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 11th, 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            )     Hospital for Sick Children
 19  Barbara Walker-Renshaw(np) )
 20  Kate Crawford             )
 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        (np) )     seven unnamed persons
 11  Peter Wardle              )     Affected Families Group
 12  Julie Kirkpatrick          )
 13  Daniel Bernstein     (np) )
 14  
 15  Louis Sokolov              )     Association in Defence of
 16  Vanora Simpson       (np) )     the Wrongly Convicted
 17  Elizabeth Widner      (np) )
 18  Paul Copeland         (np) )
 19  
 20  Jackie Esmonde        (np) )     Aboriginal Legal Services 
 21  Kimberly Murray      (np) )     of Toronto and Nishnawbe
 22  Sheila Cuthbertson    (np) )      Aski-Nation
 23  Julian Falconer      (np) )
 24  
 25

4
  1                 APPEARANCES (cont'd)
  2  
  3  Suzan Fraser              )     Defence for Children 
  4                             )     International - Canada
  5  
  6  William Manuel     (np)   )     Ministry of the Attorney
  7  Heather Mackay     (np)   )     General for Ontario
  8  Erin Rizok          (np)   )
  9  Kim Twohig                 )
 10  
 11  Natasha Egan              )     College of Physicians and 
 12  Carolyn Silver            )     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 Cross-Examination by Ms. Erica Baron 6 6 Cross-Examination by Mr. Peter Wardle 67 7 Cross-Examination by Mr. Louis Sokolov 118 8 Cross-Examination by Ms. Breese Davies 138 9 Cross-Examination by Ms. Carolyn Silver 167 10 Cross-Examination by Ms. Suzan Fraser 170 11 Cross-Examination by Mr. William Carter 191 12 Cross-Examination by Ms. Luisa Ritacca 223 13 Re-Direct Examination by Ms. Linda Rothstein 226 14 15 16 Certificate of transcript 242 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. Baron...? 8 9 DAVID ALEXANDER CHIASSON, Resumed 10 11 CROSS-EXAMINATION BY MS. ERICA BARON: 12 MS. ERICA BARON: Good morning, Dr. 13 Chiasson. I'm -- my name is Erica Baron and I'm a -- the 14 law -- one (1) of the lawyers for Dr. Smith. 15 DR. DAVID CHIASSON: Good morning, Ms. 16 Baron. 17 MS. ERICA BARON: And I have a few 18 questions for you today. 19 You told us a little bit during Ms. 20 Rothstein's examination of you about the reports, the 21 various reports that are prepared at the Hospital for 22 Sick Children as distinct from the coroner's post-mortem 23 reports. 24 DR. DAVID CHIASSON: Yes. 25 MS. ERICA BARON: And would you agree

1 with me that typically the forms prepared at the Hospital 2 for Sick Children contain more history and clinical 3 information than reports on post-mortems do? 4 DR. DAVID CHIASSON: That was my 5 impression, yes. 6 MS. ERICA BARON: Okay. And am I right 7 that there was ongoing discussion between the Hospital 8 for Sick Children and the Office of the Chief Coroner of 9 Ontario about whether it was appropriate to have internal 10 forms at the Hospital for Sick Children that had 11 different information in it than what was contained in 12 the post-mortem reports? 13 DR. DAVID CHIASSON: Yes. 14 MS. ERICA BARON: And you told us that 15 the provisional reports that are prepared at the Hospital 16 for Sick Children have to be prepared within forty-eight 17 (48) to seventy-two (72) hours of death? 18 DR. DAVID CHIASSON: Yes. 19 MS. ERICA BARON: And that's an internal 20 hospital policy? 21 DR. DAVID CHIASSON: The provisional 22 reports on the hospital cases, these are the non- 23 coroner's cases, that was felt to be, yes. That was the 24 policy as I understood it. 25 MS. ERICA BARON: Right. And is it fair

1 to say that even if a coroner had -- even if a coroner's 2 warrant had been issued for post-mortem, if the -- if the 3 child or the infant had died at the hospital there was 4 still an expectation that that provisional report would 5 be prepared within forty-eight (48) to seventy-two (72) 6 hours? 7 DR. DAVID CHIASSON: There may have been. 8 I -- I have trouble with the appropriateness of doing 9 that. I have trouble with the notion of preparing 10 provisional reports in medicolegal cases, so that's 11 always been my position. Whether in fact -- I suspect 12 you're right that in fact it was done on coroner's cases; 13 whether -- how much it was released, and -- and to who it 14 was released, I'm unclear. 15 MS. ERICA BARON: Let me see if I've -- 16 if I've got this right, or if you can tell us, that the 17 purpose of those reports was to assist the clinicians in 18 understanding the -- the treatment course that the -- 19 that the infant may have taken while at the hospital? 20 DR. DAVID CHIASSON: Yes. In the case of 21 hospital autopsies, it's a different situation obviously 22 then a medicolegal autopsy. You're -- you're trying to 23 provide some information back to the clinician early on. 24 There's usually a -- a delay. In terms of 25 finalizing a report, you know, you're usually talking two

1 (2) or three (3) months down the -- down the road before 2 you have that. Clinicians would order a post-mortem -- 3 well they would ask the family to -- to consent to a 4 post-mortem examination. And they would like some 5 feedback early, if -- if you could provide them with a 6 clear cut answer, rather then have to wait two (2) or 7 three (3) months by which time, you know, the case -- the 8 matter would certainly not be as fresh in their minds. 9 So it's -- it's standard practice, in not 10 only the Hospital for Sick Children but the Toronto 11 Hospital and most hospitals that -- with hospital 12 autopsies, one's done with the consent of the next of 13 kin, that in those situations that you do provide a 14 provisional report fairly shortly after the post-mortem 15 is done. 16 MS. ERICA BARON: And would I be right to 17 say that sometimes there might be lessons to be learned 18 from -- from what happened in the care of a particular 19 child, that -- that waiting three (3) to six (6) months 20 wouldn't be acceptable? 21 DR. DAVID CHIASSON: I -- I think that's 22 true. I mean, in some -- in some cases you clearly would 23 have some important information that wouldn't change down 24 the road, and you'd like to convey that as soon as -- as 25 soon as possible after the autopsy.

1 MS. ERICA BARON: And am I right to think 2 that the provisional reports were not typically released 3 to family members? 4 DR. DAVID CHIASSON: The provisional 5 reports in hospital cases? 6 MS. ERICA BARON: Yes, yes. 7 DR. DAVID CHIASSON: Well, my 8 understanding is they would be issued back to the 9 attending physician. Whether the report made it to a 10 family member, I think would depend on the attending 11 physician; I don't -- I don't think the intent that they 12 were released directly to the family, that's correct. 13 MS. ERICA BARON: Okay. And I'm 14 wondering if you can turn up in Volume I, Tab 22, it's 15 PFP132345. 16 DR. DAVID CHIASSON: Sorry, which tab was 17 that, Ms. Baron? 18 MS. ERICA BARON: 22. 19 DR. DAVID CHIASSON: Thank you. 20 MS. ERICA BARON: And this appears to be 21 a letter to you from Dr. Smith in April of 1998, 22 addressing a number of issues. And am I right -- 23 COMMISSIONER STEPHEN GOUDGE: Is there a 24 date on it, Ms. Baron? 25 MS. ERICA BARON: Yes. You'll see up in

1 the sort of the middle, there's a fax line that -- that 2 has the date of 21/04/98. 3 COMMISSIONER STEPHEN GOUDGE: What's the 4 PFP number? 5 MS. ERICA BARON: 132345. 6 COMMISSIONER STEPHEN GOUDGE: Yes, I 7 don't have a fax -- do you have a fax line on the top of 8 yours, Dr. Chiasson? 9 DR. DAVID CHIASSON: No, no, I don't. 10 COMMISSIONER STEPHEN GOUDGE: I'm sure 11 it's not a matter of dispute. Why don't you just give us 12 the date? 13 MS. ERICA BARON: That's fine. I 14 actually printed a different one, a different PFP number, 15 from the system that does appear to have the fax line on 16 it and that's -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 MS. ERICA BARON: -- for cross-reference 19 is 031096. 20 COMMISSIONER STEPHEN GOUDGE: So what's 21 the date? 22 MS. ERICA BARON: April 21st, 1998. 23 COMMISSIONER STEPHEN GOUDGE: Okay. 24 25 CONTINUED BY MS. ERICA BARON:

1 MS. ERICA BARON: And if you could turn 2 to the second page of that document. This -- this 3 appears to be a letter to you recording some issues that 4 had been discussed as between you and -- and Dr. Becker 5 in and around that time period. 6 And -- and I take it that that -- it 7 generally makes sense that you would have been talking 8 about issues such as workload distribution, turnaround 9 times, communication and support, in that 1998 time 10 period? 11 DR. DAVID CHIASSON: Yes. Clearly, as I 12 read this, this is pursuant to a meeting that Dr. Cairns 13 -- Dr. Smith and Dr. Becker and I, and plus or minus Dr. 14 Cairns, I don't recall, but would have had before this 15 letter. 16 MS. ERICA BARON: And -- and you said you 17 have some concerns about there being different hospital 18 reports then what is contained in the post-mortem report, 19 and am I right in understanding your concern on that to 20 be that it may be -- it may become problematic if the 21 information contained in the two (2) reports is different 22 and that comes to light at some point during the course 23 of a criminal case? 24 DR. DAVID CHIASSON: It's -- it's 25 certainly in the setting of a criminal case or poten --

1 you know, that -- that sort of setting that a preliminary 2 report is potentially problematic if things should 3 change. It was less problematic, I mean, if it was a 4 medical case, but even there if somehow the family got 5 some information and a change, that -- that could be 6 problematic, as well. So our -- our preference was that 7 in fact these reports weren't -- weren't produced. 8 MS. ERICA BARON: But am I right that at 9 page 2 of this letter Dr. Smith says the following: 10 "The provision of preliminary reports, 11 [quote], 'internal tracking 12 documents'..." 13 Which I take it is the same as the 14 provisional reports we've been talking about. 15 "...was discussed. We will continue to 16 fax them to the responsible regional 17 Coroner's Office, except in the cases 18 which are clearly homicidal. We will 19 include information from the clinical 20 history in our reports in order to 21 improve the clinical pathologic 22 correlations; in cases of homicides 23 this will be brief. A suggestion was 24 made that in other cases a more 25 complete history could be included as

1 an appendix." 2 Am I right to think that this represents 3 sort of a compromise that was reached as between the 4 Hospital for Sick Children's desire that there be these 5 internal documents and the Coroner's Office apparent 6 desire that the information contained in the post-mortem 7 report in terms of history would be brief? 8 And the idea is that the hospital reports 9 would stay at the hospital and not make their way into 10 the coroner's system? 11 DR. DAVID CHIASSON: Yes, I think that's 12 fair. I think we are trying to reach some kind of 13 compromise. The regional coroners -- there was a benefit 14 to having -- you know, it's -- it's not completely black 15 and white as there is some benefit to the Regional 16 Coroner actually being notified of preliminary results -- 17 now, of a -- of a post-mortem examination. And so from 18 that point of view it gave the Regional Coroner some hint 19 as to -- indication as to what's going on. 20 My major concern were in the -- the 21 homicidal cases that came to light; there's a provisional 22 report with one (1) diagnosis or conclusion, and then a 23 final report with a different one. That -- that would 24 create problem. 25 MS. ERICA BARON: But indeed there's an

1 additional issue raised in this and that's about the 2 amount of history that would be included in the homicidal 3 post-mortem reports. 4 DR. DAVID CHIASSON: Yes, it was my own 5 practice to limit the amount of -- of information in -- 6 in homicide reports, basically trying to keep it to 7 information that -- that was relevant to the pathology, 8 as opposed to a large discussion of -- of a number of 9 circumstantial issues. And those circumstantial issues -- 10 and the problem there is that circumstantial information 11 can change with time. 12 And so in your report you're making 13 reference to circumstantial information. By the time a 14 preliminary hearing or a trial comes around, somebody's 15 changed their story, you know, the -- the information the 16 -- with further investigation has -- has been modified 17 and you have a report with the old information or the 18 information you had at the time, and that, again, creates 19 a potential problem. 20 So the -- the notion of having history in 21 your file, I -- I think that's -- that's important. I -- 22 I will often have much more information in the file 23 that's been provided to me, but I -- the idea was that 24 the -- the report, the amount of information would be -- 25 would be restricted to that that was important in

1 arriving at forensic pathology conclusions. 2 MS. ERICA BARON: So essentially what 3 you're telling us is that you limit the history that's 4 contained in your post-mortem so as to permit greater 5 flexibility to account for the evidence that's given at a 6 preliminary hearing or a trial about the events. 7 DR. DAVID CHIASSON: Well, yes. I mean I 8 -- I think that in most cases the -- the history -- if 9 you have somebody dying of a gunshot wound to the head, 10 the history of what circumstances that was, whether there 11 was an argument between, you know, the girlfriend and the 12 boyfriend and, you know, that's -- that's irrelevant to 13 the cause of death conclusion. 14 So I -- I try to avoid any information 15 other than, you know, a body was found, had a gunshot 16 wound to the head; you know, I try to minimise that for 17 that -- for that reason. 18 MS. ERICA BARON: All right, thank you. 19 And if you could now turn forward to Tab 48 in that same 20 volume, it's PFP129426. This is your forensic pathology 21 coroner from June of 1998, so fairly shortly after this 22 letter we've just looked at from Dr. Smith? 23 DR. DAVID CHIASSON: Yes. 24 MS. ERICA BARON: And this is your take 25 on the Kaufman Report and some of the recommendations

1 arising from it in terms of the implications it has for 2 forensic pathologists. 3 DR. DAVID CHIASSON: Yes. 4 MS. ERICA BARON: And if you could look 5 forward to recommendation number 7, it provides that: 6 "There -- the Centre for Forensic 7 Sciences should establish a written 8 policy on the form and content of 9 reports issues by its analysts. These 10 reports must contain conclusions drawn 11 from the forensic testing and the 12 limitations to be placed upon these -- 13 those con -- conclusions." 14 And you go onto -- and then this is your - 15 - I -- I take it that's the -- the recommendation itself; 16 the part that's in italics. And then you go on to 17 provide your commentary on it and you state as follows: 18 "Pathologists are reminded that the one 19 (1) opinion that is specifically 20 required to complete the report of 21 post-mortem examination is in regards 22 to the cause of death. It may be 23 appropriate to indicate the degree of 24 certainty/comfort level that one has in 25 rendering this opinion be including

1 qualifying terminology. Generally 2 speaking, I am very restrictive when it 3 comes to rendering any other forensic 4 opinions in the report of post-mortem 5 examination of a homicide/suspicious 6 death case. Again, should the 7 investigating police force or Crown 8 wish such an opinion in writing, I 9 recommend that this be affected through 10 separate and distinct correspondent as 11 -- correspondence as per a consultative 12 report." 13 I think you talked about this a little bit 14 yesterday. Would you agree with me that it was not a 15 common practice for the Crown or the police to request 16 reports of this nature prior to preliminary hearings? 17 DR. DAVID CHIASSON: Correct. It wasn't 18 a common practice, no. 19 MS. ERICA BARON: And -- and that was 20 true throughout the period of time you practised as a 21 forensic pathologist in Ontario? 22 DR. DAVID CHIASSON: That -- that's 23 correct. I -- even -- certainly in my own experience it 24 was -- it was uncommon, very uncommon to have to formally 25 write -- you'd express opinions all along the -- the

1 investigation track. The police would come back to you 2 and say, Listen, doc, you know, this is -- this is new 3 information or what do you think about this now, and -- 4 and would render that and occasionally the Crown 5 attorney. 6 And certainly in preparation for a 7 preliminary hearing, you would -- you would discuss 8 various opinions that go beyond the cause of death and at 9 a preliminary hearing you certainly did that on a regular 10 basis. But formal consultative reports were unusual. 11 MS. ERICA BARON: Were they even unusual 12 after the preliminary hearing and before trial? 13 DR. DAVID CHIASSON: Yes -- 14 MS. ERICA BARON: Okay. 15 DR. DAVID CHIASSON: -- in my experience. 16 MS. ERICA BARON: And were -- can you 17 tell me whether the -- you've told us a little bit that 18 there would often be meetings between the police and the 19 pathologist or the Crown and the pathologist, prior to 20 the prelim and thereafter, to talk about various issues 21 of a forensic nature, other than the cause of the death - 22 - did the Office of the Chief Coroner provide any com -- 23 compensation to fee-for-service pathologists for engaging 24 in those sorts of conversations? 25 DR. DAVID CHIASSON: Well, any -- any

1 meeting with a Crown attorney it would be the Crown 2 attorney's responsibility to -- and my -- in my case I 3 was a salaried employee, so it -- it didn't -- that 4 wasn't an issue, and that's part of my job description. 5 But anyone that was outside of the 6 Coroner's Office, employed by the Coroner's Office, 7 certainly had a right to bill for their time in any 8 meeting with the Ministry, the AG Ministry for spending 9 time with a Crown attorney. That -- that certainly -- 10 and that I did -- have done since then and when -- 11 whenever I've been outside of the employment of the 12 Coroner's Office I would incorporate the time I would 13 spend with a Crown attorney in -- usually was in the 14 leadup. 15 The -- the vast majority of cases -- 16 there's one (1) meeting prior to a preliminary hearing. 17 And this is the usual situation is you do an autopsy, 18 police are there, you provide them a preliminary opinion 19 and -- and nothing. You -- you prepare your report, you 20 finalize your report and whenever a preliminary hearing's 21 coming out is -- that's when you usually when you hear 22 back from the police and/or Crown attorney about a -- 23 about a matter. The vast majority of cases, there's not 24 much going on between those -- those two (2) time points. 25 And then it's usually in the setting of a

1 preliminary hearing, so you have a meeting with the 2 Crown, you testify at the preliminary hearing and you 3 invoice the -- the Crown attorney for both the meeting 4 and the preliminary hearing testimony time. 5 MS. ERICA BARON: And to the extent that 6 the -- in the -- the less common case that -- where there 7 are more meetings required with the police and the Crown, 8 do you knew whether the Crown had a policy of 9 compensating for the meetings with, say, the police 10 before the Crown is even involved? 11 DR. DAVID CHIASSON: There was -- it was 12 uncommon for the police to -- I mean, the police would 13 come back and you might have a short meeting about a case 14 or telephone conversation, I -- I wouldn't bill for -- 15 for that. I certainly never billed the police force for 16 it -- for that. 17 So if -- it's simply if there was a 18 meeting with a Crown attorney, that -- that was a 19 different situation. 20 MS. ERICA BARON: Okay. I'm going to 21 turn to a different area now to talk about the rounds 22 that were conducted at the Hospital for Sick Children and 23 -- and in turn, the rounds that were conducted at the 24 Office of the Chief Coroner, particularly with respect to 25 pediatric cases.

1 And you told us a little bit about the 2 fact that there were rounds and continue to be rounds at 3 the Hospital for Sick Children. In fact, I think you 4 said you could get caught up in rounding all the time if 5 you weren't careful, at the Hospital for Sick Children. 6 DR. DAVID CHIASSON: That's -- that's 7 true in -- in the global sense of medical rounds, yes. 8 MS. ERICA BARON: Right. And you told us 9 -- you told Ms. Rothstein that you attended the rounds 10 that were held at the Hospital for Sick Children as best 11 you could? 12 DR. DAVID CHIASSON: Yes. 13 MS. ERICA BARON: And am I right to say 14 that the idea behind you being invited to the rounds at 15 the Hospital for Sick Children was to encourage a 16 reciprocal exchange of information, as between you as a 17 forensic pathologist and the pediatric pathologists who 18 were practising at the Hospital for Sick Children? 19 DR. DAVID CHIASSON: Yes, me as -- not 20 only a forensic pathologist but as the Chief Forensic 21 Pathologist. So there was a -- trying to establish a 22 relationship between the Coroner's Office and the Unit, 23 but also to -- for me to -- for me to learn about 24 pediatric pathology, forensic pathology cases and for me 25 to have input into matters of a forensic nature,

1 specifically. 2 MS. ERICA BARON: Right. So you knew 3 that the pediatric pathologists at the Hospital for Sick 4 Children, while they had experience in forensic cases 5 didn't have any formal training in forensics? 6 DR. DAVID CHIASSON: Correct. 7 MS. ERICA BARON: And so the idea was you 8 would go there and lend whatever forensic support you 9 could to help them with their cases? 10 DR. DAVID CHIASSON: Yes, that was part 11 of the -- 12 MS. ERICA BARON: But you also recognized 13 that you lacked pediatric pathology -- extensive 14 pediatric pathology training and experience and you 15 wanted to take the opportunity to learn from them? 16 DR. DAVID CHIASSON: Yes. Certainly the 17 cases that are forensic and pediatric, yes, that's -- 18 that's quite clear. 19 MS. ERICA BARON: And you told Ms. 20 Rothstein you attended, as best you could; can you give 21 us a sense of how often you were able to attend the 22 rounds at the Hospital for Sick Children? 23 DR. DAVID CHIASSON: I can't give you a 24 number and I don't know how many rounds, you know, there 25 were in that time interval. But I think I attended a --

1 a significant proportion of them; I would guess three- 2 quarters (3/4s) of them. 3 MS. ERICA BARON: Okay. And would it be 4 fair to say that certainly even for the quarter you 5 didn't attend, you knew they were happening, you just 6 weren't able to be there on that particular day? 7 DR. DAVID CHIASSON: Correct, I couldn't. 8 MS. ERICA BARON: So you were generally 9 kept informed by the Hospital for Sick Children of when 10 the rounds were happening and what was to be covered? 11 DR. DAVID CHIASSON: I would have been 12 informed by Dr. Smith; he would have been the one (1) 13 forwarding to me the list, yes. 14 MS. ERICA BARON: Okay. And I'd like if 15 we can to turn up document -- it's Volume III, Tab 43 for 16 you, Dr. Chiasson -- it's PFP056459. 17 COMMISSIONER STEPHEN GOUDGE: Sorry, tab 18 number, Ms. Baron? 19 MS. ERICA BARON: It's Volume III, Tab 20 43. 21 COMMISSIONER STEPHEN GOUDGE: Thank you. 22 23 CONTINUED BY MS. ERICA BARON: 24 MS. ERICA BARON: Is this generally 25 reflective of the way you'd be informed of -- of the

1 rounds at the Hospital for Sick Children and what was to 2 be covered when they were? 3 DR. DAVID CHIASSON: Yes. 4 MS. ERICA BARON: And I note on this one 5 in particular, it indicates that you were also going to 6 explain to the pathologist at the Hospital for Sick 7 Children about your review mechanism for homicide cases. 8 DR. DAVID CHIASSON: Yes. 9 MS. ERICA BARON: And that essentially, 10 homicide cases were to go to you, non-homicide cases were 11 to go to the Regional Coroner? That -- that seems to be 12 what -- what's reflected here and I take it that that was 13 the policy as at May of 1996? 14 DR. DAVID CHIASSON: Well, the policy 15 that's referred to -- in the formal memo, the -- the -- 16 it was set up so that the -- most cases would go to the 17 Regional Coroner and -- and -- for review and then to me. 18 In the case of the Hospital for Sick 19 Children, I -- and I -- I think I made clear, if 20 pathologists wanted to directly send me a case without 21 going through the Regional Coroner, I was -- I was fine 22 with that as long as the case came to me. And I think in 23 this case, Sick Kids -- there -- there appears to be -- I 24 may have been suggesting you can forward it to me 25 directly. I think that's what all those arrows are

1 referring to. 2 MS. ERICA BARON: Right. Is this your 3 handwriting on this document? 4 DR. DAVID CHIASSON: It is, yes. 5 MS. ERICA BARON: So I take it then, you 6 attended on that day and made some notes as to what was 7 discussed? 8 DR. DAVID CHIASSON: Yes, and obviously 9 in a very concise manner. Yes. 10 MS. ERICA BARON: Right. And you told 11 Ms. Rothstein that -- that there was varying levels of 12 detail of discussion about cases, depending on the nature 13 of the case, but what you didn't tell us is sort of what 14 the range was. 15 So let's take sort of the most detailed 16 case that was done in the most detail -- not necessarily 17 in May of 1996 -- can you give us and the Commissioner an 18 idea of what -- what you would look at, what you'd be 19 talking about. 20 MR. DAVID CHIASSON: Well, there's -- 21 just looking at the number of cases, this is fair -- this 22 isn't one of the longer lists, but this is still a fairly 23 large number of cases to try to review and I'm not sure 24 how long we held these rounds for. I suspect, given that 25 they -- they look like they start at 11:00 -- so we're

1 probably looking at just about an hour, maybe an hour an 2 a half, to try and cover this number of cases. 3 So in terms of the amount of time spent 4 per case on average; we're not talking a lot of time, ten 5 (10) minutes, fifteen (15) minutes. The -- and it -- it 6 -- as I've indicated, very much depended on the 7 pathologist and how much detail he wanted to show. There 8 was variation, certainly. Some pathologists tended to go 9 into great detail with their presentations, whereas 10 others were more brief. 11 But it was -- it was clearly up to the 12 pathologist as to what they presented and how they -- 13 they presented. Five (5) minutes would have been quick, 14 but I think very few of them were probably five (5) 15 minutes. And then maybe a longer presentation may -- we 16 may have discussed it for ten (10) or fifteen (15) 17 minutes. It's that kind of a range. 18 MS. ERICA BARON: Now would there be a 19 written document about a case? Would you be looking at 20 photographs, looking at slides, any of those things? 21 MR. DAVID CHIASSON: Well, we would 22 certainly be looking at photographs of the case. 23 Certainly now it's pretty well-structured so that the 24 pathologist presents a history, presents slides not only 25 of the gross pathology, the naked-eye pathology but also

1 the microscopic pathology, and at the end -- 2 MS. ERICA BARON: You have the ability to 3 put the microscopic slides -- to project them up on a 4 screen or something like that? 5 MR. DAVID CHIASSON: Right now it's very 6 simple. We have cameras all attached to our microscope 7 that digitally capture images, and so it's -- it's quite 8 easy. Now, I'm -- back then the technology wasn't the 9 same and whether -- how much to -- to have micro -- in 10 fact, back then I think we were using Kadachromes, so 11 there was still a capability to do photo-microscopy, but 12 the process was much more labour intense. And so a lot 13 of cases there -- unless there was some specific issue, 14 you probably wouldn't do microscopy in terms of the 15 presentation. 16 MS. ERICA BARON: But you had -- but 17 there were cases where that was done? 18 MR. DAVID CHIASSON: Yes. There were 19 cases that -- that was certainly done, yes. 20 MS. ERICA BARON: Who attended at the 21 rounds, other than you and the Hospital for Sick Children 22 pathologists? 23 MR. DAVID CHIASSON: Well, I believe that 24 Dr. Cairns would attend on occasion, perhaps Dr. -- back 25 then the regional coroner I think was Dr. Huxter, on

1 occasion. And then as I started getting pathologists, I 2 tried to encourage them, the ones -- the salaried 3 pathologists at the Coroner's Office -- to attend as 4 well. 5 MS. ERICA BARON: Did clinicians attend 6 from the Hospital for Sick Children? 7 MR. DAVID CHIASSON: I don't recall, 8 specifically. They may well have. I don't know how 9 isolated these rounds were, because certainly the regular 10 CPC rounds, the Friday morning rounds, were -- were well- 11 attended by clinicians. So there may have been some 12 clinicians attending, depending on the cases. 13 MS. ERICA BARON: So, sorry, was there -- 14 you said there was a separate set of rounds that 15 clinicians would attend? 16 MR. DAVID CHIASSON: Well, every -- every 17 Friday at the Hospital for Sick Children -- this has been 18 going on for -- before I was there as resident -- it's a 19 -- it's a tradition that -- that the autopsy cases 20 presented on Friday mornings, complete with coffee and 21 doughnuts and -- and an hour and three (3) or four (4) 22 cases be discussed. 23 And there would be -- most of the case -- 24 they'd certainly be -- all the hospital cases would be 25 discussed and some case -- in some situations you would

1 also be discussing some sudden infant death that might 2 have interesting pathology. So some coroner's cases 3 would -- could be discussed as well, if they're -- had 4 interesting findings. 5 So that's kind of the hospital's -- one of 6 their quality control measures was to have these called 7 CPC rounds, Clinical Pathologic Correlation rounds. So 8 that's always been going on. 9 These were -- these were separate and 10 distinct from that, but whether the clinicians showed up, 11 I can't recall specifically. It wouldn't have been 12 surprising. I didn't have any concern about that. 13 MS. ERICA BARON: And I take it that 14 these rounds happened on Fridays as well, so -- 15 DR. DAVID CHIASSON: Yes. 16 MS. ERICA BARON: -- probably happened 17 shortly after the rounds with the clinicians in 18 attendance? 19 DR. DAVID CHIASSON: Or whether the 20 regular rounds were cancelled in order for these rounds - 21 - I -- now, we do have forensic pathology rounds that we 22 hold at the same -- over the same time period. We cancel 23 the regular CPC rounds. 24 There's a couple of interested clinicians, 25 interested in -- in coroner's work, sudden death, who --

1 who attend for their own interest. But generally 2 speaking our forensic pathology rounds are restricted to 3 the forensic pathology unit staff and -- and 4 representation from the Coroner's Office. 5 MS. ERICA BARON: And did rounds of this 6 nature that you attended at the Hospital for Sick 7 Children carry on through to at least 1999 when they 8 appear to shift over the Office of the Chief Coroner? 9 DR. DAVID CHIASSON: There -- there seems 10 to be a gap, at least as I recall in going through these 11 -- these notes, around '98. And whether they -- they 12 continued, I don't seem to have any reference. What I've 13 seen are the rounds that I've actually attended and they 14 seem to stop in '97. 15 Now, whether -- I -- I can't recall 16 whether there was actually a breakdown of -- of this. 17 They start up again in 1999, but they're -- they're over 18 at the Coroner's Office. 19 MS. ERICA BARON: Okay. And I take it 20 the purpose of the 19 -- the rounds that start up at the 21 Office of the Chief Coroner in 1999 is the same as -- as 22 you going to the Hospital for Sick Children except now 23 the Hospital for Sick Children are coming over to you 24 folks instead? 25 DR. DAVID CHIASSON: Yes, and -- but

1 we're also in a little different environment in that were 2 -- this is the time that we're looking at revisioning and 3 bringing Dr. Smith -- you know, certainly talking and 4 considering that he -- he come over and do cases at the 5 Coroner's Office. 6 So it's -- it's in a different 7 environment, but essentially it's the same thing that -- 8 that Dr. Smith would come over and present cases, his own 9 and -- and other pathologist's cases of a pediatric 10 forensic nature. 11 MS. ERICA BARON: Am I right that 12 typically it was just Dr. Smith who came? 13 DR. DAVID CHIASSON: Correct. 14 MS. ERICA BARON: Even though often he 15 would be presenting cases that had been autopsied by 16 other pathologists at the hospital? 17 DR. DAVID CHIASSON: Correct. I -- I 18 think Dr. Taylor might -- may have come once or twice, 19 but -- but of the most part it was Dr. Smith who came 20 over and presented cases and even if they weren't his. 21 MS. ERICA BARON: And was the -- was the 22 nature of the review similar in terms of what was 23 discussed and what was looked at by the -- by the group? 24 DR. DAVID CHIASSON: Yes, I think when 25 they came to the Coroner's Office we were very much more

1 interested in -- because we're dealing -- the audience 2 was more forensic pathology than pediatric pathologists, 3 so we were more interested in the forensic aspects of -- 4 of the case. 5 But -- but otherwise they were -- they 6 were similar. I mean, they were case discussions. They 7 were opportunities to -- to -- for forensic pathologists 8 to have input into the -- the work of -- of the unit. 9 And they were -- they were review sessions, but not, 10 again, formalized and -- and no decision making, no 11 consensus decision making, as to, okay, this is the way 12 this cause of death should be signed out. 13 MS. ERICA BARON: Now, I just want to 14 understand because we all -- everybody, I think, uses the 15 term forensic a little bit differently, are you talking 16 criminally suspicious when you say forensic in that 17 context or are you talking sort of in the broader cases 18 of interest to the coroner? 19 DR. DAVID CHIASSON: Well, we're -- I -- 20 I'm talking more in -- in the former rather than the 21 latter because the Coroner's Office -- the coroner's 22 cases, obviously there's a spectrum of some essentially 23 medical cases who happen to die and have a coroner's 24 warrant. 25 So, no, we're interested in more trauma

1 cases; certainly anything that was suspicious, homicide; 2 non-natural deaths. Or as -- as in this case, catheter 3 perforation; the one in the middle I make reference to, 4 pericardial catheter perforation. So that's a -- a 5 complication of the surgery, so that would have been 6 forensically interesting even though the patient has 7 underlying pediatric medical disease; heart disease, in 8 this case. 9 MS. ERICA BARON: Okay. If you could 10 forward now to Tab 49 in that -- 11 COMMISSIONER STEPHEN GOUDGE: Are you 12 leaving the -- 13 MS. ERICA BARON: Yes, yes. 14 COMMISSIONER STEPHEN GOUDGE: Sorry. 15 MS. ERICA BARON: I'm leaving, not the 16 rounds, but this particular -- the one from May 7th, 17 1996. 18 COMMISSIONER STEPHEN GOUDGE: Let me just 19 ask, if I can, Ms. Baron, just a couple of questions -- 20 MS. ERICA BARON: Of course. 21 COMMISSIONER STEPHEN GOUDGE: -- then, of 22 Dr. Chiasson. 23 Back in the 1996/'97 period when forensic 24 rounds were held at the hospital, how often were they 25 held? They were not weekly like the departmental rounds?

1 DR. DAVID CHIASSON: No, they -- you're 2 correct, Mr. Commissioner, the departmental rounds, 3 basically weekly, every Friday. They were, I think 4 monthly would be my sense. 5 COMMISSIONER STEPHEN GOUDGE: And were 6 all the cases done under warrant reviewed at the forensic 7 rounds or was it a selection? 8 DR. DAVID CHIASSON: I think it was 9 likely a -- a selection of cases. I -- I left it to Dr. 10 Smith to choose cases for rounds. I didn't monitor, you 11 know, how many cases there were and which cases he -- he 12 chose. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. DAVID CHIASSON: It was left to him 15 to present cases that were forensically non-interesting, 16 and so I don't think all of the cases -- 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 DR. DAVID CHIASSON: -- were presented. 19 COMMISSIONER STEPHEN GOUDGE: And same 20 was true when they moved to the OCCO? 21 DR. DAVID CHIASSON: Again, it was left 22 to Dr. Smith to pick and choose cases then. 23 COMMISSIONER STEPHEN GOUDGE: Now, were 24 they combined with the cases that were of your own, the 25 adult cases that were reviewed at those rounds, or was it

1 a pediatric forensic set of rounds that you did at OCCO? 2 DR. DAVID CHIASSON: We had our own 3 adult, if you will, forensic pathology rounds, but they - 4 - this -- this is -- this was dedicated to pediatric 5 cases. 6 COMMISSIONER STEPHEN GOUDGE: Okay. 7 DR. DAVID CHIASSON: Dr. Smith on 8 occasion did attend the adult -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. DAVID CHIASSON: -- rounds. 11 COMMISSIONER STEPHEN GOUDGE: Right. And 12 we've talked about that. 13 DR. DAVID CHIASSON: And -- and at some 14 point there may have been instances where he had an 15 interesting case and was presented in an adult rounds 16 situation, but by '99, when we're talking about the 17 rounds here, these are pediatric cases -- 18 COMMISSIONER STEPHEN GOUDGE: In the pre- 19 '97 period or the '99 and following period, was the post- 20 mortem report a document that would be in front of those 21 attending the round? 22 DR. DAVID CHIASSON: No, the pathologi -- 23 at this -- most of these cases wouldn't have been signed 24 out. 25 COMMISSIONER STEPHEN GOUDGE: They would

1 not have been signed out? 2 DR. DAVID CHIASSON: Most of them would 3 not have been signed out. And so it's -- it was an 4 opportunity to discuss the case before it was being 5 signed out. 6 COMMISSIONER STEPHEN GOUDGE: Okay. 7 DR. DAVID CHIASSON: So the only one who 8 would have the -- the document in front, would be the 9 presenting pathologist. 10 COMMISSIONER STEPHEN GOUDGE: Okay. And 11 let me just ask you for your view, Dr. Chiasson. You 12 know, obviously rounds have an educational function. 13 DR. DAVID CHIASSON: Correct. 14 COMMISSIONER STEPHEN GOUDGE: Do they 15 have an effective quality assurance function, as well? 16 DR. DAVID CHIASSON: Well, I -- I think 17 there's an opportunity to -- to have it as -- again, it 18 depends how you identify qual -- or how you define 19 quality assurance, and I guess -- 20 COMMISSIONER STEPHEN GOUDGE: Does that 21 help with the quality of the end product put out by the 22 department? 23 DR. DAVID CHIASSON: I think it does, 24 yes. 25 COMMISSIONER STEPHEN GOUDGE: Could you

1 just unpack that a little as to how that happens or can 2 happen? 3 DR. DAVID CHIASSON: Well, as -- the 4 situation -- and I'll talk about the current situation. 5 When we have a case -- when we have rounds, forensic 6 pathology rounds, the pathologist and department do 7 present their case. They -- they are able to define what 8 they present. 9 Having said that, you know, they're 10 encouraged to present the things that are forensically 11 potentially of -- of importance and it's done as a 12 history. It's fairly formalised now; they do a history, 13 historically short presentation about what's going on in 14 the background and then any relevant findings. 15 The rounds are extremely valuable because 16 -- and to give you an example, we -- we had them a couple 17 of weeks ago, some hemorrhages in the back of the neck in 18 one (1) instance where an individual we knew was a 19 drowning, an infant drowned in a pool, backyard pool, had 20 these hemorrhages in the back of the neck. 21 The next case by another pathologist was 22 similar hemorrhages in the back of the neck in a case 23 that was of undetermined cause. And hemorrhages in the 24 back of the neck always raise -- always raised the hairs 25 at the back of the neck of a -- of a forensic

1 pathologist; is this possibly some manifestation of 2 injury; a shaking mechanism, for example. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. DAVID CHIASSON: So, having seen the 5 same findings in a case that was clearly defined as 6 drowning and it was kind of reassuring that just because 7 you have these hemorrhages doesn't mean you're looking at 8 anything of a -- of a suspicious nature. 9 So it -- it allows for that, I think, very 10 much education point of view. But for the pathologist 11 who is presenting the latter case of these hemorrhages 12 that he wasn't sure, he was presenting it; Listen, this 13 is what I have, what do you think? Are these of 14 potential traumatic significance or not? 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 DR. DAVID CHIASSON: And -- and we're 17 doing -- so it's -- it's both educational and I think 18 quality assurance. And in our -- in our situation the 19 report will eventually be engendered. I will re -- 20 review the report. 21 I've now had the presentation -- the 22 report shouldn't be separated by that much time. But I 23 have the opportunity; Okay, I remember that case, I 24 remember him presenting that, and now I have the report 25 and does this jibe with what I would consider to be

1 appropriate. 2 So it -- there's that element that it is 3 contributing to quality -- our formal quality assurance 4 PM report auditing at the end of the process. 5 COMMISSIONER STEPHEN GOUDGE: To the 6 degree to which, I suppose, the presenter asks for input 7 or input is given? 8 DR. DAVID CHIASSON: Exactly. I mean, 9 it's encouraged, and all my colleagues are -- that's -- 10 you know, this is the -- 11 COMMISSIONER STEPHEN GOUDGE: They all 12 speak their mind? 13 DR. DAVID CHIASSON: They do speak their 14 mind, and -- and they're happy to have somebody, you 15 know, hold their hand. And just like I'm happy to have 16 them hold my hand when I have a pediatric pathology issue 17 and you know, I'm not sure about this, you know, and I 18 get this -- this back and forth feedback. It's -- 19 COMMISSIONER STEPHEN GOUDGE: Okay. Last 20 question I have. Sorry to take so much time Ms. Baron, 21 your clock's not running. The name of the departmental 22 rounds was, Clinical Pathological Correlation Rounds? 23 DR. DAVID CHIASSON: CPC, yes. That's 24 right, Mr. Commissioner. 25 COMMISSIONER STEPHEN GOUDGE: Why is it

1 called that? I mean, why are the clinical folk there, in 2 the title? I mean -- 3 DR. DAVID CHIASSON: So -- so the -- the 4 whole purpose of a hospital autopsy really -- 5 COMMISSIONER STEPHEN GOUDGE: That's the 6 feedback to the clinician that we're talking about? 7 DR. DAVID CHIASSON: -- is the feedback 8 to the clinician. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 DR. DAVID CHIASSON: And the whole 11 purpose -- 12 COMMISSIONER STEPHEN GOUDGE: Okay. 13 DR. DAVID CHIASSON: -- of doing those 14 autopsies is actually, okay, you have -- 15 COMMISSIONER STEPHEN GOUDGE: Right, -- 16 DR. DAVID CHIASSON: -- somebody dies -- 17 COMMISSIONER STEPHEN GOUDGE: -- what 18 happened in the hospital? 19 DR. DAVID CHIASSON: -- you know, what's 20 the pathology, how does the pathology go back to 21 correlate with what happened clinically. 22 COMMISSIONER STEPHEN GOUDGE: Okay. 23 DR. DAVID CHIASSON: So it's the whole 24 thrust of -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

1 DR. DAVID CHIASSON: -- of hospital -- 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. DAVID CHIASSON: -- autopsies. 4 COMMISSIONER STEPHEN GOUDGE: So the 5 presence of clinicians at those rounds is much more 6 germane then it is to the forensic pathology rounds? 7 DR. DAVID CHIASSON: Yes. Certainly -- 8 yes, for most for -- there -- there are issues that could 9 be overlapped -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. DAVID CHIASSON: -- where there's 12 individuals who die in hospital following trauma, but 13 certainly -- 14 COMMISSIONER STEPHEN GOUDGE: Okay. 15 DR. DAVID CHIASSON: -- for most cases 16 that's -- that's true. 17 COMMISSIONER STEPHEN GOUDGE: That's 18 great. Sorry. 19 20 CONTINUED BY MS. ERICA BARON: 21 MS. ERICA BARON: That's fine. Could you 22 turn now to Tab 49 in Volume III? This is PFP132430. 23 And I take it this relates to a period in 24 time when the pathology rounds were done at the Office of 25 the Chief Coroner?

1 DR. DAVID CHIASSON: Correct. 2 MS. ERICA BARON: And I just want to 3 touch briefly on a case you -- the fifth case in the 4 list, which is the Tamara XXXX -- sorry, the Tamara Case. 5 I'm just wondering if you have any recollection of 6 discussing that case in March of 1999? 7 DR. DAVID CHIASSON: I -- I don't have 8 any independent recollection of discussing the case at -- 9 at that time. There's no -- there's none -- none of my 10 scribbles on that -- on that piece of paper, and I -- I'm 11 not even sure I was at that particular meeting. 12 I -- I may well have been, but I don't 13 have any recall of the case being discussed. 14 MS. ERICA BARON: Let me understand. 15 When the rounds happened at the Office of the Chief 16 Coroner, would there be occasions when it was Dr. Smith 17 with just Dr. Cairns and Dr. Lucas, for instance? 18 DR. DAVID CHIASSON: No, there would have 19 been other -- our other staff pathologists there. I -- 20 in all likelihood, I was at these rounds but I -- I don't 21 -- I can't -- I don't independently recall being there. 22 So there may be such situations where I 23 was not available. Most of the time, I was -- I was 24 there. And if I wasn't there, -- or regardless of 25 whether I was there or not, there were still -- I, still,

1 in March '99 have some staff pathologists still working 2 for me. 3 So they would have been in attendance at 4 these rounds. 5 MS. ERICA BARON: Was it fair to say that 6 it would always be the case that all of the staff 7 pathologists that were available would attend these 8 rounds? 9 DR. DAVID CHIASSON: Yes. It was my 10 expectation all my salaried staff pathologists over -- 11 who -- who I had more control, were -- were -- would 12 attend these rounds. 13 MS. ERICA BARON: Okay. I'm going to 14 move now into the -- into another area. I'm wondering if 15 you can turn up Volume I, Tab 52, which is PFP007950; 52. 16 And you were asked by Ms. Rothstein -- and this is the 17 Forensic Pathology Pitfalls memorandum that we've talked 18 about -- that you've talked about with Ms. Rothstein. 19 And you -- I think you told us that you 20 had never told Dr. Smith that this memo was issued in 21 response to some concerns raised in the Nicholas case. 22 And I just -- 23 DR. DAVID CHIASSON: And to clarify, and 24 I think I've said this before, but it's not -- it wasn't 25 all directed or did not come out simply of Dr. Smith's

1 issues. There -- there were other pathologists -- but 2 no, I did not -- never broached it with him that this is 3 directed at him, or partly, I don't know. 4 MS. ERICA BARON: Well, thank you -- 5 thank you for that earlier point, because I don't think 6 that had been raised earlier, or I missed it if it was. 7 Am -- am I right that the Preliminary 8 Cause of Death section, which is on the first page, that 9 that more -- more likely relates to the issues that were 10 going on in Ottawa at the -- at the time that you told us 11 about? 12 DR. DAVID CHIASSON: Correct. 13 MS. ERICA BARON: Okay. I want to talk 14 about a particular area which is found at page 3, Related 15 to Consultations. And this memo provides that a 16 consultation should be obtained in writing if they're 17 necessary, to form an opinion with respect to the cause 18 of death. 19 Am I right that this -- to your knowledge, 20 at least -- this was the first time that the Office of 21 the Chief Coroner had provided a formal position with 22 respect to consultations to pathologists in the Province? 23 DR. DAVID CHIASSON: It may well have 24 been the first formal mention of this -- this issue, yes. 25 MS. ERICA BARON: And would you agree

1 with me that, at the time it was a common practice for 2 pathologists to consult with their colleagues and, not 3 necessarily, get anything in writing? 4 DR. DAVID CHIASSON: Well, certainly. I 5 mean there's -- there's consulting and there's 6 consulting. And -- and as I've already described, you 7 know, we present at a round; we get opinions from a whole 8 range of people. That doesn't get formally documented. 9 I don't go around and ask Dr. Taylor, Okay, you said this 10 in rounds, please sign this affidavit to that. So there 11 is a lot -- there's always consultation in that general 12 sense. 13 I mean, this is, specifically, saying if 14 you're depending upon that consultation that your -- your 15 opinion is you don't know or you're -- you're unclear or 16 you need to be convinced, then that's clearly different. 17 Or if the consulta -- or the area of -- of 18 discussion is something that you're -- outside your area 19 -- and neuropathology would be an example -- that if -- 20 if you're depending on some other expertise, then clearly 21 in that situation, you would need a consultant's report. 22 MS. ERICA BARON: And is it fair to say 23 that this memorandum doesn't tell pathologists what 24 they're to do with those written consultation reports -- 25 once they're obtained?

1 DR. DAVID CHIASSON: I guess it doesn't, 2 no. 3 MS. ERICA BARON: Okay. Can I take you 4 forward then to Volume I, Tab 104? 5 DR. DAVID CHIASSON: Yeah. 6 MS. ERICA BARON: And this is PFP129217. 7 And in the -- on the first page, there's an email from 8 you to Dr. Smith, sort of in the middle of the section. 9 This is a chain of emails back and forth. And in the 10 middle of that you say this to Dr. Smith, and this is 11 October of 2000: 12 "Thank you for the neuropath reports on 13 Gadbois and Karim. I suspect you are 14 trying to avoid having Larry dragged 15 into court." 16 And I assume that's Dr. Becker you're 17 referring to there? 18 DR. DAVID CHIASSON: It is, yes. 19 MS. ERICA BARON: "I understand this, 20 however, to my mind this is not an 21 acceptable practice because of the 22 perception created in the instance 23 where a previously undisclosed 24 neuropath report would appear in the 25 middle of trial."

1 And is it fair to say that it was your 2 belief that Dr. Smith -- let me start with this. The 3 neuropathology reports that you're referring to existed 4 in that case; that Smith had -- Dr. Smith had requested 5 written -- a written consultation from Dr. Becker? 6 DR. DAVID CHIASSON: Yes. 7 MS. ERICA BARON: And when you asked him 8 to provide them to you, he handed them over? 9 DR. DAVID CHIASSON: Yes. 10 MS. ERICA BARON: And you -- your belief, 11 at least, was that he was trying to avoid the necessity 12 of Dr. Becker being called to testify at a trial? 13 DR. DAVID CHIASSON: That's what I -- 14 that was my impression; rightfully or wrongfully. 15 MS. ERICA BARON: Would it be fair to say 16 that it was generally the case that often consultants or 17 specialists might not be interested in providing written 18 consultations because they didn't want to go to court and 19 testify in these difficult cases? 20 DR. DAVID CHIASSON: Well, yes. I mean, 21 that's a -- that's a concern but if, in fact, you're -- 22 you're writing an opinion, in an area that's potentially 23 going to result in a court case, you need to be able to 24 defend that. I mean, you can't -- you can't offer 25 opinions. You should -- you should not offer an opinion

1 then if you're not going to be willing to testify in 2 court. 3 MS. ERICA BARON: Would you agree that 4 that's sometimes an impediment to finding a consultant 5 who's willing to give a written opinion -- 6 DR. DAVID CHIASSON: Yes. 7 MS. ERICA BARON: -- in these difficult 8 cases? 9 DR. DAVID CHIASSON: Yes, clearly. 10 MS. ERICA BARON: And -- and, indeed, a 11 consultant might be willing to provide an opinion if they 12 believe that the pathologist was going to keep it for 13 themselves; that it was for their purposes rather than it 14 being passed along? 15 DR. DAVID CHIASSON: Well, yes, that may 16 -- that may be -- that may be true. But, I mean, 17 certainly the environment by this time, this memo and 18 certainly since then, that that's an acceptable approach. 19 And certainly I -- I think it's well defined now that -- 20 that consultant reports are to be appended to the PM 21 report. 22 The -- the environment wasn't that evolved 23 when we're talking about the -- this per -- or the '90's, 24 let's say. 25 MS. ERICA BARON: And -- and indeed

1 through to 2001 would you agree that there wasn't a 2 policy saying that consultation reports were to be 3 appended to -- to post-mortem reports? 4 DR. DAVID CHIASSON: I don't think -- I 5 agree, I don't think there -- it was a formal policy. 6 It's my expectation and certainly was something that I 7 was trying to convey to pathologists at educational 8 seminars when I'm talking about post-mortem examination 9 reports. 10 And, suffice it to say, that in the 11 majority of cases where consult -- especially 12 neuropathology reports were being sought, they were being 13 appended in -- in many other jurisdictions, so is isn't 14 that everybody was not appending the reports; a lot of 15 pathologists were getting consults and were appending 16 them to their own reports. 17 MS. ERICA BARON: Would it be fair to 18 say, though, that even by 2001 there was an ongoing 19 concern about people obtaining consultations and not 20 getting them in writing or not providing those written 21 consultations with their post-mortem reports? 22 DR. DAVID CHIASSON: Yes, they will. It 23 is clearly an ongoing concern. 24 MS. ERICA BARON: I'm wondering -- 25 DR. DAVID CHIASSON: Documented here in -

1 - in October of 2000, yes. 2 MS. ERICA BARON: Right. But I'm 3 wondering if you -- do you have the Coroner's 4 Investigation Manual up there? 5 DR. DAVID CHIASSON: Yes. 6 MS. ERICA BARON: If you could turn to 7 page 140, that's PFP057584, page 140. And this is a memo 8 dated June 27th, 2001 related to written consultation 9 reports. 10 And I take it this is after Dr. Smith was 11 no longer doing criminally suspicious post-mortems for 12 the Office of the Chief Coroner. 13 DR. DAVID CHIASSON: Correct. 14 MS. ERICA BARON: And it's again a 15 reminder to pathologists to obtain those written 16 consultation reports. 17 DR. DAVID CHIASSON: Yes. 18 MS. ERICA BARON: And -- and indeed -- am 19 I right in saying that it's still not made clear in this 20 memorandum that those reports are to be provided with the 21 post-mortem report? 22 23 (BRIEF PAUSE) 24 25 DR. DAVID CHIASSON: It -- it isn't made

1 clear -- 2 MS. ERICA BARON: Explicit? 3 DR. DAVID CHIASSON: Yes. 4 MS. ERICA BARON: Okay. 5 DR. DAVID CHIASSON: If you want, it 6 could imply that that would be the expectation from 7 reading this, but it isn't implicit, I assume or ex -- 8 MS. ERICA BARON: Ex -- explicit? 9 DR. DAVID CHIASSON: Explicit. 10 MS. ERICA BARON: Fair enough. I want to 11 now turn to talk about the review you were doing of 12 criminally suspicious cases, which you've spent some time 13 talking about previously. And we've seen some examples 14 of what you did when you weren't satisfied with the 15 report; you would provide your comments back to the 16 Regional Coroner or the coroner who provided the report 17 to you. 18 DR. DAVID CHIASSON: The Regional Coroner 19 provided the report to me, yes. 20 MS. ERICA BARON: Right. And -- and the 21 idea was that would go back to the pathologist and -- and 22 they would make changes or not as they saw appropriate. 23 DR. DAVID CHIASSON: That -- that 24 happened most commonly sometimes, depending on the 25 pathologist. I -- I might pick up the phone and talk to

1 the pathologist directly or email the pathologist 2 directly with my concerns; it depended on the -- on the 3 pathologist and the Regional Coroner who I was dealing 4 with. 5 MS. ERICA BARON: Am I right to say that 6 that never happened with Dr. Smith? 7 DR. DAVID CHIASSON: It -- not in terms 8 of comments to the Regional Coroner, no. If -- if I had 9 concerns with Dr. Smith I would have spoken to him 10 directly. I wouldn't have gone through the Regional 11 Coroner in that case. 12 MS. ERICA BARON: Do you recall ever 13 doing that? 14 DR. DAVID CHIASSON: Speaking to Dr. 15 Smith about a report? I don't recall -- I mean, I think 16 there were cases we talked about. I don't recall going 17 specifically back to him about concerns and certainly 18 nothing that engendered a revised report or anything of 19 that nature. 20 MS. ERICA BARON: And am I right to say 21 that the purpose of the review that you were doing of 22 these cases was to ensure that: 23 1. The injuries were properly documented. 24 DR. DAVID CHIASSON: Yes. 25 MS. ERICA BARON: 2. That there were no

1 inconsistencies within the body of the report. 2 DR. DAVID CHIASSON: Yes. 3 MS. ERICA BARON: That the summary of the 4 abnormal findings was accurate. 5 DR. DAVID CHIASSON: Yes. 6 MS. ERICA BARON: And that the cause of 7 death was supported by those findings. 8 DR. DAVID CHIASSON: It was reasonable 9 conclusion, based on the findings, yes. 10 MS. ERICA BARON: Okay. Can you turn up 11 in the overview report PF -- Volume II of the overview 12 reports, Tab 14, which is the Tamara overview report. 13 This is PFP057162 -- sorry, this is PFP143345. 14 DR. DAVID CHIASSON: Okay. Sorry, the 15 tab was again? 16 MS. ERICA BARON: 14. Page 13 -- page 17 16. 18 COMMISSIONER STEPHEN GOUDGE: Paragraph 19 number...? 20 MS. ERICA BARON: Paragraph 42. 21 COMMISSIONER STEPHEN GOUDGE: Thank you. 22 MS. ERICA BARON: Sorry, it's Volume II 23 of the overview report. I think -- 24 COMMISSIONER STEPHEN GOUDGE: They are 25 the white volumes --

1 MS. ERICA BARON: -- maybe it's white. 2 COMMISSIONER STEPHEN GOUDGE: -- Dr. 3 Chiasson. 4 5 CONTINUED BY MS. ERICA BARON: 6 MS. ERICA BARON: And I haven't taken you 7 to the document, but -- but just for -- for your 8 purposes, Commissioner, 057162 is the -- the memorandum 9 demonstrating that Dr. -- Dr. Chiasson reviewed the 10 Tamara case. 11 So I want to go through with you the 12 summary of abnormal findings in this case, which was: 13 "Multiple traumatic injuries remote, 14 multiple boney fractures, femur right, 15 femur left, ribs right 4 through 7, 16 ribs left 7, pulmonary haemorrhage, and 17 adrenal haemorrhage." 18 Number 2. 19 "Asphyxia with petechial haemorrhages 20 of thoracic viscera and haemorrhage 21 left..." 22 I'm not going to be able to pronounce that 23 word. 24 DR. DAVID CHIASSON: 25 "Ster -- sternomastoid muscle"

1 MS. ERICA BARON: Thank you. 2 "...acute. 3 3. Cerebral edema 4 4. Pulmonary haemorrhage, acute 5 5. Pancreatic haemorrhage, acute 6 6. Astr -- astrogliosis of the 7 hippocampus." 8 And then turning back to paragraph 41, Dr. 9 Smith determined that the cause of death of asphyxia 10 associated with multiple traumatic injuries. 11 Am I right that you did not express any 12 concern to Dr. Smith about his conclusion on the cause of 13 death in this case in view of his abnormal findings? 14 DR. DAVID CHIASSON: No, I don't recall 15 having spoken to him about any concerns about the cause 16 of death in this case. 17 MS. ERICA BARON: Can you now turn to 18 Volume III, Tab 60. This is PFP117781. 19 And it appears to be a proposal put 20 together by Dr. Becker. And I acknowledge that you may 21 or may not have seen this document before because the 22 received stamp doesn't tell us very much about who it was 23 received by. 24 Do you recall whether you've ever seen 25 this document before -- before now?

1 DR. DAVID CHIASSON: I -- I -- not until 2 I was preparing for testimony have I ever seen this 3 document before, no. 4 MS. ERICA BARON: And you -- you've now 5 had a chance to look at this document? 6 DR. DAVID CHIASSON: I have, yes. 7 MS. ERICA BARON: And am I right that -- 8 that Dr. Becker is essentially making the case for why 9 pediatric forensic pathology belongs at the Hospital for 10 Sick Children? 11 DR. DAVID CHIASSON: Well, I think he's 12 making a case for why the cases, which are medical and 13 sudden unexpected deaths, belong at the Hospital for Sick 14 Children. As I understand this report, is that he -- 15 he's proposing that the traumatic deaths, homicides, 16 criminally suspicious deaths, should be done at the 17 Coroner's Office. 18 MS. ERICA BARON: So let me put this to 19 you: This -- would you agree with me that sudden 20 unexpected deaths are always -- raise the possibility of 21 some criminal involvement of some variety? 22 DR. DAVID CHIASSON: Correct. We -- we 23 treat all sudden unexpected infant deaths or deaths under 24 the age of five (5) as potentially suspicious. 25 MS. ERICA BARON: And I just want to read

1 to you a couple of passages and ask you whether you agree 2 with them. Dr. Becker writes: 3 "On the other hand, correctly 4 identifying medical diseases prevents 5 false accusations directed at parents 6 and families." 7 DR. DAVID CHIASSON: Sorry, can I -- 8 MS. ERICA BARON: That's on page 1. It's 9 the third paragraph, about five (5) -- five (5) lines 10 down. 11 DR. DAVID CHIASSON: I'm -- I'm with you 12 now, yes. 13 MS. ERICA BARON: So he says: 14 "On the other hand, correctly 15 identifying medical diseases prevents 16 false accusations directed at parents 17 and families." 18 Do you agree with that statement? 19 DR. DAVID CHIASSON: 100 percent. 20 MS. ERICA BARON: And he -- the last 21 sentence in that paragraph, he says: 22 "Often the reason for this aggressivity 23 [talking about the way parents of SIDS 24 cases are treated] is related to the 25 misinterpretation of autopsy finding by

1 pathologists not trained in recognizing 2 natural pediatric disease." 3 You also agree with that statement? 4 DR. DAVID CHIASSON: I do, yes. 5 MS. ERICA BARON: Then he goes on to say, 6 in the following paragraph: 7 "In children who have died suddenly and 8 unexpectedly and have been investigated 9 by the Coroner's Office, we have found 10 that 60 percent of cases have a medical 11 cause of death, 20 percent are due to 12 Sudden Infant Death Syndrome, 13 13 percent are accidental deaths and 7 14 percent are identified as homicidal or 15 other causes of death. Homicide/child 16 abuse of children under one (1) year of 17 age accounts for less than 1.5 percent 18 of deaths. 19 Without special pediatric pathology 20 expertise, this percentage could be 21 falsely elevated due to medical 22 diseases mimicking aspects of child 23 abuse. We have had several instances 24 of [quote] 'high suspicion' by the 25 Coroner's Office in cases that have

1 later turned out to be clearly of 2 metabolic origin. One (1) example is a 3 child who died of Menke Disease." 4 Does that generally reflect your -- at the 5 time and today, your -- your belief about the value of 6 having pediatric pathologists involved in investigating 7 these deaths? 8 DR. DAVID CHIASSON: Yes. I mean, I 9 think I've made clear that the importance of having 10 pediatric pathologists involved in a pediatric forensic 11 pathology unit, that that's very necessary. 12 And I concur that the -- the statistics 13 seem quite reasonable to me in terms of breakdowns. It - 14 - it coincides with my own statistical impressions and I 15 think this is very well put on the part of Dr. Becker. 16 MS. ERICA BARON: And you'd agree that by 17 the time this appears to have been dated in May of 1999, 18 Dr. Smith would have been doing a large portion of these 19 cases, these potentially criminally suspicious cases? 20 DR. DAVID CHIASSON: Correct. 21 MS. ERICA BARON: And I just want to take 22 you one (1) last sentence in the following paragraph. 23 It's about maybe ten (10) lines up from the bottom: "The 24 autopsy findings..." Starts right at the lefthand part 25 of the paragraph.

1 DR. DAVID CHIASSON: Yes, I'm -- 2 MS. ERICA BARON: 3 "The autopsy findings at the Hospital 4 for Sick Children are carefully 5 examined and scrutinized by our 6 clinical colleagues who attend autopsy 7 rounds at which time each and every 8 case is discussed in detail." 9 Do you agree that's an accurate 10 description of what happened at the clinical pathologic 11 rounds that you've told us about? 12 DR. DAVID CHIASSON: Yes. 13 MS. ERICA BARON: Now I want to contrast 14 Dr. Becker's view, which I think you've agreed with, with 15 a document from a period slightly later in time. It's in 16 Volume I at Tab 124. It's PFP136262. 17 DR. DAVID CHIASSON: Sorry, the tab 18 number again is...? 19 MS. ERICA BARON: It's 124. This is the 20 memo to you from Drs. Parai and Dr. Lee, in respect of 21 how pediatric forensic autopsies are going to be 22 conducted now that Dr. Smith has removed himself from 23 doing those autopsies. 24 Is it fair to say that Drs. Parai and Dr. 25 Lee were very trepidatious about getting into this area

1 of forensic pathology? 2 DR. DAVID CHIASSON: Yes. 3 MS. ERICA BARON: Indeed, they -- they 4 indicated that they were concerned that they didn't have 5 -- they didn't have the training and experience necessary 6 to recognize some of the issues that Dr. Becker had 7 identified in his -- in his document. 8 DR. DAVID CHIASSON: Correct. 9 MS. ERICA BARON: And they indicated that 10 they would need significant support if they were able to 11 do these autopsies. 12 DR. DAVID CHIASSON: Yes. 13 MS. ERICA BARON: Would it be fair to say 14 that while you are comfortable now as a forensic 15 pathologist working in a pediatric environment, that 16 there are and were many forensic pathologists who would 17 not be comfortable doing that kind of work? Forensic 18 pathologists. 19 DR. DAVID CHIASSON: Certainly, outside 20 of the environment, I wouldn't be comfortable doing what 21 I'm doing outside of the sort of environment I have at 22 the Hospital for Sick Children. So it goes without 23 saying there's lots of forensic pathologists and -- who 24 are -- who are uncomfortable with doing pediatric 25 forensic pathology cases for the very sorts of reasons

1 that are referred to in this memo. 2 MS. ERICA BARON: Would you agree that 3 even some forensic pathologists wouldn't even be 4 comfortable in the environment that you're practising in? 5 DR. DAVID CHIASSON: Yes. They may -- 6 they may not be comfortable in the environment I'm 7 practising in. I would suggest that there be -- they 8 could develop comfort and -- and do it more quickly, and 9 they're better off trying to get comfortable in -- in 10 kind of environment then they would be working in a -- 11 basically an adult environment. 12 MS. ERICA BARON: Okay. I want to turn 13 up one (1) last -- turn to one (1) last area of 14 questioning and I'm wondering if you -- I was to talk 15 about the review that Dr. Carpenter did of Dr. Smith's 16 non-criminally suspicious cases. 17 I think you told Ms. Rothstein that the 18 cases were selected randomly. Did you review the post- 19 mortem reports at all, or did you just pull six (6) files 20 out of the cabinet? 21 DR. DAVID CHIASSON: Oh no, I -- I 22 reviewed the post-mortem reports. The -- the -- random 23 in the sense that they were -- they were recent cases 24 that had been completed and recently received and they 25 were more or less in sequence. However, I -- I wanted to

1 make sure that there was at least one (1) trauma case in 2 -- in the group, so that they weren't all SID-like -- 3 SIDS-like deaths. 4 So it wasn't completely random. But I did 5 review the reports to get a flavour for what the report 6 looked like and -- and that was what was sent to Dr. 7 Carpenter. 8 MS. ERICA BARON: Did you feel able to 9 even take a guess at whether his opinion as to cause of 10 death was reflective of the findings? 11 DR. DAVID CHIASSON: I -- in the cases 12 that I -- I sent to Dr. Carpenter, I didn't identify any 13 -- any major issues myself. 14 MS. ERICA BARON: But I want to 15 understand. You didn't -- you didn't take things out 16 where you thought, this one doesn't look like it's going 17 to pass; I'm going to take it out of the pile? 18 DR. DAVID CHIASSON: No. In fact, if I'd 19 found something that I thought was problematic in that -- 20 in that pile, I would have been inclined to send it to 21 Dr. Carpenter, but I did not. 22 MS. ERICA BARON: All right. I want to 23 turn now to Dr. Carpenter's letter back to you, and it's 24 PF -- sorry, it's Volume I, Tab 131. 25 COMMISSIONER STEPHEN GOUDGE: You're in

1 injury time. 2 MS. ERICA BARON: I think I have -- I 3 think I have three (3) minutes, and that's all -- 4 COMMISSIONER STEPHEN GOUDGE: Fair 5 enough. 6 MS. ERICA BARON: -- and that will all -- 7 that will be all -- 8 COMMISSIONER STEPHEN GOUDGE: Fair 9 enough, three (3) minutes, Ms. Baron. 10 MS. ERICA BARON: -- that I use. 11 12 CONTINUED BY MS. ERICA BARON: 13 MS. ERICA BARON: All right, it's 14 PFP115206. I just want to read to you what he says 15 having reviewed these cases. In the first paragraph 16 about the middle: 17 "In all cases the quality of the gross 18 description, gross photographs, gross 19 sampling from microscopy and 20 microscopical descriptions were of the 21 highest quality, above average for what 22 is expected from the average pathology 23 service. Highly accurate and without 24 obvious omissions." 25 And then at the end:

1 "The causes of death were short and to 2 the point. I personally agreed with 3 all of the diagnosis and causes of 4 death. The addition of notations in 5 some of the cases was useful in fulling 6 -- fully understanding the underlying 7 pathology processes." 8 I take it that based on this you had no 9 concerns at all about Dr. Smith's competence to perform 10 non-criminally suspicious work? 11 DR. DAVID CHIASSON: Yes. 12 MS. ERICA BARON: Indeed, Dr. Carpenter 13 gave you confidence that Dr. Smith was eminently 14 qualified to do the work? 15 DR. DAVID CHIASSON: Yes. I mean at no 16 point did we have reason to believe that his work in the 17 non-criminally suspicious forensic cases was a problem. 18 We -- we didn't have any reason to suspect that -- Dr. 19 Carpenter in his review clearly confirms that there were 20 no -- at least -- agreeing that this is a selected review 21 of cases, but certainly there's nothing in here. 22 In fact, it's a -- it's a commendation of 23 the work Dr. Smith was doing in this set of cases. 24 MS. ERICA BARON: It was glowing, I would 25 -- I would put to you?

1 DR. DAVID CHIASSON: You could call it 2 that way, yes. 3 MS. ERICA BARON: Okay. Thank you, those 4 are my questions. 5 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 6 Baron. 7 Mr. Wardle...? 8 9 CROSS-EXAMINATION BY MR. PETER WARDLE: 10 MR. PETER WARDLE: Good morning. 11 DR. DAVID CHIASSON: Good morning. 12 MR. PETER WARDLE: Dr. Chiasson, I'm 13 Peter Wardle, and I act for a number of families and I'm 14 just going to give you, as I've given all the witnesses, 15 the -- the names of the -- of the deceased children who's 16 families -- and in one (1) care -- in one (1) case, a 17 caregiver, I act for. 18 So they're Nicholas, Jenna, Sharon, 19 Athena, and Tyrell. 20 DR. DAVID CHIASSON: Thank you, Mr. 21 Wardle. 22 MR. PETER WARDLE: I want to start if I 23 can with some general questions going back to your 24 examination the other day on accountability and oversight 25 of the OF -- OPFPU. And you told My Friend, Ms.

1 Rothstein, that when you became Chief Forensic 2 Pathologist, it wasn't clear what your relationship was 3 with that unit. Do you recall saying that to her? 4 DR. DAVID CHIASSON: Yes. 5 MR. PETER WARDLE: And that there was 6 nothing defined in any of the contracts, and I think, by 7 that, you were referring not just to the OPFPU but also 8 the Regional units, correct? 9 DR. DAVID CHIASSON: Correct. 10 MR. PETER WARDLE: And that 11 accountability seemed to be to the Chief Coroner rather 12 than to the Chief Forensic Pathologist. 13 DR. DAVID CHIASSON: In the contract, 14 certainly, there's no mention of the Chief Forensic 15 Pathologist. 16 MR. PETER WARDLE: And we know, of 17 course, that the unit at Sick Kids was set up before your 18 arrival, right? 19 DR. DAVID CHIASSON: Correct. 20 MR. PETER WARDLE: And that was an 21 initiative of Dr. Young and Dr. Philips, and we've heard 22 about that from other witnesses. 23 DR. DAVID CHIASSON: Yes. 24 MR. PETER WARDLE: And we've also heard 25 that Dr. Hillsdon Smith was not really involved in that

1 initiative. 2 DR. DAVID CHIASSON: Correct. That's my 3 understanding. 4 MR. PETER WARDLE: So it would appear 5 that at the time you were hired and when there was a 6 change in the line-reporting for the Chief Forensic 7 Pathologist, so that you reported up to the Chief 8 Coroner, rather than the way it had been under Dr. 9 Hillsdon Smith's tenure. 10 At that point, when that change was made, 11 there was no thought given or, you know, it was left 12 unclear what your relationship was with this unit at Sick 13 Kids. Is that fair? 14 DR. DAVID CHIASSON: That's fair, yes. 15 MR. PETER WARDLE: Okay. And is it fair 16 to say, as well, that for practical purposes, Dr. Smith 17 continued to report -- if he reported to anyone, to Dr. 18 Cairns and Dr. Young? 19 DR. DAVID CHIASSON: Yes, I think that's 20 fair. 21 MR. PETER WARDLE: Okay. So in other 22 words, you had no direct oversight role. And you've told 23 us about the steps you started to take over time, but 24 putting you -- when you arrived, you wouldn't have 25 thought yourself as having a direct oversight role over

1 the Unit? 2 DR. DAVID CHIASSON: I -- I think that -- 3 well, I -- I had -- I understood my position to have 4 responsibilities for overseeing, in a general way, all 5 the autopsies in the provinces. And so I mean, I had 6 some role to play in oversight, but a specific oversight 7 role where Dr. Smith was accountable to me for pathology, 8 I did not feel that way. I didn't sense that degree of 9 oversight. 10 MR. PETER WARDLE: You didn't sense it, 11 and you couldn't find it in a document. It just didn't 12 exist anywhere, is that fair? 13 DR. DAVID CHIASSON: No, certain -- 14 certainly there was no documentation of any role between 15 me and -- and any of the units including the OPFPU. 16 MR. PETER WARDLE: And you've also told 17 us -- and a number of the questions from other counsel 18 have been directed to this -- you didn't, at the time, 19 feel truly comfortable doing pediatric forensic 20 autopsies, correct? 21 DR. DAVID CHIASSON: Correct, correct. 22 MR. PETER WARDLE: You didn't feel you 23 were an expert in that area the way you understood Dr. 24 Smith was an expert? 25 DR. DAVID CHIASSON: Correct.

1 MR. PETER WARDLE: And you said to My 2 Friend, Ms. Rothstein that until 1997, you were content 3 that he take the lead in pediatric forensic cases working 4 directly with Dr. Jim Cairns. 5 Do you recall saying that? 6 DR. DAVID CHIASSON: Yes. That -- that 7 pediatric foren -- he -- he would be doing the pathology 8 and Dr. Cairns, with his roles and the Pediatric Review 9 Committee, would sort of take carriage of the pediatric 10 forensic pathology side of -- 11 MR. PETER WARDLE: And then, as I 12 understand it, you began to put in place these quality 13 assurance mechanisms over a period of time -- not just 14 with respect to the Sick Kids unit, but with respect to 15 the Regional units and your own unit in Toronto, right? 16 DR. DAVID CHIASSON: Well, certainly my 17 own unit started very quickly and then provincial 18 initiatives in -- starting in 1995, yes. 19 MR. PETER WARDLE: And then as I 20 understand it, about 1997, as you start to have concerns 21 about a couple of specific issues relating to Dr. Smith - 22 - first his workload and matters that we would call 23 administrative in nature -- you began to try to assert 24 oversight a little more directly. 25 Is that fair?

1 DR. DAVID CHIASSON: I think that's fair, 2 yes. 3 MR. PETER WARDLE: Okay. Can -- can I 4 just sort of -- just stopping there -- and then I'm going 5 to have some more specific questions -- that there were 6 some -- right from the outset, there were some pretty 7 obvious barriers to your ability to exercise oversight 8 and the first one was that Dr. Smith was an acknowledged 9 expert in the field and you were not at that time. 10 Correct? 11 DR. DAVID CHIASSON: Correct. 12 MR. PETER WARDLE: And the second was 13 that as you've told us, Dr. Smith tended to feel that you 14 were junior to him. In other words, he wasn't very open 15 in accepting any input you had. Is that fair? 16 DR. DAVID CHIASSON: I think that's fair, 17 yes. 18 MR. PETER WARDLE: And as we've discussed 19 there was no line-reporting between you and him. 20 DR. DAVID CHIASSON: Clearly not. 21 MR. PETER WARDLE: And finally, is it 22 also fair to say that he was used to dealing directly 23 with your superiors, Dr. Cairns and Dr. Young? 24 DR. DAVID CHIASSON: Well, he clearly had 25 a relationship with them that preceded my tenure.

1 MR. PETER WARDLE: And just for a moment, 2 I want to contrast that with the situation that exists 3 today. And I'm not going to take you to the details, but 4 there is a -- an agreement in place between Hospital for 5 Sick Children and the Ontario Chief Coroner's Office that 6 was drafted in 2004 and has been repeated annually since 7 then? 8 DR. DAVID CHIASSON: Yes. 9 MR. PETER WARDLE: And you're familiar 10 with that document? 11 DR. DAVID CHIASSON: I am. 12 MR. PETER WARDLE: And just for the 13 Commissioner's reference, it's -- I have -- there are a 14 number of these, Commissioner, but the one (1) I have 15 noted is March of 2006, 117 -- PFP117987. And I won't 16 ask the Registrar to turn it up. 17 But that spells out today, in great 18 detail, the relationship between the unit and the Office 19 of the Chief Coroner, doesn't it? 20 DR. DAVID CHIASSON: It -- it spells it 21 out in detail, yes. 22 MR. PETER WARDLE: And -- and to a level 23 that's satisfactory to you, obviously? 24 DR. DAVID CHIASSON: Well, I think 25 there's still some room for -- for massaging the -- the

1 document. For example, the reporting structure -- I 2 mean, I'm still -- as I understand the document, I don't 3 think this has changed, it's -- the accountability is 4 still to the Chief Coroner. 5 The Chief Forensic Pathologist is not -- 6 doesn't form part of that document. 7 MR. PETER WARDLE: You're anticipating me 8 a couple of questions, but one (1) of the things this 9 does -- this document does deal with is it spells out the 10 responsibility of the Director of the unit, correct? 11 DR. DAVID CHIASSON: It does that, yes. 12 MR. PETER WARDLE: And it also spells out 13 the responsibility of the Chief Coroner in connection 14 with the unit, correct? 15 DR. DAVID CHIASSON: Correct. 16 MR. PETER WARDLE: And what is left 17 unclear, at this point, is the role of the Chief Forensic 18 Pathologist? 19 DR. DAVID CHIASSON: It's not referred to 20 in the document, that's correct, yes. 21 MR. PETER WARDLE: Okay. So let me just 22 walk you through quickly a number of the documents 23 dealing with oversight, and I want to start with Volume 24 I, Tab 14. And this is PFP117913. 25

1 (BRIEF PAUSE) 2 3 MR. PETER WARDLE: And is it fair to say 4 that, up to this point in time, the unit at Sick Kids was 5 somewhat isolated from your unit, the Toronto Forensic 6 Pathology Unit? 7 And this was one (1) of the first steps to 8 try to bring the two (2) together in some fashion? 9 DR. DAVID CHIASSON: Yes, I think that -- 10 that's fair. I mean, I did have a number of meetings 11 with Dr. Becker and -- before this, and we were having -- 12 well, the rounds at Sick Kids, forensic path -- so -- so 13 there were lines of -- being opened, lines of 14 communication, lines of interaction were being open. 15 This is, sort of, the first, more 16 administrative, document -- documentation of -- of 17 changes, yes. 18 MR. PETER WARDLE: And this document 19 clearly signals that you wanted Dr. Smith to be available 20 to do the more complex cases, correct? 21 DR. DAVID CHIASSON: Correct. 22 MR. PETER WARDLE: But it also sends out 23 a bit of message, doesn't it? It says in the middle of 24 the first paragraph: 25 "This implies that your work schedule

1 allows you the time to perform forensic 2 autopsies in a comprehensive manner, 3 generate the necessary documentation, 4 and testify in court as required." 5 And just stopping there. You were 6 beginning to have concerns at this point, as I understand 7 it, just about the fact that Dr. Smith was so busy and 8 was having difficulty fulfilling some of these 9 administrative tasks? 10 DR. DAVID CHIASSON: Well, I -- I was 11 having concerns about turnaround time, I think, by -- by 12 this time. And I -- I was aware that he had 13 responsibilities to the hospital in -- in clinical 14 pathology, and that if, in fact, he was going to assume 15 more complicated cases that he, in fact, needed the time 16 within his work schedule to be able to do this. 17 MR. PETER WARDLE: And, of course, as 18 you've just discussed with My Friend, Ms. Baron, you -- 19 you can see here, you're inviting him to attend at the 20 Coroner's Office for morning rounds? 21 DR. DAVID CHIASSON: Yes. 22 MR. PETER WARDLE: And that was, I 23 gather, something that Dr. Smith did do for some period 24 of time? 25 DR. DAVID CHIASSON: Early on, following

1 this memo, he did attend, but it didn't last very long. 2 MR. PETER WARDLE: And just going on then 3 in the documents a little further to Volume I, Tab 27. 4 I'm sorry, Volume I, Tab 21; this is PFP096526. 5 6 (BRIEF PAUSE) 7 8 So this is a little bit about a more 9 formal nature now -- we have a meeting with you, Dr. 10 Smith, Dr. Becker, Dr. Cairns, and Dr. Lucas, do you see 11 that? 12 DR. DAVID CHIASSON: Yes. 13 MR. PETER WARDLE: And you're outlining a 14 number of the problems which include Triage Communication 15 Delayed reports. 16 DR. DAVID CHIASSON: Yes. 17 MR. PETER WARDLE: And by this time, 18 you've done the audit of a limited number of cases, and 19 that's referred to in this document. 20 DR. DAVID CHIASSON: Yes. 21 MR. PETER WARDLE: Okay. And then just 22 going down to the bottom it's got under "Followup": 23 "All autopsy reports from the pediatric 24 FPU to be reviewed upon receipt ongoing 25 audit."

1 Did that, in fact, take place? 2 DR. DAVID CHIASSON: No. 3 MR. PETER WARDLE: Okay, and -- and why 4 not? 5 6 (BRIEF PAUSE) 7 8 DR. DAVID CHIASSON: I -- I'm not sure 9 why it didn't take place. I -- I think that the 10 evolution was such that by the end of the year, we're 11 talking about actually bringing the cases over, or, at 12 least, a significant number of the cases over. 13 I don't recall why the actual -- the audit 14 wasn't ongoing. It's not that -- you know, we continued 15 -- I continued to monitor the situation and -- and things 16 were evolving as far as how to best deal with the 17 pediatric cases, but for whatever reason, the formal 18 auditing did not continue. 19 MR. PETER WARDLE: Let me step back a 20 little bit, if I can, and ask why you were considering 21 this at this point in time? 22 DR. DAVID CHIASSON: Well, I think it's 23 in the context we did -- we did an audit, we found some 24 issues, and we're going to monitor the -- the issues. 25 And I guess if I had sensed that things were improving --

1 well, in fact, I don't know whether all -- all the 2 reports were -- were, perhaps, not audited, but in fact, 3 we did do another audit prior to re-visioning. 4 Part of the documentation, I think, makes 5 reference to turnaround times actually getting worse, so 6 obviously, there was some degree of auditing. I don't 7 remember getting all of the pediatric reports in a -- on 8 an ongoing fashion, but we did -- I -- I obviously did 9 some more auditing down the road, although perhaps not in 10 the way it's suggested in this document. 11 MR. PETER WARDLE: So the evolution of 12 this, Doctor, is that, you know, March of '98, you have 13 these concerns outlined here, and then in the balance of 14 the year, the situation with respect to that one (1) 15 issue, turnaround times, actually worsened, correct? 16 DR. DAVID CHIASSON: Yes, yes. 17 MR. PETER WARDLE: And by the end of the 18 year, you were starting to plan this re-visioning 19 proposal. 20 DR. DAVID CHIASSON: Correct. 21 MR. PETER WARDLE: Okay. And so if we 22 look a little further, and I won't take you through this 23 -- I think My Friend, Ms. Rothstein has -- if we look at 24 Tab 27, PFP056292, that's really your summary of where 25 you were at that point in time and the need for something

1 a little more radical in nature in terms of dealing with 2 the issues, correct? 3 DR. DAVID CHIASSON: Correct. And if you 4 look at the memorandum in the third paragraph -- or 5 second paragraph down from the letter -- or the numbered 6 items, it starts with "It is now over six months", and at 7 the end of that, it makes reference to the fact that the 8 turnaround time for reports has increased. 9 MR. PETER WARDLE: And did you get the 10 support you wanted from senior management with respect to 11 this proposal? 12 DR. DAVID CHIASSON: I did not get any 13 objection to pursuing this pathway; no voiced objection 14 to taking this road. 15 MR. PETER WARDLE: Well, let me put it 16 another way. You know, were Dr. Young and Dr. Cairns, 17 you know, advocating this with you or were they simply 18 silent on the issue? 19 DR. DAVID CHIASSON: Well, I think I was 20 the one advocating the position; they weren't, as I said, 21 objecting. I mean, I -- I explained it to them. This 22 memorandum is obviously directed to Dr. Young. 23 I never got any response one way or the 24 other for that matter, but, I mean, I think it was clear 25 to me I was proceeding along this -- this pathway.

1 And Dr. Young was -- I worked under the 2 assumption, as I did with most of my work. I would 3 propose something; I would go along there. If he didn't 4 object, I was going to continue on, so. 5 MR. PETER WARDLE: And I want to take you 6 to another document I don't think we have looked at yet, 7 and this is Volume I, Tab 31, and it's PFP056815. 8 And now we're a little further along; 9 we're now into April 1999, so this is about the time 10 you've told us that you became involved in the Nicholas 11 case and the Sharon case. And this is really a -- again, 12 an attempt by you to table this re-visioning proposal, 13 correct? 14 DR. DAVID CHIASSON: Yes. 15 MR. PETER WARDLE: And I want to take -- 16 just take you to the last -- second page. And this is a 17 document that I, actually mistakenly, put to Dr. McLellan 18 a few weeks ago. 19 But first of all, this, as I understand 20 it, was your attempt to draft a job description for the 21 Director of the unit? 22 DR. DAVID CHIASSON: Yes. I think this 23 was pursuant to the meeting -- the initial meeting we had 24 with Dr. Becker to tell him about the re-visioning 25 document. I think one (1) of the -- the -- what came out

1 of that meeting -- one (1) of the things that came out of 2 that meeting was we needed a job description for the 3 Director in the context of this re-revision document, and 4 this is what I prepared. 5 MR. PETER WARDLE: So, I want to just go 6 through three (3) or four (4) of these bullets, and I 7 want to just leave the first bullet for the moment and 8 start with the second, third and fourth bullets. 9 Am I right that, first of all, the bullet: 10 "Supervises and provides consultative 11 support for all pathologists at HSCOCC 12 in matters of pediatric forensic 13 pathology." 14 That was your understanding of what you 15 thought Dr. Smith's responsibilities included at that 16 time, correct? 17 DR. DAVID CHIASSON: Yes. 18 MR. PETER WARDLE: And similarly with the 19 next bullet, "Responsible...". 20 DR. DAVID CHIASSON: Well, to be -- to be 21 completely clear. This makes reference to all 22 pathologists at HSC and OCC. It was my expectation that 23 the pathologist at HSC in his current -- at that time 24 current position would have been to -- to do that. In 25 this case, we're -- since he's coming over, we're

1 incorporating our -- 2 MR. PETER WARDLE: Right. 3 DR. DAVID CHIASSON: -- pathologists into 4 that, so. 5 MR. PETER WARDLE: So let me just -- let 6 me just make sure I've got that clear. 7 You thought, at the time, he had 8 responsibility for supervision and consultative support 9 for the pathologists at Hospital for Sick Children. The 10 proposal envisaged that he would do that for pediatric 11 cases for the Office of the Chief Coroner as well, 12 correct? 13 DR. DAVID CHIASSON: As well, yes. 14 MR. PETER WARDLE: And then -- 15 DR. DAVID CHIASSON: Correct. 16 MR. PETER WARDLE: -- similarly with 17 respect to the next two (2) bullets, in terms of his 18 existing responsibilities, you understood that he did 19 have some responsibility for quality control assessment 20 at the Unit at the Hospital for Sick Children, correct? 21 DR. DAVID CHIASSON: Yes. I -- I felt 22 all the Directors -- that was part of their 23 responsibility. 24 The -- how much that was actually done 25 wasn't clear to me, but that was the expectation and it

1 had been conveyed that that was the expectation. 2 MR. PETER WARDLE: So, in terms of -- 3 COMMISSIONER STEPHEN GOUDGE: Who 4 conveyed that expectation? 5 DR. DAVID CHIASSON: I conveyed it to 6 the -- 7 COMMISSIONER STEPHEN GOUDGE: Oh, I see. 8 DR. DAVID CHIASSON: -- Directors of -- 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 DR. DAVID CHIASSON: -- the units. 11 12 CONTINUED BY MR. PETER WARDLE: 13 MR. PETER WARDLE: So, in terms of Dr. 14 Smith's existing job functions at that point in time, and 15 appreciating he wasn't your employee, is it fair to say, 16 Dr. Chiasson, that you thought that as Director of the 17 unit, he had some oversight responsibilities for the 18 people working in his unit on forensic cases? 19 DR. DAVID CHIASSON: Yeah, that -- that 20 was my -- not only with the pediatric unit -- that was my 21 philosophy or approach as far as any Director; otherwise, 22 why are you a Director? 23 MR. PETER WARDLE: And if we can just 24 look at one (1) additional document just to -- I'm going 25 to ask you to turn up Volume I, Tab 10, and then we'll

1 come back to this document, if we may. That is 2 PFP056934. 3 And this is a letter written by Dr. Wilson 4 when you were inviting applicants for that position as a 5 regioner -- Regional Coroner's Pathologist. 6 DR. DAVID CHIASSON: Yes. 7 MR. PETER WARDLE: And if you look at the 8 bottom of the first page, you'll see Dr. Wilson says: 9 "As you know, I am one (1) of four (4) 10 staff pathologists at the Hospital for 11 Sick Children in Toronto who are 12 members of the Pediatric Forensic 13 Pathology Unit. I would be pleased to 14 continue as a staff pathologist in this 15 unit under the supervision of Dr. 16 Charles Smith." 17 And that suggests to me that the doctors 18 who worked with Dr. Smith in this unit understood that he 19 had some supervisory responsibility for their work in 20 coroner's cases. 21 DR. DAVID CHIASSON: Certainly, in the 22 case of Dr. Wilson, that's obviously true, yes. 23 MR. PETER WARDLE: So -- and then coming 24 back to where we were, Volume I, Tab 31. The job 25 description on the second page -- the major change for

1 you, as well as having Dr. Smith directly involved with 2 cases at OCCO, would be that he would have to be -- 3 report to and accountable directly to you, correct? 4 DR. DAVID CHIASSON: Correct. 5 MR. PETER WARDLE: And that, of course, 6 is -- is something that never took place, for the reasons 7 that you outlined in your evidence the other day. 8 DR. DAVID CHIASSON: Correct. 9 MR. PETER WARDLE: Okay. And is it fair 10 to say that up until the point when you left that 11 position as Chief Forensic Pathologist, there never was 12 actually anything in writing clarifying Dr. Smith's 13 responsibilities or his, you know, reporting within the 14 Office of the Chief Coroner. 15 There was never a document -- nobody was 16 ever successful in getting a document finalized 17 outlining, you know, his reporting? 18 DR. DAVID CHIASSON: That's correct, and 19 -- and to put it in perspective, neither was there ever 20 any similar initiative in regards to the other units, 21 either. 22 MR. PETER WARDLE: And I won't take you 23 through this, but, you know, with specific cases that 24 we've heard about, like Nicholas, and perhaps to a lesser 25 extent, the Jenna case, Dr. Smith appears to have been

1 dealing with the Deputy Chief Coroner, Dr. Cairns, 2 sometimes dealing directly with the Regional Coroners, 3 and there are cases where you simply weren't in the loop, 4 is that right? 5 DR. DAVID CHIASSON: That's correct. 6 MR. PETER WARDLE: Okay. And looking 7 back in retrospect, it probably would have been helpful 8 in those cases had you been in the loop more directly. 9 DR. DAVID CHIASSON: Correct. 10 MR. PETER WARDLE: Just a few questions 11 about reviews of post-mortem reports, and I know a number 12 of other people have covered this, but -- 13 COMMISSIONER STEPHEN GOUDGE: Before you 14 go to that, Mr. Wardle, did you ever discuss with Dr. 15 Young your view of Dr. Smith's quality assurance 16 responsibilities for the pathologists at the unit, 17 because you had two (2) very, very different views? 18 DR. DAVID CHIASSON: Yes, I -- I 19 understand that. I don't know that I -- I didn't have a 20 formal discussion with Dr. Young. I -- I would attend 21 the Regional Coroner's meetings on a regular basis with a 22 broad range of discussions. 23 I strongly suspect I would have made my 24 opinion in regards to that -- 25 COMMISSIONER STEPHEN GOUDGE: Did you

1 know Dr. Young thought this was purely an administrative 2 position? 3 DR. DAVID CHIASSON: Well, I -- I 4 understood he testified to that -- that effect. I'm not 5 exactly sure what is meant by purely administrative. 6 COMMISSIONER STEPHEN GOUDGE: It meant no 7 responsibility for quality assurance. 8 DR. DAVID CHIASSON: Well, I mean that -- 9 COMMISSIONER STEPHEN GOUDGE: Did you 10 know that at the time? 11 DR. DAVID CHIASSON: No. I mean, I -- I 12 didn't -- I -- it certainly wasn't my impression, as I've 13 just testified, and I'm -- I am surprised that the Chief 14 Coroner would have thought that somehow the -- the 15 Directors of the Units were simply there for 16 administrative reasons, whatever that meant. 17 COMMISSIONER STEPHEN GOUDGE: All right, 18 thanks. 19 20 CONTINUED BY MR. PETER WARDLE: 21 MR. PETER WARDLE: So just a few 22 questions about reviews, and I want to just try and make 23 sure I clarify, at least for myself, the different forms 24 of reviews and perhaps, we can do this to some extent 25 without documentation.

1 First, as I understand it, in the Toronto 2 Unit, in about June of 1995, you asked, in writing, that 3 all reports be submitted to you before they were 4 completed, correct? 5 DR. DAVID CHIASSON: No, I think it may 6 even be before '95. I don't recall exactly when I 7 instituted that, but fairly soon after I started, I 8 started reviewing -- 9 MR. PETER WARDLE: It's actually -- I'll 10 clarify, it's January 30, 1995, and it's Volume I, Tab 4. 11 And what it says is -- and I -- and I won't turn it up, 12 but it simply says: 13 "Each completed report of post-mortem 14 examination is submitted to me for 15 individual review prior to being 16 released." 17 DR. DAVID CHIASSON: Yes, and -- and I 18 agree it's dated then, but this had already been in 19 place. I'm -- I'm giving Dr. Cairns a bit of a progress 20 report about what's going on, so this actually started 21 very shortly after I -- 22 MR. PETER WARDLE: Okay. 23 DR. DAVID CHIASSON: -- assumed my role 24 in April of '94. 25 MR. PETER WARDLE: And once you took your

1 role on and decided to do this, you started automatically 2 looking at about fifteen hundred (1,500) reports a year, 3 as I understand it? 4 DR. DAVID CHIASSON: Yeah, it's a little 5 bit less than that, and I wasn't looking at my -- re- 6 looking at my own reports, so -- but, you know, over a 7 thousand (1,000) cases -- 8 MR. PETER WARDLE: All right. And you 9 did all of that initially yourself and then as time went 10 on, you began to get a little bit of help, as I 11 understand it? 12 DR. DAVID CHIASSON: Well, as -- as staff 13 pathologists, we started to circulate the peer reviews in 14 the department. 15 MR. PETER WARDLE: And then as I 16 understand it, if we go to Volume I, Tab 83, and this is 17 PFP129358. This is a memo to all pathologists and 18 coroners in the province? 19 DR. DAVID CHIASSON: Yes. 20 MR. PETER WARDLE: So this would include 21 Dr. Smith and anyone within his unit? 22 DR. DAVID CHIASSON: Yes. 23 MR. PETER WARDLE: And it asks that all 24 post-mortem examinations on, what we would call, 25 criminally suspicious deaths are to be forwarded to the

1 Regional Coroner for referral to the Office of the Chief 2 Coroner for review prior to release by the Crown 3 attorney's office, correct? 4 DR. DAVID CHIASSON: Correct. 5 MR. PETER WARDLE: And I take it that 6 there was a reason for picking criminally suspicious 7 cases. You were -- you, I assume, had in mind the 8 complexity of those cases and the potential problems that 9 could arise in those cases? 10 DR. DAVID CHIASSON: Yes, we've had 11 problems within the Criminal Justice System, correct. 12 MR. PETER WARDLE: All right. And that 13 lead to more reports coming to your attention, as I 14 understand it, is that fair? 15 DR. DAVID CHIASSON: Yes. 16 MR. PETER WARDLE: Another how many? 17 DR. DAVID CHIASSON: Well, the number of 18 homicides in the province around this was two hundred/two 19 hundred and fifty (200/250). You know, it took a little 20 while to get them all coming through or the majority 21 coming through. 22 We were already doing about eighty (80) or 23 ninety (90) in the unit, so I was already reviewing 24 those. But -- so a hundred and fifty (150) maybe. 25 MR. PETER WARDLE: Okay. I want to take

1 you to one (1) document that's in Volume III, Tab 61. 2 And the PFP number for this is 112584. And this, as I 3 understand it, is an internal hospiter -- Hospital for 4 Sick Children document, correct? 5 DR. DAVID CHIASSON: That's what it looks 6 like, yes. 7 MR. PETER WARDLE: And the top part of it 8 deals with hospital cases, and the bottom part of it 9 deals with coroner's cases, on the first page? 10 DR. DAVID CHIASSON: Yes, ML would stand 11 for medicolegal. 12 MR. PETER WARDLE: And the date of this 13 one appears to be some time in 1998, do you see that? 14 DR. DAVID CHIASSON: Yes. 15 MR. PETER WARDLE: And towards the bottom 16 under final distribution it has a little hand: 17 "If homicide highly suspicious, Dr. 18 Smith takes to Dr. Chiasson." 19 You see that? 20 DR. DAVID CHIASSON: Yes. 21 MR. PETER WARDLE: And I take it that's 22 really coming out of the directive that we just looked 23 at; that here's something formalized saying that this 24 report should go to your office before it's actually 25 delivered?

1 DR. DAVID CHIASSON: Yes. 2 MR. PETER WARDLE: Okay. And am I right 3 that that didn't always happen as a matter of routine? 4 DR. DAVID CHIASSON: No. Well, there's 5 certainly select cases we know it didn't happen, yes. 6 MR. PETER WARDLE: And -- and again, 7 we're not -- I'm not here to cast blame on you. I think 8 it's pretty obvious that you were taking a number of 9 steps to try to address quality assurance. But cases 10 slip through the system. 11 One (1) way they slip through the system, 12 I think you've already identified, was if the case was a 13 consultation rather than a post-mortem report? 14 DR. DAVID CHIASSON: Correct. 15 MR. PETER WARDLE: And another it might 16 slip through, for example in the Sharon case, was if the 17 report was very late? 18 DR. DAVID CHIASSON: Yes. 19 MR. PETER WARDLE: Am I right that the 20 Forensic Pathology Case Review -- what other people have 21 called the "Checkmark Review", is actually different then 22 what we've just been looking at? 23 DR. DAVID CHIASSON: And I'm not sure 24 what you're referring to as the forensic pathology case-- 25 MR. PETER WARDLE: Okay. I'm going -- I'm

1 going to turn one up and look at -- ask you to look at 2 Volume II, Tab 3. 3 And my question is, and maybe after this 4 point all of should understand this, but is this actually 5 a different type of review than what we just looked at, 6 or is it the same? 7 DR. DAVID CHIASSON: No, it is the same. 8 MR. PETER WARDLE: All right. 9 DR. DAVID CHIASSON: This -- this is -- I 10 would do the review and if I was happy with the review, I 11 would fax this to the Regional Coroner so that he knows 12 the review's completed, and he's able to release the 13 report outside of the -- the system. 14 If I had comments, I'd make a reference. 15 I'd usually email some comments, or if I held it back I 16 would indicate that. But if -- if I was content with the 17 report, then this is what would go to the Regional 18 Coroner. 19 COMMISSIONER STEPHEN GOUDGE: And is this 20 the same form you used for all the TFPU reports you've -- 21 DR. DAVID CHIASSON: The TFPU reports, I 22 -- I simply reviewed them. 23 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 24 DR. DAVID CHIASSON: If I had an issue, I 25 would just go to the pathologist --

1 COMMISSIONER STEPHEN GOUDGE: Yes, you 2 didn't fill out -- 3 DR. DAVID CHIASSON: I didn't fill out 4 one (1) of these. 5 COMMISSIONER STEPHEN GOUDGE: So this is 6 for the criminally suspicious from around the Province? 7 DR. DAVID CHIASSON: That's right. The - 8 - the one's that came out of my office -- I indicated to 9 the Regional Coroner, if it comes out of my office, I've 10 reviewed it already. So that -- that was fine. That was 11 -- I -- I don't think I ever from my -- the cases coming 12 out of my office, did I ever create this specific 13 document. 14 15 CONTINUED BY MR. PETER WARDLE: 16 MR. PETER WARDLE: So as -- as we 17 understand it, once you'd created this additional level 18 of oversight, you had not only the reports flowing in 19 from your own unit, but the one's across the Province, 20 and of course including pediatric cases that would be 21 coming from Sick Kids and presumably elsewhere? 22 DR. DAVID CHIASSON: Homicide and 23 criminally suspicious cases only, in regard to the 24 latter, yes. 25 MR. PETER WARDLE: All right. And so the

1 total number of reviews you would be conducting in a 2 given year would be how many do you think? 3 DR. DAVID CHIASSON: Well, I mean, when I 4 was doing both the -- the office by myself and -- and the 5 -- the external stuff, I guess we're well over a thousand 6 (1,000) -- twelve hundred/thirteen hundred (1,200/1,300) 7 maybe, reports I've been looking at. 8 MR. PETER WARDLE: So just stopping there 9 and just thinking about the systemic issues that arise 10 out of this process and realizing as you've told -- told 11 us, before you did this, there was nothing. So I think 12 we all understand that. 13 But can I suggest that, you know, the 14 deficiencies in this approach, looking back in hindsight: 15 1) you're one (1) individual, your time was limited, you 16 were doing the bulk of this yourself, correct? 17 DR. DAVID CHIASSON: Correct. I was -- I 18 was the only one doing these reviews, except in the 19 unusual circumstance -- well, I did take vacations. I 20 had a colleague who would assume that responsibility if I 21 was going to be away for any extended period of time. 22 But I -- I did, myself, all of the 23 external ones. And -- and I think to put it into a bit 24 of context, the degree of reviewing of the -- the cases 25 in the Coroner's -- in the Coroner's Office, in the unit

1 there, was not the same degree of review. 2 I mean, I -- I was reviewing pathologists 3 who I got to know very quickly. And -- and a review in 4 that case may have been simply looking at the bottom 5 line, looking at the summary, and thank you very much. 6 So I -- I don't -- I don't mean to imply 7 that I -- I spent all my time, you know, reviewing 8 reports. Clearly I'd -- I was doing other things. But 9 this review was -- was a -- this was more detailed and 10 more -- obviously -- 11 MR. PETER WARDLE: Mm-hm. 12 DR. DAVID CHIASSON: -- more care because 13 of the nature of the cases as opposed to simply reviewing 14 a heart attack case and -- at a coroner's office. 15 MR. PETER WARDLE: I guess my point was a 16 pretty simple one, Dr. Chiasson. You had limits on your 17 time, and you were a one (1) man review team, if I can 18 put it that way. 19 DR. DAVID CHIASSON: Yes, certainly, yes. 20 MR. PETER WARDLE: All right. And as 21 we've already heard, you -- you didn't look at 22 photographs or histology; presumably you didn't have time 23 to look at those. 24 DR. DAVID CHIASSON: I think that -- that 25 would have added a whole dimension of -- of time, and

1 complexity, in the sense that photographs in those days 2 weren't digital; it's not getting a cd. You know, it's - 3 - it's -- you sometimes come up with a bunch of 4 photographs like that which is, you know, it's 5 logistically problematic so -- and obviously time 6 consuming. 7 MR. PETER WARDLE: And is it fair to say 8 as well, that -- that your lack of expertise at the time 9 with pediatric cases may have played some role in the -- 10 your ability to provide oversight in this way in those 11 cases? 12 DR. DAVID CHIASSON: Yes. 13 MR. PETER WARDLE: And finally, there are 14 the gaps that we've talked about; just the -- the system 15 didn't make sure that all the reports always went to you, 16 correct? 17 DR. DAVID CHIASSON: Correct. 18 MR. PETER WARDLE: Okay. I just want to 19 ask a few questions if I may about your evidence 20 regarding Sharon's case and -- in the time I have 21 remaining, and ask you to turn up the overview report at 22 Volume II, Tab 13. 23 24 (BRIEF PAUSE) 25

1 MR. PETER WARDLE: And first of all, as I 2 understand it, aside from becoming aware that day that 3 the autopsy was taking place, you had no role in the 4 original autopsy and you had no discussions with Dr. 5 Smith about the autopsy, you know, either before or in 6 the period immediately after it was concluded? 7 DR. DAVID CHIASSON: That's correct. I 8 don't recall having any discussion with Dr. Smith about 9 this particular matter. 10 MR. PETER WARDLE: And with respect to 11 Dr. Wood's involvement, you've told us how you were 12 instrumental in getting Dr. Wood started as a consultant 13 to the Office of the Chief Coroner, correct? 14 DR. DAVID CHIASSON: He may have actually 15 started before I got there but I certainly, if you will, 16 nourished -- nurtured his career development in this 17 particular area and encouraged him and supported him. 18 MR. PETER WARDLE: I take it you weren't 19 the person who got him involved in this specific case? 20 DR. DAVID CHIASSON: I was not, no. 21 MR. PETER WARDLE: And do you know today 22 how he got involved in the case? 23 DR. DAVID CHIASSON: From my review of -- 24 of the documents, and I'm not sure where I saw this, but 25 I think it was Dr. Bechard, the Regional Supervising

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1 Coroner, Eastern Ontario, who in a discussion with the 2 Crown attorney suggested involving Dr. Wood. 3 And it's -- this is a -- I can -- refer 4 you to the Tab, et cetera, but it's a document -- it's a 5 document from I think it was Jennifer Ferguson, the 6 Assistant Crown attorney to Mr. McKenna, her boss, about 7 the Sharon case. 8 MR. PETER WARDLE: That's in the overview 9 report, Commissioner, at paragraph 109. 10 COMMISSIONER STEPHEN GOUDGE: Thank you. 11 12 CONTINUED BY MR. PETER WARDLE: 13 MR. PETER WARDLE: And I just want to ask 14 you a few questions about the process leading up to the 15 exhumation and I'd ask you, Doctor, to turn to Volume II, 16 Tab 21, and it's PFP080863. 17 DR. DAVID CHIASSON: That's Tab 21, Mr. 18 Wardle? 19 MR. PETER WARDLE: Correct. And if you 20 will turn, if we could, to the fourth page of this 21 document. 22 COMMISSIONER STEPHEN GOUDGE: What is 23 this, Mr. Wardle? 24 MR. PETER WARDLE: This is the 25 application for the exhumation, Mr. Commissioner.

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1 COMMISSIONER STEPHEN GOUDGE: Thank you. 2 3 CONTINUED BY MR. PETER WARDLE: 4 MR. PETER WARDLE: And you'll see there's 5 an affidavit, Dr. Chiasson, that starts at the fourth 6 page, and the date of that affidavit is April 19, 1999. 7 So this is approximately two (2) months after the meeting 8 that Dr. Cairns and Dr. Young went to in New York that 9 they've told us about in their evidence -- 10 DR. DAVID CHIASSON: Yes. 11 MR. PETER WARDLE: -- just to orient you. 12 And Detective Bird, you may remember, was one of the 13 officers from the Kingston Force who was involved in this 14 investigation. 15 DR. DAVID CHIASSON: Yes. 16 MR. PETER WARDLE: And if we turn to 17 paragraphs 9 through 13, you'll see he outlines some 18 information about Dr. Smith's post-mortem examination. 19 DR. DAVID CHIASSON: Yes. 20 MR. PETER WARDLE: And at the very bottom 21 of paragraph 13, you'll see there's a reference to 22 casting procedures. 23 24 (BRIEF PAUSE) 25

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1 DR. DAVID CHIASSON: Yes. 2 MR. PETER WARDLE: And then going over a 3 little further to paragraphs 18 and following, you'll see 4 that the affidavit now starts to track what you've told 5 us about. And in paragraph 18 it says: 6 "That as a matter of due course, Deputy 7 Chief Coroner for the Province of 8 Ontario, Dr. James Cairns, and Chief 9 Forensic Pathologist, Dr. David 10 Chiasson, of the Forensic Pathology 11 Unit, reviewed Dr. Charles Smith's 12 original post-mortem reports." 13 And then over the page, you'll see it 14 says: 15 "And they -- that they felt that the 16 wound description as provided by Dr. 17 Smith's report was somewhat unclear to 18 them; that they met and discussed the 19 matter with Dr. Smith. It was learned 20 that the cast of the wounds prepared by 21 Dr. Smith were no longer available." 22 I'm just stopping there. Do you recall 23 that around sometime between Dr. Cairns and Dr. Young 24 coming back from the American Academy meeting and you 25 going down to Kingston to meet with the police, that you

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1 actually had an opportunity to look at the post-mortem 2 report? 3 DR. DAVID CHIASSON: Yes, I -- I expect I 4 would have as part of the review process. 5 MR. PETER WARDLE: And -- and do you 6 recall that, at the time, you had some concerns about the 7 description of some of the injuries? 8 DR. DAVID CHIASSON: I did. I thought 9 the internal wound tracks were not well-defined. 10 MR. PETER WARDLE: And do you recall also 11 having some concerns about the fact that these supposed 12 stab wounds -- the depth of the wounds was not actually 13 delineated in many cases? 14 DR. DAVID CHIASSON: Correct. 15 MR. PETER WARDLE: Which you would have 16 expected as a forensic pathologist, correct? 17 DR. DAVID CHIASSON: Yes. In a stab 18 wound, you -- you part -- or you describe and document 19 the external aspects of the wound but you also want to 20 document the tracks and what -- 21 COMMISSIONER STEPHEN GOUDGE: By "tracks" 22 you mean the depth of the wound? 23 DR. DAVID CHIASSON: Well, the -- the 24 wound track is the -- 25 COMMISSIONER STEPHEN GOUDGE: The path it

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1 takes in it? 2 DR. DAVID CHIASSON: -- passage -- the 3 path -- the path, which direction, but also what 4 structures are being affected by -- as the -- 5 COMMISSIONER STEPHEN GOUDGE: I see. 6 DR. DAVID CHIASSON: -- weapon is being 7 inserted into the body. So you would -- you would define 8 this as going through muscle. It's then going through 9 the rib cage. It's going through the heart. And you 10 would define -- 11 COMMISSIONER STEPHEN GOUDGE: I see. 12 DR. DAVID CHIASSON: -- it in a way 13 that's continuous. 14 15 CONTINUED BY MR. PETER WARDLE: 16 MR. PETER WARDLE: And as I understand it 17 as well, if an injury actually hit bone, you would want 18 to incise that injury to the extent you could and take 19 samples, correct? 20 DR. DAVID CHIASSON: Well, the -- the 21 ideal, yes, would be to actually excise the bone -- 22 MR. PETER WARDLE: Sorry. "Excise." 23 DR. DAVID CHIASSON: -- yeah. "Excise." 24 Take it out -- that bone -- with the -- the area of 25 damage. So that if there is a weapon recovered, there's

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1 a potential to compare the nature of the bone injury to 2 the weapon. 3 MR. PETER WARDLE: And -- 4 DR. DAVID CHIASSON: Weapon matching -- 5 MR. PETER WARDLE: And that hadn't been 6 done in this case, correct? 7 DR. DAVID CHIASSON: The bones had not 8 been retained, no. 9 MR. PETER WARDLE: And am I right, as 10 well, that you did have an opportunity to look at the 11 photographs? 12 DR. DAVID CHIASSON: I did, yes. 13 MR. PETER WARDLE: And that from your 14 review of the photographs, it looked to you as if some of 15 the wounds, at least, could be dog bites? 16 DR. DAVID CHIASSON: Well, as I've 17 indicated, my experience with dog bites was -- was 18 limited at that extent, and I was unclear in my mind as 19 to whether these were dog bites or whether in fact they 20 were stab wounds. 21 There was certainly many, many injuries; 22 they weren't all stab wounds by the nat -- surface 23 injuries were clearly not all stab wounds. 24 MR. PETER WARDLE: Is it fair to say, as 25 well, that you and others had some concern about the fact

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1 that Dr. Smith had prepared these casts and that they 2 were no longer available? 3 DR. DAVID CHIASSON: Well, it's always of 4 concern when you lose samples of any nature; a cast 5 sample. 6 I think, though, the ideal in a 7 circumstance like this, rather than try to cast an injury 8 would be to, in fact, retain the bone. Retain. If 9 there's an injury to the skull, you retain that part of 10 the skull; that, to me, is the preferable way and then 11 you can have whoever you're going to have to analyse it 12 actually, have that specimen available to them. 13 MR. PETER WARDLE: Is it fair to say, as 14 well, that at this point, this was from your experience, 15 a somewhat unprecedented situation in the sense that, you 16 know, you had this case which had gone along the criminal 17 track for a certain point. 18 Now you've heard, anecdotally, through 19 this meeting in the US that, you know, prominent people 20 in the field were raising concerns about it. You'd 21 looked at the report yourself. You had some concerns 22 about it. 23 And you had these, you know, two (2) -- 24 two (2) fairly prominent experts, Dr. Ferris on the one 25 (1) side and Dr. Smith on the other. And that would have

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1 been unprecedented in your experience? 2 DR. DAVID CHIASSON: Well, I don't know 3 unprecedented, but it was certainly unusual to have such 4 a dispairing opinion. 5 I mean, you get -- you get opinions 6 varying, but obviously the -- the significance of -- if 7 these injuries are dog bites versus stab wounds is -- is 8 very -- very much extreme in terms of any criminal 9 proceeding. 10 So that -- that was unusual; that such a - 11 - a diversity of opinion. 12 MR. PETER WARDLE: And to be fair, it 13 wasn't just Dr. Smith versus Dr. Ferris, as you've told 14 us about the meeting you attended. There were other 15 people within your organization who were supporting Dr. 16 Smith's opinion; Barry Blenkinsop and Dr. Woods, as I 17 understand it? 18 DR. DAVID CHIASSON: Correct, yes. 19 MR. PETER WARDLE: Okay. So let's just 20 go forward to the second autopsy. And as I understand 21 it, you told us that you were the pathologist of record, 22 using that term, I think, loosely, but...? 23 DR. DAVID CHIASSON: Well, I mean, I -- I 24 was in charge, -- 25 MR. PETER WARDLE: Okay.

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1 DR. DAVID CHIASSON: -- put it that way, 2 and the pathologist in charge. There were three (3) 3 pathologists in attendance and two (2) forensic 4 odontologists, as well, in attendance, but I was the one 5 that was conducting the procedure. 6 MR. PETER WARDLE: And you were not 7 rendering a review of the original material. You told My 8 Friend, Ms. Rothstein, that, correct? 9 DR. DAVID CHIASSON: No, I -- I mean, my 10 intent, at that time, was to procure samples for which we 11 could do further analysis. That was the -- that was the 12 reason for the exhumation. And I produced a report that 13 addressed that the issue related to what we learned from 14 these samples. 15 And it certainly, in large part, depended 16 upon Dr. Wood's evaluation that, ultimately, I made the 17 conclusions I did. 18 MR. PETER WARDLE: And your report wasn't 19 intended, as I understood your evidence the other day, to 20 be any kind of a global opinion on the cause of death or 21 manner of death, is that correct? 22 DR. DAVID CHIASSON: That's correct. I - 23 - I decided to restrict my report of second post-mortem 24 examination to a report of second post-mortem 25 examination; not to be offering any global opinion about

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1 the nature of the case. 2 MR. PETER WARDLE: Okay. Let's just have 3 a look at one (1) document, if we might, in Volume II, 4 Tab 24, and it's PFP088115. Now, the exhumation was in 5 July of 1999, so this is now November, do you see that? 6 DR. DAVID CHIASSON: Yes. 7 MR. PETER WARDLE: And this is a letter 8 from the assistant Crown attorney on the case to one (1) 9 of the defence counsel acting for Ms. Reynolds. And it 10 deals with disclosure of the application for 11 disinterment. And you'll see there's a long paragraph at 12 the bottom of the first page. It says: 13 "As you know, Sergeant Bird, Constable 14 Barrett, and I met with Drs. Chiasson 15 and Wood on October 26th, 1999." 16 Do you remember having that meeting at 17 some point in the fall of 1999 with a Crown and some 18 police officers in connection with this case? 19 DR. DAVID CHIASSON: I have a vague 20 recall. I mean, I'm certainly -- I'm sure I was there. 21 MR. PETER WARDLE: 22 "Dr. Chiasson indicated that he 23 believes the x-rays from the first 24 post-mortem are currently missing, 25 although they did not reveal anything

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1 worthy of noting." 2 Just stopping there. Is that your 3 recollection that, in fact, Dr. Smith had been unable to 4 locate the x-rays? 5 DR. DAVID CHIASSON: Yes. I'm -- I'm not 6 clear in my mind -- normally if a post-mortem's done in 7 our facility, we keep the x-rays in-house, but this was a 8 case where he -- he probably took them back to have his 9 pediatric radiologist review the case. 10 So that's -- it's not our standard 11 protocol here. And at -- as indicated there, and I think 12 we -- we could not find the x-rays, at that time. 13 MR. PETER WARDLE: And then you'll see 14 the next sentence he also confirmed that: 15 "He was unable to offer an opinion on 16 issues requiring examination of the 17 tissue of the deceased since the tissue 18 was missing at the second autopsy." 19 And that's really what you explained to us 20 about the decomposition process the other day? 21 DR. DAVID CHIASSON: Correct. 22 MR. PETER WARDLE: I want to just take 23 you to the next sentence: 24 "He confirmed that there were many 25 penetrating wounds and described the

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1 manner as undetermined." 2 And -- and I'm assuming manner refers to 3 manner of death? Do you recall making a statement to 4 that affect in this meeting? 5 DR. DAVID CHIASSON: No, and I -- I 6 suspect that this is not manner of death; it's not what 7 is being referred to there. I wouldn't have rendered an 8 opinion as to manner of death. I may have rendered an 9 opinion as to, I don't know what exactly is causing these 10 wounds, and therefore undetermined nature, but I -- I 11 think manner is not being used in the -- in the way 12 manner of death is -- is meant to imply. 13 MR. PETER WARDLE: Do you recall if you 14 gave the Crown or the police at this time your own view 15 as to what you thought the cause of death and -- and the 16 -- given what you had now reviewed? 17 DR. DAVID CHIASSON: Well, if -- I assume 18 by this time I have finalised my report and Dr. Wood has 19 finalised his report. I'm -- I'm trying to put it into 20 the context of -- 21 MR. PETER WARDLE: Yes, I think -- I 22 think we can see that from the overview report. If you 23 need the dates -- let me just find you the dates. 24 DR. DAVID CHIASSON: Or what -- what I 25 need to know is whether my report was completed at that

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1 time. I think it was. 2 MR. PETER WARDLE: I'm just going to find 3 it. Dr. Wood's report is dated September 13, 1999 and 4 your report was dated September 30, 1999. 5 DR. DAVID CHIASSON: Okay. So this is 6 the 10th of November, so clearly I -- I've done my report 7 and you've seen that and that's -- we're discussing that 8 report. And based on that report, it's clearly that 9 there's evidence of dog injury to the body. 10 Whether I was asked whether all the 11 injuries could be attributable to dog bites or not, I 12 don't recall whether I was asked that. And I suspect I - 13 - given my level of comfort and expertise in the whole 14 issue, I probably wasn't -- did not give a definitive 15 opinion one way or the other -- another, and that may be 16 where this undetermined -- may be part of the 17 undetermined issue as to whether there could have been 18 something other than dog bite injuries. 19 MR. PETER WARDLE: I guess what I'm 20 getting at is this: Are -- are you confident that the 21 Crown and the police understood the limits of your 22 opinion after the second autopsy? 23 DR. DAVID CHIASSON: Well, I -- I -- when 24 I'm issuing a report in a second post-mortem examination, 25 being aware -- I mean, I -- I try to be as clear as I

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1 possibly can as to what I'm doing. This isn't a standard 2 report of post-mortem examination format that -- 3 MR. PETER WARDLE: Right. 4 DR. DAVID CHIASSON: -- I'm using and my 5 opinion at the end is not -- I'm not rendering an opinion 6 as to the cause of death, which you would normally do; 7 I'm rendering an opinion as to the results of the 8 findings and -- and ultimately that -- yes, there is 9 evidence of dog injury to the bones that are -- that have 10 been demonstrated. 11 And I -- I am being, I think -- I think 12 I'm being clear about that, and that's -- that's the 13 extent of the opinion. 14 MR. PETER WARDLE: No, and I understood 15 you to say the other day you were being conservative in 16 that you felt to some extent this was outside your area. 17 DR. DAVID CHIASSON: Well, arguably, 18 whether it's outside my area or not, but as a forensic 19 pathologist, dog bite injuries would be within the area, 20 but it's an -- it's a specific issue where I didn't -- 21 not have a lot of personal experience. And certainly in 22 dealing with children having dog -- potentially dog bite 23 injuries, that was not -- 24 MR. PETER WARDLE: Right. 25 DR. DAVID CHIASSON: -- an area that I

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1 had any experience with -- 2 MR. PETER WARDLE: Right. 3 DR. DAVID CHIASSON: -- at that time. 4 MR. PETER WARDLE: And I'm not trying to 5 put you on the spot here, but I just -- I just -- 6 thinking about what happens later and just thinking about 7 the systemic issues that arise from this case, you know, 8 you've told us that really at that point there were sort 9 of two (2) solitudes: there was Dr. Farris, the defence 10 pathologist who you knew and there was Dr. Smith, and -- 11 and, you know, there was this divide between them, 12 correct? 13 DR. DAVID CHIASSON: Correct. 14 MR. PETER WARDLE: And -- and everybody 15 was dug in at that point. 16 DR. DAVID CHIASSON: It would appear to 17 be, yes. 18 MR. PETER WARDLE: Okay. And -- and the 19 impression I got from your evidence was that not only 20 you, but others at the Chief Coroner's Office at this 21 point, were content to let the criminal process unwind to 22 its conclusion, if I can put it that way, given that 23 that's where you were. 24 DR. DAVID CHIASSON: I -- I think that's 25 fair, yes.

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1 MR. PETER WARDLE: Okay. And have you 2 thought in retrospect that perhaps your office might have 3 had a different obligation, given what had come out of 4 the second autopsy, that maybe that would have been an 5 opportunity for something to take place, some dialogue, 6 some further attempt to get to the bottom of things, 7 rather than let the case simply just, you know, proceed 8 on its way through the system? 9 DR. DAVID CHIASSON: I -- I think that 10 there certainly, in retrospect -- there was an 11 opportunity to -- to revisit everything from a forensic 12 pathology point of view, and to consider the possibility 13 of having a -- another forensic pathologist look at this 14 case, a third, to see what kind of opinion they could 15 come out of. 16 I think one (1) of the issues that we were 17 waiting to sort out -- and so even at this time there was 18 still this issue of some injuries to the bones that 19 weren't defined. And I certainly -- the way this 20 unfolded was, we needed to define what those injuries 21 are. 22 So then we -- we eventually get Dr. Symes 23 involved in -- in that and that took some more time. And 24 I think that was important, because if in fact there was 25 evidence of sharp force objects --

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1 MR. PETER WARDLE: Mm-hm. 2 DR. DAVID CHIASSON: -- that were non- 3 related to the autopsy, were in fact found on the skull, 4 then the Crown -- you know, that would have obviously had 5 an impact on -- on how the Criminal Justice System would 6 have dealt with it. 7 So when all of that was done, and after 8 Dr. Symes' report was received at that time -- and I 9 think we're now several months down the road still -- to 10 have, Okay, should we be looking at this case, and 11 getting in the -- and my suggestion would have been -- 12 not that there weren't enough consultants and experts 13 involved in this -- was to facts -- find somebody else to 14 say, you know, What -- what do you think? 15 MR. PETER WARDLE: So one (1) of the -- 16 one (1) of the systemic issues then that -- I don't want 17 to put words into your mouth, but we've seen this come up 18 in a number of cases. There may be a need for some kind 19 of guidance as to when in a case like this that has some 20 controversy, and when people are well dug in, you go 21 outside, and how quickly you do it, and you know, there 22 doesn't appear to have been any formal guidance for you 23 to go to in this case, correct? 24 DR. DAVID CHIASSON: Well there's -- 25 there's no format. I mean, we did it with Nicholas, so

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1 it's not something that -- that was unheard of. And, I 2 mean, a lot of these cases would have probably been 3 resolved earlier on if I, as the forensic pathologist, 4 was -- was comfortable rendered -- rendering an opinion 5 one way or the other. 6 You know, that -- that would have been -- 7 I guess in some ways, ideal. But I certainly respect 8 that -- or -- you know, I have limits to my areas -- 9 MR. PETER WARDLE: Absolutely. 10 DR. DAVID CHIASSON: -- of -- of 11 expertise, and we certainly have demonstrated we would go 12 outside, and I think in -- in the Sharon Case, that that 13 could have expedited the unfolding of -- of the matter 14 from a Criminal Justice point of view. 15 MR. PETER WARDLE: All right. 16 DR. DAVID CHIASSON: I think that's a 17 very reasonable suggestion. 18 MR. PETER WARDLE: Thank you, sir. Those 19 are all my questions. 20 DR. DAVID CHIASSON: You're welcome. 21 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 22 Wardle. We'll take our morning break now and be back at 23 11:50 and we'll commence with you, Mr. Sokolov. 24 25 --- Upon recessing at 11:35 a.m.

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1 --- Upon resuming at 11:51 a.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Mr. 6 Sokolov...? 7 8 CROSS-EXAMINATION BY MR. LOUIS SOKOLOV: 9 MR. LOUIS SOKOLOV: Thank you. Good 10 morning, Mr. Chiasson, my name -- Dr. Chiasson, excuse me 11 -- my name is Louis Sokolov, and I'm counsel to AIDWYC in 12 this Inquiry. 13 DR. DAVID CHIASSON: Good morning, Mr. 14 Sokolov. 15 MR. LOUIS SOKOLOV: The -- the issue that 16 I'd like to probe with you this morning in my time, 17 concerns the Ottawa Unit which you spoke to Ms. Rothstein 18 about on Friday. And I'd like to go into a little bit 19 more detail about the issues surrounding that unit, to 20 the extent that it may be instructive in understanding 21 how the Chief Coroner's Office responded generally to 22 performance issues among forensic pathologists. 23 The -- as I understand it, that was a 24 separate unit that started in 1994 prior to -- to you 25 becoming Chief Forensic Pathologist?

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1 DR. DAVID CHIASSON: Correct. 2 MR. LOUIS SOKOLOV: Dr. Johnston was 3 director of that unit, and you started having concerns 4 about the quality of his work fairly early on. 5 Is that fair? 6 DR. DAVID CHIASSON: Yes. 7 MR. LOUIS SOKOLOV: And the -- the number 8 of cases you reviewed with My Friend, Ms. Ritacca, 9 yesterday afternoon, approximately two hundred and fifty 10 (250) to three hundred (300) cases per year, were coming 11 out of that unit under Dr. Johnston. 12 Is that right? 13 DR. DAVID CHIASSON: I certainly wasn't 14 reviewing all of the cases coming out of the Ottawa Unit. 15 The numbers at that time period was 16 probably three hundred (300), maybe three hundred and 17 fifty (350). 18 MR. LOUIS SOKOLOV: All right. And of -- 19 of those, approximately 5 percent were homicides? 20 DR. DAVID CHIASSON: Well, as a general 21 rule you would expect 5 percent to be homicides. 22 MR. LOUIS SOKOLOV: Now, you spoke of a 23 number of cases yesterday, including the Dan Jones case. 24 DR. DAVID CHIASSON: I believe on 25 Friday --

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1 MR. LOUIS SOKOLOV: On Friday. 2 DR. DAVID CHIASSON: -- I spoke to that, 3 yes. 4 MR. LOUIS SOKOLOV: Mr. Registrar, could 5 you turn up PFP141787, which I believe is Volume III, Tab 6 5. And that's your handwritten notes, February 13, '96, 7 I think you identified the year there. 8 That's '96, correct? 9 DR. DAVID CHIASSON: It's ambiguous. 10 MR. LOUIS SOKOLOV: All right. 11 COMMISSIONER STEPHEN GOUDGE: It could be 12 anything from '92 to '97. 13 DR. DAVID CHIASSON: I -- I think it's 14 either '96 or '97. 15 16 CONTINUED BY MR. LOUIS SOKOLOV: 17 MR. LOUIS SOKOLOV: All right. The -- 18 now, you go through a number of points there. 19 First of all, who was this document to or 20 was it just a file memo? 21 DR. DAVID CHIASSON: It's a file -- it's 22 a file memo, it wasn't directed at anybody. 23 MR. LOUIS SOKOLOV: Now the most serious 24 concern appears to be under number 2, the one that you 25 star, that Dr. Johnston makes unwarranted conclusions.

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1 Would you agree with me that was your most 2 serious concern? 3 DR. DAVID CHIASSON: Yes. 4 MR. LOUIS SOKOLOV: And by that I took to 5 mean that he was getting fundamental questions of 6 forensic pathology wrong. 7 Is that -- is that what you meant by that? 8 DR. DAVID CHIASSON: Well, I -- I mean, 9 what I meant was that he was arriving at forensic 10 pathology conclusions that weren't supported by the 11 evidence that was being documented. 12 MR. LOUIS SOKOLOV: And you weren't just 13 talking about one (1) case, this was a conclusion that 14 you had drawn from a number of different cases? 15 DR. DAVID CHIASSON: Certainly, there was 16 a couple of cases where this was -- I had clearly 17 different opinions about his -- his conclusions. 18 MR. LOUIS SOKOLOV: But it wasn't just an 19 isolated case you were drawing about it -- it was -- this 20 was your general impression of what he was doing with his 21 reports? 22 DR. DAVID CHIASSON: Well, it wasn't all 23 of his reports that were -- you know, that he was making 24 unwarranted conclusions, but certainly in a select group 25 of his reports. A small number of his reports there were

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1 conclusions that I thought were unwarranted. 2 MR. LOUIS SOKOLOV: And would I be 3 correct that this would have given you a concern that his 4 reports could either wrongly inculpate people or wrong 5 exculpate people -- exculpate people? 6 DR. DAVID CHIASSON: Correct. 7 MR. LOUIS SOKOLOV: These concerns, I 8 take it, are concerns that you raised with Dr. Cairns and 9 Dr. Young as well? 10 DR. DAVID CHIASSON: Yes. 11 MR. LOUIS SOKOLOV: At or around that 12 time, 1996? 13 DR. DAVID CHIASSON: Yes. 14 MR. LOUIS SOKOLOV: And the concerns that 15 you had, were they just with respect to Dr. Johnston or 16 other people who were working under him in the Ottawa 17 Unit as well? 18 DR. DAVID CHIASSON: My major concerns 19 had to do with Dr. Johnston himself at that time. Yes. 20 MR. LOUIS SOKOLOV: Now when you raised 21 these -- 22 DR. DAVID CHIASSON: Oh, excuse me. No, 23 that's -- that's not true. That's incorrect. 24 There was another pathologist who I -- who 25 I was seeing issues of some -- some significance, so it

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1 wasn't just Dr. Johnston. 2 MR. LOUIS SOKOLOV: All right. And that 3 other pathologist, was that a Dr. Wenckebach? Is that-- 4 DR. DAVID CHIASSON: Correct. Dr. 5 Wenckebach. 6 MR. LOUIS SOKOLOV: And you raised those 7 concerns about this other pathologist with Dr. Cairns and 8 Dr. Young as well. 9 Would that be correct? 10 DR. DAVID CHIASSON: They -- they were -- 11 well, most of my, sort of, coroner's's contact with any 12 problems with the Ottawa Unit would have been the 13 Regional Coroner, Dr. Bechard, at that time. 14 Again, these would have been discussed in 15 the context of Regional Coroners' meetings and either 16 that or informally with Dr. Cairns and Dr. Young. So I 17 don't think there was any secret that there were issues 18 going on in Ottawa; secrets from -- that -- that Dr. 19 Young and Dr. Cairns were not aware of. 20 MR. LOUIS SOKOLOV: All right. Back 21 then, in 1996, just to -- to be clear about it -- the 22 concerns that you raised with Dr. Cairns and Dr. Young -- 23 you would have been clear that you had concerns about the 24 -- the fundamentals of forensic pathology that Dr. 25 Johnston was doing there.

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1 DR. DAVID CHIASSON: Yes. 2 MR. LOUIS SOKOLOV: Now, what was their 3 response to you in 1996, when you raised these issues? 4 DR. DAVID CHIASSON: Well, I was 5 informing them. I was letting them know what we were 6 doing; what we were attempting to do about it. We -- we 7 obviously met with Dr. Johnston; discuss how -- how these 8 issues might be addressed, so I kept them apprised of -- 9 of activities. 10 They -- I don't recall any specific 11 direction as to what to do. I assumed this to be part of 12 my mandate, my responsibility, and I -- I'm dealing with 13 it as best I can. 14 MR. LOUIS SOKOLOV: Well, and dealing 15 with -- dealing with it how, in terms of rehabilitating 16 his skills as a forensic pathologist or searching for a 17 new -- 18 DR. DAVID CHIASSON: Well, ultimate -- 19 ultimately, we meet with Dr. Johnston and suggest a plan 20 of remedial training; that he would spend time at the 21 Coroner's Office. 22 He, in fact, did spend a short amount of 23 time in the Coroner's Office early on -- I think it was 24 '94 or '95 -- but the -- the plan that was presented to 25 me, eventually, it was that he would spend a number of

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1 months there. 2 MR. LOUIS SOKOLOV: And -- and let's turn 3 up that memo to Dr. Young, which is PFP130640, which I 4 believe is at Volume III, Tab 13, of your materials. No, 5 130640, please, Mr. Registrar -- if you could. Thank 6 you. 7 So, by -- by this time that you have these 8 meetings, it's the end of January 1998, so it's two (2) 9 years into the process after your handwritten note. And 10 you write there, in the second paragraph, that your 11 concerns are really twofold; the first being his 12 performance as a forensic pathologist performing 13 autopsies, and the second as the Director of the Eastern 14 Ontario Forensic Pathology Unit. 15 Let me just deal with the second first. 16 Was there ever any discussion between you and Dr. Young 17 regarding the issue of him being a director, and Dr. 18 Young saying to you, Well, he's -- he just carries out 19 administrative duties only; that's not a particular 20 worry? 21 DR. DAVID CHIASSON: Dr. Young never 22 conveyed that opinion to me or that philosophy of -- 23 MR. LOUIS SOKOLOV: Did -- 24 DR. DAVID CHIASSON: -- what the director 25 did or didn't do.

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1 MR. LOUIS SOKOLOV: Did -- did you 2 understand Dr. Young to share your view as to what a 3 director did and the specific responsibilities? 4 DR. DAVID CHIASSON: Well, I -- I thought 5 we had a similar view. 6 MR. LOUIS SOKOLOV: All right. You talk 7 about, in this memorandum -- you -- you express the 8 concern in terms of urgency, is that fair? 9 DR. DAVID CHIASSON: Yes. Well, the 10 urgency was to recruit a new director; that was -- that 11 needed to be done urgently. 12 MR. LOUIS SOKOLOV: Because the problem 13 itself was an urgent problem. 14 DR. DAVID CHIASSON: In my view, yes. 15 MR. LOUIS SOKOLOV: And you -- you said 16 on Friday that there was no written response to this 17 memorandum. 18 DR. DAVID CHIASSON: From Dr. Young, no. 19 MR. LOUIS SOKOLOV: There were some 20 verbal conversations. 21 DR. DAVID CHIASSON: Yes. Again, I'm 22 sure we discussed this. Again, it would have been 23 discussed in the context of Regional Coroner's meetings 24 and -- and within the Office. 25 MR. LOUIS SOKOLOV: And just to put a

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1 little bit more meat on those verbal discussions, did you 2 get any sense of whether or not your belief in urgency 3 was shared by Dr. Young? 4 DR. DAVID CHIASSON: I don't know -- I 5 don't know -- I don't remember him ever conveying that or 6 -- or suggesting that -- that from his point of view. I 7 -- I -- again, this, I felt, to be part of my mandate as 8 the Chief Forensic Pathologist. This was my problem to 9 try to deal with as best I could. 10 I was carrying the ball, so to speak. I 11 thought it was urgent and nobody was slowing me down, so 12 it's exactly what Dr. Young and how he felt and how 13 urgent he felt, I really don't know. 14 MR. LOUIS SOKOLOV: All right. So -- so 15 you say that nobody was slowing you down in -- in dealing 16 with this, but were you getting support that you required 17 to deal with this? 18 DR. DAVID CHIASSON: Well, I was -- I was 19 pushing forth and -- and having meetings with Dr. Bechard 20 and -- and the people in Ottawa -- the -- in the hospital 21 and the department of pathology -- to try and push to 22 recruit somebody, which was our -- our major response to 23 this issue was to, in fact, replace Dr. Johnston with a - 24 - a director who -- who we thought we -- had had this -- 25 the right forensic pathology qualifications and

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1 administrative abilities. 2 MR. LOUIS SOKOLOV: And had Dr. 3 Johnston's skills as a forensic pathologist improved at 4 all between 1996 and 1998, to your mind? Had the quality 5 of the work that he was turning out gotten any better? 6 DR. DAVID CHIASSON: I -- well, it's -- 7 it's important to realize, I continued to review his PM 8 reports, and I would say with a heightened degree of -- 9 of care. And -- 10 COMMISSIONER STEPHEN GOUDGE: Just the 11 criminally suspicious? 12 DR. DAVID CHIASSON: Just the criminally 13 suspicious and homicide cases, although I did on 14 occasion, if -- if asked by the Regional Coroner -- if he 15 got a report and he wasn't clear, -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID CHIASSON: -- and there were 18 cases that were non-criminally suspicious that I did 19 review where he was rendering opinions where I -- I was 20 struggling to seeing where -- where he was coming from. 21 So even the non-criminally suspicious cases, I had 22 concerns. 23 So I continued to monitor -- I continued 24 to see problems. So I -- I didn't sense that there was 25 any major change in his approach to doing cases, and --

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1 and certainly, I didn't see any great signs of 2 improvement. 3 4 CONTINUED BY MR. LOUIS SOKOLOV: 5 MR. LOUIS SOKOLOV: And the reviews that 6 you conducted, those were the paper review, correct? 7 DR. DAVID CHIASSON: Yes, unless I found 8 something of particular concern -- 9 MR. LOUIS SOKOLOV: Right. 10 DR. DAVID CHIASSON: -- then I would do a 11 more detailed review. 12 MR. LOUIS SOKOLOV: The -- why then, not 13 remove him from doing forensic pathology altogether? 14 DR. DAVID CHIASSON: Well, it's -- it's 15 the ongoing recurring theme is that there's a shortage of 16 forensic pathologists, and so if we removed Dr. Johnston, 17 who's -- who's -- was doing a large number of cases who 18 was -- that was his role was to do forensic pathology. 19 To try to find other pathologists who were 20 not forensic pathologists -- it's not like there's a 21 whole coterie of forensic pathologists looking for jobs 22 at this time. There was just nobody -- nobody to take up 23 the slack. So to completely stop him from doing it would 24 have been -- created major human resource problems. 25 And suffice it to say, I don't think the -

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1 - the response to -- to someone not -- whose work is -- 2 is not up to par, let's say to -- to just let him go. I 3 mean, this was his -- his professional life right now was 4 doing forensic pathology. This obviously would have had 5 a devastating impact upon him on -- on his life to -- to 6 -- for us at the Coroner's Office to simply cut him off 7 of all cases. 8 COMMISSIONER STEPHEN GOUDGE: Was he 9 doing most of the criminally suspicious cases out of 10 Ottawa? 11 DR. DAVID CHIASSON: He was doing a 12 significant proportion. He -- he was working full-time 13 in the unit. There were -- there was another pathologist 14 working basically half time, and the rest of the 15 autopsies were doing -- were being done by a group of -- 16 of other pathologists. 17 COMMISSIONER STEPHEN GOUDGE: And I 18 assume they would have been the non-criminally suspicious 19 warrant cases? 20 DR. DAVID CHIASSON: That's right. So -- 21 so the -- Dr. Johnston or this 50 percent person would 22 have been doing the majority of the -- but not all 23 because part of the issue with Dr. Wenckebach was that he 24 wasn't a Regional Coroner's Pathologist, and he was doing 25 cases that were homicidal in nature.

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1 That was one (1) of my administrative 2 issues with Dr. Johnston. 3 4 CONTINUED BY MR. LOUIS SOKOLOV: 5 MR. LOUIS SOKOLOV: Just going back to 6 your last answer about why you -- you didn't remove him, 7 and I appreciate you didn't want to do anything that was 8 rash. 9 But by this time, by 1998, these issues 10 had been going on for years, and Dr. Johnston was, to say 11 the least, recalcitrant in his approach to you in 12 refusing to -- to change his practises? 13 DR. DAVID CHIASSON: Well, he may not 14 have thought he was being recalcitrant. All -- all I was 15 doing was reviewing his reports, and I was continuing to 16 have concerns about -- not to the level that I've had in 17 the past, but I still -- I mean, his -- his -- the way he 18 would issue -- do his reports was very similar; didn't 19 change significantly. 20 MR. LOUIS SOKOLOV: Was the issue of 21 removing him from doing these cases ever discussed with 22 Dr. Cairns and Dr. Young? 23 DR. DAVID CHIASSON: Well, certainly in 24 this memo, it's clear we're talking about getting -- not 25 getting -- to -- to remove him as Director. And I think

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1 that was -- that would have been our ideal approach -- is 2 for him to work under the supervision of somebody that we 3 had confidence in as a forensic pathologist. 4 And then to try -- if -- if it would have 5 continued on, obviously -- continued to be problems, then 6 we would deal with it. You know, it's a step-wise 7 approach to -- to dealing with a -- an employee or in 8 this case, not an employee, but somebody working for you 9 under -- under contractual arrangement, if you will, and 10 step-wise approach to try and -- and remediate the 11 situation. 12 And if -- if that doesn't work, then 13 you're -- you'll -- you'll increase the -- the nature of 14 the -- the response. That would be the... 15 MR. LOUIS SOKOLOV: Would it be helpful, 16 in the future, in situations such as this, to have a 17 explicit policy setting out the steps that should be 18 taken with forensic pathologists who don't meet basic 19 quality levels? 20 DR. DAVID CHIASSON: I think a first step 21 is to clearly delineate, and this is -- was among my 22 recommendations I -- that I didn't make specifically 23 yesterday -- but is to have the individuals who are 24 working as Directors of the unit to be accountable to the 25 Chief Forensic Pathologist, and that's clearly defined.

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1 This is -- this is the person to whom you 2 are accountable to when you are doing forensic pathology 3 work. And then you're -- you're -- that -- at least, 4 that part -- to me that's -- that's the primary step. 5 And then, if -- if things -- if you're not doing what 6 you're -- what you should be doing at the level that you 7 should be doing it, then obviously the Chief Forensic 8 Pathologist needs to take steps to deal with that. 9 To have a formal policy, -- I mean, we're 10 not talking about a large number of individuals, and in 11 all likelihood, the situations are going to be different 12 in different situations; you know, geographically or 13 whatever. 14 So the respon -- I mean, I don't think 15 there's -- there's anything that's going to set out a 16 basic; you know, this is what you do when you have a 17 problem, because the problems are going to be variable in 18 -- in extent. 19 But clearly, you need -- you need the 20 Chief Forensic Pathologist having the -- the power to 21 deal with the situation which clearly wasn't the 22 situation back in the late '90's. 23 MR. LOUIS SOKOLOV: Thank you. 24 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 25 Sokolov. Just let me ask you a couple of questions about

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1 taking it out of the Ottawa context, Dr. Chiasson. 2 In the future, going forward, if the Chief 3 Forensic Pathologist is the person to whom the Regional 4 Directors are accountable, and a problem like this were 5 to develop, you've clearly enunciated the systemic 6 concern about attempting to improve the, somewhat, 7 inadequate skills that might be observed. 8 At some point, is it worth considering 9 whether the Chief Forensic Pathologist or the Coroner's 10 Office has a responsibility to examine whether the 11 inadequacies that have been identified have caused 12 adverse impacts on the Criminal Justice System in 13 specific cases in the past, or is that someone else's 14 responsibility? 15 DR. DAVID CHIASSON: Well that's a -- 16 that's a big question obviously, and -- 17 COMMISSIONER STEPHEN GOUDGE: Just what's 18 your sense of that as the Chief Forensic Pathologist? 19 DR. DAVID CHIASSON: Well, I think the 20 Chief Forensic Pathologist, in case -- individual cases 21 come to his attention, then obviously, he has the 22 responsibility to deal with those on an individual basis. 23 To go back in and create or to have an 24 audit of -- of prior cases -- 25 COMMISSIONER STEPHEN GOUDGE: I mean, I'm

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1 not thinking of any particular schema to discharge that 2 responsibility -- 3 DR. DAVID CHIASSON: Okay. 4 COMMISSIONER STEPHEN GOUDGE: -- but 5 whether that's an aspect of the oversight that should be 6 expected of the Chief Forensic Pathologist; that is not 7 just ensuring that on a going-forward basis the pathology 8 skills are sufficient to do the -- 9 DR. DAVID CHIASSON: Mm-hm. 10 COMMISSIONER STEPHEN GOUDGE: -- job 11 properly in future cases, but should it be part of the 12 oversight responsibility of the Chief Forensic 13 Pathologist to, at least, have an eye to impacts that may 14 have occurred in individual cases in the past because of 15 the inadequate skill level? 16 DR. DAVID CHIASSON: I -- I think that's 17 a reasonable thing to consider to be within the purview 18 of the Chief Forensic Pathologist. Obviously, he can't 19 do the job by himself, and obviously, he would need to -- 20 to -- resources would be made -- 21 COMMISSIONER STEPHEN GOUDGE: Absolutely. 22 DR. DAVID CHIASSON: -- to -- to make him 23 avail of that. I mean, I think in large part, Dr. 24 Pollanen has -- has done that in -- in this case. He's 25 been a -- a driving force in this particular situation

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1 within the context of him being the Chief Forensic 2 Pathologist. 3 COMMISSIONER STEPHEN GOUDGE: Yes. In 4 this particular set of twenty (20) cases. Obviously, we 5 have an example of just that. What I'm getting at, is 6 systemically, and if that is to be an element of 7 oversight on the part of either the Chief Forensic 8 Pathologist or the Office of the Chief Coroner, sort of, 9 at what stage does it kick in? 10 And I know those are tough questions -- 11 DR. DAVID CHIASSON: Yes. 12 COMMISSIONER STEPHEN GOUDGE: But -- 13 DR. DAVID CHIASSON: Well, you know -- 14 COMMISSIONER STEPHEN GOUDGE: -- you've 15 worn the hat, and I just wonder how -- 16 DR. DAVID CHIASSON: Yeah. 17 COMMISSIONER STEPHEN GOUDGE: -- you feel 18 about having that as a part of your job description, in 19 effect? 20 DR. DAVID CHIASSON: Well, I mean, I 21 think that we want to build a system from the ground 22 level. And you know, if -- if we are, in fact, have the 23 resources at the ground level, we have appropriately 24 trained forensic pathologists. We have appropriate 25 accountability in place.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID CHIASSON: We have appropriate 3 qualified people in these roles that, hopefully, you 4 would never get the situation that I'd been faced with in 5 the '90's of having individuals showing, you know, such a 6 -- you know, hopefully this kind of thing would not recur 7 in -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. DAVID CHIASSON: -- in this setting. 10 But if it did, and assuming that the Chief Forensic 11 Pathologist isn't also trying to run a -- a -- a Toronto 12 Forensic Pathology Unit with -- with no staff or -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. DAVID CHIASSON: -- you know, staff 15 issues, and all of these other responsibilities. If -- 16 if you had your Chief Forensic Pathologist in a -- in a - 17 - in that role, and not, you know, with the -- a lot of 18 his other responsibilities delegated downward, I think 19 it's -- it's a reasonable thing for him, certainly, to be 20 involved in a process. 21 I don't know that he's the be-end and end- 22 all answer to what you would -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. DAVID CHIASSON: -- do. 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. DAVID CHIASSON: Obviously it's very 2 complex. 3 COMMISSIONER STEPHEN GOUDGE: Okay. 4 Thanks. Thanks, Mr. Sokolov. 5 MR. LOUIS SOKOLOV: Thank you. 6 COMMISSIONER STEPHEN GOUDGE: Ms. 7 Greene...? We will get to you, Ms. Silver. I know you - 8 - we'll go a little longer to finish you before lunch, if 9 I can put it that way. 10 11 CROSS-EXAMINATION BY MS. BREESE DAVIES: 12 MS. BREESE DAVIES: Good afternoon, Dr. 13 Chiasson. My name is Breese Davies. I'm counsel for the 14 Criminal Lawyers Association -- 15 COMMISSIONER STEPHEN GOUDGE: Sorry, Ms. 16 Davies, sorry. 17 MS. BREESE DAVIES: That's okay. I know 18 that I haven't been here yet -- 19 COMMISSIONER STEPHEN GOUDGE: Yes. 20 MS. BREESE DAVIES: -- so my first 21 appearance so to speak. 22 23 CONTINUED BY MS. BREESE DAVIES: 24 MS. BREESE DAVIES: I'm hopefully just 25 going to focus on the role of the forensic pathologist on

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1 -- in the Criminal Justice System and how we can make 2 some changes to make that better. 3 I have some general questions at the 4 beginning. Hopefully, these aren't controversial. I 5 think you'd agree with me that as a general principle, 6 the work that you do as a forensic pathologist should be 7 reviewable by other people? 8 DR. DAVID CHIASSON: Yes. 9 MS. BREESE DAVIES: And so somebody else, 10 be it another pathologist, a lawyer, a police officer, 11 should be able to look at your report and know precisely 12 what information you're relying on and how you came to 13 your opinion? 14 DR. DAVID CHIASSON: That's a different 15 question, but yes, obviously the report should be such 16 that it conveys what I'm looking at and the evidence upon 17 which I'm basing an opinion, yes. 18 MS. BREESE DAVIES: And you testified 19 earlier that you consider autopsy reports to be an 20 important communication tool with families of the 21 deceased, with the police and the coroners, correct? 22 DR. DAVID CHIASSON: Well, it's a form -- 23 it's a way forensic pathologists, if you will, 24 communicates his findings. And it isn't only to the 25 Criminal Justice System obviously, although that's the

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1 focus here. Many reports end up in the hands of 2 families. 3 MS. BREESE DAVIES: Right. But you would 4 agree with me that in formulating the report, you also 5 have to be mindful of making them useful to Crown 6 counsel, defence counsel and the courts, in criminally 7 suspicious cases? 8 DR. DAVID CHIASSON: Yeah. The -- the 9 reports need to be friendly, if you will, to a layperson. 10 It -- it should not be -- it needs to be detailed. It's 11 a medical document, so it has to have medical jargon. 12 But it should be prepared and created in a way that is 13 organized and -- and makes sense as to what his 14 conclusions are and why it's making the conclusions that 15 it's making. 16 MS. BREESE DAVIES: And it should also 17 act as somewhat of a forecast for any testimony you might 18 give in a criminal process down the road? 19 DR. DAVID CHIASSON: Well, it's -- it's 20 the basis of whatever testimony you're going to give. I 21 mean, it's -- it's -- the report should encompass all of 22 your findings. There shouldn't be -- and I -- I know 23 criminal defence lawyers always like to see the working 24 notes of the pathologist. 25 You know, my own practice is if it's in a

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1 working note, it ends up in the final report, if -- if 2 I'm making -- you know, there are no additional findings. 3 So it should be comprehensive in that way; and is the 4 table or the foundation upon which testimony will be 5 eventually given. 6 MS. BREESE DAVIES: Okay. And you've 7 testified that from your perspective, one (1) of the main 8 problems with Dr. Smith -- some -- one (1) of the main 9 problems -- that have been identified -- really arose 10 from his testimony in criminal trials, is that fair? 11 DR. DAVID CHIASSON: In -- in my 12 reviewing the expert reports and -- and the overview 13 reports, I think that's a major theme running through the 14 -- the cases -- is -- is what Dr. Smith said in court as 15 opposed to what was in his report. 16 MS. BREESE DAVIES: And often that 17 testimony and those problems related to opinions that 18 didn't have to do with the cause of death, per se, 19 correct? 20 DR. DAVID CHIASSON: Correct. 21 MS. BREESE DAVIES: And you agreed with 22 Mr. Campbell that the review mechanisms that you put in 23 place obviously didn't catch those problems? 24 DR. DAVID CHIASSON: No, if -- if he's 25 commenting on things outside of cause of death then, yes.

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1 No, it wouldn't be picked up by the -- 2 MS. BREESE DAVIES: Right. 3 DR. DAVID CHIASSON: -- review process 4 unless -- unless it's in the report. Unless a comment is 5 in the report. In Dr. Smith's case, they were not. 6 MS. BREESE DAVIES: Let me talk just 7 briefly or a few questions about including circumstantial 8 information in post-mortem reports. I know you've, sort 9 of, answered a lot of questions about this already, so 10 hopefully, I can focus. 11 I take it there's no guidelines or 12 protocols about how much information of a circumstantial 13 nature to include in a post-mortem report, correct? 14 DR. DAVID CHIASSON: I think the latest 15 guidelines in criminally suspicious death does address 16 this in a -- in, at least, some form. And certainly 17 there may have been a memo or forensic pathology coroner 18 where I -- where I talked about it in a general way, but 19 the -- there are no firm guidelines. 20 I mean, practice varies and, -- and I 21 think there are certain guideli -- or -- or suggestions 22 as to information that's inappropriate to put in and very 23 much depending on the type of the case, as well. 24 MS. BREESE DAVIES: So -- just if I can 25 be clear, at a minimum, the pathologist should include

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1 any circumstantial information that they're relied upon 2 in reaching their conclusions in the post-mortem report? 3 DR. DAVID CHIASSON: Well, clearly and 4 the -- the prime example is the drowning example, I think 5 I gave ear -- 6 MS. BREESE DAVIES: Right. 7 DR. DAVID CHIASSON: -- earlier on that, 8 you know, you need information that the body's being 9 recovered from water or has been in water in order to 10 render a diagnosis of drowning. So that's obviously 11 somewhere where that circumstantial information is 12 critical to arriving at the opinion. 13 MS. BREESE DAVIES: Right. And do you 14 agree that the police should provide the pathologist with 15 as much circumstantial evidence as possible, and it 16 should be up to the pathologist to filter out what's 17 relevant and not relevant? 18 DR. DAVID CHIASSON: Basically. I mean, 19 you know, there's -- there's -- the police are going to 20 provide the pathologist with information in a general way 21 and what might be useful to the pathologist. They -- 22 they will not, you know, give us every detail about their 23 investigation. But -- but it's better to give us too 24 much information than not enough. 25 MS. BREESE DAVIES: Than too little?

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1 DR. DAVID CHIASSON: Yeah. And -- and as 2 a responsible forensic pathologist, part of our job is to 3 filter through that information and glean from us -- the 4 problem with leaving it to the police officer -- okay, 5 the pathologist only needs this and this. 6 Well, he's not the patholo -- he's not the 7 forensic pathologist. He really doesn't have an 8 appreciation as to what information I -- I may or may not 9 need. 10 MS. BREESE DAVIES: Right. 11 DR. DAVID CHIASSON: So you over inform 12 the pathologist; let him filter it out. 13 MS. BREESE DAVIES: Okay. And you said 14 that you take notes of those briefings and you keep those 15 notes in your file, and my question is: Do you turn 16 those notes over to the Crown attorney as a matter of 17 practice? 18 DR. DAVID CHIASSON: The briefing notes 19 are usually brief and when I meet with the Crown 20 attorney, you know, I'll make her -- her or him aware 21 that they're there if they want to -- want to -- want 22 them, well, they're certainly entitled to them; I don't - 23 - I don't by routine. And the same with my working 24 notes; I don't routinely provide the working notes to the 25 Crown attorney, un -- unless upon request. And if it's

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1 upon request, then that's -- that -- I'll, of course, do 2 it, but it's not -- 3 MS. BREESE DAVIES: And you -- 4 DR. DAVID CHIASSON: -- my routine 5 practice to turn all this over. 6 MS. BREESE DAVIES: So your routine 7 practice is just to hand over the post-mortem report; if 8 they ask for anything else, you'd happily give it to 9 them. 10 DR. DAVID CHIASSON: I'd certainly 11 happily give it to them. The post-mortem report comes 12 through other channels -- 13 MS. BREESE DAVIES: Right. 14 DR. DAVID CHIASSON: -- to them. I don't 15 direct my post-mortem reports directly to a Crown 16 attorney. 17 MS. BREESE DAVIES: Okay. And I think 18 you agreed that there -- you could see some benefit to 19 the police providing you with a written briefing with all 20 of the details in it, in response to Mr. Campbell's 21 questions. 22 DR. DAVID CHIASSON: Yes, I mean the 23 problem I have, of course, is how much time am I going to 24 spend trying to document what the police are telling me. 25 In, you know, fifteen (15) min -- I'm -- I'm not a lawyer

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1 and I -- I know lawyers are used to scribbling all the 2 time while people are talking, well, it's -- I'm -- I'm 3 a... 4 COMMISSIONER STEPHEN GOUDGE: I make a 5 living out of -- 6 MS. BREESE DAVIES: I think -- I think we 7 all do. 8 DR. DAVID CHIASSON: So, you know, it's - 9 - and it's not my practice and I've -- I'm trying to 10 think while they're telling me this and I'm trying to 11 filter it out, and so my notes are by -- brief. 12 If in fact the police have a police -- if 13 -- I will ask for a police report if it's available. 14 Now, having said that, in a lot of homicide cases we 15 don't get police reports available at the time that 16 they're -- that they're there for debriefing. 17 18 CONTINUED BY MS. BREESE DAVIES: 19 MS. BREESE DAVIES: Right. 20 DR. DAVID CHIASSON: If they have them, I 21 -- I certainly ask for them. And so the notes are -- 22 you're going to get brief notes in my case. 23 MS. BREESE DAVIES: Right. Would you see 24 any problem with a system whereby the police provide you 25 with a written briefing and you attach that to your post-

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1 mortem report in criminally suspicious and homicide 2 cases? 3 DR. DAVID CHIASSON: Yeah, I would have 4 problem with that. 5 MS. BREESE DAVIES: Wouldn't you agree, 6 though, that that would allow you, when you were the 7 Chief Forensic Pathologist, to better review the post- 8 mortem report? 9 DR. DAVID CHIASSON: I would -- I would - 10 - yes, and I'm not saying that -- and again, it -- if -- 11 the ideal thing may be that the pathologist who's 12 reviewing a case is provided with a copy of the police 13 report and/or briefing notes at the time of the -- at the 14 time of the review. I wouldn't want to append it to my 15 report because it's probably going to have all sorts of 16 details that are not necessary and protec -- potentially, 17 you know, could cause problems. 18 The same way as we did with the coroner's 19 warrant, where there's references in the coroner's 20 warrant to -- to things that may or may not be of 21 relevance to the pathology, and at the same time could be 22 seen as somehow prejudicial to some -- some things. 23 So I'm not saying that -- you know, to me 24 the briefing note provided to me, I'll keep it in my 25 file. I would assume that the Crown would have it as

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1 part of their package and I -- I fully accept that it -- 2 that sort of information should be disclosed to the 3 defence, but I'm not -- I don't think the way that 4 should go about it by attaching it to my report. 5 MS. BREESE DAVIES: Okay. But you see no 6 problem with the -- reviewing regional coroner -- getting 7 a copy of it, as well, through some mechanism? 8 DR. DAVID CHIASSON: Oh, I think that -- 9 that would make a lot of sense. I mean normally the -- 10 when we do an autopsy in the Coroner's Office, we -- we 11 do get police reports and -- and if that's available to 12 review as part of the document for the reviewer, I think 13 that's -- that's great. 14 But I'm just saying I don't think it 15 should be appended to a PM report. 16 MS. BREESE DAVIES: Or seem to have been 17 adopted by you or accepted by you; that's your concern? 18 DR. DAVID CHIASSON: Exactly. I mean -- 19 MS. BREESE DAVIES: Okay. 20 DR. DAVID CHIASSON: -- the police may 21 have some thoughts and, you know, if I happen to agree 22 with the thoughts, then, you know, it looks like I'm -- 23 it could -- the perception could be that, well, you know, 24 I'm being influenced -- unduly influenced. 25 MS. BREESE DAVIES: Right.

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1 DR. DAVID CHIASSON: It's -- somebody -- 2 I think it would create perception problems. 3 MS. BREESE DAVIES: Okay. Let me turn 4 then to the issue of documenting other opinions. And 5 I've heard your evidence about your view and your 6 concerns about including them in post-mortem reports. 7 And I think what you said is that one of 8 the reasons, or perhaps the main reason, you don't 9 include other opinions beyond the cause of death in your 10 post-mortem report is because you really don't know what 11 a variety of issues might ultimately be of significance 12 in a criminally suspicious or homicide case. 13 Is that fair? 14 DR. DAVID CHIASSON: That's very fair. 15 And as I've indicated, in the vast 16 majority of cases you meet the police, you know, it's 17 kind of like there's a lot of excitement, you're doing 18 the autopsy and you get a lot of police attention, and 19 then it stops and nobody -- nobody talks to you -- 20 MS. BREESE DAVIES: Nobody calls you 21 until the preliminary -- 22 DR. DAVID CHIASSON: -- nobody calls you. 23 MS. BREESE DAVIES: -- inquiry. 24 DR. DAVID CHIASSON: Until, if there is a 25 preliminary hearing then people get all excited again.

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1 So you've got this big lull period. 2 MS. BREESE DAVIES: Right. 3 DR. DAVID CHIASSON: And I don't know 4 what's happening during this period and so I'm supposed 5 to prepare my report. 6 And there could be all sorts of major 7 issues that I'm totally unaware of. And to me, to start 8 rendering opinions on, Well, maybe this is important or 9 maybe not -- it's not to say I don't render any opinions. 10 I made the reference to a gun shot wound. 11 If it's a contact gunshot wound, that should be made 12 clear. Now you could make it as a diagnosis and leave it 13 at that but if you have sooty staining or, you know, 14 there's -- there's pathology issues which I think can be 15 addressed and opinion rendered. 16 But issues as to, you know, survivability 17 or how long the person survived and stuff like that, it's 18 -- it's a difficult area, it's not black and white, and 19 to try and -- and to have a concise little opinion in an 20 area that's full of grayness is a difficult thing. Very 21 problematic. 22 MS. BREESE DAVIES: Okay. Let me just 23 suggest an alternative scenario to you, though. 24 If you in fact do know that an issue 25 beyond the cause of death is forensically significant in

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1 a homicide or a criminally suspicious case, either 2 because of your own experience as a forensic pathologist 3 or because of discussions with the police officer, is 4 there any reason not to include that in your post-mortem 5 report if, in fact, you know it's going to be a 6 significant issue? 7 DR. DAVID CHIASSON: If you know it's 8 going to be a significant issue and it's an opinion that 9 can be stated, sort of in a relatively definitive 10 fashion, then yes. But the majority of the times, you 11 know, any opinion of that nature is -- is going to be a 12 gray opinion. 13 And, you know, it goes back to how a 14 certain one is about one's opinion. And, you know, it's 15 very much, I think, a thing that is -- it's either 16 broached separate from the report in a separate document 17 that the -- that the Crown writes to the -- or the police 18 officer, on behalf of the Crown, writes to the 19 pathologist, so that, you know, this is why I'm answering 20 this question and -- and this is the specific question. 21 Because that's the other thing: Any time 22 I have discussions with police officers or -- or lawyers, 23 I say to them, Okay, you want this opinion in writing, 24 fine, you send me the letter and you -- you phrase your 25 question. And we all know a little turn of the phrase

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1 can have a major impact upon, you know, the nature of the 2 question and the nature of answer, so. 3 MS. BREESE DAVIES: Okay, but if -- I 4 mean, we know -- which I'm going to come to in a minute - 5 - that there can be weeks or months between when you do 6 the autopsy and when you do the final report -- 7 DR. DAVID CHIASSON: Yes. 8 MS. BREESE DAVIES: -- and I know you say 9 that the police tend to ignore you at that point in time. 10 But should you become aware of an issue, certainly you 11 could include it in your post-mortem report and put in 12 comments about how certain you are about it and all of 13 the language you would put in a supplementary report. 14 Isn't that fair? 15 DR. DAVID CHIASSON: You could. I'm -- 16 I'm -- 17 MS. BREESE DAVIES: You're still 18 sceptical? 19 DR. DAVID CHIASSON: I'm still sceptical. 20 I'm still resisting. I would prefer to do it in a -- in 21 a separate document. I would prefer to do it -- yeah, I 22 mean, I -- frankly, I guess what I would say is maybe my 23 practice could change in the sense that I'm talking to a 24 police officer, he's raising an issue; and in the past it 25 may have been I'm giving him an opinion.

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1 And -- and this happened relatively 2 recently. You give a verbal opinion and they're going to 3 go and take this information and proceed on that basis. 4 That perhaps -- and this obviously involves, you know, 5 changing practises of police officers and Crown attorneys 6 I suspect. 7 Okay, this is important to what I'm doing, 8 why don't you send me a letter. And I've done this. 9 I've done this with senior Crowns and -- and said, 10 Listen, just -- I'm happy to answer this question. This 11 is really important to you. Why don't we document it. 12 Maybe I should be encouraging the documentation, but at 13 the same time, you know, it's -- it's -- there's 14 multiple players at play here. 15 But do it separate from the PM report 16 because what I -- and again, I -- the PM report, as it's 17 -- I'm doing this under the direction of the Coroner's 18 Act. The coroner is simply, as I've said, the bottom 19 line is, is asking for a cause of -- 20 MS. BREESE DAVIES: Right. 21 DR. DAVID CHIASSON: -- cause of death. 22 And so I'm really satisfying my responsibility to the 23 coroner by issuing -- restricting my -- my opinion in 24 that regards. If it's beyond that then, you know, I 25 think a separate document makes -- makes more sense.

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1 MS. BREESE DAVIES: And I take it you 2 agree that a separate document before you hit the witness 3 box is also a good idea, so that counsel know what you're 4 going to say, can digest it, can be better prepared? 5 DR. DAVID CHIASSON: I -- I think that's 6 -- that's completely fair, yes. 7 MS. BREESE DAVIES: So long as the 8 request of you is clear and the issue is clear, you agree 9 that they should be in written format? 10 DR. DAVID CHIASSON: Oh, I -- I think 11 there's a major role for forensic pathologists to provide 12 opinion. They obviously do in -- in -- but has been 13 largely a verbal world and in oral testimony at a -- a 14 preliminary hearing. If -- if it's deemed to be valuable 15 that -- that we need to tighten this up or we need more 16 documented findings, it's -- I'm -- I'm -- I don't have a 17 problem with that at all. 18 MS. BREESE DAVIES: Okay. And you would 19 also agree though that in addition to just, sort of doing 20 it for someone else's benefit, it also would make your 21 testimony clearer, would make the examinations more 22 concise, would make sure that everybody understands the 23 limits of what you're saying and what you're not saying, 24 correct? 25 DR. DAVID CHIASSON: Exactly. And the

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1 limits of -- of an opinion -- I mean, that -- that, in 2 and of itself, does require some forethought, you know. 3 And to put it pen to paper when you're talking about the 4 limits -- how comfortable are you -- I -- that's -- I 5 think there is advantage for the pathologist to say, 6 Okay, how comfortable I am -- you know, where am I going 7 to go on a piece of paper, as opposed to what you might 8 say in -- in a courtroom of law. 9 And I -- a courtroom is a situation, if 10 you're comfortable in that area you sometimes say things 11 that are -- that you might not put pen to paper on, and 12 it's just the nature of -- of the -- the environment. 13 you know, it's -- it's -- it is a different environment. 14 MS. BREESE DAVIES: But you would agree 15 that having the opportunity to reflect on what you might 16 say is a valuable tool to make sure that your opinion is 17 accurate and defensible, correct? 18 DR. DAVID CHIASSON: I agree. 19 MS. BREESE DAVIES: Okay. Let me just 20 suggest also that by having opinions put in writing, it 21 would also afford you another level of quality assurance 22 should those supplementary reports be subject to review? 23 DR. DAVID CHIASSON: They aren't 24 currently, that's not the current practice, but certainly 25 that would be. And, in fact, you know, there's a good

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1 argument to have that, because a lot of the problems, I 2 think, that we have in -- in this matter are problems of 3 what -- the opinions in court. And so, you know, if 4 we're going to address that it would be another way to -- 5 to potentially address what is being testified to. 6 MS. BREESE DAVIES: Are you familiar with 7 the form used by the forensic -- the Centre for Forensic 8 Sciences, to review testimony given by their experts, 9 after the fact? 10 DR. DAVID CHIASSON: I -- I've seen the 11 form, yes. 12 MS. BREESE DAVIES: And would you agree 13 that a similar form might be useful for reviewing the 14 testimony of forensic pathologists? 15 DR. DAVID CHIASSON: I -- I could see 16 that there's a potential to -- to use a form, something 17 like that -- 18 MS. BREESE DAVIES: That's it's valuable 19 to get the input of the police officers and the Crown and 20 the defence, in respect of the testimony specifically? 21 DR. DAVID CHIASSON: Yes, I mean, I -- I 22 could see that being a -- a potential quality control 23 measure. I think the -- the issue and the problem is 24 that, okay, who -- who gets the forms and -- 25 MS. BREESE DAVIES: That was -- that was

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1 going to be my next question. 2 DR. DAVID CHIASSON: Yes. So the chief 3 forensic pathologists, we're really loading them up this 4 morning and -- and -- yes, I mean, and then he gets a 5 form and then what does he do with it? I mean, that -- 6 MS. BREESE DAVIES: Well, -- 7 DR. DAVID CHIASSON: -- that's a -- 8 that's a big problem. 9 MS. BREESE DAVIES: Well, I -- that was 10 actually my next question. 11 DR. DAVID CHIASSON: I mean -- 12 MS. BREESE DAVIES: What thoughts you 13 have about who would be the best person to get that 14 information. You know, some of the people that I would - 15 - had thought of were the chief forensic pathologists; 16 perhaps the directors of the units, which would be you 17 now; or perhaps the Chief Coroner, him or herself. 18 Do you have a sense of who the best person 19 would be, if we were to design a system like that, to get 20 this information and be able to act on it? 21 DR. DAVID CHIASSON: Well, I -- I think 22 it's a forensic -- we're talking about forensic 23 pathologists testifying in a court. It -- it should be a 24 -- another forensic pathologist who's -- who experienced 25 in -- in the courtroom setting, that would review this

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1 document. And that -- so chief forensic pathologists 2 perhaps in the case of -- of a pathologist within the 3 unit, the director of the unit in that -- in that case; 4 perhaps some delegation -- well, I mean, we're looking at 5 a little form. 6 So at that stage we're not talking about a 7 -- a big issue. 8 MS. BREESE DAVIES: Right. 9 DR. DAVID CHIASSON: I mean, it wouldn't 10 take very long to -- to read the form. But then -- then 11 the problem starts. 12 MS. BREESE DAVIES: What -- what you do 13 with it after. Perhaps we'll -- 14 DR. DAVID CHIASSON: What you do with it 15 after. 16 MS. BREESE DAVIES: -- leave that for 17 other people to think about. 18 Let me ask you a bit about your contact 19 with the defence. I want to make sure I -- defence 20 counsel, when you are acting as the pathologist for the 21 coroner. 22 So if I understand your position, or your 23 practice, you have absolutely no objection to 24 communicating with defence counsel, meeting with them and 25 making yourself available before you testify, correct?

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1 DR. DAVID CHIASSON: I -- I encourage 2 that. 3 MS. BREESE DAVIES: And you agree that -- 4 that those meetings have, in your experience, contributed 5 to the more orderly presentation of your evidence? 6 DR. DAVID CHIASSON: Yes. And I -- I 7 happened to be speaking to one of my colleagues at the 8 hospital who yesterday was testifying at a preliminary 9 hearing, and had the opportunity, at the request of the 10 defence, to talk to the defence lawyer, and his time on 11 the stand was -- I'm sure, was truncated. 12 I mean, that's the reason to talk to a 13 defence lawyer before had; find out where you're coming 14 from, you find out where I'm coming from. And it's a lot 15 easier to do that then on the stand where sometimes 16 you're trying to pull teeth and you don't know where 17 you're -- you prolong the process. 18 MS. BREESE DAVIES: Right. 19 DR. DAVID CHIASSON: The less time I 20 spend on the stand, the better I like it. 21 MS. BREESE DAVIES: I won't take offense 22 to that. 23 DR. DAVID CHIASSON: No, it isn't meant 24 to offend any lawyer. 25 MS. BREESE DAVIES: No. And you also

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1 said that you would make yourself available to defence 2 pathologists, should they be retained in a particular 3 case, to talk about the issues? 4 DR. DAVID CHIASSON: That -- I don't know 5 if I said that. And I -- I'm not sure -- the -- I think 6 with defence pathologists certainly I -- the pathologist 7 of -- of record is -- is -- has a responsibility to 8 provide the defence pathologist with whatever materials 9 are available and -- and that he wants to review, and to 10 facilitate that as -- as well as he can. 11 Going back to the issue of whether you're 12 going to -- defence pathologist talking to a Crown 13 pathologist about a case -- I'm certainly, if I know the 14 pathologist -- I don't have a -- a problem with doing 15 that. I'm not sure -- I don't think it would happen very 16 often, and I'm not sure that there's added value. 17 If I was the defence pathologist, I want 18 to -- to do my work -- basically -- based on the 19 information I have. If you start having conversations, 20 you know, how does that sort of filter into your work? 21 Well, you know, it's part of your materials and methods - 22 - sort of materials -- you know, you have this 23 conversation and he said, blah, blah, blah, well I -- I 24 see problems. 25 I -- I think 1), the path -- the defence

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1 pathologist should do his work. If then there are 2 variations in -- in opinions, there could be an 3 opportunity for defence counsel, pathologists and the 4 Crown, Crown pathologist, to somehow put their heads 5 together -- 6 MS. BREESE DAVIES: Right. 7 DR. DAVID CHIASSON: -- I can see that. 8 But not -- not so much as a -- 9 MS. BREESE DAVIES: One on one. 10 DR. DAVID CHIASSON: -- pathologist to 11 pathologist thing -- 12 MS. BREESE DAVIES: Okay. 13 DR. DAVID CHIASSON: -- at that level, I 14 -- I think that wouldn't work very well. 15 MS. BREESE DAVIES: Okay. I might have 16 misunderstood. But nonetheless, your view is that your 17 discussions with defence counsel are not confidential, 18 correct? 19 DR. DAVID CHIASSON: Yes. I mean, 20 there's no -- as I understand, there's no client 21 confidentiality. 22 MS. BREESE DAVIES: Are you aware that 23 Dr. Pollanen testified that he would not necessarily -- 24 although there's no policy, he would not necessarily 25 disclose communications that he has with defence counsel

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1 to the Crown. 2 DR. DAVID CHIASSON: Oh, and I wouldn't 3 necessarily disclose it either. 4 MS. BREESE DAVIES: Okay. 5 DR. DAVID CHIASSON: I mean I'm not -- 6 I'm not saying, you know, I talk to you and then I call 7 up the Crown; You know by the way, Ms. Davies was here 8 and -- 9 MS. BREESE DAVIES: So -- 10 DR. DAVID CHIASSON: -- it's not -- I 11 mean, if Crown counsel -- or sorry, if the Crown attorney 12 asks me what -- 13 MS. BREESE DAVIES: Right. 14 DR. DAVID CHIASSON: -- you -- you -- 15 what issues, I'm going to -- 16 MS. BREESE DAVIES: Okay. 17 DR. DAVID CHIASSON: -- convey that 18 information. 19 MS. BREESE DAVIES: So it's a matter of, 20 if they ask for a report, you will provide it. You don't 21 feel an obligation to call them up and report what the 22 conversation was? 23 DR. DAVID CHIASSON: Well, I don't know 24 if -- I couldn't see providing a report as to what we'd 25 spoke about. I mean --

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1 MS. BREESE DAVIES: Sorry, the wrong with 2 a -- with a doctor. But just sort of a briefing about 3 what it is you said? 4 DR. DAVID CHIASSON: Well if they ask me 5 what, you know, what was discussed in a general way, then 6 I would -- I wouldn't -- I would tell them. I mean 7 that's -- 8 MS. BREESE DAVIES: Would you tell 9 defence counsel, if they asked, what you had spoken to 10 the Crown and the police about in your preparations for 11 the preliminary inquiry? 12 DR. DAVID CHIASSON: Well, I -- I 13 certainly get asked that question on the stand and my 14 usual answer, because my notes regarding the meeting are 15 usually quite brief; discuss issues, and -- and if there 16 were some specific issues, I -- I would not that. I 17 don't have a problem with answering that question. 18 MS. BREESE DAVIES: What if I called you 19 up two (2) days before the preliminary inquiry and said, 20 has the Crown called you, and if so, what have they asked 21 you? 22 Would you tell me? 23 DR. DAVID CHIASSON: So this is outside 24 the -- 25 MS. BREESE DAVIES: Outside a courtroom.

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1 If they happen to get to you first, instead of me getting 2 to you first? 3 DR. DAVID CHIASSON: I think as a 4 courtesy I would speak to the Crown and indicate that 5 I've been approached by you and that you want to talk to 6 me about the case -- 7 MS. BREESE DAVIES: And -- and -- 8 DR. DAVID CHIASSON: -- and -- and ask if 9 -- if there's any -- you can sort of get a legal opinion 10 as to, you know, my, you know, role, and is there any 11 problem with doing that. 12 MS. BREESE DAVIES: And your sense, I 13 take it, is that because you feel that you are, in 14 essence, retained by the Crown, and therefore need their 15 permission, but you are not obviously retained by the 16 defence, and therefore you can disclose as of right the 17 information of the Crown. 18 Is that the thinking? 19 DR. DAVID CHIASSON: I -- I think that's 20 my impression. I'm -- certainly I will send the invoice 21 to the Crown, so if you want to argue, you know, I'm -- 22 I'm being retained by them. 23 You know, if there is a set policy within 24 the Crown attorney's office that they don't want to be 25 notified -- I mean if -- if some kind of direction could

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1 be provided. I have not had a -- it doesn't happen very 2 often, as you could imagine, and I would -- I would -- 3 because I'm not sure what the, you know, the -- the legal 4 aspects of this are, I would -- I would seek the opinion 5 of the Crown attorney. 6 MS. BREESE DAVIES: And I -- 7 DR. DAVID CHIASSON: And if it's fine 8 with them to talk to you, before or whatever -- and -- 9 and usually, and this is where I will meet with the Crown 10 attorney and I will say, Listen, you talked to the 11 defence counsel, say -- listen, I'm quite available for 12 them to talk to me, and, you know, that -- encourage that 13 kind of -- but that I'm -- I'm sort of -- you're getting 14 the message through -- obviously if she tells you, If you 15 want to a pathologist, it's fine, then I'm -- 16 MS. BREESE DAVIES: Then you're free to 17 do it. 18 DR. DAVID CHIASSON: I'm free to do it. 19 MS. BREESE DAVIES: And I take it from 20 your answer that there is no policy that you know of 21 either within OCCO, or within Sick Kids, or within the 22 Crown's Office, that would give you guidance on how to 23 conduct yourselves in these sorts of discussions. 24 DR. DAVID CHIASSON: That's correct. 25 MS. BREESE DAVIES: I have one last area,

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1 Commissioner. 2 COMMISSIONER STEPHEN GOUDGE: You've got 3 to be quick. 4 5 CONTINUED BY MS. BREESE DAVIES: 6 MS. BREESE DAVIES: I have one (1) 7 minute. You said that you had not yet, as the Director 8 of the Hospital for Sick Kids Unit, met the 90 percent in 9 ninety (90) days target, despite all of your efforts when 10 you were the Chief Forensic Pathologist. 11 What are the time limiting factors, if you 12 can identify them briefly? 13 DR. DAVID CHIASSON: May -- toxicology 14 reports remain a -- turnaround time there remains an 15 issue in some cases, not all. Some of them we do get 16 within the ninety (90) days. 17 The amount of work in the pediatric 18 setting is -- there's a lot of ancillary testing that is 19 done, the complexities, we try to -- to present them at - 20 - at rounds on a regular basis. You know, what we're 21 trying to do as complete a job as we possibly can going 22 through our -- our rounds, et cetera, so we aren't 23 meeting the target of 90 percent of cases in -- in ninety 24 (90) days. 25 And I -- my sense is, maybe it's -- maybe

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1 it's just a totally unrealistic target. The more 2 important thing is I want to have a quality product in 3 terms of -- of the PM Report, everything done in a -- in 4 as excellent a fashion as we can do it. If it means 5 taking more than the ninety (90) days, hundred and twenty 6 (120) days, then that -- suffice it to say that, you 7 know, we're much driven, or at least I'm driven by 8 squeaky wheels. 9 So if there's a case that is -- that 10 requires a rapid response, then those go to the top of my 11 pile. And I -- I think that's the issue and it remains - 12 - I don't know which -- where things are in the legal 13 setting often and if there is a case that for whatever 14 reason needs to be expedited, my suggestion to the Crown, 15 to defence counsel, is to convey that information to the 16 pathologist. 17 MS. BREESE DAVIES: Well, you might see a 18 lot more squeaky wheels. Thank you. 19 Thank you, Commissioner. 20 DR. DAVID CHIASSON: You're welcome. 21 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 22 Davies. 23 Ms. Silver...? 24 25 CROSS-EXAMINATION BY MS. CAROLYN SILVER:

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1 MS. CAROLYN SILVER: I'm Carolyn Silver. 2 I represent the College of Physicians and Surgeons. I 3 just have a few questions for you. 4 DR. DAVID CHIASSON: Good -- good 5 afternoon. 6 MS. CAROLYN SILVER: Good afternoon. You 7 -- you've talked -- you've given a lot of evidence, and I 8 don't want to take you through all of it, about your 9 concerns about Dr. Johnston's work as a forensic 10 pathologist? 11 DR. DAVID CHIASSON: Correct. 12 MS. CAROLYN SILVER: And I think you said 13 on Friday that you had -- there were significant forensic 14 pathology issues? 15 DR. DAVID CHIASSON: Correct. 16 MS. CAROLYN SILVER: And I think you 17 agreed today with Mr. Sokolov that you had concerns about 18 the fundamentals of the forensic pathology he was doing, 19 correct? 20 DR. DAVID CHIASSON: Correct. 21 MS. CAROLYN SILVER: And you talked then 22 about certain steps you took to address those concerns? 23 DR. DAVID CHIASSON: Yes. 24 MS. CAROLYN SILVER: And one (1) of them 25 was meeting with Dr. Johnston, correct?

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1 DR. DAVID CHIASSON: Yes. 2 MS. CAROLYN SILVER: And suggesting 3 remedial activities? 4 DR. DAVID CHIASSON: Yes. 5 MS. CAROLYN SILVER: You also spoke with 6 Dr. Young, correct? 7 DR. DAVID CHIASSON: A memo to Dr. Young 8 and speaking to him, as well, yes. 9 MS. CAROLYN SILVER: Okay. And you spoke 10 also about trying to recruit someone who could oversee 11 Dr. Johnston's work, correct? 12 DR. DAVID CHIASSON: Correct. 13 MS. CAROLYN SILVER: And act in a 14 supervisory role? 15 DR. DAVID CHIASSON: Correct. 16 MS. CAROLYN SILVER: I -- I take it from 17 your evidence because we haven't heard so far that you 18 didn't notify the College of Physicians and Surgeons 19 about your concerns? 20 DR. DAVID CHIASSON: No. 21 MS. CAROLYN SILVER: And I take it as 22 well that you didn't ask anyone else, such as the 23 regional coroners, Dr. Young, or Dr. Cairns to notify the 24 College of your concerns? 25 DR. DAVID CHIASSON: No, I did not.

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1 MS. CAROLYN SILVER: And I take it that 2 none of those people advised you that they had notified 3 the College about your concerns about Dr. Johnston. 4 Fair enough? 5 DR. DAVID CHIASSON: That's correct. 6 MS. CAROLYN SILVER: Those are all my 7 questions. Thank you very much. Thank you for you 8 indulgence. 9 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 10 Silver. We will rise now and come back at 2:05 with you, 11 Ms. Fraser. 12 13 --- Upon recessing at 12:49 p.m. 14 --- Upon resuming at 2:05 p.m. 15 16 THE REGISTRAR: All rise. Please be 17 seated. 18 COMMISSIONER STEPHEN GOUDGE: Ms. 19 Fraser...? 20 21 CROSS-EXAMINATION BY MS. SUZAN FRASER: 22 MS. SUZAN FRASER: Thank you, Mr. 23 Commissioner. Doctor, is it Dr. Chiasson? 24 DR. DAVID CHIASSON: That's correct, yes. 25 MS. SUZAN FRASER: Okay. Dr. Chiasson,

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1 my name is Sue Fraser. Our paths have crossed at a 2 couple of inquests in the past, but you probably don't 3 remember me. Your role was a little more central then 4 mine. 5 But I'm here today on behalf of a group 6 called Defence For Children International. And that is a 7 children's rights organization founded in Geneva. And 8 its role -- or what it hopes to do is promote and protect 9 the rights of the children, as spelled out in the UN 10 Convention on The Right to the Child. 11 And so here, the sort of two (2) competing 12 rights are the right to survival and development, and the 13 preservation of their identity in family relationship. 14 So I heard your comments about your faith 15 in the unit at the Hospital for Sick Children as it's 16 currently constituted, and the benefits of having the 17 pediatric and the forensic pathology elements. 18 And I'm interested -- much of the focus 19 has been on Death of Under Five, and would you see those 20 benefits for pediatric cases in the traditional sense, 21 ie; those up to the age of seventeen (17)? 22 DR. DAVID CHIASSON: Well, certainly 23 there's an overlap between the work of the Pediatric 24 Forensic Pathology Unit and the Adult Forensic Pathology 25 Unit when you talk about the children between let's say

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1 ten (10) and twelve (12) and seventeen (17); teenagers 2 certainly. 3 We would do autopsies, certainly, in any 4 patient of the hospital who happened to die and became -- 5 it was warranted under The Coroners' Act. And then 6 outside as to where the autopsy might be done very much 7 depends on the circumstances. 8 I mean, we don't routinely -- if a young 9 person was shot, that would normally go to the Coroner's 10 Office, for example. If there was a -- a young person 11 who had chronic neurologic disease or was a patient of 12 the hospital -- significant medical problems - who died 13 that was thirteen (13), fourteen (14), fifteen (15), 14 whatever; that -- that may well come to the -- our unit. 15 So there's a -- there's an overlap and it 16 really depends on the nature of the -- the case as to 17 where the autopsy would be done. 18 MS. SUZAN FRASER: Okay. So that it -- 19 to the extent that there'd be any recommendations about 20 where cases should go, there should be some flexibility 21 in the, sort of, end of the spectrum of pediatrics, is 22 that fair? 23 DR. DAVID CHIASSON: That's fair. And I 24 -- I think we're -- we're -- anything certainly of a 25 medical nature, I would -- I would suggest is -- the unit

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1 really, is -- is -- still has -- pediatric expertise -- 2 pediatric pathology, in a general way, does deal with 3 patients up to the age of sixteen (16), seventeen (17). 4 MS. SUZAN FRASER: All right. I want to 5 turn your attention to the Coroner's Investigation 6 Statement for Children's Under Two Sudden Unexpected 7 Death. That would be PFP142286, and it'll be on your 8 screen. 9 10 (BRIEF PAUSE) 11 12 MS. SUZAN FRASER: And if the Registrar 13 could turn to the twelfth page of that document. 14 This is the form that I understand is part 15 of the Coroner's Manual for investigation of sun -- 16 Sudden Unexpected Deaths in Children Under Two, and are 17 you familiar with this form, Dr. Chiasson? 18 DR. DAVID CHIASSON: I have some 19 familiarity. I don't complete it myself, but I -- as 20 pathologists doing an autopsy on a Sudden Unexpected 21 Death now Under Five, as opposed to two (2), and I'm not 22 sure whether the form has been modified since -- 23 MS. SUZAN FRASER: All right. 24 DR. DAVID CHIASSON: -- what we're 25 looking at here, but -- but in -- in essence, this would

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1 be the form that I would often receive, along with a copy 2 of the coroner's warrant. 3 MS. SUZAN FRASER: All right. And so -- 4 and is it -- is it your expa -- experience that you 5 always receive it or that you sometimes receive it? 6 DR. DAVID CHIASSON: We don't always 7 receive it. 8 MS. SUZAN FRASER: All right. 9 DR. DAVID CHIASSON: Ideally, we should 10 receive it, and I would say currently we receive a copy 11 in the majority; probably three quarters (3/4s) of cases. 12 MS. SUZAN FRASER: All right. And I 13 wanted to -- in my review of the form, there was nothing 14 in the form that the investigator would have taken to 15 detail the child's sleep environment which I understand, 16 from the evidence we've heard, to be a pretty significant 17 factor in -- in a sudden unexpected death. 18 Would that be something that you would 19 expect to see as part of a form relating to sudden 20 unexpected death? Would that be a benefit? 21 DR. DAVID CHIASSON: Yes, and I -- I 22 thought it was in the form. Certainly the position at 23 the time of death of the infant would have been noted -- 24 should have been noted. 25 MS. SUZAN FRASER: All right. And there

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1 don't seem to be questions in the form about describing 2 the baby's condition in the previous twenty-four (24) 3 hours. 4 Is that something that you'd want to know 5 as a pathologist? 6 DR. DAVID CHIASSON: Yes, but again, I -- 7 I think there is some reference in the form to illness 8 within the last twenty-four (24) hours. 9 MS. SUZAN FRASER: All right. History of 10 present illness within forty-eight (48) hours of death, 11 that's -- 12 DR. DAVID CHIASSON: Yes. 13 MS. SUZAN FRASER: All right. And so to 14 your knowledge, that speaks to more to than just medical 15 problems, rather than -- 16 DR. DAVID CHIASSON: Well, I think it's a 17 combination. I mean, most of these are unexpected deaths 18 and any history of -- of a cold or sneezing, you know, 19 those kinds symptomotology -- that -- that's usually 20 where it's referred to. 21 MS. SUZAN FRASER: All right. And is 22 this kind of protocol helpful to you as a pathologist in 23 understanding the circumstances of death? 24 DR. DAVID CHIASSON: Very much so, yes. 25 MS. SUZAN FRASER: All right. And is it

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1 fair to say that the more information that's on the form, 2 if it's relevant to your determination, the better? 3 DR. DAVID CHIASSON: Yes. 4 MS. SUZAN FRASER: All right. I want to 5 turn then to the question of -- or the issue relating to 6 the SCAN Team. I have some questions about the SCAN 7 Team, and I understand that's the Suspected Child Abuse 8 and Neglect Team at the Hospital for Sick Children. 9 DR. DAVID CHIASSON: That's correct. 10 MS. SUZAN FRASER: All right. And you're 11 familiar with that team? 12 DR. DAVID CHIASSON: I am. 13 MS. SUZAN FRASER: All right. And what 14 was its -- what is your understanding of its relationship 15 to the Pediatric Forensic Pathology Unit during the time 16 that you were the Chief Forensic Pathologist? Was it a 17 formal relationship? 18 DR. DAVID CHIASSON: No, I didn't see 19 that there was any formal relationship. The SCAN Team 20 has, obviously, an important function to play within the 21 context of the hospital and the clinical work, and -- but 22 I -- I didn't think there was any formal connection 23 between the -- that unit and the Pediatric Forensic 24 Pathology Unit. 25 MS. SUZAN FRASER: All right. And what -

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1 - I guess, what is their current relationship with the 2 SCAN Team? Do they provide advice consults to the 3 Ontario Pediatric Forensic Pathology Unit now? 4 DR. DAVID CHIASSON: No. 5 MS. SUZAN FRASER: All right. And why is 6 that the case? 7 DR. DAVID CHIASSON: Why is -- why isn't 8 it not the case. Well, I should step back. There have 9 been on rare occasions where I have asked for assistance 10 at a post-mortem examination if I have concerns about the 11 possibility of sexual assault; it's -- it's a very 12 uncommon situation. 13 I have, in the past, consulted a -- a 14 representative of the SCAN Team in that context, but 15 beyond -- beyond that, there is a -- I mean, there's an 16 overlap to some degree. 17 If I -- if I'm dealing with the death of 18 child who has evidence of child abuse, I'm often asked 19 questions about the nature of the abuse and what kinds of 20 -- of events may have precipitated the trauma. 21 I will often give a degree -- a certain 22 level of opinion from my perspective, but it will often 23 suggest to the investigators that the SCAN personnel, the 24 physicians that work for the SCAN Team, are in a better 25 position to, in fact, often render opinions in this area

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  1  because they deal with it much more frequently in -- in
  2  the living.  
  3                 So we -- we oft -- I'll often suggest that
  4  they become involved in a case, but the -- it's -- they
  5  carry on their function along one (1) track, if you will,
  6  and it's -- it's separate and distinct from my -- my own
  7  work.  
  8                 MS. SUZAN FRASER:   Would you agree with
  9  me that they seem to function as forensic medical
 10  professionals that their -- part of what they do in
 11  detecting abuse has a necessary sort of interface or
 12  interaction with the Justice System?
 13                 DR. DAVID CHIASSON:   Clearly -- clearly
 14  they do, yes.
 15                 MS. SUZAN FRASER:   All right.  And do
 16  they have the same -- is there a same kind of forensic
 17  training body -- you're -- you have your speciality, is
 18  there a similar forensic speciality or certification
 19  process for this area of expertise?
 20                 DR. DAVID CHIASSON:   That's a good
 21  question.  I don't know the answer.
 22                 MS. SUZAN FRASER:   All right.  And do you
 23  know when they're consulted whether they're subject to
 24  the same side -- sort of peer review or oversight?
 25                 DR. DAVID CHIASSON:   I don't know the

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1 answer to that either. 2 MS. SUZAN FRASER: All right. And in the 3 cases where you've had occasion to consult with them, did 4 those consultations form written report that would be 5 appended to the post-mortem? 6 DR. DAVID CHIASSON: Exactly. If -- if 7 I'm asking them to provide some kind of examination of 8 the body post-mortem that would there -- I would ask for 9 a report. And -- and that would be appended to my -- my 10 own report, yes. 11 MS. SUZAN FRASER: All right. And I 12 think you've already given your opinion on whether you 13 would co-author reports. You always see that if there's 14 a second person consulted that they would issue or author 15 their own report, is that fair? 16 DR. DAVID CHIASSON: Yes, I mean, most of 17 the time it's in specialized area. So just like I have 18 my neuropathologist prepare an neuropathology report on 19 examination of the brain, I don't carry out a concurrent 20 examination and so that's his role. 21 If -- if it's a sexual assault 22 examination, that potential, I would -- I'm asking him -- 23 him or her to -- to do that then I'm -- I'm deferring 24 that role to them. And -- and they are providing an -- 25 an opinion in that restricted area; that -- that report,

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1 I -- I would append. 2 MS. SUZAN FRASER: All right. 3 DR. DAVID CHIASSON: It's not a conjoint 4 -- I would not cosign their report, and I certainly 5 wouldn't expect them or ask them to cosign my full post- 6 mortem examination report. 7 MS. SUZAN FRASER: All right. In 8 circumstances where that type of evidence -- a 9 consultation report -- is being used for a purpose either 10 to affect somebody's liberty or to affect a familiar 11 relationship through -- a familiar relationship in a 12 child protection proceeding, can you see the need for 13 those types of opinions to be subject to some kind of 14 review? 15 DR. DAVID CHIASSON: Well, again, this -- 16 it's clearly an area of work outside of my own -- my own 17 area. I certainly respect and -- and see the value of 18 having oversight. I mean, the large part of what we've 19 been talking about the last few days certainly and -- has 20 been the issues of oversight. 21 So if you will, it's -- it's, I think, a 22 good thing for us. I would expect in -- in a similar 23 fashion there -- there would be value in having oversight 24 on the -- on the SCAN Team reports, particularly those 25 that are aimed in -- in a -- in a Criminal Justice System

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1 or the Child Protection System. 2 MS. SUZAN FRASER: All right. And many 3 of the questions that have been put to you about how to 4 monitor testimony reports, evidence, forensic 5 pathologists in criminal proceedings would -- that would 6 have equal application for child protection proceedings, 7 is that fair? 8 DR. DAVID CHIASSON: I think certainly -- 9 yeah, issues of child protection are -- are important 10 issues, and I think there -- there is a -- it's 11 reasonable to expect a -- a similar level of scrutiny in 12 -- in that kind of situation as there might be in a 13 Criminal Justice situation. 14 MS. SUZAN FRASER: All right. There has 15 been much talk about potential improvements in the system 16 to hope to -- in the future that we have good pathology, 17 good evidence that innocent people go free and that those 18 who are responsible for the deaths are convicted. 19 That's sort of the ultimate goal, you'd 20 agree with that, being tha -- a good situation? 21 DR. DAVID CHIASSON: Yes. One (1) of the 22 motto's that I've picked up over the years is from the 23 Seattle Medical Examiner's Office -- the King's County 24 Medical Examiner's Office, "The innocent shall be 25 exonerated and murder shall be recognized", which, I

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1 think, is what you're saying. 2 MS. SUZAN FRASER: All right. So 3 developing a system where -- I'm going to leave that to 4 some of the other evidence -- but where we don't get 5 those kinds of results and where we discover failings 6 after the fact, there seems to be some difficulty in 7 terms of tracking where evidence has been given and -- 8 and when it's been given 9 And so my question for you is: Can you 10 see the benefit to tracking pathology evidence through 11 the Justice System, either in the Criminal Justice System 12 or in the Child Protection System? 13 DR. DAVID CHIASSON: I think you'd have 14 to elaborate on what you mean by tracking, and who -- 15 who's tracking and -- 16 MS. SUZAN FRASER: Well, that -- those 17 are some of the -- the issues that I think are raised, 18 but if a pathology report is used for a legal purposes -- 19 purpose, is it important for us to know, a) that the 20 pathology report is going to be used for legal purpose, 21 when it was used as for legal purpose, and what the 22 outcome of that proceeding was? 23 So that if there's an issue after the fact 24 -- someone has made a suggestion that we review shaken 25 baby cases. Is it important for us to be able to track

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1 where that and when that evidence was used? And can you 2 envision -- envisage a way that that might happen? 3 DR. DAVID CHIASSON: Well, I'm -- I'm 4 struggling with envisioning a way, practically speaking, 5 how that could happen. I mean, I appreciate the concept 6 and the -- the value that there might be in -- in 7 tracking that. 8 I mean, in any given case, you have one 9 (1) pathologist. He certainly would keep track of what 10 he's testifying on and where he's testifying. That -- 11 and how you would do that in some central way, I think, 12 as I understand -- at least the mechanisms of government 13 -- Coroner's Office -- I can't speak, of course, about 14 other ministries. 15 I -- I sense that would be, logistically, 16 a difficult thing to do. 17 MS. SUZAN FRASER: You can see from a 18 child's perspective -- somebody who's separated from 19 their parent -- the parent is wrongfully convicted or 20 wrongfully charged, and the result of that is that the 21 person is separated from their parent. 22 They might not even know that -- that -- 23 that their parent was wrongfully charged. Is there a way 24 for this -- if -- if you're going to track testimony, and 25 the evidence that's given -- we've sort of identified

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1 that as being a key area for pathology, there's going to 2 have to be some way of basically following these cases in 3 the case of homicide. Would you not agree? 4 DR. DAVID CHIASSON: Well, I mean, in 5 terms of tracking what's going on when a pathologist 6 testifies in a criminal case, I mean, we've talked about 7 the Chief Forensic Pathologist potentially -- this was 8 raised this morning -- being given a -- a form or present 9 a form with comments about the -- 10 MS. SUZAN FRASER: Yes. 11 DR. DAVID CHIASSON: -- pathology, which 12 would -- the pathologist testimony, and that would, of 13 course, depend on the -- the Crown or police or the 14 defence actually taking the time to -- to fill that out. 15 So the Chief Forensic Pathologist in that 16 system could have some sense, Okay, that on such and such 17 a day, such and such a pathologist testified at such and 18 such a proceeding. To try and somehow tie that in with 19 issues and subsequent -- what might happen down the road, 20 I -- again, certainly looking at it from my previous 21 position as Chief Forensic Pathologist within the 22 Coroner's Office, I -- I still find it difficult to see 23 how that Office could -- could somehow keep track of -- 24 of that particular issue. 25 It -- it sounds like a big job --

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1 MS. SUZAN FRASER: All right. 2 DR. DAVID CHIASSON: -- a big 3 undertaking. 4 MS. SUZAN FRASER: But if -- if there are 5 two hundred and fifty (250) homicide cases in the course 6 of a year, as the Chief Forensic Pathologist or somebody 7 with oversight for pathologists, you might want to know 8 when those pathologists are giving evidence and what was 9 the evidence. 10 Would you agree with that? 11 DR. DAVID CHIASSON: Well, I mean, the 12 outcome of the evid -- I mean, it's the outcome of the 13 trial -- 14 MS. SUZAN FRASER: Right. 15 DR. DAVID CHIASSON: It's not the 16 evidence, you know, the relevance of the evidence in -- 17 in any particular homicide trial may be little or -- or 18 may be great; it -- it varies, so the two (2) aren't tied 19 together. 20 All travesties of -- of justice -- 21 MS. SUZAN FRASER: Yes. 22 DR. DAVID CHIASSON: -- and wrongful 23 convictions aren't because -- 24 MS. SUZAN FRASER: I -- I understand 25 that.

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1 DR. DAVID CHIASSON: -- of pathology -- 2 MS. SUZAN FRASER: I -- I was thinking of 3 one (1) -- one (1) specific case where -- where the 4 pathologist was criticized by the trial judge and -- and 5 so there have been some questions about whether that's 6 something that should have come to the attention of the 7 Chief Coroner or the Chief Forensic Pathologist. 8 So I'm just trying to see if you can 9 envisage a way of tracking those, and I don't think that 10 you can at this point in time, is that fair? 11 DR. DAVID CHIASSON: Well, that's fair, 12 but I -- to me, I -- I agree with you. If -- if, in 13 fact, there is a judgment that is critical of a 14 pathologist, then I think that the -- the Chief Forensic 15 Pathologist should be made aware of that. 16 How that procedure happens, I -- I don't 17 think -- I can't see the Chief Forensic Pathologist 18 spending, you know, time sort of trying to -- 19 MS. SUZAN FRASER: No, I think -- 20 DR. DAVID CHIASSON: -- follow all of 21 this through, I mean -- 22 MS. SUZAN FRASER: The Forensic 23 Pathologist might have a good clerk who does this for him 24 or her. 25 DR. DAVID CHIASSON: Well, no, but even -

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1 - even then, I mean, to me it's if there's a problem in a 2 -- in a -- whether it's the -- the judge, and I don't 3 know what the avenues are for a justice to do -- to do -- 4 to actually send a report to the Chief Forensic 5 Pathologist, a judgment, or the Crown attorney, or a 6 defence counsel. 7 I mean, that to me is your -- your -- 8 these are -- these are relatively isolated problems. The 9 way to -- that I would see -- see dealing with them is 10 that there is a problem -- an identified problem -- then 11 it's for the people that -- that know of the problem to - 12 - to pass the information on to the Chief Forensic 13 Pathologist; not that the Chief Forensic Pathologist sets 14 up some global scheme to try and pick this up. To me, 15 that -- that's getting the whole thing backwards. 16 MS. SUZAN FRASER: All right. Thank you, 17 Mr. Commissioner. 18 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 19 Fraser. Just one (1) question about the SCAN Team. 20 You've indicated that it now works, 21 essentially, on a separate track from you in any 22 particular case, that you -- your office -- that is the 23 unit might be involved in -- and from your perspective, 24 is that different than its relationship with the unit 25 when Dr. Smith was your predecessor?

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1 DR. DAVID CHIASSON: Well, I'm aware, 2 from some of the evidence that I think has been before 3 the Commission, that there were -- at least, one (1) 4 incidence where -- one (1) instance where Dr. Smith and 5 Dr. Mian appears to have co-written a report of some 6 sort. 7 So there's clear -- that's something 8 that's never happened on my watch and -- and something 9 that I personally would not -- would not do. So, I -- I 10 mean it's not to say that I don't -- SCAN Teams see the 11 same patients that I do after death; obviously they 12 render opinions. 13 I've had contact with SCAN Teams providing 14 me with some followup opinions because some of the 15 testing comes back later on. I think that's very 16 helpful. I take that information as part of the package, 17 but I don't sit down with the SCAN Team and say, Well, 18 you know -- you know, I -- whatever opinions they have, I 19 think, you know, I would take into consideration and -- 20 and look at, but their -- their function and role, I 21 think, is quite clearly separate -- 22 COMMISSIONER STEPHEN GOUDGE: Yes. 23 DR. DAVID CHIASSON: -- from the function 24 of -- 25 COMMISSIONER STEPHEN GOUDGE: Yes.

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1 DR. DAVID CHIASSON: -- a pediatric 2 forensic pathologist. 3 COMMISSIONER STEPHEN GOUDGE: They deal 4 with the living and -- 5 DR. DAVID CHIASSON: Well, they deal with 6 the living and -- and as I've said, I also -- I think 7 there's a lot of value because they deal with the living 8 and they deal with many more cases of rib fractures, for 9 example -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. DAVID CHIASSON: -- than I would in 12 the deceased. The issue as to how a rib fracture might 13 have happened, I think they could well be in a much 14 better position to say, Well, you know, we have all this 15 experience, we see that we have this story of -- of falls 16 and -- and causing this kind of rib fractures, et cetera, 17 so there -- there's obviously a significant and very 18 important role that they -- that they play in terms of 19 how injuries might -- might occur. 20 But I don't see this as -- as being -- 21 that's fine, that's their view and they're entitled to 22 their opinion. I -- I see it as a separate and distinct 23 opinion as to what my role is and -- and my opinion might 24 ultimately be into -- in a case. 25 COMMISSIONER STEPHEN GOUDGE: When you

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1 began as Director of the Unit, did you have any sense 2 that this description of the two (2) roles -- the SCAN 3 Team and pathologists in the unit, was -- you weren't 4 doing anything different, that is, did you have any sense 5 that you were changing a prior relationship? 6 DR. DAVID CHIASSON: Well, I think my 7 sense was that there was more connection between Dr. 8 Smith, who was a longstanding hospital physician in the 9 unit, and the SCAN Team. Then I -- I came on board, and 10 I didn't have any history with anybody on the -- on the 11 SCAN Team. 12 And I -- I -- my sense is the relationship 13 was -- was closer in some -- whether it's -- it's just 14 the personnel knowing each other and -- and -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. DAVID CHIASSON: -- perhaps, 17 discussing cases, I -- I don't know the extent of that. 18 But it's -- probably was closer than certainly it is -- 19 it is now. 20 I -- I, on rare occasion, have attended, 21 for example, SCAN meetings. I -- I'd like to, in fact, 22 go to more because I -- I learn about what they're doing. 23 I learn about trauma, and the kinds of stories and -- and 24 the kinds of circumstances where they're seeing trauma. 25 I think -- I think I -- I need to know

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1 about they're experience, but at the same time, I do see 2 them as -- as separate and distinct. 3 I don't see this as part of a -- I don't 4 see pediatric forensic pathology part of the SCAN Team 5 and -- 6 COMMISSIONER STEPHEN GOUDGE: Or vice 7 versa? 8 DR. DAVID CHIASSON: -- or vice versa. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 Thanks. Thanks, Dr. Chiasson. Ms. Twohig, you do not 11 have any questions, I gather? 12 MS. KIM TWOHIG: No, sir. 13 COMMISSIONER STEPHEN GOUDGE: Thank you. 14 Mr. Carter...? 15 16 CROSS-EXAMINATION BY MR. WILLIAM CARTER: 17 MR. WILLIAM CARTER: Thank you, 18 Commissioner. Dr. Chiasson, I'm Bill Carter. I act for 19 the Hospital for Sick Children. 20 DR. DAVID CHIASSON: Good afternoon, Mr. 21 Carter. 22 MR. WILLIAM CARTER: Good afternoon. If 23 I might just pick up where the Commissioner left off in 24 the discussion of the SCAN Team. As I understand it, 25 your view is that the area in which the SCAN Team

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1 operates is a sub-specialty of pediatrics, is that fair? 2 DR. DAVID CHIASSON: That's my 3 understanding, yes. 4 MR. WILLIAM CARTER: Right. And would I 5 be right in suggesting to you that it's a -- a relatively 6 new field? 7 DR. DAVID CHIASSON: Well, I -- I don't 8 know how long the unit -- the SCAN unit -- has been in -- 9 in place at -- at the Hospital for Sick Children. I 10 mean, child abuse has been recognized over the years. 11 The approach is a specialized area; I would agree is a 12 relatively new area. 13 MR. WILLIAM CARTER: Well -- well, when 14 you were doing your rotations as an intern, I take it you 15 didn't rotate through the SCAN Team, did you? 16 DR. DAVID CHIASSON: Well, I did my 17 pediatrics in Fredericton, New Brunswick. There was no 18 SCAN Team there. 19 MR. WILLIAM CARTER: Right. 20 DR. DAVID CHIASSON: There was -- there 21 was three (3) pediatricians, so it wasn't a very big -- 22 MR. WILLIAM CARTER: Okay. 23 DR. DAVID CHIASSON: -- setup. 24 MR. WILLIAM CARTER: Well, I guess the 25 point I'm asking you to accept is that in the scheme of

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1 things, the way the SCAN Team has been developed and 2 operated is relatively new? 3 DR. DAVID CHIASSON: I -- that's my 4 impression, yes. 5 MR. WILLIAM CARTER: And as I understand 6 it, you consider they have a role -- a consulting role -- 7 for the forensic pathologist, like any other sub- 8 specialty? 9 DR. DAVID CHIASSON: Well, no, I don't 10 think that that's what I -- I said. What I -- what I 11 suggest is that they have a consulting -- well, the -- 12 the exception being in the issue of sexual assault -- I 13 may have them involved in that. Because that's an area 14 that I -- I don't have any particularly com -- comfort 15 level in. 16 I don't do sexual assault examinations. 17 So there are occasions where I have consulted them for 18 that specific role. 19 MR. WILLIAM CARTER: So you -- there -- 20 there may be a -- a relatively narrow area in which they 21 have a consulting role? 22 DR. DAVID CHIASSON: There -- there may 23 be, yes. 24 MR. WILLIAM CARTER: Yeah. And it's, I 25 think, as I understand you, it's certain types of human

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1 behaviour with which they have experience that may be 2 somewhat foreign to your realm? 3 DR. DAVID CHIASSON: Yes, anything having 4 to do really with behaviour is -- is not -- it's not 5 within the area of pediatric forensic pathology, in my 6 view. 7 MR. WILLIAM CARTER: Right. So that's 8 where they may be of assistance to you? 9 DR. DAVID CHIASSON: Well, they -- they - 10 - no, I -- I -- they may be of assistance to the death 11 investigator. They may be of assistance to the police. 12 And -- and as I say, I freely will say to the police, 13 Listen, I -- I think you should get a -- a SCAN Team 14 opinion on the issues related to how trauma may occur. 15 And if that could extend to behavioural 16 issues, well that's -- that's up to them to decide where 17 -- you know, how far they go in terms of what they look 18 at, et cetera. But I -- I -- the police will then 19 consult with them as they see fit. 20 MR. WILLIAM CARTER: Okay. 21 DR. DAVID CHIASSON: Other than my narrow 22 area, which I've referred to -- and I think I've done 23 this maybe once or twice in the last five (5) or six (6) 24 years -- there is no direct connection that I see between 25 the SCAN Team and pediatric forensic --

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1 MR. WILLIAM CARTER: Okay. 2 DR. DAVID CHIASSON: -- pathology. 3 MR. WILLIAM CARTER: So there may rarely 4 be but there usually isn't, in your experience? 5 DR. DAVID CHIASSON: That's correct. 6 MR. WILLIAM CARTER: Okay. Now I'm going 7 to begin my cross-examination. 8 You, and I think others, have told us -- I 9 want to start at a general level; I want to start with 10 the field of pediatrics and then move down into pediatric 11 pathology and then into forensic pediatric pathology. 12 So if we just start with pediatrics. 13 You'll agree with me -- 14 DR. DAVID CHIASSON: I'd like to assume 15 you're going up there, but you're saying going down. But 16 anyway, we'll -- we'll accept that. 17 MR. WILLIAM CARTER: Well, I'm looking at 18 pediatrics as a general field, and I'm looking at 19 pathology as a specialty, and I'm looking at forensic 20 pathology as a sub-specialty. 21 Will you accept that declension? 22 DR. DAVID CHIASSON: That -- that sounds 23 neutral, yes. 24 MR. WILLIAM CARTER: Well. So if we can 25 start with the field of pediatrics itself. It's the

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1 study of illness and disease in children, isn't it? 2 DR. DAVID CHIASSON: Yes. 3 MR. WILLIAM CARTER: Generally speaking. 4 DR. DAVID CHIASSON: Yes, I agree. 5 MR. WILLIAM CARTER: And the study of 6 disease and illness in children is different from the 7 study of disease and illness in adults, isn't it? 8 DR. DAVID CHIASSON: That's the basic 9 principle, and that's why we have pediatrics as a 10 specialized area of medicine, yes. 11 MR. WILLIAM CARTER: And it's -- and 12 children are just not miniature adults, are they? 13 DR. DAVID CHIASSON: I think every 14 pediatrician learns that very, very early on in their 15 career. Anybody going to medical school learns that very 16 on -- from talking to a pediatrician. 17 MR. WILLIAM CARTER: And what 18 differentiates pediatrics from the field of adult 19 medicine is that you're developing -- you're studying the 20 development of the human being in its infancy through to 21 adolescence? 22 DR. DAVID CHIASSON: That's certainly a 23 large part of it, yes. 24 MR. WILLIAM CARTER: And when you look at 25 illness and disease, you're looking at -- what you may be

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1 looking at will differ depending on the age of the child? 2 DR. DAVID CHIASSON: Correct. 3 MR. WILLIAM CARTER: Some diseases 4 manifest differently in children of different ages? 5 DR. DAVID CHIASSON: Yes. 6 MR. WILLIAM CARTER: And that's not 7 necessarily true in adults when they've reached the full 8 maturation process? In some cases. 9 DR. DAVID CHIASSON: Yes. 10 MR. WILLIAM CARTER: And so the practice 11 of pediatrics has been organized into highly specialized 12 units such as the Hospital for Sick Children? 13 DR. DAVID CHIASSON: Yes. 14 MR. WILLIAM CARTER: And when you deal 15 with pediatric pathology again, you're dealing with the 16 pathological study of disease in the infant and 17 adolescent population? 18 DR. DAVID CHIASSON: Correct. 19 MR. WILLIAM CARTER: And the -- this -- 20 this study is again different from adult pathology, is it 21 not? 22 DR. DAVID CHIASSON: Yes. 23 MR. WILLIAM CARTER: And I think we're 24 now getting to the forensic field, but I take it that 25 when it comes to forensics, the forensic approach, may or

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1 may not vary, depending on whether the field is pediatric 2 or adult. Is that fair? 3 There's some things that you might do from 4 a different forensic approach if it's a children's case; 5 whereas, in an adult, you might do it differently. Is 6 that fair? 7 DR. DAVID CHIASSON: Well, I think there 8 are certainly fairly broad areas within pediatric 9 forensic pathology versus adults that are -- they're 10 different, yes. 11 MR. WILLIAM CARTER: Right. And some may 12 be the same? 13 DR. DAVID CHIASSON: There are some 14 issues that are -- are the same. But one (1) thing -- 15 even -- even in areas where I thought there wouldn't be 16 much difference, for example, falls from great heights, 17 what I'm learning is that even in their patterns of 18 injuries, for example, for children falling from great 19 heights than adults, there are variations. Even in 20 something that on -- on a -- I would have thought on a 21 practical sort of level that you'd be dealing with the 22 same thing. 23 There are a lot of it that overlaps, I 24 mean, obviously. But there are -- there are differences. 25 MR. WILLIAM CARTER: And your job at the

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1 Hospital for Sick Children is to conduct autopsies, is it 2 not, primarily? 3 DR. DAVID CHIASSON: Yes. 4 MR. WILLIAM CARTER: And that would 5 include hospital autopsies or is it just forensic 6 autopsies? 7 DR. DAVID CHIASSON: My responsibilities 8 include both. 9 MR. WILLIAM CARTER: Okay. 10 And you also told us that on weekends, you 11 do some adult post-mortems? 12 DR. DAVID CHIASSON: I do. 13 MR. WILLIAM CARTER: And you told us that 14 you do fifty (50) to sixty (60) post-mortems a year in 15 the hospital setting? 16 DR. DAVID CHIASSON: Yes, somewhere 17 around there. Yeah. 18 MR. WILLIAM CARTER: So that's a little 19 more than one (1) a week? I mean, if you just -- 20 DR. DAVID CHIASSON: Mm-hm. 21 MR. WILLIAM CARTER: -- average it out. 22 DR. DAVID CHIASSON: Yes. 23 MR. WILLIAM CARTER: And when you were 24 working in the adult setting at the Toronto Forensic 25 Pathology Unit, how many autopsies a week were you doing?

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1 DR. DAVID CHIASSON: When I was working 2 more-or-less -- 3 MR. WILLIAM CARTER: Yes. 4 DR. DAVID CHIASSON: -- full time? 5 MR. WILLIAM CARTER: Yes, yes. 6 DR. DAVID CHIASSON: Well, per -- two 7 hundred and fifty (250) cases a year for -- as a ballpark 8 figure. So one (1) a day. 9 MR. WILLIAM CARTER: Okay. So -- 10 DR. DAVID CHIASSON: One (1) a working 11 day, if you will. One (1) a working weekday. 12 MR. WILLIAM CARTER: So I'm -- I'm just 13 trying to get a sense of how much longer it takes to do 14 an infant or child case or pediatric case than an adult 15 case. 16 I take it that it takes considerably more 17 time? 18 DR. DAVID CHIASSON: The actual procedure 19 takes more time, on average, -- 20 MR. WILLIAM CARTER: Yes. 21 DR. DAVID CHIASSON: -- and the detailed 22 ancillary testing and assessing that. The report writing 23 takes more time. 24 MR. WILLIAM CARTER: Why is that? Why 25 does it take more time to do the ancillary testing? And

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1 why does it take more time to do the report writing? 2 DR. DAVID CHIASSON: Well, the ancillary 3 testing -- the amount of microscopy, for example, that we 4 routinely look at in a pediatric case, the -- the sort of 5 basic minimal number of slides I have to look at in a 6 pediatric case is -- is now twenty-nine (29); and that's 7 the minimum. 8 MR. WILLIAM CARTER: And why is it 9 twenty-nine (29) as opposed to four (4) or whatever you 10 do in an adult case? 11 DR. DAVID CHIASSON: In an adult case, 12 it's usually four (4), five (5), maybe six (6). 13 Because we are within an academic setting, 14 we're looking at the complete spectrum of organs. And 15 when we look at an organ in pediatrics, we actually look 16 at multiple areas. 17 And it's -- it's in part -- many of the 18 cases are of undetermined nature, so we're looking for a 19 diagnosis or looking for abnormalities much more intently 20 than we are in an adult situation where usually the cause 21 of death is apparent at the end of the autopsy. 22 So, for example, somebody dies of heart 23 disease, I can make the diagnosis at the autopsy. Okay, 24 I'll take a few slides to confirm what I'm seeing but 25 there's no need for me to look at a whole spectrum of

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1 organ pathology because I've -- I've really gotten to the 2 nubbin of the case by -- by -- at the time of gross 3 examination, so. 4 A lot of the deaths are -- sudden infant 5 deaths are -- are of undetermined cause. But the only 6 way we can make a -- an undetermined conclusion is to 7 exclude pathology in all these organs. 8 As well, we do it as a -- as a learning 9 exercise because we may see what could be an incidental 10 abnormality, for example, in the pediatric setting which 11 you learn is an incidental finding by -- by looking at a 12 whole series of cases where you may have a cause of 13 death, ultimately. 14 And it's part of the academic setting. 15 This is what you would do in a hospital autopsy is the 16 same what you do in a pediatric setting; I mean, the 17 basic minimum number of slides. So part of the academic 18 thrust is to do a detailed examination and by doing that, 19 there's the opportunity to learn from such a 20 comprehensive degree of analysis. 21 MR. WILLIAM CARTER: Well, is it fair to 22 say it takes four (4) to five (5) times as much time to 23 do a pediatric -- a routine pediatric autopsy as it does 24 the routine adult autopsy that doesn't have forensic -- 25 in the sinister sense of the word -- implications?

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1 DR. DAVID CHIASSON: Well, I think -- and 2 the other layer that we haven't touched on is that the 3 extent of interaction. We do -- we present all the cases 4 -- the CPC rounds for example -- which is not something 5 that we would do in the adult world. I mean, most of the 6 cases do not get presented in any kind of formal format. 7 So there's a -- there's a certain amount 8 of time spent in preparing the findings. 9 As I've indicated, we do microscopy. 10 Well, we're actually, if there findings, we'll -- we'll 11 photograph the microscopy and present that. 12 So we are in a very academic setting in 13 the Hospital for Sick Children and part of that is -- is 14 to -- is to have these rounds; these clinical pathologic 15 correlations. 16 We deal with Residents and Fellows 17 training on an ongoing basis, so involvement of there is 18 taking time as well. 19 All told, as you suggest, four (4) to five 20 (5) times the amount of work per case. I mean, if you 21 turn it around, I am working just as hard doing fifty 22 (50) to sixty (60) autopsies at the Toronto -- sorry, at 23 the Hospital for Sick Children as I was before, doing two 24 hundred and fifty (250) adult cases. 25 MR. WILLIAM CARTER: The hospital is

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1 delighted to hear that. 2 DR. DAVID CHIASSON: Well, hopefully, 3 nobody -- nobody looks at this and says, Well, he's only 4 doing this number of cases; we got -- we're not getting 5 our money's worth out of him. I -- I'd like to think 6 you're getting your money's worth. 7 MR. WILLIAM CARTER: But the utility, as 8 I understand it, is multiple; one (1), you get a highly 9 refined analysis of the circumstances and cause of death 10 for the infant in question -- 11 DR. DAVID CHIASSON: Yes. 12 MR. WILLIAM CARTER: -- and you also get 13 the benefit of being able to have a broad collegial 14 discussion about the learning aspects of the case. 15 DR. DAVID CHIASSON: Yes. 16 MR. WILLIAM CARTER: And you also advance 17 the -- a knowledge in learning of Residents and Fellows 18 who are in the course of their training. 19 DR. DAVID CHIASSON: Yes. 20 MR. WILLIAM CARTER: Now, you've said 21 that -- that your full time job is doing post-mortems. I 22 take it you don't do surgical rotation. 23 DR. DAVID CHIASSON: I do -- surgical 24 pathology rotation, no. 25 MR. WILLIAM CARTER: No. And, in fact,

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1 you're not qualified to do that in your own -- by your 2 own admission, is that fair? 3 DR. DAVID CHIASSON: Well, I -- I don't 4 feel qualified, although theoretically, as a -- I'm an 5 anatomic pathologist training; by that I -- I 6 theoretically, could do surgical pathology, but I -- I 7 don't feel qualified. 8 MR. WILLIAM CARTER: Well, you have the 9 license, but you know your limitations. 10 DR. DAVID CHIASSON: Exactly. 11 MR. WILLIAM CARTER: Okay. And so within 12 your limitations, you don't do surgical pathology. 13 DR. DAVID CHIASSON: Correct. 14 MR. WILLIAM CARTER: And you work full 15 time doing post-mortems. 16 DR. DAVID CHIASSON: Yes. 17 MR. WILLIAM CARTER: And you hold a 18 hospital medical staff appointment. 19 DR. DAVID CHIASSON: I do. 20 MR. WILLIAM CARTER: And what is your 21 academic rank? 22 DR. DAVID CHIASSON: Assistant Professor. 23 MR. WILLIAM CARTER: Thank you. And 24 that's in the Department of Pathology at the University 25 of Toronto?

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1 DR. DAVID CHIASSON: Actually, I have two 2 (2) academic titles; Assistant Professor in the 3 Department of -- of Pathobiology -- laboratory medicine 4 pathobiology -- which is the Department of Pathology at 5 the University of Toronto, and I have an Associate 6 Position -- professor position in forensic sciences -- 7 which is part of the Arts and Science faculty at the 8 University of Toronto, Massasauga campus. 9 MR. WILLIAM CARTER: Now -- 10 COMMISSIONER STEPHEN GOUDGE: Sorry, is 11 there a department there? What's it called? 12 DR. DAVID CHIASSON: There's a depart -- 13 there's an arts and science faculty -- 14 COMMISSIONER STEPHEN GOUDGE: No, I 15 understand that. 16 DR. DAVID CHIASSON: -- and there is a -- 17 COMMISSIONER STEPHEN GOUDGE: Is it 18 called forensic sciences or something? 19 DR. DAVID CHIASSON: -- and there is a -- 20 there is a -- I think a Division of Forensic Sciences. 21 They -- they have a forensic sciences program there 22 that's been going on for about, I think, ten (10) years 23 or so, and my activities -- I was more active in the 24 past. 25 I would give lectures to their -- to their

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1 students. And this is -- you can get a -- I think a 2 Bachelor of Forensic Science, and I think they're now 3 starting a Masters program, or they have started a 4 Masters program -- 5 COMMISSIONER STEPHEN GOUDGE: All right. 6 DR. DAVID CHIASSON: -- in forensic 7 science. 8 COMMISSIONER STEPHEN GOUDGE: Sorry, Mr. 9 Carter. 10 11 CONTINUED BY MR. WILLIAM CARTER: 12 MR. WILLIAM CARTER: Not at all. I 13 understand from your evidence that your -- your 14 information is that Dr. Smith, back in the mid to late 15 '90's, was doing approximately the same caseload as 16 you're now doing? 17 DR. DAVID CHIASSON: Or perhaps a little 18 bit more, yes. 19 MR. WILLIAM CARTER: And I'm talking 20 about -- 21 DR. DAVID CHIASSON: Oh, just the -- the 22 same amount of caseload on the pathology side. 23 MR. WILLIAM CARTER: Yeah, well, let's -- 24 let's break it down. 25 DR. DAVID CHIASSON: On the autopsy side.

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1 MR. WILLIAM CARTER: On the autopsy side, 2 he was doing fifty (50) to sixty (60) cases per year, 3 roughly. 4 DR. DAVID CHIASSON: I think that's -- 5 that was -- yes. 6 MR. WILLIAM CARTER: We understand he was 7 doing approximately half the cases in the unit. 8 DR. DAVID CHIASSON: Yes. 9 MR. WILLIAM CARTER: And we understand 10 the unit was doing approximately a hundred and twenty 11 (120) coroner's cases per year. 12 DR. DAVID CHIASSON: Yes. 13 MR. WILLIAM CARTER: Okay. And in 14 addition to that, we understand that he was doing other 15 work involving surgical pathology in teaching. 16 DR. DAVID CHIASSON: Correct. 17 MR. WILLIAM CARTER: Okay. So, to that 18 extent, at least to the extent he was doing surgical 19 pathology, his caseload was -- or his workload, exceeded 20 your current workload. 21 DR. DAVID CHIASSON: Correct. 22 MR. WILLIAM CARTER: All right. And 23 you've -- you were asked some questions related to some 24 information that's before this Commission concerning some 25 problems Dr. Smith was having with some surgical

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1 pathology cases, and without -- I think you were taken to 2 four (4) of five (5) and you didn't think three (3) of 3 the four (4) were of particular concern; the fourth you 4 thought might be of some concern. 5 I'm kind of paraphrasing your evidence, 6 but I'm just trying to orient you for my questions. Do 7 you recall that? 8 DR. DAVID CHIASSON: Yes. 9 MR. WILLIAM CARTER: And you indicated 10 that the subject matter of those concerns was in the 11 field of surgical pathology. 12 DR. DAVID CHIASSON: Yes. 13 MR. WILLIAM CARTER: And you indicated 14 that you didn't feel comfortable evaluating the 15 significance of those problems as they relate to the 16 skills of a pediatric pathology conducting post-mortem 17 exams. 18 DR. DAVID CHIASSON: Correct. 19 MR. WILLIAM CARTER: And you would defer, 20 I take it, to someone like Dr. Glen Taylor on that score. 21 DR. DAVID CHIASSON: Very defin -- very 22 definitely. 23 MR. WILLIAM CARTER: Yeah, Dr. Taylor is 24 a Pediatric Pathologist of considerable experience, is he 25 not?

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1 DR. DAVID CHIASSON: He is, yes. 2 MR. WILLIAM CARTER: And a high degree of 3 qualification? 4 DR. DAVID CHIASSON: Yes. 5 MR. WILLIAM CARTER: And in addition, he 6 has a considerable amount of -- of forensic pathology 7 experience both in Ontario and British Columbia? 8 DR. DAVID CHIASSON: He does, yes. 9 MR. WILLIAM CARTER: Yeah. And I just 10 want to ask you a little about how things are working out 11 at the unit at the hospital now. And I don't want to 12 repeat or cover ground that's already been touched upon, 13 but it's important for this -- one (1) of the important 14 mandates of this Commission is to address the public 15 concern about the quality of pediatric forensic pathology 16 in the province, so I think it's germane. 17 As I understand it, the coroner's work 18 that is being done by your unit at the hospital remains 19 approximately in the same volume as it was eight (8) or 20 ten (10) years ago, is that fair? 21 DR. DAVID CHIASSON: Yes, we're around a 22 hundred and twenty/hundred and thirty (120/130) cases per 23 year. 24 MR. WILLIAM CARTER: Okay. And as I 25 understand it, the post-mortem examinations done on

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1 coroner's warrants are being done by you, is that right? 2 DR. DAVID CHIASSON: Yes. 3 MR. WILLIAM CARTER: And Dr. Taylor? 4 DR. DAVID CHIASSON: Yes. 5 MR. WILLIAM CARTER: And Dr. Pollanen, 6 from time to time? 7 DR. DAVID CHIASSON: Yes. 8 MR. WILLIAM CARTER: And is there anyone 9 else doing them, currently? 10 DR. DAVID CHIASSON: Dr. Wilson. 11 MR. WILLIAM CARTER: Dr. Wilson. That's 12 Dr. Greg Wilson? 13 DR. DAVID CHIASSON: That's correct. 14 MR. WILLIAM CARTER: And he's been there 15 for twenty-five (25) or thirty (30) years, at least? 16 DR. DAVID CHIASSON: Since the early part 17 of the '80s, at least, yes. 18 MR. WILLIAM CARTER: Yeah. And as I 19 understand it, the -- the -- that group of coroner's 20 cases are being handled by those four (4) or five (5) 21 pathologists you indicated, but when it comes to the 22 forensically sinister cases -- the criminally suspicious 23 homicidal cases -- those are for you, is it not the case, 24 in the main? 25 DR. DAVID CHIASSON: Yes, if I'm -- I --

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1 I assume responsibility for the majority of them, 2 certainly if I'm around. If I'm not available, Dr. 3 Pollanen is -- is there in backup. And if neither of us 4 are -- are available, Dr. Taylor is -- is the -- is 5 prepared to assume responsibility for these cases. 6 MR. WILLIAM CARTER: Okay. And what is 7 your level of confidence as to the quality of the output 8 of these three (3) physicians on -- when it comes to the 9 serious forensic cases? 10 DR. DAVID CHIASSON: Well, you're asking 11 me what I think of the quality of my output -- 12 MR. WILLIAM CARTER: Well, your -- your 13 work is covered, is it not? Is it not vetted by Dr. 14 Taylor? 15 DR. DAVID CHIASSON: It is vetted by Dr. 16 Taylor. 17 MR. WILLIAM CARTER: Yeah. 18 DR. DAVID CHIASSON: And I vet Dr. Taylor 19 and Dr. Pollanen's work within the context of the -- of 20 the unit. I -- I think the provision of service that is 21 being -- that the service being provided in the 22 criminally suspicious, homicidal -- forensically sinister 23 type cases that you refer to -- is at -- is at an 24 extremely high level. 25 MR. WILLIAM CARTER: Okay. And do you

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1 still have the same amount of assistance in terms of 2 administrative help, secretarial help and that sort of 3 thing as there was eight (8) or ten (10) years ago? 4 DR. DAVID CHIASSON: I don't think it's 5 changed significantly, but I'm not completely familiar 6 with what was there eight (8) or ten (10) years ago. 7 MR. WILLIAM CARTER: You're not aware of 8 anybody being hired on specifically to help you out? 9 DR. DAVID CHIASSON: No. 10 MR. WILLIAM CARTER: Okay. And you 11 don't -- 12 DR. DAVID CHIASSON: Well, I'm aware that 13 nobody has been hired on to specifically help me, so. 14 MR. WILLIAM CARTER: That's a very 15 unfortunate way of putting my question. But would you 16 agree with me that there has been no single individual 17 dedicated purely to the administrative activities of the 18 unit? 19 DR. DAVID CHIASSON: No. And there 20 should be, but there isn't. 21 MR. WILLIAM CARTER: I understand, but 22 that was -- that was a song that we heard in the '90s, as 23 well, from Dr. Smith, is that fair? 24 DR. DAVID CHIASSON: Yes. 25 MR. WILLIAM CARTER: Okay. And you still

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1 haven't got one, have you? 2 DR. DAVID CHIASSON: No. 3 MR. WILLIAM CARTER: Those come from 4 hospital resources, do they not? 5 DR. DAVID CHIASSON: Yes. 6 MR. WILLIAM CARTER: Tho -- that kind of 7 hiring? 8 DR. DAVID CHIASSON: Yes. 9 MR. WILLIAM CARTER: And that's a whole 10 different kind of problem when you get into base funding 11 for public hospitals, isn't it? 12 DR. DAVID CHIASSON: It -- it is. 13 Suffice it to say, I've -- I've broached this with Dr. 14 Taylor, and we are making strides in the direction of 15 this. I -- I think we'll -- we'll be able to achieve our 16 goal. 17 MR. WILLIAM CARTER: Well, let's talk 18 about -- about turnaround times. You said that you 19 embraced -- maybe clung to -- a somewhat unrealistic 20 ninety (90) day turnaround time for 90 percent of the 21 cases. 22 You acknowledge that you haven't met that 23 objective? 24 DR. DAVID CHIASSON: That's correct. 25 MR. WILLIAM CARTER: Where does that come

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1 from? Is that some kind of standard from some -- I don't 2 want to call it the industry, but whatever the equivalent 3 is -- is it a standard of practice in the field of 4 pediatric forensic pathology that coroner's reports or 5 pathologist's reports get sent to coroner's offices 6 within ninety (90) days? 7 DR. DAVID CHIASSON: No. I think it was 8 -- I had my Chief Forensic Pathologist hat on at the 9 time, and I envisioned the ninety (90) days for most of 10 the cases as being a -- an ideal situation, recognizing 11 that there were constraints -- outside constraints -- in 12 cases where toxicology was part of it. 13 And I -- I think it -- it's what I was 14 trying to do -- affect at the Toronto Unit with variable 15 success there, as well. But I recognize it now -- it 16 sounds good -- it's got a nice catchy sound to it, but 17 it's -- it's not a realistic thing. I -- I realize that 18 now. 19 MR. WILLIAM CARTER: Well, it may have 20 been a fond hope when you were Chief Forensic 21 Pathologist, but now that you're on the other side, and 22 now that you've learned a little bit more about pediatric 23 forensic pathology and what's involved, you'd have to 24 acknowledge that it's not realistic? 25 DR. DAVID CHIASSON: I -- I'd say, it's -

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1 - it's -- certainly within the resource situation we have 2 now, we do occasionally do have cases completed within 3 the ninety (90) days. Many of them though take one 4 hundred and twenty (120) -- within a hundred and twenty 5 (120) days. 6 And I think there is still an important -- 7 I mean, I think it's important to have some kind of 8 guideline to -- to aim for. But, having said, under the 9 current resource situation that we're doing, we're not -- 10 we're not coming close to that. 11 MR. WILLIAM CARTER: But -- but are there 12 any kind of acknowledged, whether they be provincial, 13 national, international, standards for this kind of work 14 product? 15 DR. DAVID CHIASSON: Not -- not for 16 pediatric forensic pathology. I think there are some 17 suggested guidelines for autop -- hospital autopsies, but 18 that's a different situation. 19 MR. WILLIAM CARTER: Are you talking 20 about pediatric autopsies, or just adult or -- 21 DR. DAVID CHIASSON: I was talking -- 22 MR. WILLIAM CARTER: -- or generic 23 autopsies. 24 DR. DAVID CHIASSON: -- I was talking 25 about generic autopsies -- hospital autopsies under next-

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1 of-kin consent. I don't know whether there are pediatric 2 guidelines or not. I'm aware -- unaware of that. 3 MR. WILLIAM CARTER: Okay. So you may, 4 in fact, be exceeding the guidelines that you're not 5 aware of. It doesn't feel like it, does it? 6 DR. DAVID CHIASSON: It doesn't feel like 7 it, no. 8 MR. WILLIAM CARTER: So in terms of turn 9 around time, how does it compare to the turn around times 10 that you were struggling with eight (8) or ten (10) years 11 ago? 12 DR. DAVID CHIASSON: Turn around times 13 for -- for -- 14 MR. WILLIAM CARTER: For -- for -- 15 DR. DAVID CHIASSON: -- the Toronto Unit, 16 or from -- 17 MR. WILLIAM CARTER: No, for -- for the - 18 - the Sick Kids Unit? 19 DR. DAVID CHIASSON: Well, there's 20 variation from pathologist to pathologist, but it's 21 probably not all that much different. 22 MR. WILLIAM CARTER: So it's still a 23 struggle? 24 DR. DAVID CHIASSON: It's still a 25 struggle.

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1 MR. WILLIAM CARTER: 'Cause now you're 2 struggling from the inside instead of from the outside? 3 DR. DAVID CHIASSON: Yes, it's still a 4 struggle. 5 MR. WILLIAM CARTER: And it's a struggle 6 across the province, isn't it? 7 DR. DAVID CHIASSON: Well, in -- in terms 8 -- again, there's variability. Some units -- some 9 pathologists are much more efficient at getting out PM 10 reports then -- then others. So there's always 11 variability. But certainly Dr. Pollanen has yet to, you 12 know, pull me aside and said, You know, Sick Kids is way 13 out of line with the rest of -- of the province. I don't 14 think that's true. 15 MR. WILLIAM CARTER: And in particular, 16 when you're dealing with pediatric cases, and there's 17 only a limited number of those, but more then half of 18 them are being done here in Toronto, but you'd expect, 19 across the board, for those to be longer than the adult 20 cases? 21 DR. DAVID CHIASSON: That would be my 22 first excuse in discussing it with Dr. Pollanen; would be 23 that the natu -- specialized nature -- and given that he 24 -- some of his cases are -- are ones I have to monitor 25 from turn around time, I think he'll be sympathetic to --

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1 to my position. 2 MR. WILLIAM CARTER: Those are my 3 questions, thank you. 4 DR. DAVID CHIASSON: Thank you, Mr. 5 Carter. 6 COMMISSIONER STEPHEN GOUDGE: Do you have 7 any sense of the actual numbers for turn around times? I 8 mean back in '98, it sounds like the numbers were one 9 hundred and fifteen (115) days, one hundred and twenty 10 (120) days, one hundred and thirty-one (131) days in '97. 11 What are they now? 12 DR. DAVID CHIASSON: It's not a great 13 time to ask me that, Mr. Commissioner, since -- 14 COMMISSIONER STEPHEN GOUDGE: Well, 15 you've been here for the last three (3) days. 16 DR. DAVID CHIASSON: -- I've been -- well 17 it's not only the last three (3) days, I -- I didn't come 18 out of here unprepared, and -- we -- we do have cases 19 that certainly far exceed, in terms of turn around time, 20 a hundred and twenty (120) days, even a hundred and fifty 21 (150) days. I would say, realistically, if I had to 22 revise the goals, I think we're looking at a hundred and 23 twenty (120) days or -- that -- that would be my -- my 24 next reasonable goal. 25 I mean, obviously, I don't want to start

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1 by suggesting that they can take -- my pathologists can 2 take as long as they want. I mean, I -- I would think 3 that we're still -- we're above a hundred and twenty 4 (120), probably a hundred -- 5 COMMISSIONER STEPHEN GOUDGE: I guess 6 what I am getting after, Dr. Chiasson, is that throughout 7 the period of the '90s, there was obviously considerable 8 concern in the Coroner's Office about Dr. Smith's 9 turnaround time. 10 DR. DAVID CHIASSON: Yes. 11 COMMISSIONER STEPHEN GOUDGE: And, I 12 mean, how would you compare the turnaround time today 13 with the turnaround times that raised the concerns in the 14 mid '90s? 15 DR. DAVID CHIASSON: Well, I -- you know, 16 in reality, I don't they're all that much different, but 17 I think the -- the point I would make, and -- and I refer 18 to my own approach about the squeaky wheel. And I've 19 been -- over the years, I've not only done cases at Sick 20 Kids, I've been doing that at the Coroner's Office, and 21 I'm -- I'm juggling a fair -- fairly heavy caseload. 22 My approach has always been to -- if 23 somebody is looking for a report to -- to produce that 24 report; that goes to the top of the pile and to -- to 25 respond to that request. Many of the autopsies that are

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1 performed, the Coroner's Office is -- is obviously keen 2 to get the reports, but they're particularly keen if 3 somebody else is looking for them. 4 So if a family is looking for a report 5 then I -- you know, they've -- they've been kind enough 6 to give me a heads up -- you know, this is a report, so 7 they want to look good in -- in releasing it to the 8 family or if it's a criminally -- a criminal case, a 9 homicide case, the police are look -- 10 COMMISSIONER STEPHEN GOUDGE: The police 11 are asking for it, -- 12 DR. DAVID CHIASSON: -- police are asking 13 for it -- 14 COMMISSIONER STEPHEN GOUDGE: -- the 15 Crown is asking for it. 16 DR. DAVID CHIASSON: -- so that's been my 17 -- my sort of approach, and it's, basically, kept me out 18 of -- out of hot water. I think with Dr. Smith is in so 19 much -- if we were -- if we weren't getting the 20 complaints about specific cases, then we probably 21 wouldn't have been so hard on him in terms of the general 22 sense of -- you know, it's -- 23 COMMISSIONER STEPHEN GOUDGE: So the 24 measure in the mid '90s might not have been so much the 25 average turnaround as the failure to meet the complaints

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1 from users of the reports? 2 DR. DAVID CHIASSON: That's right. So he 3 wasn't responding. So because he wasn't responding to 4 specific requests, this was coming back on me, and -- and 5 I -- you know, landing in my plate. And even with 6 prompting and -- 7 COMMISSIONER STEPHEN GOUDGE: I see. 8 DR. DAVID CHIASSON: -- attempts to 9 respond, he still wasn't responding. So I think then, we 10 started looking and auditing and being -- being more 11 critical about the situation. I don't think that out of 12 the blue -- you know, unless he wasn't -- you know, if -- 13 if he had been responding to these requests, I'm not sure 14 that, out of the blue, we would have started auditing 15 Sick Kids as opposed to any other unit. And -- 16 COMMISSIONER STEPHEN GOUDGE: And you 17 would not have started watching turnaround times, as an 18 average, in attempting to move them down provided the 19 squeaky wheels were getting served? 20 DR. DAVID CHIASSON: Exactly. 21 COMMISSIONER STEPHEN GOUDGE: Okay. 22 Thanks. 23 MR. WILLIAM CARTER: So if I may, just -- 24 COMMISSIONER STEPHEN GOUDGE: Absolutely, 25 Mr. Carter.

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1 2 CONTINUED BY MR. WILLIAM CARTER: 3 MR. WILLIAM CARTER: So -- so to the ext 4 -- just following up on the Commissioner's questions. To 5 the extent that an individual, such as yourself, may 6 respond positively or not at all to a request for an 7 autopsy, it's an individual reaction to a problem? 8 DR. DAVID CHIASSON: Well, I think so, 9 yeah. I mean, it's -- 10 MR. WILLIAM CARTER: Yeah, it's not a 11 systemic problem? 12 DR. DAVID CHIASSON: No. 13 MR. WILLIAM CARTER: Thank you. 14 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 15 Carter. Back to you, I guess, Ms. Ritacca? 16 MS. LUISA RITACCA: You look so 17 disappointed. 18 COMMISSIONER STEPHEN GOUDGE: No. I 19 consider this real progress. 20 21 CROSS-EXAMINATION BY MS. LUISA RITACCA: 22 MS. LUISA RITACCA: I'll be very brief. 23 Dr. Chiasson, you were asked by Ms. Fraser and Mr. Carter 24 about your use of the SCAN Team physicians on a 25 consulting basis, and if I understood your answer

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1 correctly, you said that on the very rare occasion where 2 there is a sexual assault or a potential sexual assault, 3 that you do use them as consultants. 4 Can you explain to us, exactly, what it is 5 you ask the SCAN Team physician to do in that particular 6 circumstance? 7 DR. DAVID CHIASSON: Again, and -- and 8 this is in the past. I have actually not used the SCAN 9 personnel in the last two (2) or three (3) years. I have 10 done it early on when I started working at Sick Kids. 11 The intent was to perform an examination 12 of the external genitalia of a -- an -- an infant female 13 and render an opinion as to whether there was any 14 evidence of -- of sexual interference, any evidence of -- 15 of injury to -- to that area, and that was basically the 16 -- the extent of the opinion. 17 Currently, I may well -- my practice -- 18 I'm not sure, I haven't -- I haven't had a case of late 19 where it's really come up. 20 I might be inclined, given now that I'm 21 feeling a little more comfortable with the -- the total 22 spectrum of pediatric forensic pathology -- is carry out 23 the examination myself; ensure that it's documented in a 24 reviewable fashion. 25 And if necessary, if there was evidence of

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1 injury, actually retain the -- the area as a -- as a 2 specimen for detailed examinations, so I think my 3 practice really has -- has changed, and if anything, has 4 moved away from. 5 I -- I think it unlikely that I would 6 involve a SCAN team myself in the performance of 7 pediatric forensic pathology duties. 8 MS. LUISA RITACCA: And why have you 9 changed your practice in the last two or three years? 10 DR. DAVID CHIASSON: I've gotten more 11 comfortable with the approach to -- to pediatric forensic 12 pathology. Dr. Pollanen has provided some excellent 13 guidelines in terms of the approach to criminally 14 suspicious death, including in potential sexual assaults 15 and -- and infants as to an approach, from a pathology 16 point of view. 17 And I'm for -- for those reasons, I don't 18 feel the necessity to involve somebody from -- from a 19 SCAN team -- in -- in that performance of my duties. 20 MS. LUISA RITACCA: Thank you. Those are 21 my questions, thank you. 22 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 23 Ritacca. 24 Ms. Rothstein...? 25

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1 RE-DIRECT EXAMINATION BY MS. LINDA ROTHSTEIN: 2 MS. LINDA ROTHSTEIN: Just to follow up 3 on the -- the use of the SCAN team with you, Doctor, do I 4 hear some hesitation from you about the use of the SCAN 5 team; some conservatism in the use of a SCAN team 6 physician who is a clinical physician with training and 7 sexual abuse and the potential risk that such a person 8 might view an injury as traumatic in a deceased child 9 that a forensic pathologist would not view in that way? 10 DR. DAVID CHIASSON: Well, I'm certainly 11 aware of the -- the Valin case and -- and the involvement 12 there of -- of a clinician and the problems that that -- 13 that that caused. 14 I think that's made me more conservative 15 and -- and cautious. And frankly, when I did use a -- an 16 individual from the SCAN team. It was back years ago. 17 It was an individual I knew personally and -- and had 18 confidence in. 19 I -- right now, my -- my hospital 20 colleagues within the SCAN team I -- I've met and I know, 21 but I -- I don't have a close working relationship and I 22 would -- I would -- I wouldn't feel comfortable about 23 involving them in -- in this particular function. 24 MS. LINDA ROTHSTEIN: All right. Arising 25 out of Ms. Fraser's questions, the -- she put to you the

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1 protocol for Death Under Two, and you thought that it had 2 perhaps been superceded. 3 Let me see if I can help you with that and 4 ask the Registrar to pull up PFP149431, which is from the 5 OCCO Institutional Report, and I believe will be the form 6 now used in Death Under Five Investigations. 7 If we can turn to page 211. Looking at 8 that, Dr. Chiasson, can you help us, is that the new form 9 that one uses when investigating an sudden unexpected 10 death in children under the age of five (5)? 11 It's a number of pages in length starting 12 there at 211 and continuing through 212, 13, and so on. 13 DR. DAVID CHIASSON: Yes, the fact of it 14 makes reference to under the age of five (5); that is 15 something that -- that certainly has occurred within the 16 last couple years, so that -- that is the new form. 17 MS. LINDA ROTHSTEIN: Right. It's 18 considerably longer. If you turn to page 212, please, 19 Registrar, and 213 and 214. Revised, October 2006. It 20 obviously calls for a lot more information than its 21 predecessor form. 22 Is that right? 23 DR. DAVID CHIASSON: Yes, it does. 24 MS. LINDA ROTHSTEIN: Arising out of Ms. 25 Silver's questions to you about the response that you or

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1 others had to the situation in Ottawa involving Dr. 2 Johnston and the questions about whether or not you knew 3 of any complaint to the College of Physicians and 4 Surgeons arising out of those concerns. 5 Dr. Chiasson, assuming there was, indeed, 6 no legal obligation to report that particular concern to 7 the College, what are your views on a systemic basis 8 about the helpfulness of creating a system where concerns 9 of that nature and significance about the quality of 10 forensic pathology would be the subject of a mandatory 11 report to the regulator? 12 What do you think about that as a systemic 13 change? 14 DR. DAVID CHIASSON: Well, to back track 15 and -- and to put it in the setting of the late '90's, as 16 I understood it, -- and -- and this -- there was 17 evolution. I -- I was involved, in fact, in some 18 complaints and -- and certainly one (1) of the items 19 within the Coroner's Office was -- was a -- the -- the 20 coroner back then, if there was a complaint to the 21 coroner, there was Coroners' Council which was eventually 22 dissolved. 23 At the same time, the impression -- and 24 this was not a common situation, you know, in terms of 25 being reported to the CPSO -- but this -- the sense was,

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1 that well if a pathologist doing forensic pathology, 2 there was an issue or complaint, that it would be dealt 3 with, if not within Coroners' Council, at least, within 4 the Coroners' Office. 5 And I think you're probably aware that 6 there was some ongoing back and forth as to whether the 7 CPSO had jurisdiction over pathologists performing work 8 under the Coroner's Office or not. 9 And I -- as I understand it, this -- this 10 -- this has been ongoing. But back then, it was 11 certainly unclear as to whether it should be reported. 12 Suffice it to say, back then, you know, we assumed 13 responsibility for dealing with issues related -- we 14 thought it was our -- our job to -- to oversee that and 15 to deal with that systemic -- or that -- that kind of 16 issue. 17 Your question -- to get back to your 18 question -- I think is, what do I think today? 19 MS. LINDA ROTHSTEIN: Going forward. 20 DR. DAVID CHIASSON: Going forward? I -- 21 you know, my sense is is that the people that are best 22 equipped to deal with forensic pathologists are -- are 23 the Chief Forensic Pathologist; individuals that 24 understand the system and have the expertise to deal with 25 the issues of complaint.

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1 And -- and I think that that's -- I -- I 2 see it as our responsibility within the Coroner's System 3 -- the Coroner's Office responsibility now, to -- to in 4 fact deal with -- with these kinds of issues. 5 A family, should they have a complaint, 6 I'm sure that they're entitled to report it. To suggest 7 that every time we -- every time the Coroner's Office 8 found a problem with a forensic pathologist report, that 9 it would be reported to the CPSO -- I mean that's -- I 10 mean that -- that could -- you know, where do you -- 11 where do you define a problem, the seriousness of an 12 issue -- I think that's a big can of worms that would be 13 difficult to close. 14 MS. LINDA ROTHSTEIN: Well, this isn't 15 the place to debate it at length, I grant you that, Dr. 16 Chiasson. But assume the level of seriousness that 17 requires you, in your view, to remove someone from their 18 duties. So assume that level of seriousness. 19 And assume -- accept what you say, that 20 the Coroner's Office is the right place to do it in some 21 fashion. Do you accept that that would involve some 22 level of public transparency about the process you adopt 23 to deal with that problem? 24 DR. DAVID CHIASSON: Yes, I accept there 25 should be transparency about the process, yes. How --

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1 how that would be effective, I'm -- I'm not sure. But 2 I -- 3 MS. LINDA ROTHSTEIN: But that would -- 4 DR. DAVID CHIASSON: -- in concept, yes. 5 MS. LINDA ROTHSTEIN: -- but that would 6 entail that the consequences of any process that's put in 7 place would ultimately become public? Would they? In 8 your view, would that be necessary, appropriate? 9 DR. DAVID CHIASSON: Well, I mean, we're 10 talking in -- in this most serious of cases -- 11 MS. LINDA ROTHSTEIN: Mm-hm. 12 DR. DAVID CHIASSON: -- I think that -- 13 that the answer is probably yes. I -- I'm hesitant, 14 because obviously, you know, if -- if I'm listening and 15 I'm a forensic pathologist working in a -- in a unit now, 16 and I'm glad I'm not the Chief Forensic Pathologist to 17 have to -- to deal with that. 18 That -- that might cause a lot of 19 potential concern and distress, so -- I mean, I think 20 you'd have to be -- this is a very serious issue and 21 would have to be looked at very seriously and the types 22 of problems would have to be major problems. 23 I'm not talking about a pathologist who's 24 late with his reports or, okay, he sort of suggested it 25 was three (3) stab wounds and maybe one (1) of them are

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1 connected and, you know -- I mean, sort of relatively 2 minor and -- and isolated problems. 3 I think you'd -- you'd need to very well- 4 document a -- an ongoing series of problems. And that 5 wou -- you're looking at -- at really serious -- serious 6 measures. In that case, I think, yes. I think the 7 process should be transparent. 8 MS. LINDA ROTHSTEIN: And following on 9 Mr. Sokolov's question of you arising again, in respect 10 of the Dr. Johnston matter, what efforts were made to 11 recruit a successor for Dr. Johnston? 12 DR. DAVID CHIASSON: Well, we were -- we 13 were certainly in negotiations with a certain -- a Dr. 14 Irvine, who was being trained in, I think it was 15 Albuquerque at the time. In fact, I think it was junior 16 staff in -- in Albuquerque. 17 So we were trying to -- to recruit her. 18 She came up, I think we had a coroner's educa -- 19 coroner's pathologist education course. I think she came 20 up, we -- we involved Dr. Michaud, who was the head of 21 pathology at the Ottawa Hospital in trying to -- to bring 22 her on board. 23 That did not -- not succeed. 24 MS. LINDA ROTHSTEIN: And -- and when 25 that didn't succeed, was any thought given to doing the

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1 other things one might do, in the ordinary course, to 2 recruit a forensic pathologist or a Director of that -- 3 of that kind? 4 DR. DAVID CHIASSON: Sorry, to look for 5 somebody else -- 6 MS. LINDA ROTHSTEIN: Yeah. 7 DR. DAVID CHIASSON: -- is what you're -- 8 MS. LINDA ROTHSTEIN: Yeah. 9 DR. DAVID CHIASSON: Well, it certainly 10 remained -- it took a long time to -- to -- the process 11 whereby Dr. Irvine was -- was courted, if you will, and 12 then -- and then eventually said no was -- was a rather 13 elongated process. 14 Beyond that, I mean, there were no obvious 15 individuals that we could identify that were -- that were 16 suitable. I don't recall us pursuing that beyond -- 17 beyond that -- that situation. 18 MS. LINDA ROTHSTEIN: Why not? 19 DR. DAVID CHIASSON: I guess the -- you 20 know, it's in the context of a lot of other things going 21 on. Probably by this time, we're dealing with my own 22 staffing issues; I suspect were starting to play a role. 23 It, perhaps, just fell through the cracks. 24 Other than to say, we continued to 25 monitor, through the review process, Dr. -- Dr.

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1 Johnston's work, and we were certainly doing it with a 2 heightened awareness, so at least, there were going to be 3 no -- no more new problems evolving. 4 And how much of a Director's role -- even 5 though he maintained the position, it was unclear to me 6 actually whether he was actually functioning all that 7 much as the -- as the Director. So I guess at some 8 point, frustration about inability to deal with the 9 problem, it was just left there on the back burner. 10 MS. LINDA ROTHSTEIN: And finally, just a 11 couple of questions arising from Ms. Baron's cross- 12 examination. Firstly, on the issue of compensation avai 13 -- available to fee-for-service forensic pathologists 14 when they go to court or meet with Crown attorneys or 15 that sort of the thing. 16 Could you turn up 044244, please, 17 Registrar. And if you would look at your screen. We 18 have there a memo from Dr. Smith to Dr. Cairns in April 19 of '97: 20 "From time to time, I get asked to 21 write a consultation report on a case 22 for another pathologist. I don't know 23 how I should handle the reporting 24 process. Maybe you can tell me." 25 It talks about who he spoke with:

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1 "Here's my report. 2 And then the question: 3 "When I look at cases for others and 4 write reports, should I send them to 5 anyone other than the referring doctor, 6 pathologist, or coroner? In the past, 7 I haven't done so, but more recently, 8 I've begun to think that, perhaps, a 9 copy should be sent to the Head Office. 10 And if I do write a report, can I bill 11 for my time? In this case I haven't, 12 but a nine (9) page report that's 13 packed with details is a bit of a chore 14 to write, especially knowing that the 15 defence lawyer's going to go over it 16 with a fine tooth comb." 17 Fair enough. And if we look at the 18 response from Dr. Cairns, which is at 044243. There we 19 go. 20 "Thank you for your letter asking for 21 certain directions. I feel if you are 22 requested by another pathologist to 23 write a consultation report that is 24 being investigated, then it would be 25 appropriate to forward a copy to the

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1 referring pathologist, Investigating 2 Coroner, the Regional Coroner, and me." 3 And it's interesting to note there, Dr. 4 Chiasson, that regrettably, and this isn't meant to be a 5 criticism particularly, you weren't on that list, which 6 may explain why those consultation reports don't appear 7 to have been routed through you. 8 Is that what your concluding from this? 9 DR. DAVID CHIASSON: They -- they were 10 not routed through me, yes. 11 MS. LINDA ROTHSTEIN: Okay. 12 DR. DAVID CHIASSON: And then Dr. Cairns 13 goes on to say: 14 "I have made it widely known throughout 15 the Province that you were the 16 Director, and you are willing to assist 17 local coroners and pathologists with 18 difficult cases. While I am happy that 19 you are very liberal at offering your 20 services, it certainly was not my 21 intention that you should not be fully 22 reimbursed. I feel it would be most 23 appropriate for you to bill me directly 24 for each of these reports." 25 And so on. Was that your understanding of

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1 how the Coroner's Office dealt with the time that any of 2 your fee-for-service pathologists spent preparing 3 consultation reports? 4 DR. DAVID CHIASSON: Yes, suffice it to 5 say that most fee-for-service pathologists, forensic 6 pathologists, weren't being consulted for -- 7 MS. LINDA ROTHSTEIN: Okay. 8 DR. DAVID CHIASSON: -- for this. If -- 9 if it was an adult case -- 10 MS. LINDA ROTHSTEIN: You got it. 11 DR. DAVID CHIASSON: -- I got it, and of 12 course, being a salaried government employee, you got 13 that without any additional costs to the -- to the 14 taxpayer. And then Dr. Smith would have been probably 15 the -- almost the only exception; that could be wrong; 16 that there may have been an occasion where -- where other 17 directors were consulted, but I would have thought that 18 was fairly rare. 19 And -- and, yes, I mean Dr. Smith is not a 20 government employee and I'm glad that -- that's the kind 21 of response that I would have expected. If he had 22 directed it to me is, Listen, you're doing work basically 23 for the Coroner's Office, even though it's, you know, 24 another pathologist happens to be asking that -- that's I 25 think irrelevant and should certainly be billed -- the

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1 Coroner's Office should be billed and you should be 2 renumerated in an appropriate fashion -- 3 MS. LINDA ROTHSTEIN: So, in other words, 4 we can all debate about whether the -- the amount of the 5 fee was the appropriate fee. I have the sense from your 6 evidence, Dr. Chiasson, that at least the principle that 7 if one was doing fee-for-service work that went beyond 8 the post-mortem report, the notion was one would indeed 9 get compensated for that. 10 DR. DAVID CHIASSON: Yes. 11 MS. LINDA ROTHSTEIN: All right. And 12 then finally, dealing with your email exchange with Dr. 13 Smith about documenting another cons -- consultant's 14 opinions, PFP129217. Ms. Baron showed you that, and that 15 was your October 20th, 2000 exchange with Dr. Smith. 16 And am I right in understanding, sir, that 17 when you talk about -- if you would just go further down 18 that page, where is it? I can't read my own page for the 19 moment. Yeah, when -- when you were making the comment 20 in the second line there: 21 "I suspect you are trying to avoid 22 having Larry dragged into Court." 23 You were being a little bit -- that was a 24 bit of a joke; that really wasn't your point, is that 25 fair, Dr. Chiasson?

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1 DR. DAVID CHIASSON: I -- I don't -- I'm 2 not sure I see where -- 3 MS. LINDA ROTHSTEIN: My question is -- 4 DR. DAVID CHIASSON: -- you would see -- 5 see that as being a joke. I -- I -- 6 MS. LINDA ROTHSTEIN: Okay. 7 DR. DAVID CHIASSON: It is what it -- I 8 suspect that he was trying -- 9 MS. LINDA ROTHSTEIN: Okay. 10 DR. DAVID CHIASSON: -- to -- that -- 11 that was my impression at that time, that Dr. Becker was 12 prepared to do this work. He's obviously -- was very -- 13 very busy with a load of administrative and other 14 responsibilities and the concept was that Dr. Becker, by 15 -- by him incorporating Dr. Becker's report, and I 16 recognized that he was doing that. 17 I mean, I -- I -- reading, if you will, 18 between the lines, but that -- it was to try and -- and 19 avoid Dr. Becker having to testify. And I would say that 20 in my own practice, I certainly go to Court with 21 neuropathology reports appended to my report. And 22 depending on the nature of the case, I may well speak to 23 the neuropathology report -- not to say -- making it 24 clear, I didn't do this -- but as I would with a 25 toxicology report on -- on occasion say that, you know,

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1 I'll provide some guidance in the system as to what is 2 being -- is being said. 3 So not -- it's not necessary to have 4 neuropathologists be dragged into court every time he 5 does a -- a report. 6 MS. LINDA ROTHSTEIN: Well, if I am 7 wrong, Dr. Chiasson, in mistaking humour where it wasn't 8 intended, am I right, at least, in -- in concluding that 9 you were trying to make clear to Dr. Smith the importance 10 of documenting these additional consultations which were 11 part of his decision making? 12 DR. DAVID CHIASSON: Yes. I mean, it's 13 clear, I think, in the next paragraph that not disclosing 14 this for what it is, as somebody's else's work, could -- 15 could cause problems. 16 MS. LINDA ROTHSTEIN: And indeed, Dr. 17 Chiasson, did you become aware in January of 2001, that 18 that was one (1) of the reasons that the Crown, in the 19 Tyrell case, determined it was necessary and appropriate 20 to withdraw the charges in that case. 21 That is to say that there had been another 22 case in which Dr. Becker's involvement in the matter had 23 not been clearly documented by Dr. Smith? 24 DR. DAVID CHIASSON: Yes, I was aware of 25 that.

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1 MS. LINDA ROTHSTEIN: All right. 2 Commissioner, that completes my questions of Dr. 3 Chiasson. So unless you have some additional questions 4 arising out of mine or anyone else's, I think we can 5 excuse Dr. David Chiasson, for the moment anyway. 6 COMMISSIONER STEPHEN GOUDGE: I don't. 7 Ms. Rothstein, Dr. Chiasson, thank you very much. 8 DR. DAVID CHIASSON: You're very welcome, 9 Mr. Commissioner. 10 COMMISSIONER STEPHEN GOUDGE: You spent a 11 lot of time with us, and we're very grateful for the 12 information. I suspect we will see you again. 13 DR. DAVID CHIASSON: Well, I appreciate 14 the opportunity to have testified to date, and I look 15 forward to the opportunity to testify further. 16 COMMISSIONER STEPHEN GOUDGE: We'll rise 17 now until 9:30 tomorrow morning. 18 19 (WITNESS STANDS DOWN) 20 21 --- Upon adjourning at 3:25 p.m. 22 23 24 25

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