the same position that Dr. Smith 9 was in as the Director of the OPFPU, are you able to 10 comment on the complexity of the types of cases that Dr. 11 Smith was doing, at the time, for the Unit? 12 DR. DAVID CHIASSON: Well, as Chief 13 Forensic Pathologist I was -- part of my responsibilities 14 involved doing -- taking on complex adult cases. And so 15 I've had a fair amount of exposure and -- and experience 16 within the adult world with the particularly complicated 17 cases. 18 I would -- I would take -- I would have a 19 disproportionate number of those relative to the number I 20 did overall. And, you know, with that sort of background 21 experience, it's my view that the pediatric forensic 22 pathology cases are -- are certainly among the -- the 23 most challenging cases that one can encounter. 24 And especially all -- virtually anything 25 that is homicide criminally suspicious in -- in the area

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1 of pediatrics is -- is wrought with all sorts of 2 complexities; whereas, with the adult world, you know -- 3 in fact, most of them cause of death is not an issue, 4 gunshot wound, stab wound. 5 There may -- there's forensic issues 6 beyond the cause of the death that can be -- cause -- 7 cause difference of opinion and gray areas when you're 8 testifying. But that's -- in pediatrics, it's almost 9 inevitable. So the degree of complexity of the cases, 10 not only of the homicide criminally suspicious, even the 11 natural disease cases is quite remarkable. 12 And I think I've already commented that 13 I'm doing fifty (50), maybe sixty (60) cases a year 14 medicolegal autopsies, and -- and that's really filling 15 up my -- my book as -- my calendar as far as cases. And 16 I wouldn't feel comfortable about doing very much more 17 than that. 18 MS. LUISA RITACCA: And I know you -- 19 COMMISSIONER STEPHEN GOUDGE: What is the 20 number? 21 DR. DAVID CHIASSON: Fifty (50) to sixty 22 (60). 23 COMMISSIONER STEPHEN GOUDGE: Thanks. 24 Sorry. 25

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1 CONTINUED BY MS. LUISA RITACCA: 2 MS. LUISA RITACCA: That's all right. 3 And Dr. Chiasson, I -- I know you talked a little bit 4 about this with the Commissioner on Friday, I believe, 5 but can you give use a sense of what you do 6 administratively as the Director of the Unit. 7 So in addition to the fifty (50) or sixty 8 (60) cases that you do a year? 9 DR. DAVID CHIASSON: Well, we're -- we're 10 in an environment of -- of intense scrutiny, and 11 certainly we've been looking at -- at how we do things at 12 the hospital, and trying to detail this. So as Director, 13 I have regular, what I call business meetings every three 14 (3) months or so, meet with all the pathologists, discuss 15 ways to improve the -- the work and -- and the way that 16 we oversee the work at the hospital. 17 Implemented a number of -- of new 18 procedures and protocols over the last number of years. 19 And so there's that, and then there's my ongoing more 20 supervisory role on a day to day basis. 21 I'm involved in triaging cases -- 22 MS. LUISA RITACCA: Right. 23 DR. DAVID CHIASSON: -- on a -- on a 24 fairly regular basis. Part of the triaging often 25 involves me actually taking over cases even though it's

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1 not my -- my week on -- on the schedule, for example. 2 And the other large aspect of what I do is 3 reviewing all the PM reports for all the patholog -- all 4 the other pathologists before they leave. So we -- we 5 actually carry out a -- an audit of all the reports, not 6 just the criminally suspicious ones. 7 Those, in fact, are -- are submitted to 8 the Chief Forensic Pathologist for his review after they 9 go through an internal review process as well. So that 10 takes up time. And I regularly -- we have forensic 11 pathology rounds which I organize with the capable 12 assistance of -- of Dr. Perrin, and attend autopsy rounds 13 on a regular basis, and that's where cases are presented. 14 MS. LUISA RITACCA: And how much of your 15 time is spent in communication with or in dealings with 16 the Office of the Chief Coroner, in your role of Director 17 of the Unit? 18 DR. DAVID CHIASSON: Well I -- I've 19 certainly maintained a fairly regular contact with the -- 20 the Chief Forensic Pathologist. He is, in fact, part of 21 -- of the coterie of pathologists who are now doing 22 autopsies. So he -- he plays a role in my business 23 meetings. 24 I play a role as the Director in any 25 meetings that he organizes with the forensic -- the other

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1 Directors of the Units. I've been involved in working 2 with him on the -- the protocols for criminally 3 suspicious deaths as it applies specifically to children. 4 And in turn, he's been involved with our 5 own protocol dealing with Sudden Unexpected Infant Deaths 6 where it's not criminally suspicious at the outset. So 7 we have protocols that are similar, but -- but somewhat 8 different in terms of our approach. 9 So -- so that kind of ongoing relationship 10 is -- is happening. I attend the continuing forensic 11 pathology education sessions on -- on Wednesdays, and 12 part of that now has evolved into having business 13 meetings with the forensic pathologists. 14 COMMISSIONER STEPHEN GOUDGE: I take it 15 you consider yourself as having come kind of quality 16 assurance role for the work of the Unit at the hospital? 17 DR. DAVID CHIASSON: Very much so, Mr. 18 Commissioner. 19 COMMISSIONER STEPHEN GOUDGE: Is that 20 something that you took unto yourself, or was that 21 explicitly discussed with you? Because we've heard that 22 that was very different under Dr. Smith. 23 DR. DAVID CHIASSON: I read the tea 24 leaves, I guess. But I mean I -- I think that -- as -- 25 in the Coroner's Office when I was there, even before any

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1 of this happened, I was reviewing autopsy reports on my 2 pathologists before they left the office. 3 That was kind of my -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID CHIASSON: -- first initiative 6 inside the office, so I -- I basically formalized the 7 process within the pediatric unit. Now we have a form we 8 fil -- we all -- 9 COMMISSIONER STEPHEN GOUDGE: But that 10 was your initiative? 11 DR. DAVID CHIASSON: Yes, basically my 12 initiative, yes. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 15 CONTINUED BY MS. LUISA RITACCA: 16 MS. LUISA RITACCA: When you were 17 performing cases at the Hospital for Sick Children while 18 Dr. Smith was still the Director, in late 2001 and -- and 19 beyond, were -- are you aware of whether or not Dr. Smith 20 was reviewing any of your case reports before they went 21 to the Office of the Chief Coroner? 22 DR. DAVID CHIASSON: I was unaware if he 23 was. 24 MS. LUISA RITACCA: Dr. Chiasson, I think 25 I won't be overstating this when I've said -- I say that

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1 I'm pretty sure your view is that the Hospital for Sick 2 Children Unit is the ideal setting for pediatric forensic 3 pathology. 4 Are you able to assist the Commissioner in 5 understanding how pediatric forensic pathology services 6 work in the other units throughout the province? 7 DR. DAVID CHIASSON: Well as I understand 8 it in the other units, I mean, it varies from area to 9 area. In Ottawa, in fact, the cases aren't done in the 10 Forensic Pathology Unit, they are done at the Children's 11 Hospital of Eastern Ontario, so they're done within the 12 context of a pediatric hospital. 13 MS. LUISA RITACCA: And if I can stop you 14 there, just to interrupt you for a moment, does the -- 15 are you aware of whether or not the Office of the Chief 16 Coroner has, or the Ministry, has a contract with the 17 Children's Hospital? 18 DR. DAVID CHIASSON: As I understand it, 19 there is no contract between the -- the Coroner's 20 Office/Government and the CHEO. 21 MS. LUISA RITACCA: All right. Sorry, 22 and I interrupted you. 23 DR. DAVID CHIASSON: So that's the 24 situation there. I don't know how much interplay or how 25 much communication exists between the Ottawa Unit and the

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1 Children's Hospital Unit. My sense is that there is -- 2 they're very separate facilities, separate units. 3 So London, there the pediatric autopsies 4 are done by forensic pathologists who basically are adult 5 forensic pathologists, so they do the cases for 6 southwestern Ontario, and there is no, as far as I'm 7 aware, pediatric pathologists working in the western 8 London Health Science's Group, so -- so -- but basically 9 you have the adult forensic pathologists doing pediatric 10 cases. 11 In Hamilton, there the autopsies are done 12 at the Hamilton Forensic Pathology Unit by adult forensic 13 pathologists; although, I would indicate that Dr. Rau is 14 in fact have -- has had a longstanding interest in 15 pediatric forensic pathology and -- and sort of as 16 specialised in -- in that area. 17 There is a -- at least one (1) pediatric 18 pathologist within the Hamilton pathology system. I know 19 on occasion she provides consultative opinions to the 20 unit, but I think that's an exception rather than any 21 ongoing involvement. I think most of the cases are 22 handled by the forensic pathologist, the adult forensic 23 pathologist. 24 MS. LUISA RITACCA: And is your Unit ever 25 called upon by the other units to assist or provide

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1 consults on pediatric cases? 2 DR. DAVID CHIASSON: We have certainly 3 been referred cases that, if you will, ha -- have gone 4 through the other units or we've had cases that were sort 5 of bypassed London on the way to -- to Toronto for 6 various reasons. 7 That ca -- happens on occasion; it's not 8 common. And certainly recently more and more of the 9 criminally suspicious deaths from the Ottawa area are 10 coming to our -- to our Unit. 11 The hope is, and -- and this is in some 12 recent discussions with Dr. Shkrum in London, in fact, 13 and then we've -- trying to set it up so that they -- 14 they've expressed an interest in attending our pediatric 15 forensic pathology rounds at the Hospital for Sick 16 Children. So I think something looking towards the 17 future I think would be very important to try and develop 18 lines of communication, much more so than exists at the 19 present time, between the other pediatric units or the 20 other units performing pediatric autopsies. 21 MS. LUISA RITACCA: And when a case gets 22 referred or goes through another unit to the Hospital for 23 Sick Children's Unit, can you help us understand how that 24 works; is it -- does -- is it a pathologist at the London 25 Unit that refers it, or is it a coroner, or is it the

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1 Chief Forensic Pathologist? 2 Can you explain that to us? 3 DR. DAVID CHIASSON: Well, the London 4 situation and the only one (1) I can remember right now 5 was a situation where you had a clearly highly suspicious 6 child death, as opposed to an infant death, where the 7 pathologist who was on call for forensic pathology didn't 8 feel comfortable doing it, so it -- it kept on going down 9 the -- the 401 to -- to Toronto in that case, so that -- 10 that's an exception. 11 What's happening in -- in Ottawa of late, 12 most of these deaths now I think the Regional Coroner's 13 getting involved in -- in where the autopsy is being done 14 and I think the decision is, if it's criminally 15 suspicious and/or an apparent homicide, the body is being 16 transferred to -- to Toronto. 17 MS. LUISA RITACCA: And so if I 18 understand you correctly, in the Ottawa situation, as an 19 example, it's -- it's not necessarily that the child is 20 brought to the hospital in Ottawa, and then transferred 21 to the Hospital for Sick Children by the pathologist in 22 the Ottawa hospital? 23 Or is it a decision made by the regional 24 coroner and the body is transported directly to Sick 25 Kids, or is it variable?

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1 DR. DAVID CHIASSON: Well, the cases 2 we've had recently, happen to be hospital -- they die in 3 hospital at -- at GO, and were transferred. We did a 4 second post-mortem examination on a case that was 5 initially directed to there. And subsequently, a second 6 post-mortem examination was felt to be indicated and the 7 body was transferred here. 8 Offhand, I can't recall any case where the 9 infant's basically dead at home, in the Ottawa region and 10 was transferred directly to -- to Toronto. 11 MS. LUISA RITACCA: All right. 12 COMMISSIONER STEPHEN GOUDGE: Is there a 13 protocol or anything about this yet? 14 DR. DAVID CHIASSON: The coroner's 15 office, I imagine, has some kind of protocol. I'm not 16 aware of it in a formal sense. And it's kind of a -- I 17 guess an internal coroner's office, whether it -- how 18 formalized a protocol it is, I don't know. But I've 19 certainly become aware that we were to expect, down the 20 road, more cases from the Ottawa area. 21 COMMISSIONER STEPHEN GOUDGE: Criminally 22 suspicious cases. 23 DR. DAVID CHIASSON: Criminally 24 suspicious forensic, pathology cases. 25

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1 CONTINUED BY MS. LUISA RITACCA: 2 MS. LUISA RITACCA: And you spoke about 3 your experience with the London unit for example, calling 4 upon the Hospital for Sick Children for assistance on the 5 pediatrics side. 6 Did you have any experience, short of a 7 body being transported, with the Ottawa Children's 8 Hospital calling upon you as a forensic pathologist to 9 assist on a consulting, advisory basis in a case? 10 DR. DAVID CHIASSON: I -- I've not 11 personally had that experience, no. 12 MS. LUISA RITACCA: And Dr. Chiasson, I'm 13 going to suggest that you are perhaps in an ideal 14 position to be the Director of the OPFPU, given your 15 forensic experience and -- your forensic credentials, 16 rather, and your pediatric experience. 17 What are your thoughts on that? 18 DR. DAVID CHIASSON: Well, I think that 19 if it isn't -- become apparent until now, I'm actually a 20 strong proponent of what we have in place now at the 21 Ontario Pediatric Forensic Pathology Unit at the Hospital 22 for Sick Children. 23 I started working there in 2001, and the 24 reason that -- it was part to expand my own forensic 25 pathology practice I felt as a forensic pathologist. And

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1 it certainly -- I certainly saw it as weakness of me as a 2 Chief Forensic Pathologist not having a particular 3 experience in that area. 4 That's not to suggest I want to turn 5 around and go back to my old job. Dr. Pollanen's quite 6 welcome to it. 7 COMMISSIONER STEPHEN GOUDGE: The job you 8 tried to resign from several times. 9 DR. DAVID CHIASSON: Something like that, 10 yeah. 11 12 CONTINUED BY MS. LUISA RITACCA: 13 MS. LUISA RITACCA: How generous. 14 DR. DAVID CHIASSON: So 2001 -- but -- 15 but for me as well, I thought -- there's challenges, I -- 16 I was interested in pediatric pathology and I saw this as 17 a challenge in my own career development. 18 But the only reason that I would have done 19 it, the only reason I did do it, and I spoke to Dr. 20 Becker about this, was in fact that, I knew that I would 21 be welcome there, and able to access the pediatric 22 pathology expertise that was there, the pediatric 23 pathology assistant expertise. 24 We have people there, Don Perrin, Jimmy 25 Choi, who have been doing pediatric forensic pathology

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1 cases for years. And I'm -- I'm a major proponent of -- 2 believer in the value of having very good assistants, and 3 the importance of pathologists assistants. So I knew the 4 players from that point of view. 5 And with the pediatric neuropathology 6 support, et cetera, I was prepared to stick my -- my toe, 7 into the -- into the water. And that's basically, I 8 started doing, covering a week a month. And in the first 9 six months, I might have done four or five cases. 10 I didn't do that very much. But then 11 gradually built up. And as I got more comfortable with 12 the -- the environment and developed a greater expertise 13 in the area, I -- I've come to appreciate, and I guess I 14 really bought into it when I assumed the directorship. I 15 -- I think this is a concept, I've said is a unique 16 concept. It's a unique way to tackle what is a very 17 difficult issue within forensic pathology and that's how 18 -- how to best do pediatric forensic pathology. 19 I've bought into this model. I think 20 there's unique concept and also unique opportunities for 21 to develop research, education mandates to provide the 22 evidence for evidence-based pediatric forensic pathology 23 in this case. 24 So I'm obviously a big believer in -- in 25 the setup that we have now in place at this Hospital for

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1 Sick Children. 2 COMMISSIONER STEPHEN GOUDGE: Is there a 3 risk, Dr. Chiasson, that you will get isolated or someone 4 in your position will get isolated from your forensic 5 colleagues doing the criminally suspicious cases, albeit 6 the adult cases? 7 DR. DAVID CHIASSON: Well, I think, as 8 I've indicated, Mr. Commissioner, I'm -- I'm -- part of 9 my strategy here is in fact to maintain that close 10 connection with the -- 11 COMMISSIONER STEPHEN GOUDGE: But is that 12 not important? 13 DR. DAVID CHIASSON: I think that's 14 critically important. And even though I'm the only 15 forensic pathologist there, certainly, full time, I'm the 16 -- I do have Dr. Pollanen when he's not off doing -- 17 doing other things, and I -- you know, he's got many 18 responsibilities, obviously. But it -- it's nice to know 19 that he's there as well. 20 And -- and Dr. Taylor, who's over the 21 years, although his -- his background is obviously from a 22 different point of view, he's devel -- he's had quite a 23 bit of experience with forensic pathology, infant deaths, 24 the issues that -- some of which we were talking about 25 this morning -- live birth, et cetera.

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1 So I'm -- I'm not feeling isolated now. 2 But I think it's important that one maintains a very 3 close relationship with the -- the adult side of the -- 4 of the world. 5 6 CONTINUED BY MS. LUISA RITACCA: 7 MS. LUISA RITACCA: And this may be self- 8 evident, but do you think that the Director of the OPFPU 9 should be a forensic pathologist? 10 DR. DAVID CHIASSON: Yes. The reasons -- 11 you know, we're having a -- an inquiry into issues that 12 are forensic pathology -- forensic in the sense of 13 homicide criminally suspicious cases. And even though 14 it's a small proportion of the cases, I think that's -- 15 they're the cri -- they're really critical issues here. 16 And it's only a forensic pathologi -- 17 forensic path -- I shouldn't say it's only, but I think 18 the forensic pathologist is the one that's going to be 19 most attune to these sorts of -- of -- of issues. 20 And, you know, when you're looking at 21 issues of quality control and -- and making sure that the 22 reports that are issued are -- are forensically as good 23 as they can be, I think you really do need a forensic 24 pathologist as the Director. 25 So its emphasis is Pediatric Forensic

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1 Pathology Unit, but you've got to underline the forensic 2 part of that long -- long title. 3 MS. LUISA RITACCA: And do you think that 4 the directors of the other regional units should be 5 forensic pathologists? 6 DR. DAVID CHIASSON: Yes. 7 MS. LUISA RITACCA: Certified as such? 8 DR. DAVID CHIASSON: Well, you know, 9 ideally, yes. I mean, I -- I understand, you know, and 10 appreciate the environment in which some of the Directors 11 were -- were appointed and -- and where they came from. 12 But I mean -- but I think the ultimate goal is -- is that 13 the individuals who are actually directing your forensic 14 pathology units are -- are recognized readily as forensic 15 pathologists. 16 That's -- and the easiest way to recognize 17 somebody is to say they have -- their -- their Board 18 Certification. And, certainly, with young people 19 nowadays, I mean, I think they -- they do need to get the 20 appropriate training, get their exams. 21 MS. LUISA RITACCA: Dr. Chiasson, I'm 22 going to change paths slightly. 23 When you were the Chief Forensic 24 Pathologist, did you feel hindered in your ability to run 25 your unit in Toronto because you didn't have specific

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1 control over a line item in the OCCO budget? 2 DR. DAVID CHIASSON: No. No, I -- I 3 raised this morning this issue as Chief Forensic 4 Pathologist should have some form of -- of input into 5 budgetary issues as they relate to forensic pathology, 6 and I -- I think that -- that's true. 7 I think -- you know, I think one would 8 want to monitor the forensic pathology budget in terms of 9 what's being spent and -- and where's the money going. 10 And so that, in fact, you know, there's opportunities to 11 -- to jig it so that, in fact, you can focus on, Okay, we 12 need to pay our forensic pathologists more or we need -- 13 we need another forensic pathologist -- another foren -- 14 So I think there should be -- they -- they 15 should be aware of what's going on from a budget point of 16 view. But I'm -- I'm not suggesting -- the Chief 17 Forensic Pathologist has -- has lots of important 18 professional functions related to the -- to pathology and 19 forensic pathology. 20 It's -- it's not a question of we're 21 trying to convert them into some kind of financial 22 administrator. I'm -- that's not what I'm trying to 23 suggest. 24 MS. LUISA RITACCA: And when you're 25 suggesting input or awareness of the -- of the forensic

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1 pathology services' budget, do you include in that 2 involvement or awareness of the -- the budget as it 3 relates to the forensic pathology units, other than the 4 Toronto Unit? 5 DR. DAVID CHIASSON: Well, I think that 6 that would -- that should form part and parcel of -- of 7 the forensic pathology unit line items. You know, that - 8 - that should be clustered together, yes. 9 MS. LUISA RITACCA: And do you think that 10 kind of involvement in the transfer payments to the units 11 would assist the Chief Forensic Pathologist in providing 12 in his supervisor role over the units? 13 DR. DAVID CHIASSON: Well, I think, yes. 14 If -- if, in fact -- and I mean, you'd -- you'd have to 15 look at contracts and -- and -- I mean, a part of the 16 problem with the contracts now are that there is no 17 reference, as I understand it, to the Chief Forensic 18 Pathologist. 19 And clearly, you know, you want to tie 20 that into the contract. And if, in fact, the Chief 21 Forensic Pathologist is -- is assuming some kind of 22 ownership of this issue, then if I'm working in the unit 23 and he's the guy I'm supposed to be reporting to and has 24 some kind of budgetary -- lev -- leverage, at least, in 25 terms of the money, it's -- it's much easier to, sort of,

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1 feel that you're -- you're being supervised, you know, if 2 -- if that's the case. 3 As opposed to the monies coming from the 4 Chief Coroner and you're -- you're sort of supposed to be 5 supervised by a Chief Forensic Pathologist. I mean, I -- 6 I think it makes sense that the one that sort of is -- 7 has some input into the money -- 8 And again, I'm not -- not suggesting, you 9 know, nickels and dimes and -- and that kind of level, 10 but at least have some sense that there's -- there's -- 11 he's got budgetary input. 12 MS. LUISA RITACCA: And, Dr. Chiasson, 13 under the post-mortem review process that you instituted 14 in 1994/1995, were your reports being reviewed? 15 DR. DAVID CHIASSON: No. 16 MS. LUISA RITACCA: And why not? 17 DR. DAVID CHIASSON: Well, my -- my 18 criminally suspicious homicide reports were not being 19 reviewed. I -- I really didn't know how to go about 20 having my reports reviewed. I -- I thought about having 21 my staff review it. 22 I -- I had -- I had some problems with 23 that as being seen as some kind of rubber stamp 24 procedure. That's not to say I didn't discuss review of 25 -- of my -- I didn't discuss reports with my -- my

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1 colleagues. In fact, you know, the reason to have rounds 2 and to seek input was to -- was to do that. 3 And so I didn't think that -- well, I 4 don't think I was putting them into a very comfortable 5 position of having to review my -- my reports, since they 6 worked for me. You know, if -- if -- with time, would I 7 have revised that attitude? Maybe. 8 I -- I was working with a lot of 9 relatively junior people. If I was able to hire somebody 10 with some real seniority as a forensic pathology -- and 11 that's not meaning any disrespect to Dr. Deck, who was a 12 -- who -- who had been hired on -- had some seniority, 13 but clearly I was the one that was priding -- providing 14 direction as to how reports should be wrou -- written. 15 I think it may have been different. 16 MS. LUISA RITACCA: And under the current 17 peer review process that we've Dr. Pollanen talk about, 18 who do you believe should be responsible for reviewing 19 the reports of the Chief Forensic Pathologist? 20 DR. DAVID CHIASSON: Well, I think within 21 the system we have -- I mean, I -- I think this is 22 something that needs to be done within the context of the 23 Coroner's Office here in Ontario. I mean -- and I think 24 that the unit directors, the other unit directors, seems 25 to be the most logical choice as far as reviewing the

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1 Chief Forensic Pathologists. 2 I think it would provide the units -- 3 they're -- they're experienced forensic pathologists. 4 Suffice it to say, people have different approaches to 5 reports; this would provide an opportunity for the Chief 6 Forensic Pathologist to -- to actually try to disseminate 7 what his approach is. 8 You know, I -- I've certainly reviewed a 9 number of Dr. Pollanen's reports, for example, before he 10 became the Chief Forensic Pathologist. It was my 11 function. And I saw the -- how he evolved and how he did 12 his reports, and it's -- it's a good learning experience 13 for the reviewer to do that. 14 And I think that, and -- and this is, I 15 think, in -- in credit to Dr. Pollanen, who -- who's 16 really working hard at trying to bring all the unit 17 directors and the units closer together\; better working 18 relationship. 19 I -- I think that that's something that 20 could be done in a way that would be -- would be useful, 21 would be -- would be -- I -- a fair way to do it, a 22 reasonable way to do it. And -- and if there are issues 23 and problems, they could be discussed. 24 If -- if they continue, then I guess you'd 25 have to think about some kind of -- you know, what

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1 happens if you have an issue beyond -- with the Chief 2 Forensic Pathologist's report. 3 That's perhaps where a Chief Coroner might 4 have a role in saying, Okay, we -- do we need to go 5 outside, or that sort of thing. It becomes -- and I -- 6 I'm looking at the Chief Coroner, not as somebody that's 7 going to review the reports, but as somebody, okay, we've 8 got a management issue here. 9 MS. LUISA RITACCA: Facilitate another 10 review, is that -- 11 DR. DAVID CHIASSON: Facilitate another 12 review, or convene a case conference, or something of 13 that nature. 14 MS. LUISA RITACCA: And, Dr. Chiasson, I 15 wanted to ask you a few questions about defence pathology 16 and something that you -- you discussed with Ms. -- Ms. 17 Rothstein this morning. 18 Do you do defence work? 19 DR. DAVID CHIASSON: I -- I -- yes, I 20 have done defence work. I haven't done a lot of defence 21 work and in large part because as Chief Forensic 22 Pathologist and in my capacity there, I was reviewing all 23 the reports of other pathologists within the Province. 24 It really, I thought, put me in a conflict 25 of interest to get involved in any criminal procedure --

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1 criminal homicide procedure -- within the Province 2 because I've already reviewed and -- and, if you will, 3 approved the pathologist's report in all likelihood. So 4 that -- that has handicapped me in terms of doing a lot 5 of defence work. 6 Most of the defence work that I have done 7 has been in criminal cases that -- where the individual 8 hasn't died. So that's -- that's another sort of area 9 within the forensic pathology scope, although you'd think 10 a forensic pathologist as being somebody that does 11 autopsies and deals with dead people. 12 In fact, there is a role to be played in 13 cases of injury and determination nature of injury as to 14 what they -- what -- what might have occurred and -- and 15 that sort of thing. So I've been involved in that, and 16 some appeal work at that level; not a large amount of it, 17 and some it out of Province, but not a large amount 18 overall. 19 MS. LUISA RITACCA: And do you think that 20 the forensic pathologist that the Coroner's Office either 21 employs or uses on a fee-for-service basis should be 22 required to do defence pathology as part of their 23 professional responsibility? 24 DR. DAVID CHIASSON: Well, I think 25 required is -- is not something I -- I could advocate. I

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1 should say, the other way I've -- I've assisted defence 2 lawyers when -- when they do call me, is to in fact 3 direct them to where they might be able to get an 4 opinion, and I would say, Well, this is -- I -- I can't 5 do that because of this, but here are some names of 6 individuals who -- who I would recommend to you. 7 I think requiring a forensic pathologist 8 to -- to do defence work is -- is problematic, but I 9 think they should be encouraged. And I think -- 10 especially the ones that are working within the unit 11 settings -- I think it should be an expectation that they 12 -- they will make themselves available to defence 13 pathologists -- sorry -- to defence -- to defence 14 lawyers. 15 And I think that, to me, is much 16 preferable that -- that we have, again, an in-province 17 approach to dealing with this issue rather than having 18 them go out of -- out of province and finding people of 19 that nature. 20 I think the likelihood then of -- if I 21 know Dr. Scrum has, for example, reviewed one (1) of my 22 reports and I found out that he's got some serious 23 concern, well, I know Dr. Scrum, I have a lot of respect 24 for him, and he's not somebody that's going to go off. 25 And he's -- he's conservatively minded; he's not going to

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1 be issuing dissenting opinions unless he really thinks 2 there's something going on. 3 So the likelihood of getting together in 4 some format is much greater than it is if it's some 5 pathologist I haven't heard of or somebody that might 6 have a reputation as a bit of a hired gun. And that -- 7 that provides for some more dissent and -- and conflict 8 in that kind of situation. 9 So I -- I would think encourage. It does 10 raise the whole issue as to, you know, how -- how do you 11 fund that. 12 MS. LUISA RITACCA: Right. 13 DR. DAVID CHIASSON: Was I -- 14 MS. LUISA RITACCA: I was going to get to 15 that but go ahead, yes. 16 DR. DAVID CHIASSON: Well, I think one 17 (1) of the big prob -- I -- I think, and I've said this 18 morning, is that the -- one (1) of the big issues I see 19 in -- in the Inquiry before us as to what -- what went 20 wrong, are -- are the -- is the issue of monitoring and 21 what's going on in criminal courts. 22 And, I mean, the system that we have now 23 is -- is that a defence lawyer will have a defence 24 pathologist to assist and advise him in -- in issues of 25 this nature.

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1 That, I think, is -- is what we have and I 2 think that the concept is a good one; I think -- on a 3 functioning point of view there are major -- major 4 challenges, and money is a major challenge. 5 I mean, if you -- if you think about try - 6 - forensic pathologists in this Province have more than 7 enough to do. I don't think anybody is sitting on their 8 thumbs waiting for a call to find some more work. 9 I think, you know, as a group, we are -- 10 we are under-resourced and -- and over-serviced. I mean, 11 -- we we've got lots to do without having to find other 12 work. And so when you're approached by a defence lawyer, 13 then, you know, you've got all -- you know, you're 14 looking at your desk and there's this pile of cases 15 you're trying to sign out, and he's calling and he wants 16 an opinion. 17 And, from my own point of view, I think 18 it's an interesting part of -- of the work. I -- I've 19 always enjoyed reviewing other pathologist's reports; I 20 mean, I've done it for years. And again, you always 21 learn something and -- and you're there to try to seek 22 the nuances that -- that, you know, what's reading 23 between the lines which, I think only, really, a forensic 24 pathologist can -- can do for the most part about a 25 forensic pathology report.

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1 So, I find it challenging and it's 2 interesting work. But if, on the other hand, you're, you 3 know, offering to pay me the current Legal Aid rates, and 4 it does involve obviously more work and the potential of 5 coming into some kind of conflict with a -- with a 6 colleague and all of that, it's -- it's certainly 7 something that you have to think twice about. I -- 8 COMMISSIONER STEPHEN GOUDGE: Do you 9 consider you have to do it on your own time? 10 DR. DAVID CHIASSON: Well, it is, yeah. 11 And that's, I think, part of the point here. It's really 12 overtime work, if -- if you're going to take it on. 13 And I can tell you that of all the times 14 I've been consulted and contacted and reviewed a report 15 for defence lawyers -- criminal defence lawyers -- in 16 this Province, I've yet to bill Legal Aid anything, 17 because it's -- the rates are so poor that it really is 18 hardly worth the -- most of the time we're talking, you 19 know, not a lot of hours, et cetera, but to go through 20 the -- the procedure, it's not worth it. 21 So all the criminal defence assistance 22 I've done over the years has been pro bono. 23 24 CONTINUED BY MS. LUISA RITACCA: 25 MS. LUISA RITACCA: And, Dr. Chiasson,

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1 can we talk a little bit about the fee structures, as far 2 as you understand them. And -- and just to assist on 3 that, if I could ask you to turn up -- and it actually 4 might be easier to look at the screen, because I'm not 5 sure if there's page numbers on the Institutional Report 6 that should be in front of you; the Coroner's Office 7 Institutional Report at PFP149431, page 118, which is 8 Appendix H. 9 Oh, page 118. Yeah, that's okay. 10 So this, Dr. Chiasson, is a chart of the 11 fees that the Coroners Office pays for the completion of 12 an autopsy and a post-mortem report. 13 Is that correct? 14 DR. DAVID CHIASSON: Yes. I -- I've seen 15 the table recently. 16 MS. LUISA RITACCA: Right. 17 DR. DAVID CHIASSON: I had nothing to do 18 with its creation, of course. 19 MS. LUISA RITACCA: That's right. And as 20 I understand from just looking at the table, there's a 21 fairly significant pay increase in the last two (2) 22 decades, from 1990. 23 Is that fair to say? 24 DR. DAVID CHIASSON: Yes, well, you've 25 gone from four sixty (460) in December 1st, 1990 to a

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1 thousand (1,000) on April 1st, 2007 and -- 2 MS. LUISA RITACCA: And it is it -- am I 3 correct in -- and as I understand the table, it -- it's 4 not until 2002 that there are a pay increase for complex 5 cases? 6 DR. DAVID CHIASSON: That's right. It 7 was about that time that the -- there was a differential 8 fee for complex cases, yes. 9 MS. LUISA RITACCA: All right. And by 10 comparison, how much does a forensic pathologist get paid 11 by the Crown Attorney for testifying at a criminal trial? 12 DR. DAVID CHIASSON: Well, the fees 13 haven't changed, as I understand it, Unless some -- 14 there's some late-breaking news that I'm unaware of. It 15 goes back to 1991, I believe, somewhere around there, and 16 the fees are three twenty-five (325) for a half day, six 17 fifty (650) for a full day of testimony at a criminal 18 trial. 19 MS. LUISA RITACCA: And can -- 20 COMMISSIONER STEPHEN GOUDGE: That's what 21 the Crown Attorney pays. 22 DR. DAVID CHIASSON: That's what the 23 Crown Attorney pays, yes. 24 25 CONTINUED BY MS. LUISA RITACCA:

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1 MS. LUISA RITACCA: And -- and is there 2 any prep time worked into that number? 3 DR. DAVID CHIASSON: Prep -- prep time is 4 a hundred and twenty five dollars ($125) an hour. 5 MS. LUISA RITACCA: And does the 6 pathologist get that money or that payment from the 7 Ministry of the Attorney General, or how does that work? 8 DR. DAVID CHIASSON: Yes. I -- if -- 9 well, if you're a salaried employee of the Government, 10 you don't bill the other -- you don't bill for your time; 11 that's considered to be part of your responsibilities. 12 If you're outside of the Government, then yes, you would 13 bill the Ministry of the Attorney General. 14 Well, I send my bills to the Crown 15 Attorney. Interestingly, I got a bill back recently 16 because they -- they -- some jurisdictions seem to divide 17 up the amount that the court administration will pay for, 18 and how much the actual Crown Attorney's office will pay 19 for. And they -- they sent back a bill and asking to 20 breakdown what's prep time versus what's court time. 21 MS. LUISA RITACCA: And -- and again, by 22 comparison, how much does the forensic pathologist get 23 paid to do defence work by Legal Aid. 24 DR. DAVID CHIASSON: Well, again, I -- as 25 I've said, I've never billed them. But as I understand

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1 it, it's a -- I think a hundred dollars ($100) an hour. 2 MS. LUISA RITACCA: And is there a per 3 diem court fee? 4 DR. DAVID CHIASSON: I'm unaware of -- of 5 a per diem court -- like I said, I've never -- I've never 6 testified for the defence. I have in -- in non-criminal 7 cases, but that's -- I didn't bill Legal Aid for that. 8 MS. LUISA RITACCA: And I think Ms. 9 Rothstein asked you this with regard to the Coroners 10 Office fees that you get and -- and what you do with them 11 in your unit. 12 What do you do with the money that you 13 receive from the Ministry of the Attorney General in the 14 Unit? Does -- 15 DR. DAVID CHIASSON: The agreement I have 16 with my Head of Pathology is that if I have to go to 17 court, I'm able to bill, and -- and I -- I -- it's bill - 18 - I -- I invoice direct -- it gets invoiced -- a cheque 19 comes back to me. 20 MS. LUISA RITACCA: And, Dr. Chiasson, in 21 the few moments that I have remaining with you, I know 22 that you had hoped that you would be able to tell the 23 Commissioner of some of your ideas. 24 I understand that you -- you're likely to 25 be invited back, but in the last few minutes, if there's

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1 anything that I haven't covered, that you'd like to cover 2 now before you come back. 3 DR. DAVID CHIASSON: Well, thank you for 4 the opportunity. And I -- I think the Commissioner has 5 heard a number of -- of ideas that I -- that I have. 6 Maybe in a very brief summary, in terms of the -- my 7 previous position as Chief Forensic Pathologist, I think 8 the roles and responsibilities of that position need to 9 be clearly defined. 10 And it's my belief I think it should be 11 codified within the Coroner's Act. That there should be, 12 in addition to a Chief Forensic Pathologist, a Deputy 13 Chief Forensic Pathologist who is responsible -- who acts 14 as Director of the Toronto Forensic Pathology Unit. 15 I see those as two (2) jobs and -- and 16 that, I think, is important that it -- it be identified 17 as two (2) -- two (2) -- really two (2) -- two (2) 18 different jobs. 19 I think that the critical thing is -- 20 well, yes, really I come back to the importance of 21 staffing the Toronto Forensic Pathology Unit with full- 22 time staff forensic pathologists. 23 I -- 1994; that was my five (5) year plan. 24 We're now thirteen (13) years down the road and it 25 remains, I think, the most significant challenge to

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1 forensic pathology within the coroner's system right now. 2 I mean, I think that's a -- that's a core 3 -- a core issue that really needs to be addressed. The - 4 - in terms of the other units, I made reference I think 5 they should be forensic pathologists, recognized as -- as 6 that that are dir -- directors, that they be 7 appropriately resourced and -- and staffed. 8 And as far as the -- I've basically talked 9 about defence lawyers, which is kind of a side issue -- 10 sorry, not defence lawyers. I'm not qualified to talk 11 about defence lawyers -- 12 MS. LUISA RITACCA: Mm-hm. 13 DR. DAVID CHIASSON: -- but defence 14 pathologists, I think is -- is that -- that whole issue, 15 I think, is -- is a very important one in terms of 16 monitoring what's going on in a courtroom situation. 17 I think that the idea of having 18 pathologists sit in and watch other pathologists testify, 19 that sort of thing, I -- I just don't think it's -- is -- 20 is really a feasible one given the shortage of 21 pathologists we have. 22 And, finally, nearest and dearest to my 23 heart is in regards to the Ottawa, Ontario Pediatric 24 Forensic Pathology Unit. I've -- I've said it; I think 25 the -- the concept is a -- is a good one.

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1 I have not heard or aware of any, I don't 2 think, better way to deal with pediatric forensic 3 autopsies. I think the Unit Director there needs to be a 4 forensic pathologist, and he needs to -- obviously there 5 are resource issues and staffing issues which I would 6 perhaps be able to speak to at greater length down -- 7 down the road. 8 But, again, resources in -- in that 9 context are -- are important, but -- an endorsement of -- 10 of the concept of a unit separate and distinct from the 11 adult or the Toronto of Forensic Pathology Unit is -- is 12 ,I think, my vision, and situated, as it is, at Hospital 13 for Sick Children. 14 MS. LUISA RITACCA: Thank you, Dr. 15 Chiasson. Commissioner, those are my questions. 16 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 17 Ritacca. Just a couple of questions arising out of the 18 very helpful set of answers, Dr. Chiasson. 19 What would you say to whether the regional 20 units ought to move in the same direction as you've 21 described being so important for Toronto; that is, with 22 separate pediatric forensic pathology units housed in 23 children's hospitals? 24 I mean the obvious example is Ottawa. An 25 idea that is so useful for Toronto; would it be useful in

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1 Ottawa, as well, or if not, why not? 2 DR. DAVID CHIASSON: Well, again, you 3 know, the -- the issue is to find somebody with a 4 forensic pathology background who is prepared to assume 5 the responsibility in a pediatric setting. 6 I -- I think there -- there needs to be 7 closer ties between the adult unit and the -- and -- and 8 the CHEO Unit, and if -- I know they're in a process of - 9 - of revitalisation in Ottawa. 10 I think the ideal situation would be to 11 bring somebody onboard with -- you know, a forensic 12 pathologist who has a pediatric pathology experience and 13 could act as a -- be involved -- 14 COMMISSIONER STEPHEN GOUDGE: Be a bridge 15 or something. 16 DR. DAVID CHIASSON: A bridge, but not 17 only a bridge, but be prepared to get involved in those 18 cases and -- and maybe act as a -- the dir -- for the 19 sake of argument, the Director of the Ottawa Unit. The 20 adult unit could be responsible for triaging cases. 21 You're not right onsite. 22 I -- I think that the -- the -- it's a big 23 department in -- in -- at the Hospital for Sick Children 24 -- pathology department -- and -- because of the number 25 of cases we can do.

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1 Thank God my -- my higher-ups think I'm 2 justified as a -- as a position. I'm very fortunate. I 3 -- I think it would be much more difficult to perhaps 4 administratively justify having somebody like me working 5 in CHEO, because of the number of cases we're dealing 6 with. 7 COMMISSIONER STEPHEN GOUDGE: Okay. 8 DR. DAVID CHIASSON: So there's -- but I 9 think you could setup a -- a model whereby the Otto -- 10 sorry -- the Ottawa -- the main forensic pathology unit 11 would be responsible for what's done over there and cases 12 -- the appropriate pathologist get involved. 13 COMMISSIONER STEPHEN GOUDGE: Okay. I am 14 not sure it is an either/or, but let me put it as an 15 either/or. 16 Would it be better to move in the 17 direction you have just outlined, or would it be better 18 to move in the direction of, at least for the criminally 19 suspicious pediatric cases, centralizing them at one (1) 20 location in Ontario? 21 DR. DAVID CHIASSON: Well, right now we 22 are doing most of the sudden infant deaths in northern 23 Ontario. Some of the ones in the northwest part actually 24 go to Winnipeg. But Thunder Bay and, certainly, east of 25 Thunder Bay and northern communities, bodies are being

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1 flown down to our unit. 2 So, I mean, we -- we're certainly acting 3 in -- at that level as a central unit for -- and this is 4 -- these are not criminally suspicious death -- or some - 5 - some of them are, but, I mean, most of them are not. 6 So, you know, the Coroner's Office, I think, is prepared 7 to provide pediatric forensic pathology service to even 8 the northern parts at -- at -- not in consequential 9 cause. 10 So your -- your thought that maybe -- 11 maybe what we -- would be best was if it's identified as 12 criminally suspicious, maybe -- maybe it's -- you know, 13 that they should all be sent to -- to our unit. I -- I - 14 - as a director, I mean, I'm -- I'm prepared to -- to -- 15 COMMISSIONER STEPHEN GOUDGE: Go back and 16 put your hat on as Chief Forensic Pathologist -- 17 DR. DAVID CHIASSON: Well -- 18 COMMISSIONER STEPHEN GOUDGE: -- which 19 produces the highest quality service, I mean. 20 DR. DAVID CHIASSON: Provide the highest 21 quality service and accept the responsibility. 22 Obviously, there's resources issues that need to be 23 addressed -- 24 COMMISSIONER STEPHEN GOUDGE: Oh, 25 absolutely.

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1 DR. DAVID CHIASSON: -- addressed, as 2 well, But, no, I thin -- southern Ontario, per se, is not 3 that large a -- an area when you're thinking about what 4 we are now accepting in terms of pediatric cases. So I - 5 - I think that's a feasible alternative, and -- and 6 certainly need more thought and consideration, but it -- 7 it's possible, certainly. 8 COMMISSIONER STEPHEN GOUDGE: Okay. Last 9 question. Sorry, but it's a nuts and bolts budget 10 question. 11 The units, the regional forensic pathology 12 units, are now funded by way of grant from the OCCO? 13 DR. DAVID CHIASSON: The -- 14 COMMISSIONER STEPHEN GOUDGE: You get a 15 grant at Sick Kids? 16 DR. DAVID CHIASSON: We get a grant. It 17 doesn't cover all the costs. 18 COMMISSIONER STEPHEN GOUDGE: Oh, that is 19 my question. 20 DR. DAVID CHIASSON: Yes. 21 COMMISSIONER STEPHEN GOUDGE: What is the 22 shortfall; rough number? 23 DR. DAVID CHIASSON: We've -- well, Dr. 24 Taylor's usually the numbers guy in -- in our department. 25 COMMISSIONER STEPHEN GOUDGE: I guess I

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1 should have both sides of that. 2 DR. DAVID CHIASSON: Well, yes. 3 COMMISSIONER STEPHEN GOUDGE: Both the 4 cheque-writer and the cheque-receiver what the shortfall 5 is? 6 DR. DAVID CHIASSON: We -- we've looked 7 at that and we're shortfall -- as far as simply the 8 technical aspects, assistants, administrative assistants 9 and -- 10 COMMISSIONER STEPHEN GOUDGE: Yes. 11 DR. DAVID CHIASSON: -- that sort of 12 thing. 13 COMMISSIONER STEPHEN GOUDGE: Do not work 14 the capital cost into it. 15 DR. DAVID CHIASSON: No. And -- and nor 16 the pathologists' costs because, as I've indicated, I -- 17 I can't justify my salary based on, you know, the amount 18 of money I bill back for my professional services to the 19 Coroner's Office. 20 So, I think there is that -- that aspect 21 of -- of the funding of -- of the pathologist, who -- who 22 do the work in the unit. But even putting that aside, 23 the grant, we're -- we're shortfalled at least a hundred 24 thousand dollars ($100,000). 25 COMMISSIONER STEPHEN GOUDGE: On a grant

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1 of what, two hundred (200)? 2 DR. DAVID CHIASSON: Our grant is -- two 3 hundred (200) I think is the -- is -- is our grant, yes. 4 COMMISSIONER STEPHEN GOUDGE: And if I 5 asked you to guess as to the other regional units? 6 DR. DAVID CHIASSON: The grants vary. 7 COMMISSIONER STEPHEN GOUDGE: But in 8 terms of short -- 9 DR. DAVID CHIASSON: Oh, in terms of 10 shortfall. 11 COMMISSIONER STEPHEN GOUDGE: In terms of 12 shortfall. Same order of magnitude, or do you know? 13 DR. DAVID CHIASSON: I would guess tha -- 14 I -- I'm sure nobody is running a -- a surplus. And I'm 15 sure you'll get a -- a deficit in -- in that range, 16 arguably maybe -- maybe a bit more. With the 17 pathologists there, because they do so many more cases, 18 they're -- they're getting more money from a pathologist 19 side than we are, since we do so few cases, but -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 Right. Okay, thanks. 22 DR. DAVID CHIASSON: You're welcome. 23 COMMISSIONER STEPHEN GOUDGE: We will 24 rise now until shortly after 3:30 and then I gather it is 25 you next, Mr. Campbell?

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1 MR. PHILLIP CAMPBELL: It is, 2 Commissioner. 3 4 --- Upon recessing at 3:20 p.m. 5 --- Upon resuming at 3:33 p.m. 6 7 THE REGISTRAR: All rise. Please be 8 seated. 9 COMMISSIONER STEPHEN GOUDGE: Mr. 10 Campbell...? 11 12 CROSS-EXAMINATION BY MR. PHILLIP CAMPBELL: 13 MR. PHILLIP CAMPBELL: Good afternoon, 14 Dr. Chiasson, I'm Phil Campbell and I represent a group 15 of people who were found guilty of offences in whole or 16 in part on the strength of Dr. Smith's evidence. 17 DR. DAVID CHIASSON: Good afternoon, Mr. 18 Campbell. 19 MR. PHILLIP CAMPBELL: I hope to spend 20 most of the afternoon, or my -- my share of it, on -- on 21 pure systemic issues, but I'd like to just review a 22 little bit of the past specific to Dr. Smith. 23 You -- you've described and been 24 questioned at some length on the paper review that you 25 instituted and largely conducted during your term -- your

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1 tenure as Chief Forensic Pathologist. And it had, just 2 by its nature, including the volume of the reports and 3 the -- and the purely paper review, it had certain limits 4 as a quality assurance mechanism. 5 DR. DAVID CHIASSON: I agree. 6 MR. PHILLIP CAMPBELL: But, in your view, 7 it was, nonetheless, an improvement on what had gone 8 before which was a virtual vacuum of supervision? 9 DR. DAVID CHIASSON: That's correct. 10 MR. PHILLIP CAMPBELL: You picked up 11 nothing in the reports of Dr. Smith that you reviewed 12 that gave you concern. 13 Is that correct? 14 DR. DAVID CHIASSON: I don't recall any 15 of the reports of Dr. Smith causing me any -- any. 16 I -- I think there may have been one (1) 17 or two (2) where I discussed some things with him, but I 18 don't recall a major issue being picked up by the review 19 process. 20 MR. PHILLIP CAMPBELL: Knowing now what 21 you didn't know then, it would be fair to say that you 22 needed a bit more insight into the factual substratum of 23 the -- the autopsies to identify some of the things that 24 we now know were in error. 25 Is that -- would you accept that?

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1 DR. DAVID CHIASSON: I would accept that, 2 yes. 3 A lot of the issues revolve -- specific 4 questions relating to circumstances of a death that were 5 not information that wasn't provided in the PM reports, 6 yes. 7 MR. PHILLIP CAMPBELL: And I'm going to 8 get back to that at a systemic level but I just wanted to 9 confirm it in relation to Dr. Smith. 10 You were, I assume, widely employed by 11 other working pathologists around the Province as a 12 resource during your term as Chief. 13 Is that right? 14 DR. DAVID CHIASSON: I'm not sure how 15 widely; I was certainly -- would be approached by 16 pathologists to render assistance; sometimes police 17 officers. I mean, it depended. There was a spectrum. 18 MR. PHILLIP CAMPBELL: I'm referring 19 specifically to pathologists. So, did they call you and 20 say, Can you give me some advice, or here's a problem 21 I've got, how would you deal with it? 22 DR. DAVID CHIASSON: I would get that 23 kind of call on a -- somewhat a regular basis, especially 24 early on. It -- it took a while -- when I came on board, 25 I -- most pathologists didn't -- didn't know who I was

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1 and I'm sure -- so there had to be a -- a learning phase 2 or a growth phase of that kind of thing. 3 But eventually, with more education 4 courses, getting -- getting to know more pathologists, 5 that happened with increasing frequency. But early on, 6 it -- it wasn't that common. 7 I don't think Dr. Smith really engendered 8 that close of a -- that kind of relationship with 9 pathologists and therefore, I think it took a little 10 while to realize that there was this resource; the Chief 11 Forensic Pathologist, who was willing and able to assist 12 pathologists. 13 MR. PHILLIP CAMPBELL: Sorry, Doctor, I 14 didn't understand the Dr. Smith reference in there. 15 Did Dr. Smith -- 16 DR. DAVID CHIASSON: Sorry -- 17 MR. PHILLIP CAMPBELL: -- consult you? 18 DR. DAVID CHIASSON: Sorry. Dr. Hillsdon 19 Smith -- 20 MR. PHILLIP CAMPBELL: Oh, I see. 21 DR. DAVID CHIASSON: Not Dr. Charles 22 Smith. I -- I got to remember the two (2) -- 23 COMMISSIONER STEPHEN GOUDGE: I had the 24 same question. 25 DR. DAVID CHIASSON: That's right, yes.

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1 2 CONTINUED BY MR. PHILLIP CAMPBELL: 3 MR. PHILLIP CAMPBELL: Did Dr. Charles 4 Smith ever consult you for advice on cases? 5 DR. DAVID CHIASSON: We -- we had some 6 discussions at times; informal discussions about some of 7 his cases, but nothing of a formal nature. And it's -- 8 it was as much as he's telling me about an interesting 9 case and some interesting issues, as opposed to really 10 seeking my opinion. 11 MR. PHILLIP CAMPBELL: And were you aware 12 that he was rather widely consulted by other pathologists 13 around the Province? 14 DR. DAVID CHIASSON: I was aware that he 15 was certainly, yes, consulted by other pathologists, yes. 16 MR. PHILLIP CAMPBELL: Okay. You were 17 questioned at some length by Ms. Rothstein about your 18 familiarity with Dr. Smith's work on the Nicholas case 19 and the Sharon case. And that would -- that would have 20 come to your attention and been a theme in your own 21 supervisory work in the late '90's, broadly speaking. 22 DR. DAVID CHIASSON: Yes. 23 MR. PHILLIP CAMPBELL: And you testified 24 with Ms. Rothstein that you began, at that time, to have 25 doubts about the actual professional quality of his work,

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1 as opposed to his administrative shortcomings, and 2 especially the delay in -- in preparing reports, correct? 3 DR. DAVID CHIASSON: Well, certainly, I 4 had concerns about his administrative issues; delay in 5 reports, that -- that sort of professional issue, yes. 6 MR. PHILLIP CAMPBELL: But you also, as a 7 result of those cases, began to have concerns about the 8 quality of his work as medicine. 9 Isn't that what you testified to last 10 week? 11 DR. DAVID CHIASSON: I'm not sure that I 12 -- that I maybe said that. As far as his pathology 13 competence, I don't think that became a theme until -- 14 until later on. '98/'99; I'm -- I'm not seeing, I don't 15 think, good evidence of pathology, pediatric pathology 16 competency issues. 17 MR. PHILLIP CAMPBELL: So you didn't get 18 that concern as a result of your acquaintance with the 19 Nicholas matter? 20 DR. DAVID CHIASSON: Well, I got -- I got 21 -- with Dr. Case's report in 1999, it was clear that in - 22 - in this area, that there was -- there was some -- some 23 concern about that -- that particular matter. But 24 clearly, it's -- it's a -- it's a difficult issue. It 25 was not a -- not a -- it's a gray area, if you will.

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1 MR. PHILLIP CAMPBELL: I had thought I 2 had understood you to testify that it was the concerns 3 which arose from your familiarity with those two (2) 4 cases that prompted you to want to bring Dr. Smith more 5 squarely under the umbrella of the -- the Toronto 6 Forensic Pathology Unit and -- and his colleagues there. 7 DR. DAVID CHIASSON: No, I -- I don't 8 think that's -- that's quite correct. I was trying to 9 bring him in under the umbrella of the Coroner's Office 10 in -- in '99 with the revisioning. 11 Was -- was really spurred on by the 12 administrative issues I was having; trying to get reports 13 out of him, those kinds of issues. Because, in fact, 14 that initiative is starting in the latter part of '98 and 15 in -- into '99. That had already started before 16 receding, for example, Dr. Case's report and -- and 17 certainly before the Sharon issues I really became all 18 that aware of. 19 20 (BRIEF PAUSE) 21 22 MR. PHILLIP CAMPBELL: All right, I -- 23 I've got your evidence from Friday, just because I 24 couldn't be here in this regard, and at page 223 of what 25 I think is probably a provisional transcript, you're

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1 quoted as saying -- Ms. Rothstein asks you at line 13: 2 "So, to the extent that your notes 3 record that you reviewed the issues 4 with respect to Charles Smith, there 5 was indeed some specific discussion of 6 the concerns that you had about Dr. 7 Smith's timeliness, at a bear minimum." 8 And your answer is: 9 "Well, I think, yes, and as I'm looking 10 at this I -- I suspect that we -- we 11 were starting to broach the issues 12 beyond simply administrative turnaround 13 issues, such as the Nicholas matter. 14 And, by this time, the issue about 15 Sharon was also beginning to gel, if 16 you will, in terms of -- this is after 17 the meeting -- the proposal was -- 18 [sorry] this was after the meeting, the 19 forensic meeting. 20 "So you're saying that you, yourself, 21 Dr. Chiasson, had a heightened level of 22 concern about Dr. Smith by that point." 23 Your answer: 24 "Well, I think we were starting to -- 25 to insert these other issues into the

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1 mix, and therefore making our argument 2 about the proposal that in, with Dr. 3 Becker, that we wanted to do that. 4 Including these issues with regard to 5 Dr. Smith. And I think our preference 6 was to not have Dr. Smith present, you 7 know." 8 And the Commissioner asks you: 9 "I take it these concerns that were 10 starting to emerge, Dr. Chiasson, were 11 about his lack of forensic ability. And 12 so putting him in a forum, the OCCO, 13 where he would be working in a more 14 collaborative way with forensic 15 pathologists would be an improvement." 16 And your answer: 17 "Yes. I mean clearly, the Sharon case 18 was issues about forensic pathology and 19 as was the -- the Nicholas matter. So - 20 - and they were -- they were forensic, 21 as opposed to pediatric pathology. And 22 you're absolutely correct that it was a 23 way to remediate, if you will, his 24 forensic view. It's not unlike what had 25 been proposed with Dr. Johnston earlier

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1 on." 2 I took that to indicate that with the 3 Nicholas and Sharon case, for you, a light had gone on, 4 even if dimly rather than brightly, suggesting that there 5 were substantive concerns about the quality of Dr. Smith's 6 work in '98 or '99. 7 DR. DAVID CHIASSON: Well, we're into '99 8 when the meeting with Dr. Becker that's made reference to 9 -- to there. It wasn't the init -- the initiating event 10 for the revisioning really proceeded the -- the gelling of 11 the issues regarding both Nicholas and Sharon. 12 So we were moving in that direction. As 13 we're moving in this direction and certainly in meeting 14 with Dr. Becker and trying to make an argument, Hey, we 15 gotta do something different about the unit and bringing 16 it over. It was used as part of the -- of our argument. 17 And I think, yes, I -- I think that what -- 18 what I said on Friday remains that, yes, at this time, 19 we're starting and -- and I -- I guess at a dim level, as 20 you suggest, thinking that there may be more here than -- 21 than simply administrative issues. 22 MR. PHILLIP CAMPBELL: Did you share that 23 concern with the Chief Coroner or the Deputy Chief at the 24 time? 25 DR. DAVID CHIASSON: Well, the Deputy

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1 Chief Coroner certainly. We were at the same meeting with 2 Dr. -- Dr. Becker. 3 MR. PHILLIP CAMPBELL: The 2001 review, is 4 a thing that I would like to make tangible, if there is -- 5 if it has any tangible sort of substance. 6 Let me just preface my question by saying 7 that there's been a series of media criticisms of Dr. 8 Smith and he's become a figure of -- of attention, public 9 attention and criminal justice system attention by the 10 beginning of 2001, correct? 11 DR. DAVID CHIASSON: Yes. 12 MR. PHILLIP CAMPBELL: And two cases have 13 very visibly gone down on -- in flames, where he was a 14 central figure and his name is being attached to those -- 15 I suppose they could be called failed prosecutions, 16 although it might be, you know, thought that they failed 17 for a good reason -- but to those aborted prosecutions, 18 correct? 19 DR. DAVID CHIASSON: Yes. 20 MR. PHILLIP CAMPBELL: And this has to 21 have occupied a considerable amount of the attention of 22 the Chief Coroner's Office and your ensconced in that 23 office as a Deputy Chief Coroner by this time, in early 24 2001. 25 DR. DAVID CHIASSON: Yes.

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1 MR. PHILLIP CAMPBELL: And as far as I can 2 tell, one of the immediate outcomes of -- of that crisis - 3 - but crisis may be too strong a word -- but highly 4 elevated concern, was the announcement of an external 5 review, correct? 6 DR. DAVID CHIASSON: Yes. 7 MR. PHILLIP CAMPBELL: And the implication 8 of a external review is that pathologists unconnected 9 with, probably with Ontario pathology, maybe even 10 unconnected with Canadian pathology, will be brought in to 11 examine the work of the Office. 12 DR. DAVID CHIASSON: The work of Dr. 13 Smith, yes. 14 MR. PHILLIP CAMPBELL: In the Office? 15 DR. DAVID CHIASSON: Within the conf -- 16 within his coroner's cases, yes. 17 MR. PHILLIP CAMPBELL: It just seems to 18 me, that this had to be a significant and consequential 19 decision when it was taken? 20 DR. DAVID CHIASSON: The decision to call 21 for a review? 22 MR. PHILLIP CAMPBELL: To announce a 23 review? 24 DR. DAVID CHIASSON: Well, I think it is a 25 consequential decision. It implies a great deal of work,

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1 yes. 2 MR. PHILLIP CAMPBELL: That's one (1) 3 thing it implies is a great a deal of work, so you might 4 have expected in the aftermath of it a -- a memorandum 5 announcing it or a memorandum recording the decision. You 6 might have expected a delegation of work to identify the 7 cases and potential reviewers. 8 You might have expected a protocol: Here's 9 how we're going to go about it. This will be the scope of 10 the review. 11 And in the plumbing of the -- the 12 documentary record, which I've fortunately been spared 13 from having to participate in, I understand that nothing 14 like that has emerged to create a skeleton for the 15 proposed review. Granting that it never get flesh put on 16 it, it's hard to detect even the skeleton of this 17 consequential decision in early 2001. And you were there, 18 and it must have mattered to you how this -- how this 19 turned out and how it was conducted. 20 Can you breathe some life into this -- this 21 creature, which -- which died early? 22 DR. DAVID CHIASSON: Well, just to put in 23 my role, I -- I was involved in meeting with Dr. Young and 24 Dr. Cairns before Dr. Young met with Dr. Smith. The -- 25 the -- where we were at, at that stage, was we needed to

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1 ask Dr. Smith to step down from -- from doing cases. 2 Dr. Young there -- thereafter met with Dr. 3 Smith, and I understand the sequence of events, Dr. Smith 4 is -- seemed to be asking for an external review process 5 and that's -- that's announced that that would be done by 6 Dr. Young. 7 There is no skeleton that I'm aware of. We 8 did carry out specific reviews of cases that were before 9 the courts -- or we did -- we didn't carry them out, we -- 10 we advised Crown attorneys as to where they might get 11 assistance to carry out such reviews because we thought 12 that was important and that was -- that was being done. 13 Dr. Smith was no longer doing cases, which 14 was our number 1 concern. The -- my notion, at that time, 15 was that before Dr. Smith could come back to doing a full 16 range of coroner's cases that a -- some kind of a review 17 would have to be carried out. 18 But at the same time -- you know, it's in 19 the context, at this time, we're having a -- a strike by 20 pathologists across the Province. There's -- there's a 21 lot of other things going on, at this time and, you know, 22 as long as Dr. Smith was not doing any cases, I think it 23 was felt that -- that -- you know, that was the main thing 24 and that, you know, eventually I guess we would have 25 gotten around to -- to doing a -- a review, at that time.

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1 But as I think you're aware, Dr. Young then decided that 2 there would be no -- no external review. 3 MR. PHILLIP CAMPBELL: I -- no, I 4 understand he cancelled the external review. I'm just 5 trying to determine what it was that he cancelled; what -- 6 what the substance was of what he cancelled. 7 Were you ever recruited or asked to 8 identify possible outside reviewers? Did it go that far? 9 DR. DAVID CHIASSON: Well, I think we -- 10 we had a meeting to discuss what this might look like and 11 who we might think about, but I -- there's nothing -- I -- 12 it was a very preliminary discussion that -- that would 13 have had. It -- it never gestated beyond a very 14 preliminary discussion, in my mind, that at -- that at 15 least I was involved in. 16 MR. PHILLIP CAMPBELL: Is that surmise or 17 recollection that there was a meeting that at least talked 18 about the shape of the review and who you might get 19 involved in it? 20 DR. DAVID CHIASSON: Well, I think the -- 21 the meeting that was referred to that Al O'Marra had -- 22 had written notes on, I think, there is some reference to 23 who might be -- 24 MR. PHILLIP CAMPBELL: Okay. 25 DR. DAVID CHIASSON: -- be asked. And --

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1 and I know that Mr. Mainland, who is Dr. Cairns' executive 2 assistant, at some point, did broach the issue of 3 reviewing with a Dr. Ranson, who is down in Melbourne -- 4 MR. PHILLIP CAMPBELL: From Australia, 5 yeah. 6 DR. DAVID CHIASSON: -- in Australia, 7 about who might. So there was very preliminary efforts in 8 that regards but it never -- there were no formal meetings 9 to say, Okay, now what are we going to do and how is this 10 going to look. That -- that never happened, that I was at 11 anyway. 12 MR. PHILLIP CAMPBELL: From your 13 perspective, however far advanced the review notion was or 14 was not, what was your understanding of the cases that it 15 was going to touch upon? 16 What cases were subject to review? 17 DR. DAVID CHIASSON: Well, I guess what we 18 were interested in were the ones that were -- that he was 19 involved in of a criminal nature. Criminally -- the cases 20 that had made it to -- to a courtroom. 21 MR. PHILLIP CAMPBELL: So potentially say, 22 dozens of cases? 23 DR. DAVID CHIASSON: Yes. 24 MR. PHILLIP CAMPBELL: And it was not, in 25 your understanding of it, just to be limited to the two

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1 (2) recent and very controversial cases that had already 2 been heavily reviewed? 3 DR. DAVID CHIASSON: No, I saw it going 4 beyond just the two (2) cases, yes. Clearly. 5 COMMISSIONER STEPHEN GOUDGE: And beyond 6 the existing cases that were still in the Court system? 7 DR. DAVID CHIASSON: Yes. I would say 8 that, yes. 9 We -- we hadn't established a parameter in 10 terms of how far back we would go. I don't think we got 11 that far. But my sense was that we would be looking at 12 the cases that had gone through the courts as well as 13 cases that -- that were pending. 14 I mean, those had to be dealt with in an 15 acute fashion because they were before the courts. And I 16 think those, rightfully, had to be dealt with in an 17 individual basis in order for the Court proceedings to 18 carry on or not as -- 19 MR. PHILLIP CAMPBELL: Right. 20 DR. DAVID CHIASSON: -- as fitting. 21 MR. PHILLIP CAMPBELL: But as I understand 22 the logic of this -- the premise of a review of cases that 23 are in the system, in light of the dom -- the demonstrated 24 errors on a couple of high profile cases, the logic of 25 conducting a review of cases that are in the system is:

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1 If Dr. Smith has made errors on some cases he may have 2 made errors on others and we'd better attempt to detect 3 them. 4 Is that the logic? 5 DR. DAVID CHIASSON: I think that's fair. 6 Or if he didn't make any, are we looking at isolated cases 7 or not? 8 In terms of, you know, do we have a bigger 9 problem than what we think we had and how's that -- 10 obviously it would have impact on to as to how we would 11 use Dr. Smith in the future to do -- to do such cases. 12 MR. PHILLIP CAMPBELL: And would that 13 logic also have been part of the review of past cases? 14 If he's made mistakes in that era in these 15 two (2) cases, he may have made them in other cases and 16 we'd better find out. 17 DR. DAVID CHIASSON: Well, I think that -- 18 that was part of, yes, what we were looking at, is whether 19 there were errors. And obviously that would -- that would 20 need to be revisited from a -- from a criminal justice 21 point of view, yes. 22 MR. PHILLIP CAMPBELL: In light of what 23 was now known about some of his -- some of his documented 24 errors? 25 DR. DAVID CHIASSON: Yes.

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1 MR. PHILLIP CAMPBELL: All right. 2 Now, if that is being done prospectively on 3 the cases in the system and for a month or two (2) at 4 least retrospectively for cases that are in the past, what 5 did you conceive of as its purpose at that time in purely 6 a practical and utilitarian terms? Was it to determine 7 whether he was fit to continue doing cases or did it have 8 a broader objective? 9 DR. DAVID CHIASSON: I'm not sure what 10 broader objective you might be referring to, but. 11 MR. PHILLIP CAMPBELL: Well, let me -- let 12 me help you with that. To determine whether anybody was 13 living under a criminal conviction and possibly living in 14 prison who oughtn't to be. 15 That's really the -- the point of this 16 Inquiry. 17 DR. DAVID CHIASSON: Well -- and I 18 appreciate that. I don't know that at that sta -- I mean, 19 at that stage I think our primary concern was, you know, 20 how big a problem are we dealing with and really, are we 21 looking at, you know, bringing Dr. Smith back or not. 22 I mean -- and, again, I think to put it 23 into context, this didn't go very far at all in term -- I 24 -- I -- you know, I'm -- I'm suggesting to you what I sort 25 of would have thought in my own mind but there were no

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1 formal meetings as to, Okay, this is -- we're going to 2 look at X number of cases and the reason, you know. And 3 the impact this is going to have. 4 I'm -- I'm aware of the process that -- it 5 subsequently evolved and the amount of work and effort 6 that went into that and I don't think we had any expecta - 7 - or any -- I didn't have any understanding of really the 8 magnitude of the -- the review process and what it would 9 look like. I mean, this -- for me was -- was new -- new 10 territory, and as I said, we didn't get very far at all in 11 terms of what we were going to do, how we were going to do 12 it, that was -- 13 MR. PHILLIP CAMPBELL: I -- I -- no, I 14 appreciate that, but for sure, with regard to the cases in 15 the system, the premise of that review, which did unfold, 16 at least in a paper format, the premise of it was that 17 there's a possibility from a small number of errors that 18 there have been a larger number of errors, isn't that the 19 only logic that leads to a broader review than the cases 20 where there have already been documented errors? 21 DR. DAVID CHIASSON: Yes, I mean we -- we 22 were trying to look at the scope, is this two (2) isolated 23 events and, you know, can we somehow, you know, understand 24 and justify that, okay, this is a complex business, 25 pediatric forensic pathology, there are two (2) cases in

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1 which there are problems is very much different than there 2 are problems in ten (10) cases or twenty (20) cases, as to 3 how one (1) is going to -- to utilise the pathologist, you 4 know, that's being reviewed, it's -- 5 MR. PHILLIP CAMPBELL: Yeah. Do you 6 recall now in the events of 2001, or let's say 1999 when 7 your own concerns at least begin to crystalize, or 2001 8 when there is a swirl of controversy and he's taken off 9 cases, do you recall at either of those stages anybody 10 asking the question, should we be worried about other 11 cases that Dr. Smith has been a pivotal witness in from 12 the past where convictions have been entered? 13 DR. DAVID CHIASSON: I -- I don't think -- 14 I -- I don't recall anyone, you know, bringing that up 15 specifically as -- as an issue in discussion. 16 MR. PHILLIP CAMPBELL: So the past, in so 17 far as Dr. Smith and reviewing him was concerned, was 18 being primarily used as -- as a way to help plan for the 19 future, not as a way to correct possible injustice from 20 the past. 21 DR. DAVID CHIASSON: I think that's -- 22 that's fair. The little -- the few baby little steps we 23 took along this process, that's as far as we got -- as far 24 as my sense of where we got in terms of the process. 25 I suspect, you know, as we thought about it

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1 more, and I think -- and being part of the Forensic 2 Services Committee, I'd -- I have seen how the process did 3 develop and evolve that -- that ended up in the actual re 4 -- review process, that we would have moved beyond the 5 sort of management issue, if you will, of -- of Dr. Smith 6 and his role in the future, you know, from an employee -- 7 employment point of view or work point of view. 8 MR. PHILLIP CAMPBELL: Sorry, I didn't 9 understand that. You -- you would have or you would like 10 -- you would wish you would have or what are you saying? 11 DR. DAVID CHIASSON: I -- I think -- I 12 think that if -- if we had gone beyond the baby steps that 13 that would have come out. I don't think we -- we reached 14 it -- didn't reach my -- my thinking about the whole 15 issue. 16 MR. PHILLIP CAMPBELL: Okay. And I just, 17 finally on this subject, and then I am going to draw on 18 you for system assistance, did -- was there or should 19 there have been that kind of logic, that is concern about 20 past cases, applied by the Chief Coroner's Office to the 21 Dr. Johnston example in light of your own emphasis on it 22 and documentation of his shortcomings? 23 Should there have been a concern, I wonder 24 if anybody from the past is doing time now on the strength 25 of his evidence?

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1 DR. DAVID CHIASSON: I think your point's 2 very -- very well taken and that -- that did not come to 3 my mind in -- in the evolution of the events of that. I - 4 - I fully respect and -- and appreciate that the -- that 5 is a significant issue and certainly warrant thinking 6 about it, I guess. 7 MR. PHILLIP CAMPBELL: Okay. Just one (1) 8 other thing that -- that concerns me, having said I was 9 going to move off this. You -- you've testified about Dr. 10 Johnston on a large number of cases that gave you concern 11 and that you went to some pains to draw to the attention 12 of the Chief Coroner, correct? 13 DR. DAVID CHIASSON: Yes. 14 MR. PHILLIP CAMPBELL: And as far as your 15 own history with that was concerned, nothing was done in 16 the early part of this decade, to address Dr. Johnston's 17 problems. 18 He didn't do anything himself, and he 19 remained in office, correct? 20 DR. DAVID CHIASSON: He -- he continued to 21 be the Director of the unit. I continued to review his PM 22 reports, and I -- I can assure you it was with a 23 heightened degree of -- of awareness about the background. 24 And if I found issues in his -- his reports, they were 25 conveyed back to the regional coroner and -- and they were

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1 addressed as best -- as best we could. 2 MR. PHILLIP CAMPBELL: I just want to ask 3 you ab -- about the number of cases that had arisen with 4 Dr. Smith. And here I'm asking you to draw on what is 5 now, a pretty long experience as a pathologist with a 6 supervisory role and in the both pediatric and adults 7 sphere. 8 By the late '90s, we've got Dr. Smith being 9 either criticized or disagreed with professionally, in at 10 least Amber's case, Jenna's case, Nicholas' case, and 11 Sharon's case. You know those cases and you can accept 12 that as a premise? 13 DR. DAVID CHIASSON: I -- I know those 14 cases. I'm -- I'm -- temporally, I don't know where Jenna 15 fits into that group, but that -- I -- 16 MR. PHILLIP CAMPBELL: I -- I think it 17 clusters around the late '90s and -- and Amber's case is 18 in the early '90s. 19 DR. DAVID CHIASSON: I -- I'm in your 20 hands as far as grouping them together. 21 MR. PHILLIP CAMPBELL: Okay. 22 DR. DAVID CHIASSON: I'm aware of all 23 three (3) -- four (4) cases. 24 MR. PHILLIP CAMPBELL: All right. And we 25 know that in at least Am -- we know that in Amber's case

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1 there was very pointed and arguably very accurate, 2 salient, judicial criticism of Dr. Smith. 3 DR. DAVID CHIASSON: There was very in- 4 depth criticism of -- of Dr. Smith, yes. 5 MR. PHILLIP CAMPBELL: From your own 6 perspective, knowing how the world of forensic pathology 7 works, was this, to your mind at the time -- yeah, to your 8 mind at the time I think is the perspective I want you to 9 bring to this first. 10 Was this an unusual amount of controversy 11 and disagreement to -- to center on the work of one 12 forensic pathologist? 13 DR. DAVID CHIASSON: You're talking about 14 all the four (4) cases, and -- 15 MR. PHILLIP CAMPBELL: That -- yeah, that 16 much disagreement, that much criticism, does -- does that 17 make Dr. Smith's history stand out for you as compared to 18 other pathologists? Or was this just a run of the mill 19 kind of pattern? 20 MR. PHILLIP CAMPBELL: Well, no, I'm happy 21 to -- to report it wasn't a run of the mill, kind of 22 pattern. There wasn't a large number of pathologists 23 with, you know, this number of -- of issues. 24 I think though, it's to stress that Dr. 25 Smith was doing work in a specific area, pediatrics, which

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1 is, you know, proportionately, as I've tried to indicate, 2 the cases are -- are complex. The issues are continually 3 evolving and therefore -- I mean he was unique in a sense, 4 he was the Pediatric Forensic Pathologist and most of what 5 the other pathologists were dealing with -- were dealing 6 with, were -- were adult issues, more run of the mill type 7 issues. 8 So I don't think it's fair to suggest that 9 what Dr. Smith's doing necessarily, you know, is 10 equivalent to what other pathologists were doing in the 11 province. 12 MR. PHILLIP CAMPBELL: Okay. I accept 13 that distinction. And it's a distinction you live with 14 now, as a primarily Pediatric Forensic Pathologist? 15 DR. DAVID CHIASSON: Yes. 16 MR. PHILLIP CAMPBELL: That's a reality? 17 DR. DAVID CHIASSON: That's a reality, 18 yes. 19 MR. PHILLIP CAMPBELL: Okay. Having said 20 that, and acknowledging the distinction between somebody 21 working in the pediatrics sphere and -- and the adults 22 sphere, was this an unusually large amount of controversy 23 to focus on one pathologist, in that span of years? 24 DR. DAVID CHIASSON: Yes. 25 MR. PHILLIP CAMPBELL: All right. Now I

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1 want to sa -- now truly turn, in the twenty-nine (29) 2 minutes remaining to me, to -- to systemic issues. And 3 I'd -- I'd like if we can to sort of walk through a -- an 4 autopsy, which I hope will give rise to four (4) or five 5 (5) systemic issues that I want to raise. 6 And I'm gonna ask you, if I get something 7 wrong, just correct me, quickly, and we'll see if we can 8 move through all these -- all these issues. 9 A homicide occurs and the alarm goes out, 10 and the police arrive. And in the course of very early 11 developments, the Coroner is called to the scene. 12 Is that correct? 13 DR. DAVID CHIASSON: Yes, at some point. 14 It -- it varies as to when the Coroner will actually 15 examine the body depending on the nature of the case. I 16 mean, if it's a homicide, then maybe some time to secure 17 the scene, and allow Ident to do some preliminary work; it 18 varies. But the coroner should obviously attend the 19 scene. 20 MR. PHILLIP CAMPBELL: Right. And here 21 I'm giving you a defence lawyer's perspective on this, but 22 you tell me if it's wrong. 23 My own experience in looking though now a - 24 - a large number of homicide briefs, heavily documented 25 files, is that the coroner's role at the scene of a death,

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1 whether the body is allowed to remain in situ because it's 2 obviously dead, or whether the body is removed for 3 attempted life-saving, the role of the coroner, at least 4 insofar as it's documented in things a defence lawyer 5 sees, is negligible in terms of documenting the scene, 6 photographing the scene, measuring the scene, controlling 7 the perimeter -- which is an important function, obviously 8 -- deciding who -- what witnesses should be reviewed. 9 All -- in all of those things that are 10 crucial to the early moments of homicide investigation, my 11 own experience is that the coroner plays a -- an almost 12 invisible role. And I'd -- I'd just like to know if you 13 have a different experience or if you can help us 14 understand what value the presence of the coroner adds to 15 the scene. 16 DR. DAVID CHIASSON: Well, a lot of the 17 things you refer, I -- I consider to be police functions - 18 - Identification functions; securing the scene and -- and 19 preserving the evidence. I would agree that -- well, it 20 varies too from coroner to coroner. 21 I mean, there -- not all coroners are -- 22 are -- approach a homicide scene the same way. And it -- 23 whether it's experience or nature of their -- their 24 particular practice, it -- there is variability. 25 I -- I would agree that in many homicide

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1 cases, the coroner's involvement in -- in terms of what's 2 happening is -- is relatively minimal -- minimalistic in 3 the context of -- of everything. 4 They do have a responsibility in order to 5 ensure death, if the body is still at the scene. So they 6 have a -- a pronouncement responsibility. And they have a 7 responsibility to certain coronial functions. 8 The warrant for post-mortem, exa -- for 9 example, and -- and to allow the body -- the body remains 10 -- in fact, the -- the coroner's responsibility, and -- 11 and the coroner is -- is the one who's allowed to -- who's 12 -- who has the jurisdiction to have the body moved, for 13 example. 14 MR. PHILLIP CAMPBELL: In law, it remains 15 the coroner's jurisdiction but, in fact, it's -- the 16 body's handled by police services, right? 17 DR. DAVID CHIASSON: Well, the body -- you 18 know, the body's usually removed by -- by removal services 19 and -- and certainly, in my experience, the -- the coroner 20 defers to the homicide investigators, for example, as to 21 when to -- to remove the body in many -- many instances. 22 MR. PHILLIP CAMPBELL: And determining 23 when death actually takes place is formally the 24 pronouncement of the coroner. But at a practical level, 25 it's a determination almost certainly made by first

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1 responders, in -- if not the police or fire officials, 2 then paramedics when they get on the scene. 3 DR. DAVID CHIASSON: Well, they -- they 4 may determine that the person is dead, but you need to be 5 a medical doctor, in -- in fact, to formally pronounce 6 death. 7 MR. PHILLIP CAMPBELL: But formally 8 pronouncing death and formally signing a warrant are both 9 fairly formal steps that the coroner takes, aren't they, 10 as a opposed to lending a lot of substance to the on-the- 11 scene investigation? 12 DR. DAVID CHIASSON: Well, I think it's 13 safe to say, we're -- we're not dealing with a Quincy type 14 of situation where most coroners do not go in and take 15 over the investigation when it's a obvious homicide. It's 16 -- the police have a large role to play. 17 MR. PHILLIP CAMPBELL: Just in passing, do 18 they, in Baltimore, in the medical examiner system, do 19 they -- do the forensic pathologists, which is what they 20 are, do they go in and dictate how the scene will be 21 handled and participate in seizing evidence? 22 DR. DAVID CHIASSON: As a rule, no. In 23 fact, most homicides, the forensic pathologist wouldn't 24 attend the scene. The -- the representa -- the 25 investigator attends the scene and -- and takes some --

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1 some information. But in -- in most cas -- now, there are 2 some cases where the medical examiner will be asked to 3 attend the scene and -- and could provide direction as to 4 how best to move a body, or -- or -- and I've had -- I've 5 personally had that circumstance. 6 And -- and it's rare, but there are -- 7 there are circumstances where that's the case; provides 8 a -- 9 MR. PHILLIP CAMPBELL: Do the coroner's -- 10 DR. DAVID CHIASSON: -- preliminary 11 opinions. 12 MR. PHILLIP CAMPBELL: Do the coroners who 13 attend the scene actually make notes of their own 14 observations or -- or prepare a report, if only for the 15 coroner's file? Because again, a defence lawyer doesn't 16 see that kind of material and wonders sometimes if a 17 medically-trained person on the scene might have had some 18 useful observations. 19 DR. DAVID CHIASSON: Well, you know, I'm - 20 - I am a coroner, I don't function as a coroner, I don't - 21 - I don't attend very many scenes. It's my understanding 22 that the coroner is to do an examination of the body at 23 the scene and take some -- some basic notes as to issues; 24 rigor, lividity, that sort of thing. 25 I -- I would agree with you that the way a

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1 coroner usually approaches a homicide scene as opposed to 2 a routine death scene; in that case they -- they will 3 often be more active, more directive. Because it's a 4 coroner's case, they -- they take often a greater role. 5 If it's an obvious homicide, the involvement of -- of the 6 coroner -- and again, it -- it varies from coroner to 7 coroner -- but it can be minimalistic. 8 MR. PHILLIP CAMPBELL: Let's assume now 9 that our -- our deceased's body has been removed by body 10 removal people and is at Grenville or at Sick Kids. 11 How quickly from that point does a forensic 12 pathologist want to begin the autopsy, ideally? 13 DR. DAVID CHIASSON: Well, most autopsies 14 are performed during the day. And if a body comes in, in 15 the evening or the night, it's the next morning that the 16 examination is commenced. That's -- 17 MR. PHILLIP CAMPBELL: And if -- if it's 18 done within that time frame, there's usu -- it's usually 19 assumed that nothing much is lost. 20 Is that fair to say? 21 DR. DAVID CHIASSON: I think it's fair to 22 say. The exception might be a sexual assault homicide or 23 where one is suspected where you might want to take swabs 24 earlier on and -- and arguably when the body comes in to 25 the coroner's office.

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1 Or in an ideal circumstance you may have 2 the pathologist attending the scene, and then, generally 3 speaking, we don't do swabs at the -- at the scene, but it 4 might be then taken in to the coroner's office; swabs, 5 preliminary examination performed, body put into storage 6 and the full autopsy done the next day. 7 MR. PHILLIP CAMPBELL: All right. 8 I'd like to think a little bit more about 9 the value of pathologists attending the scene, but I'm 10 going to budget my time and move on to the next stage. 11 At the autopsy, there will be a pathologist 12 and a pathology assistant. There's likely to be three (3) 13 or more police offices; fair to say? 14 DR. DAVID CHIASSON: At least one (1), if 15 not two (2), Ident officers; usually one (1), if not two 16 (2), homicide investigators, yes. 17 MR. PHILLIP CAMPBELL: Right. And does -- 18 DR. DAVID CHIASSON: And usually at least 19 two (2) assistants, sometimes three (3). 20 MR. PHILLIP CAMPBELL: I appreciate your 21 real-world view that a pathologist needs some factual 22 context for beginning an autopsy, and can't start in a -- 23 as though the -- the remains are a laboratory specimen. 24 I'll -- I'll take that as given. 25 Would you accept that the dialogue between

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1 a pathologist and a police officer can have an obvious 2 role in shaping the direction of the autopsy and, perhaps, 3 an unconscious role in shaping the opinions of the 4 pathologist? 5 DR. DAVID CHIASSON: Well, to answer the 6 first part first. It clearly can provide direction as to 7 what the pathologist does and how he approaches the 8 autopsy. 9 And certainly, at least theoretically, 10 there's the opportunity for the police officer to -- to 11 point the pathologist in a -- in a certain direction. 12 MR. PHILLIP CAMPBELL: You -- Dr. 13 Chiasson, you would not dispute the real-world fact that 14 police officers who have a theory occasionally come into 15 autopsies pointing the pathologist in the direction of 16 that theory and very visibly hoping that evidence will 17 emerge to support it. 18 That -- that happens in the real world, 19 doesn't it? 20 DR. DAVID CHIASSON: Well, again, you 21 know, there's variability in the real world as to what 22 kind of police officers you're dealing with and as to what 23 kind of pathologists you're dealing with. And -- 24 MR. PHILLIP CAMPBELL: Exactly. 25 DR. DAVID CHIASSON: -- and, you know, with

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1 an experienced pathologist, the -- you know, you might 2 have a keen homicide investigator trying to point you in 3 some direction, you know; Thank you very much for your 4 opinion, I'm going to get on with my job. You know, so -- 5 but is -- is there a potential that the pathologist could 6 be influenced in -- in a particular direction at the 7 outset in terms of his thinking? Yes, of course. 8 MR. PHILLIP CAMPBELL: Thank you. And you 9 can take it from me, I hope, as a defence lawyer, that if 10 that dynamic has gone on in the first hours of an 11 investigation, at a stage as crucial as the autopsy, a 12 defence lawyer might very well like to know about it and 13 be able to play it our for a jury. 14 You -- you don't have any doubt about that 15 premise? 16 DR. DAVID CHIASSON: No, I've certainly 17 seen that done on many -- many occasions. 18 MR. PHILLIP CAMPBELL: Here's my question. 19 Is there any mechanism in place for recording the briefing 20 that the police give to the pathologist? 21 DR. DAVID CHIASSON: Well, practically 22 speaking, you know, I've changed my practice. In the 23 early days, I would listen to the police and -- and not 24 make very much notes. Nowadays I think we've moved ahead. 25 I will make some notes as to what the

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1 briefing -- the police are briefing about. However, my 2 notes are not detailed. I mean, the briefing can be quite 3 detailed, and ideally what I like to see is them provide 4 me with a police report if one's available, because that 5 crystalizes what -- where they're coming from. But, you 6 know, at the very least, some -- some degree of note 7 taking. 8 There is no -- I'm unaware of anyone that's 9 -- that's video taping or -- or audio taping, you know, 10 the actual briefing and the information provided up front. 11 MR. PHILLIP CAMPBELL: But you'd accept 12 that creating a record of the initial briefing -- of its 13 content and emphasis -- can be of value to the defence in 14 taking -- in -- in perhaps contesting an autopsy or it's 15 results, and to the jury in trying to decide how much 16 weight to attach to a -- a pathologist's opinion? 17 DR. DAVID CHIASSON: Well, I mean, you're 18 -- you're the defence lawyer and, therefore, best position 19 to judge what would be useful to you. I mean, I can see 20 where you're coming from. 21 MR. PHILLIP CAMPBELL: Sure. And I am -- 22 you know, this is not just theatre on my part. I am 23 actually inviting you to talk practical solutions, if 24 there are any. If we're going to get the autopsy done 25 within, say, eight (8) or ten (10) hours of the discovery

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1 of the body the night before, there's a limited amount of 2 time for typing up reports, ideal as it may be. 3 DR. DAVID CHIASSON: Yes, I appreciate 4 that. 5 MR. PHILLIP CAMPBELL: The pathologist 6 wants to get down to work, and there's a limited amount of 7 time for recording the briefing. 8 DR. DAVID CHIASSON: Yes. 9 MR. PHILLIP CAMPBELL: But from a defence 10 lawyers standpoint, in front of a jury two (2) years 11 later, those are crucial minutes, and -- and if there's 12 some mechanism for recording them for posterity and 13 litigation, it -- it would be of value to -- to lay them 14 out. 15 Do you have any ideas now, or...? 16 DR. DAVID CHIASSON: Well no, I -- I 17 appreciate it. I mean there's logistical issues. It's 18 not something I've -- you know, to have a briefing with 19 the police being audio taped would be -- would be, for me, 20 a different situation if it -- you know, the Commissioner 21 decided that that was something that would -- that should 22 be done and needed to be done, you know, I'm certainly 23 open to the -- to the idea, to change in my practice. But 24 I -- I don't have a moral objection to it. 25 COMMISSIONER STEPHEN GOUDGE: Do you have

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1 a practical objection to it? 2 DR. DAVID CHIASSON: Well, yeah, Mr. 3 Commissioner, I mean, you know, again, the real world, you 4 know, I have ongoing relationships with homicide 5 detectives who I've gotten to know over the years. They 6 provide me with the information. 7 I -- I -- you know, I don't think I'm 8 unduly influenced by whatever theory that they -- they 9 have. A lot of homicide investigators; they're -- they're 10 hoping you'll conclude suicide, not homicide. 11 I mean there's -- there's this sort of 12 balance. Well, you know, I mean they've got lots of work 13 to do, and you know, there are cases. I mean, so, it's 14 not always the homicide investigator trying to push his 15 homicide theory. It's sometimes suspicious death, and, 16 Gee doc, this look -- look like suicide with four (4) -- 17 four (4) stab wounds in the back? 18 I mean, that's the kind -- but that's the 19 kind of repartee that -- that goes on among experienced, 20 you know, individuals. And -- and -- you know, obviously, 21 if I was being audio taped, you know, you wouldn't get 22 that. 23 So it would change the dynamics, but like I 24 said, I'd -- I'd -- you know, if that's the way it was to 25 be done; the police said, Okay, do you mind if we audio

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1 tape this, or I'm not sure whether you're going to -- 2 who's going to audio tape it is another issue. 3 Whether it's okay for the police to audio 4 tape it, I mean, there's -- there's logistic issues of 5 that nature, but -- 6 7 CONTINUED BY MR. PHILLIP CAMPBELL: 8 MR. PHILLIP CAMPBELL: Well I didn't 9 actually mention audiotape. 10 DR. DAVID CHIASSON: Well -- 11 MR. PHILLIP CAMPBELL: I appreciate it 12 getting put on the table. 13 DR. DAVID CHIASSON: But -- okay, are you 14 suggesting detailed note taking? 15 MR. PHILLIP CAMPBELL: I -- I'm not 16 suggesting anything, I'm asking. 17 DR. DAVID CHIASSON: Yeah. 18 MR. PHILLIP CAMPBELL: I really am. 19 DR. DAVID CHIASSON: Well, I -- I can tell 20 you that I, you know, I do make notes in -- and I don't 21 think they'd be particularly enlightening, because I don't 22 write a lot of notes. And I am -- I'm keen on getting on 23 with -- with what I have to do, and I don't want to spend 24 a lot of time writing notes. 25 MR. PHILLIP CAMPBELL: Just to be -- and I

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1 want to move away from this, but you've -- you've laid 2 some emphasis on your own ability to resist police 3 theories or the little undercurrent of wishful thinking of 4 the -- 5 DR. DAVID CHIASSON: In either direction, 6 yes. 7 MR. PHILLIP CAMPBELL: Okay. But you've 8 got now a great deal of experience in forensic pathology; 9 a lot of seniority in this office, a lot of autopsies and 10 testimony behind you. 11 You'd have to acknowledge that there are a 12 lot of pathologists with a -- who may have a lot less 13 immunity than you do to the kind of phenomenon I'm talking 14 about. 15 DR. DAVID CHIASSON: I -- I agree with 16 that, yes. 17 MR. PHILLIP CAMPBELL: All right. The 18 autopsy's now concluded; it takes a few hours and it's 19 done. Will you, by its conclusion, in order to assist the 20 police, have communicated to them your initial thoughts? 21 DR. DAVID CHIASSON: Yes, it's standard 22 practice if you do have a cause of death that's obvious -- 23 gunshot wound to the head -- you render a preliminary 24 cause of death. And if it happened to be a contact wound 25 or some other aspect of the pathology that you can clearly

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1 make a comment at -- at the time, you'd render that kind 2 of opinion. 3 MR. PHILLIP CAMPBELL: And the police may 4 also have asked you questions in the course of the autopsy 5 or immediately after. 6 DR. DAVID CHIASSON: Of course, yes. 7 MR. PHILLIP CAMPBELL: Right. What -- and 8 let me just see if I can come up with a list of some 9 things that do not emerge in answer to the five (5) 10 questions, but that may be very crucial to the -- to the 11 litigation that follows a year or two (2) later. I -- I 12 just sat down and scrawled these out quickly; whether 13 blows were sustained before or after death? 14 DR. DAVID CHIASSON: That could be a 15 question, yes. 16 MR. PHILLIP CAMPBELL: The age of bruises? 17 DR. DAVID CHIASSON: Yes. 18 MR. PHILLIP CAMPBELL: Whether injuries 19 are defensive or not? 20 DR. DAVID CHIASSON: Yes. 21 MR. PHILLIP CAMPBELL: The time that a 22 deceased may have lived after sustaining injuries? 23 DR. DAVID CHIASSON: Yes. 24 MR. PHILLIP CAMPBELL: When the deceased 25 would have been incapable of purposeful action, fallen

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1 unconscious or have been dis -- completely disabled? 2 DR. DAVID CHIASSON: Yes. 3 MR. PHILLIP CAMPBELL: The position of the 4 accused physically in relation to an attacker, whether 5 it's gunshot tracks or -- or blows to the head? 6 DR. DAVID CHIASSON: Yes. 7 MR. PHILLIP CAMPBELL: And the order in 8 which wounds were sustained? 9 DR. DAVID CHIASSON: Yes. 10 MR. PHILLIP CAMPBELL: And I -- I bet I 11 could go on if I spend some more time at that, right? 12 DR. DAVID CHIASSON: I'm sure you could. 13 MR. PHILLIP CAMPBELL: And those are all 14 kinds of questions that are -- a pathologist may form 15 opinions on and be asked even to form opinions on during 16 an autopsy. 17 DR. DAVID CHIASSON: Correct. 18 MR. PHILLIP CAMPBELL: Now, those opinions 19 are not going to emerge in the autopsy report, correct? 20 DR. DAVID CHIASSON: Most of those 21 opinions would not emerge in an autopsy report that I 22 would create. The amount -- 23 MR. PHILLIP CAMPBELL: And as matter -- 24 exactly. 25 DR. DAVID CHIASSON: The amount of opinion

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1 I put into a report usually is limited. 2 MR. PHILLIP CAMPBELL: And as matters now 3 stand, they're not likely to emerge, as you've described 4 it, until the preliminary inquiry, if in fact defence 5 counsel thinks to broach them at the preliminary or the 6 Crown chooses to. 7 DR. DAVID CHIASSON: I think that's true 8 in most cases, yes. 9 MR. PHILLIP CAMPBELL: But you -- I think 10 you accepted my premise here that sometimes, in fact 11 frequently, those are issues of equal or greater 12 significance to the criminal litigation than the five (5) 13 questions that are the heart of an autopsy report. 14 DR. DAVID CHIASSON: Well, the five (5) 15 questions you're referring to really refer to the 16 functions of the coroner; who, what, when, why and where. 17 I forget the -- 18 COMMISSIONER STEPHEN GOUDGE: By what 19 means? 20 DR. DAVID CHIASSON: Mm-hm? 21 COMMISSIONER STEPHEN GOUDGE: By what -- 22 DR. DAVID CHIASSON: By -- by what means 23 is the bottom one (1). 24 COMMISSIONER STEPHEN GOUDGE: By what 25 means.

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1 DR. DAVID CHIASSON: But from a pathology 2 report, I mean the -- the bottom line, most important, is 3 cause of death. But I agree with you completely that 4 those issues that you raise -- those questions you raise - 5 - may be a lot more important from a criminal prosecution 6 point of view or criminal justice point of view, than the 7 cause of death, which may be apparent to anyone. 8 9 CONTINUED BY MR. PHILLIP CAMPBELL: 10 MR. PHILLIP CAMPBELL: And it may well be 11 that there is either no disclosure of the early opinions 12 of the pathologist on that subject, or no more disclosure 13 than whatever a police officer has recorded in a notebook, 14 which may or may not have all the nuances a pathologist 15 would want. 16 Isn't that correct? 17 DR. DAVID CHIASSON: That's correct. Yes. 18 MR. PHILLIP CAMPBELL: Doesn't it seem 19 obvious, in light of the importance of these ancillary 20 issues and the lack of uniformity about whether they 21 should appear in the formal autopsy report, that there's 22 value in some mechanism for identifying the question and 23 recording the answer before the preliminary, which may or 24 may not get at these issues? 25 DR. DAVID CHIASSON: I'm unclear. If

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1 you're not getting them at the preliminary, yet you want 2 them beforehand? I'm -- I'm -- 3 MR. PHILLIP CAMPBELL: Yeah. I'm saying 4 that it would be good insofar as we can identify certain 5 issues as significant. 6 To get answers to them insofar as answers 7 are available in documented form early on, rather than 8 having no answers or potentially incomplete or 9 misunderstood answers in an officer's notes. 10 DR. DAVID CHIASSON: Well, I -- I think 11 the -- the crux of the issue is that in any given case, a 12 lot of those questions may be potentially applicable. 13 And the problem with the pathologist, when 14 he's writing his PM report, of course, is that he -- he 15 doesn't know what, most of the time, is a potential 16 circumstantial criminally significant question. 17 So, to do it in the PM report, I think is - 18 - is -- I really struggle with the idea of, you know, how 19 you pick and choose. And so, I would suggest that, as 20 I've done, keep the PM report as a PM report. 21 If there are issues of that nature, as 22 you're raising, that there be correspondence between the 23 Crown or whoever has got -- or the defence lawyer, and if 24 he wants the information before the preliminary hearing, 25 that -- that the questions be posed. The -- the specific

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1 issues be raised and -- and broached with the pathologist. 2 I don't -- I don't have any problem with -- 3 with that sort of happening. 4 MR. PHILLIP CAMPBELL: Accepting that you 5 would like to keep your formal post-mortem report clean 6 and -- and focussed, two (2) possibilities, at least, 7 strike me. 8 One (1) is that the pathologist could 9 include a parallel or -- or supplementary report that 10 describes other opinions that he or she has been asked for 11 and has already communicated. That can't be too hard to 12 do. 13 DR. DAVID CHIASSON: Well, I think what I 14 would want as -- as a pathologist is that -- that the 15 questions be formalized; not somebody raising something 16 during an autopsy while I'm dissecting the heart and he 17 says, Oh, by the way, you know. 18 I mean, I -- I don't keep track of, you 19 know, all the questions that are -- that are asked. 20 MR. PHILLIP CAMPBELL: Right. 21 DR. DAVID CHIASSON: The autopsy, you 22 know, with a homicide investigator is -- there's a -- 23 there is communication; otherwise it would be pretty 24 boring to stand there for two (2) hours and not say -- 25 MR. PHILLIP CAMPBELL: Sure.

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1 DR. DAVID CHIASSON: -- anything. And, 2 you know, they're thinking things, I'm thinking things. 3 I'll throw a question back at them. I look in the 4 stomach. Oh, you know, I see green peas; you know, do we 5 have information about the -- when his last meal was, for 6 exam -- I mean, so all of this is going on during a post- 7 mortem examination. 8 You know, the green peas may, down the 9 road, become an important forensic issue. But, you know, 10 I'm not usually going to be apprised of that until maybe 11 the preliminary hearing, which is the usual way that it's 12 done now. 13 I think, though, if -- if, for example, the 14 green peas are -- are relevant to something, then the 15 pathologist need -- that needs to be broached with him 16 formally. Not that he starts, you know, pulling things 17 out of the air. While this might be an issue, so I'll 18 comment on this, or this might be -- there's such a -- the 19 possibilities are so endless. You know, you could devise 20 issues. 21 So I think we need to be focussed and -- 22 and, you know, I think the pathologist -- to be fair to 23 the pathologist, he has to be addressed whatever questions 24 that are important in a formal manner. 25 Again, practically speaking -- and I don't

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1 want to take up all your time here -- most of this done, 2 as I sense it, during a preliminary hearing. But if -- if 3 for some reason it's -- it's wanted beforehand, then I 4 think it behooves whoever is looking for this information 5 earlier to actually lay it out in a -- in correspondence. 6 MR. PHILLIP CAMPBELL: Which you would be 7 prepared to answer? 8 DR. DAVID CHIASSON: Of course. 9 MR. PHILLIP CAMPBELL: All right. 10 COMMISSIONER STEPHEN GOUDGE: You have 11 about five (5) minutes, Mr. Campbell. 12 13 CONTINUED BY MR. PHILLIP CAMPBELL: 14 MR. PHILLIP CAMPBELL: I understand, 15 Commissioner. 16 You formed an opinion, you've communicated 17 it to the police. The police are out acting pursuant to 18 it. And let's say it's an opinion that there's a 19 homicide. Am I correct that, as matters now stand, you 20 will not commit your personally held and communicated 21 opinion -- you will not commit it to writing until you've 22 spoken with the Chief Forensic Pathologist? 23 I -- I'm trying to understand the practical 24 implications of the system of peer review put in place 25 prior to autopsy reports.

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1 What do they mea -- what's it mean? 2 DR. DAVID CHIASSON: Well, there's a -- 3 there's a -- we're talking about homicide criminally 4 suspicious deaths -- 5 MR. PHILLIP CAMPBELL: Yes. 6 DR. DAVID CHIASSON: -- so within a unit, 7 the director is responsible for -- 8 MR. PHILLIP CAMPBELL: Peer review? 9 DR. DAVID CHIASSON: -- peer review of -- 10 of the report to whatever extent he's decided that -- that 11 it needs to be done. 12 MR. PHILLIP CAMPBELL: Does he peer review 13 a written report or an oral report? 14 DR. DAVID CHIASSON: Oh, he -- he -- it's 15 the written report. That's a peer review process. That's 16 just before the report is released. There is a -- now, at 17 the Coroner's Office there's always been -- and we've 18 started this practice now at Sick Kids -- of producing a 19 preliminary opinion at the time of the post-mortem 20 examination. 21 Well, we've always, you know, rendered 22 preliminary opinions. 23 MR. PHILLIP CAMPBELL: In what form? 24 DR. DAVID CHIASSON: Well, in -- we -- we 25 convey it verbally, but it's documented at the Coroner's

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1 Office on a -- on a Morgue Death Report. So whatever I 2 would tell the police about a cause of death, I -- I would 3 write down on a Morgue Death Report. 4 And that's done at the time of the autopsy. 5 It has the time of the start of the autopsy, date. 6 MR. PHILLIP CAMPBELL: And then there is 7 oral communication with whom? 8 DR. DAVID CHIASSON: There is -- the 9 current practice in the -- that Dr. Pollanen recently set 10 up is that that preliminary opinion, if you're not in the 11 -- in that -- in the Coroner's Office, but somewhere else, 12 is to be faxed over to the Coroner's Office so he's aware 13 that there's a homicide that -- that was done wherever in 14 the Province. 15 MR. PHILLIP CAMPBELL: Does he have any 16 input into the cause of death determination that will go 17 on the autopsy report? 18 DR. DAVID CHIASSON: Not -- this is to 19 inform him that there's a case. If he sees something that 20 causes him interest, to -- to find out more, you may get a 21 call and, you know, he may get involved in the case. 22 But if it's a gunshot wound to the head, 23 you know, I wouldn't expect him to -- to react very -- you 24 know, to -- to get a call because of that, you know, if it 25 seems to be clear cut.

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1 MR. PHILLIP CAMPBELL: So you would say 2 that it is not the case that pathologists' opinions are to 3 be reviewed in advance of being included in an autopsy 4 report for their cogency or correctness by Dr. Pollanen or 5 any other supervisor. 6 That's not the case? 7 DR. DAVID CHIASSON: Well, the -- the 8 review process is such that the pathologist does his work, 9 he's ready to issue his report and depending on -- it 10 probably varies from unit to unit -- in -- in our unit 11 we've been tending to not finally sign it out until it's 12 been reviewed, but -- but the report is there. 13 This is the way I want to sign it out, have 14 it peer reviewed. Or in some cases, it is signed out, but 15 if there's an issue or a problem, it hasn't left the -- 16 the Coroner's Office. It hasn't -- it hasn't made it 17 beyond that. And -- and can -- 18 MR. PHILLIP CAMPBELL: And can be amended? 19 DR. DAVID CHIASSON: -- can be addressed 20 by -- by whoever, whoever's the reviewer can -- 21 MR. PHILLIP CAMPBELL: Last question. Who 22 decides? 23 DR. DAVID CHIASSON: Who decides...? 24 MR. PHILLIP CAMPBELL: Yeah, if a 25 pathologist says, I think it was -- I don't know, pick X

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1 and -- and the Chief Coroner's Office says it was Y -- or 2 the Chief Forensic Pathologist -- who decides on the 3 content of the report in the end? 4 DR. DAVID CHIASSON: Well, each -- each 5 pathologist would decide on the content of his report. If 6 he has one (1) opinion -- if -- if it goes for review and 7 Dr. Pollanen looks at it and says, Well, you know, I think 8 you're -- you're off base here, and I think it should be 9 so and so, that opinion would be conveyed back to the 10 pathologist. 11 The pathologist would consider that 12 opinion. If it makes sense to him -- Oh, you know, well, 13 they should have thought about this -- he might change his 14 report to amend it, and that's -- might be the way it goes 15 out. 16 Or he might say, Well, no, I don't think 17 Dr. Pollanen's right on this -- on this occasion and issue 18 a report. 19 I suspect, if that was the case, as I did 20 in the Venoss (phonetic) matter years ago, and there's a 21 major dissenting opinion between the reviewer and the 22 pathologist and the pathologist is sticking to his guns, 23 that the reviewer would in fact, then issue a -- a report, 24 an opinion report on the PM report. 25 MR. PHILLIP CAMPBELL: All right, thank

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1 you. 2 DR. DAVID CHIASSON: Your welcome. 3 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 4 Campbell. We'll rise now until 9:30 tomorrow morning, and 5 begin with you, Ms. Baron. 6 7 (WITNESS RETIRES) 8 9 --- Upon adjourning at 4:36 p.m. 10 11 12 Certified correct, 13 14 15 16 _________________ 17 Rolanda Lokey, Ms. 18 19 20 21 22 23 24 25