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 17th, 2007 25

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

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

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

1 TABLE OF CONTENTS Page No. 2 3 MAXINE JOHNSON, Sworn 4 5 Examination-In-Chief by Mr. Robert Centa 6 6 Cross-Examination by Mr. Phillip Campbell 82 7 Cross-Examination by Ms. Vanora Simpson 111 8 Cross-Examination by Ms. Luisa Ritacca 120 9 Cross-Examination by Mr. William Carter 127 10 Re-Direct Examination by Mr. Robert Centa 137 11 12 DONALD PERRIN, Sworn 13 Examination-In-Chief by Mr. Robert Centa 143 14 Cross-Examination by Mr. Niels Ortved 195 15 Cross-Examination by Mr. Phillip Campbell 200 16 Cross-Examination by Mr. Peter Wardle 220 17 Cross-Examination by Ms. Luisa Ritacca 226 18 Re-Direct Examination by Mr. Robert Centa 236 19 20 21 Certificate of transcript 238 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. Thank you all for getting here. 7 Mr. Centa...? 8 MR. ROBERT CENTA: Good Morning, 9 Commissioner. This morning we have with us Ms. Maxine 10 Johnson from the Hospital for Sick Children. Ms. 11 Johnson's evidence will completed by the lunch break 12 today and I will complete my examination at or by 11:00 13 this morning. 14 15 MAXINE JOHNSON, Sworn 16 17 EXAMINATION-IN-CHIEF BY MR. ROBERT CENTA: 18 MR. ROBERT CENTA: Good morning, Ms. 19 Johnson. You are presently the Administrative 20 Coordinator for the Pathology Division at the Hospital 21 for Sick Children? 22 MS. MAXINE JOHNSON: Yes, I am. 23 MR. ROBERT CENTA: And I just want to ask 24 you a few questions about your background. You received 25 a medical secretarial diploma from Shaw College in 1984?

1 MS. MAXINE JOHNSON: Yes, I did. 2 MR. ROBERT CENTA: And in 2002 you 3 completed a modern management certificate from the 4 Canadian Health Care Association in connection with 5 Athabasca University? 6 MS. MAXINE JOHNSON: Yes, I did. 7 MR. ROBERT CENTA: You started work at 8 The Hospital for Sick Children in September of 1985? 9 MS. MAXINE JOHNSON: Yes. 10 MR. ROBERT CENTA: And where did you 11 first work at the hospital? 12 MS. MAXINE JOHNSON: I started in the 13 pharmacy department. 14 MR. ROBERT CENTA: And how long did you 15 spend in pharmacy? 16 MS. MAXINE JOHNSON: Two (2) years. 17 MR. ROBERT CENTA: And from there? 18 MS. MAXINE JOHNSON: I went to -- I 19 became the Secretary for the Division of Allergy. 20 MR. ROBERT CENTA: And when did you start 21 in the Pathology Departm -- then -- the Pathology 22 Department? 23 MS. MAXINE JOHNSON: In September 1989. 24 MR. ROBERT CENTA: And you've been in 25 Pathology from '89 to present?

1 MS. MAXINE JOHNSON: Yes. 2 MR. ROBERT CENTA: And you currently hold 3 the title of Administrative Coordinator? 4 MS. MAXINE JOHNSON: Yes, I do. 5 MR. ROBERT CENTA: Commissioner, we have 6 with us today, an institutional report that was prepared 7 by the Hospital for Sick Children. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 MR. ROBERT CENTA: In it's a separate 10 binder. 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 I've got it, thanks. 13 14 CONTINUED BY MR. ROBERT CENTA: 15 MR. ROBERT CENTA: It is PFP301353. And 16 paragraph 64 of the institutional report, Ms, Johnson, 17 describes the administrator coordinator position as 18 follows: 19 "In 2001, the position of 20 administrative coordinator for the 21 division of pathology was created. The 22 administrative coordinator acts as 23 assistant to the division head and also 24 acts as a central resource and a 25 communication link to facilitate the

1 completion of projects and information 2 for that pathology division." 3 Do you agree with that description? 4 MS. MAXINE JOHNSON: For that role, yes. 5 MR. ROBERT CENTA: And if you look in 6 your binder of documents, Ms. Johnson, at Tab 2, 7 PFP137567, that's a job description for the 8 Administrative Coordinator position? 9 MS. MAXINE JOHNSON: Yes, it is. 10 MR. ROBERT CENTA: And do you agree that 11 that's a fair description, from about thirty thousand 12 30,000 feet? 13 MS. MAXINE JOHNSON: Yes. 14 MR. ROBERT CENTA: Okay. I'm going to 15 return to some of your job duties as we go through your 16 examination. But before you were the Administrative 17 Coordinator in the department what was you job title? 18 MS. MAXINE JOHNSON: I was one (1) of 19 five (5) senior secretaries. 20 MR. ROBERT CENTA: And in the 21 institutional report at paragraph 65, the Hospital for 22 Sick Children describes -- or states that administrative 23 assistants are responsible for the provision of 24 administrative and general assistance including 25 administrative support to medical scientific staff, such

1 as the transcription of autopsy reports and neuro- 2 procedures for autopsies, as well as for copying and 3 mailing out final autopsy reports. 4 And you agree with that description? 5 MS. MAXINE JOHNSON: Yes, I do. 6 MR. ROBERT CENTA: And if we look at Tab 7 1 in your binder of documents, that is the job 8 description for the senior secretary in pathology? 9 MS. MAXINE JOHNSON: Yes, it is. 10 MR. ROBERT CENTA: And do you agree that 11 that is a fair description of the job duties of the 12 senior secretaries? 13 MR. ROBERT CENTA: At 30,000 feet, yes. 14 MS. MAXINE JOHNSON: Now -- 15 COMMISSIONER STEPHEN GOUDGE: There is a 16 lot more to it than that? 17 MS. MAXINE JOHNSON: Yes, there is. 18 19 CONTINUED BY MR. ROBERT CENTA: 20 MR. ROBERT CENTA: Now, Ms. Johnson, you 21 had -- you had -- came to the position of Administrative 22 Coordinator in 2001, formally? 23 MS. MAXINE JOHNSON: Yes. 24 MR. ROBERT CENTA: But had you started to 25 adopt some of those job duties before you accepted the

1 formal position? 2 MS. MAXINE JOHNSON: Yes, I did. 3 MR. ROBERT CENTA: Can you please explain 4 that? 5 MS. MAXINE JOHNSON: We were finding that 6 a lot of the secretaries -- we weren't consistently doing 7 things exactly the same way. And I discussed it with Dr. 8 Becker about trying to get some best -- best practises in 9 place so that everyone was doing exactly the same thing. 10 If someone was away and we had to have a 11 temp that person could just step in without the outside 12 world really recognizing that anyone was really missing 13 from our pool. 14 MR. ROBERT CENTA: And when did you start 15 to take on those responsibilities of trying to facilitate 16 that kind of workflow? 17 MS. MAXINE JOHNSON: Probably from about 18 1997/1998. 19 MR. ROBERT CENTA: Okay. And one (1) of 20 your current duties in the administrative coordinator job 21 description, which is found at Tab 2, PFP137567 is to 22 ensure the efficient operation of the office. 23 MS. MAXINE JOHNSON: Yes, it is. 24 MR. ROBERT CENTA: And that involves 25 ensuring support is available for pathologists for

1 correspondence and other documents that they have to 2 prepare? 3 MS. MAXINE JOHNSON: Yes. 4 MR. ROBERT CENTA: And you assist with 5 ensuring that workflow is implement efficiently across 6 the department or the division? 7 MS. MAXINE JOHNSON: Definitely, for the 8 division, yes. 9 MR. ROBERT CENTA: Okay. And can explain 10 to me what system do you put in -- or you put in place to 11 ensure that workflow is managed appropriately? 12 MS. MAXINE JOHNSON: We have a -- a team - 13 - like we -- our group works as a team, so if one (1) 14 secretary is -- is overwhelmed with the designated person 15 that -- or persons that they've been assigned to as their 16 primary support, the others would just fall in and pick 17 up, help out. 18 We all knew that we could go to anyone of 19 the others in the group if we were overwhelmed just to 20 say, Hey, you know, I have, you know, X, Y, and Z to do, 21 and X, Y, and Z are of the same importance, could you 22 help? And we were always happy to do that. 23 MR. ROBERT CENTA: And how long have 24 secretaries been assisting each other to ensure that work 25 is completed in a timely fashion?

1 MS. MAXINE JOHNSON: It's been happening 2 since I started in 1981 -- 89. 3 MR. ROBERT CENTA: And when you started in 4 1989, did each assistant have a pathologist to which they 5 were primarily assigned? 6 MS. MAXINE JOHNSON: Yes. 7 MR. ROBERT CENTA: And when you started in 8 1989, who was assigned to Dr. Smith? 9 MS. MAXINE JOHNSON: In 1989 it was Nancy 10 Fayder, primarily. 11 MR. ROBERT CENTA: And when did Ms. Fayder 12 leave the department? 13 MS. MAXINE JOHNSON: She left -- she -- 14 she stopped working for Dr. Smith in 1994 to assist a 15 researcher with starting a research lab, so she actually 16 left the department -- the division, it was at that time 17 in 1995. 18 MR. ROBERT CENTA: How do you spell her 19 name, Ms. Johnson? 20 MS. MAXINE JOHNSON: F-A-Y-D-E-R. 21 MR. ROBERT CENTA: Thank you. 22 MS. MAXINE JOHNSON: You're welcome. 23 24 CONTINUED BY MR. ROBERT CENTA: 25 MR. ROBERT CENTA: And who was next

1 assigned to provide assistance to Dr. Smith? 2 MS. MAXINE JOHNSON: I was next for a 3 short time. 4 MR. ROBERT CENTA: And what period of time 5 of was that, roughly? 6 MS. MAXINE JOHNSON: That was from 1995 to 7 about 1997; 1996 or 1997. 8 MR. ROBERT CENTA: And what happened in 9 1997? 10 MS. MAXINE JOHNSON: We had a new 11 secretarial staff come on board and she became primarily 12 Dr. Smith's assistant. 13 MR. ROBERT CENTA: And who was that? 14 MS. MAXINE JOHNSON: That was Burnett 15 Wint. 16 MR. ROBERT CENTA: And how do you spell 17 her name? 18 MS. MAXINE JOHNSON: First name is B-U-R- 19 N-E-T-T; last name is W-I-N-T. 20 COMMISSIONER STEPHEN GOUDGE: W-I-N-E-T? 21 MS. MAXINE JOHNSON: No, W-I-N-T; no E. 22 COMMISSIONER STEPHEN GOUDGE: Okay, 23 thanks. 24 MS. MAXINE JOHNSON: Wint. You're 25 welcome.

1 COMMISSIONER STEPHEN GOUDGE: Thanks. 2 3 CONTINUED BY MR. ROBERT CENTA: 4 MR. ROBERT CENTA: And throughout the 5 period from 1989 to date, is it fair to describe the 6 efficient production of work as a shared responsibility 7 among all of the administrative assistants? 8 MS. MAXINE JOHNSON: Yes. 9 MR. ROBERT CENTA: And were the assistants 10 responsible for triaging the work or attempting to assess 11 how important any particular project was? 12 MS. MAXINE JOHNSON: We sort of knew -- 13 especially with the clinical work, we always knew that 14 anything that was clinical, whether it was a surgical, an 15 autopsy, you know, cytology, any clinical work was -- took 16 priority, unless, of course, you know, there was an 17 impending grant and the deadline is today and we're just 18 getting the work today, So that -- you know another group 19 would work on facilitating getting that work completed. 20 But the clinical work always took priority because we 21 always needed to get that out because we knew that patient 22 care depended on it. 23 MR. ROBERT CENTA: And when you say the 24 clinical work took priority, it took priority over what 25 other kinds of work?

1 MS. MAXINE JOHNSON: A letter, for 2 instance. Or just pulling slides for someone's research 3 paper, for instance. 4 MR. ROBERT CENTA: And during your time in 5 the pathology, first department and then division, you 6 spoke to Dr. Smith on numerous occasions? 7 MS. MAXINE JOHNSON: Yes. 8 MR. ROBERT CENTA: And in fact after Ms. 9 Wint left the department -- and when did Ms. Wint 10 approximately leave? 11 MS. MAXINE JOHNSON: She left in 2001. 12 MR. ROBERT CENTA: And who assumed 13 responsibility for working with Dr. Smith after Ms. Wint 14 left? 15 MS. MAXINE JOHNSON: Primarily myself. 16 MR. ROBERT CENTA: Primarily you from 2001 17 onward? 18 MS. MAXINE JOHNSON: Yes. 19 MR. ROBERT CENTA: So you spoke to Dr. 20 Smith on -- regularly? 21 MS. MAXINE JOHNSON: Oh, yeah. 22 MR. ROBERT CENTA: And during your time in 23 pathology did Dr. Smith ever tell you that he had 24 inadequate secretarial support to permit him to complete 25 his reports of post-mortem examination in a timely

1 fashion? 2 MS. MAXINE JOHNSON: No, he did not. 3 MR. ROBERT CENTA: Did he ever tell you 4 that the secretaries who were assigned to him were not 5 completing his reports of post-mortem examination in a 6 timely fashion? 7 MS. MAXINE JOHNSON: No. 8 MR. ROBERT CENTA: And did he ever tell 9 you the -- that he was forced to type his own reports 10 because of insufficient secretarial support? 11 MS. MAXINE JOHNSON: Dr. Smith was never 12 forced to type his report as far as we were cons -- 13 concerned. That was one (1) of the functions of our jobs 14 as admin assistants, was to facilitate getting those 15 reports completed. Dr. Smith made a choice to type his 16 own reports. 17 MR. ROBERT CENTA: Okay. And I'll come 18 back and ask you some more questions about the kinds of 19 reports that you would prepare. 20 And I take it during your time you also 21 spoke with secretaries about their workload. 22 MS. MAXINE JOHNSON: Sure. 23 MR. ROBERT CENTA: They would come to you 24 if they had any concerns? 25 MS. MAXINE JOHNSON: Yes.

1 MR. ROBERT CENTA: And did any of Dr. 2 Smith's -- of the assistants assigned to Dr. Smith, did 3 they ever tell you that they could not complete their work 4 for him in a timely fashion? 5 MS. MAXINE JOHNSON: No. 6 MR. ROBERT CENTA: Okay. If you could 7 turn to Tab 14 in your document brief, which is PFP137530, 8 Tab 14. This -- this is an email from 2003 that you sent 9 to Dr. Smith with copies to Dr. Phillips and Dr. Taylor. 10 MS. MAXINE JOHNSON: Yes. 11 MR. ROBERT CENTA: And it read: 12 "Charles, I have just been informed that 13 you have ten (10) autopsy cases that are 14 ready to be put in CoPath for sign out, 15 but that you have no secretarial 16 assistants to do so. If this is in fact 17 the case, I'm concerned that you have 18 not informed me of this since you are 19 aware that Anna is away this week. In 20 the past it has always been the practice 21 that if your secretary is away that 22 these reports be emailed to me so that 23 they can be processed for sign-out since 24 this is not a big task. I will speak 25 with you directly about this when you

1 get to the office this afternoon and 2 pick up the folders of cases from you so 3 that we can speed up the sign-out before 4 the end of the month [parenthesis] 5 (tomorrow)." 6 And do you recall who told you that Dr. 7 Smith had this particular concern? 8 MS. MAXINE JOHNSON: Yes. 9 MR. ROBERT CENTA: Who was that? 10 MS. MAXINE JOHNSON: It was Dr. Phillips. 11 MR. ROBERT CENTA: And can you explain to 12 us what it means to have ten (10) autopsy cases that are 13 ready to be put into CoPath for sign-out? 14 MS. MAXINE JOHNSON: Dr. Smith normally 15 types his autopsy reports on his own computer in a 16 Microsoft Word document and so he apparently told Dr. -- 17 Dr. Phillips that he had these ten (10) reports because 18 there was a concern that these reports had not yet been 19 signed out. 20 And Dr. Phillips came to me and said, You 21 know, Dr. Smith has these reports, and I said, We weren't 22 aware of it. So in order just to, you know, allow Dr. 23 Smith to know that Dr. Phillips had in fact spoken to me - 24 - and I copied it to Dr. Taylor because he was Division 25 Head at that time --

1 MR. ROBERT CENTA: Mm-hm. 2 MS. MAXINE JOHNSON: -- for him to send me 3 those reports. He could send them electronically. 4 Sometimes he would put them on a -- on a floppy disk and 5 give it to us and we would just insert it in our own hard 6 drive and copy the material into the LIS system. 7 MR. ROBERT CENTA: And why did you write 8 this email at this time? 9 MS. MAXINE JOHNSON: Because I wanted Dr. 10 Phillips -- Dr. Smith, sorry, to recognize that, you know, 11 I am aware that he said this. Because there's been, you 12 know, a few circumstances where he said that, you know, 13 secretaries weren't available. And I just wanted to -- to 14 just send it as a confirmation and to let him know that, 15 Okay, here it is on the table, if you do have these ten 16 (10) then you just simply have to give them to me so that 17 there wouldn't -- wouldn't be any misunderstanding about, 18 you know, a week from now saying that these ten (10) 19 autopsies weren't looked after. 20 MR. ROBERT CENTA: And during your time in 21 pathology, did anyone else from inside the Pathology 22 Department ever suggest to you that Dr. Smith had 23 inadequate secretarial support to accomplish the comple -- 24 to complete his reports of post-mortem examination in a 25 timely fashion?

1 MS. MAXINE JOHNSON: No, never. 2 MR. ROBERT CENTA: Did you ever learn that 3 the Office of the Chief Coroner of Ontario wanted Dr. 4 Smith to have increased access to secretarial support? 5 MS. MAXINE JOHNSON: I had just sort of 6 heard it, you know, sort of floating around. 7 MR. ROBERT CENTA: And would it have been 8 your job to take steps to address those concerns? 9 MS. MAXINE JOHNSON: It would have been 10 and I did. Because we had ample secretarial support that 11 Dr. Smith or any of the other pathologists could access 12 any time they felt like they had a backlog of cases that 13 they hadn't gotten to, so there should never have been an 14 issue for Dr. Smith. 15 MR. ROBERT CENTA: Okay. Commissioner, 16 I'd now like to turn to the Kenneth overview report which 17 is found in Volume I, Tab 11, PFP144159. 18 And just by way of background, 19 Commissioner, Kenneth was born in Scarborough, Ontario on 20 May 18th, 1991. He died at the age of two and a half (2 21 1/2) years, on October 12th, 1993 at the Hospital for Sick 22 Children. Criminal proceedings were initiated against 23 Kenneth's mother. 24 Paragraph -- from page 113 of the overview 25 report, paragraph 340, sets out a description of the

1 criminal proceedings. Kenneth's mother was alone with the 2 child at the time of death and there was no doubt that if 3 the death was caused by an unlawful act, she had committed 4 that act. And it was the theory of the Crown that 5 Kenneth's mother had intentionally caused the child's 6 death through suffocation. It was the theory of the 7 defence the child had died accidentally after becoming 8 twisted in a sheet or suffering a seizure. 9 And at page 4 of the same overview report, 10 it sets out that the criminal proceedings concluded on 11 October 24th, 1995, when she was convicted of second- 12 degree murder. 13 Page 32, paragraph 106, Dr. Smith conducted 14 the post-mortem examination under coroner's warrant on 15 October 13th, 1993. 16 And at page 33, paragraph 110, on February 17 21, 1994 a note from Detective Sergeant Carroll to Crown 18 Counsel stated: 19 "I've provided you with disclosure. The 20 pathologist has yet to provide me with 21 his report so I have the Regional 22 Coroner putting the squeeze on him. 23 Hope to have it soon? [question mark]" 24 And page 36, paragraph 111 confirms that 25 Dr. Smith completed and signed his report of post-mortem

1 examination on April 15th, 1994, six (6) months after the 2 exam -- the post-mortem examination was completed. 3 The preliminary hearing was held in Oshawa, 4 on September 27, 29 and 30, 1994, and Dr. Smith testified 5 at the preliminary hearing as its first witness. 6 So if you could turn up please, page 58, 7 paragraph 166 of the Kenneth Report. 8 9 (BRIEF PAUSE) 10 11 MR. ROBERT CENTA: Do you have that, Ms. 12 Johnson? 13 MS. MAXINE JOHNSON: Page 56? 14 MR. ROBERT CENTA: Yes. 15 MS. MAXINE JOHNSON: Okay. 16 MR. ROBERT CENTA: Sorry, 58, paragraph 17 166. It's up on your screen if you're having some 18 trouble. 19 And during the cross-examination at the 20 preliminary hearing, Dr. Smith was asked what the length 21 of time it took him to prepare his report: 22 "Q: These cases take a long time to 23 come to court, and I say this with the 24 utmost respect, but your report took a 25 long time in getting to us, and is there

1 any explanation for that?" 2 Next page, answer from Dr. Smith: 3 "Yes there is actually. First of all 4 I'm not fast with reports. That is the 5 first statement. 6 The second statement is that we use 7 examination techniques especially for 8 the brain, which take a lot longer than 9 is employed in a number of different 10 institutions. And the asphyxiation 11 examination techniques we use of a brain 12 which has been profoundly injured by 13 edema and swelling take even longer, so 14 that's the second statement. 15 The third statement has nothing to do 16 with these factors. The third statement 17 is that thanks to government cutbacks, I 18 no longer have a secretary, so I have to 19 actually type my own reports, and any 20 report that gets out is because I've sat 21 there at 8:00 at night typing it myself. 22 And so I did a flurry of reports earlier 23 this year, and then with my other 24 activities didn't actually write the 25 next group of reports out and finalize

1 them until during the summer months. So 2 the honesty is that while there are 3 reasons for some delay, the truth of 4 matter is the rate limiting step is the 5 fact that I have to do all the work 6 myself." 7 Ms. Johnson, with respect to the third 8 statement that Dr. Smith has provided, do you agree with 9 it? 10 MS. MAXINE JOHNSON: Absolutely not. 11 MR. ROBERT CENTA: And to the best of your 12 knowledge, did government cutbacks ever result in Dr. 13 Smith not having access to secretarial services in 14 pathology? 15 MS. MAXINE JOHNSON: No, it did not. 16 MR. ROBERT CENTA: Did government cutbacks 17 ever force Dr. Smith to type his own reports? 18 MS. MAXINE JOHNSON: No, as far as I'm 19 concerned, not. 20 MR. ROBERT CENTA: In 1994, was there ever 21 a time that Dr. Smith could only get a report out if he 22 typed it himself? 23 MS. MAXINE JOHNSON: No. 24 MR. ROBERT CENTA: We've talked a little 25 bit about the preparation of reports, and now I'd like to

1 take you back to Tab 1 in your binder, which is PFP137570. 2 And this is the job description for the Senior Secretary 3 in Pathology. And if you look under the heading, "List of 4 Duties and Responsibilities: Surgicals and Autopsy", the 5 responsibilities include: 6 "Entering patient demographics of 7 surgical specimens in a timely matter, 8 transcription using dictaphone, 9 transcription of autopsy reports, typing 10 procedures for autopsies, and copying 11 and mailing out final autopsy reports." 12 Those were all duties then and now? 13 MS. MAXINE JOHNSON: Yes. 14 MR. ROBERT CENTA: And the Pathology 15 Department at the Hospital for Sick Children used a 16 variety of forms to record data and opinions obtained 17 through post-mortem examination? 18 MS. MAXINE JOHNSON: Yes. 19 MR. ROBERT CENTA: And they included 20 internal tracking documents? 21 MS. MAXINE JOHNSON: Yes. 22 MR. ROBERT CENTA: And neuro-procedure 23 forms? 24 MS. MAXINE JOHNSON: Yes. 25 MR. ROBERT CENTA: And reports of post-

1 mortem examination on Form 12? 2 MS. MAXINE JOHNSON: Yes. 3 MR. ROBERT CENTA: And some -- a document 4 called, "The Final Autopsy Report"? 5 MS. MAXINE JOHNSON: Right. 6 MR. ROBERT CENTA: And you've prepared all 7 of these documents over your career? 8 MS. MAXINE JOHNSON: Yes, I have. 9 MR. ROBERT CENTA: And you're familiar 10 with them? 11 MS. MAXINE JOHNSON: Yes. 12 MR. ROBERT CENTA: Commissioner, we're 13 going to look at a few of these forms and how they are 14 prepared, and we're going to do that via the Joshua Case. 15 And the Joshua overview report is found at PFP143053, 16 Volume I, Tab 8 of the overview report binder. 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 MR. ROBERT CENTA: The background to that 19 case is set out on page 3, paragraphs 1 to 4. 20 21 CONTINUED BY MR. ROBERT CENTA: 22 MR. ROBERT CENTA: Joshua was born in 23 Belleville on September 23rd, 1995 to Sherry and Peter. 24 Joshua died on January 23rd, '96 at the age of four (4) 25 months in Trenton. On March 27th, Sherry was charged with

1 first degree murder in Joshua's death and after 2 preliminary inquiry she was committed to stand trial on 3 that charge. However, the committal was subsequently 4 quashed and was instead ordered to stand trial on a charge 5 of second degree murder. 6 On January 4, a new indictment charging 7 infanticide was placed before the Ontario Court of 8 Justice. Sherry entered a plea of not guilty. However, 9 the Crown then read into the record certain agreed facts. 10 The defence called no evidence in response to the facts 11 read in and did not dispute them. As a result, Sherry was 12 convicted of infanticide. 13 In March 1996, the overview report at 14 paragraph 108 to 112 sets out the -- the understanding of 15 the police that by March of 1996 the police were -- felt 16 that Sherry had killed Joshua. If you turn up page 42 of 17 that overview report at paragraph 114. And this is a -- 18 this paragraph 114 takes place on March 8th, 1996. 19 "Sergeant MacLellan then spoke with Dr. 20 Smith by telephone. His notes of that 21 conversation stated quote, 'Called Dr. 22 Smith, requested a prelim report. 23 States he doesn't usually do this in 24 Toronto, but does for out of town 25 forces.'"

1 And skipping down to paragraph 116. 2 "On March 12, 1996, Staff Sergeant 3 MacLellan called Dr. Smith to inquire 4 about the preliminary report. His notes 5 of that conversation stated, 'Called Dr. 6 Charles Smith. I asked him about the 7 preliminary report that was supposed to 8 be here yesterday. He states they have 9 stolen his secretaries and the temporary 10 person was supposed to have faxed it 11 out. He will ensure that they do.'" 12 Now, Ms. Johnson, in March of 1996, had 13 anyone stolen Dr. Smith's secretary? 14 MS. MAXINE JOHNSON: No. 15 MR. ROBERT CENTA: And to the best of your 16 knowledge, did Dr. Smith continue to have access to 17 secretarial services upon his request? 18 MS. MAXINE JOHNSON: Yes. 19 MR. ROBERT CENTA: And were there 20 assistants available to ensure that urgent material was 21 either prepared or faxed out in a timely fashion? 22 MS. MAXINE JOHNSON: Yes, there were. 23 MR. ROBERT CENTA: And if you could turn 24 up Tab 3 in your binder of documents, which is PFP099990. 25 This is an internal tracking document from

1 Sick Kids? 2 MS. MAXINE JOHNSON: Yes. 3 MR. ROBERT CENTA: Can you please explain 4 what information is contained in this document above the 5 heading, "Sudden and Unexpected Death"? 6 MS. MAXINE JOHNSON: Above the heading 7 that's the demographics, usually the -- you know, the date 8 and time of death, autopsy time, the person assisting. As 9 this is an internal tracking document, sometimes at the 10 time of entry some of this information might not be as it 11 is. 12 There might be -- for instance, on this -- 13 you know, the assistant might -- might have been someone 14 else, but that's always corrected before this document 15 leaves the department. 16 MR. ROBERT CENTA: Okay. And in the -- 17 beside Joshua's name there's typed ML 36/96. 18 Can you explain what is -- what is that 19 number? 20 COMMISSIONER STEPHEN GOUDGE: Where is 21 that, Mr. Centa? 22 MR. ROBERT CENTA: Just beside Joshua's 23 name? 24 COMMISSIONER STEPHEN GOUDGE: I have got 25 to find it first. Okay. Thanks.

1 MS. MAXINE JOHNSON: The ML will tell me 2 that -- that is a medicolegal autopsy. Thirty-six (36) 3 would be the 36th autopsy that was performed in the 4 division in the year '96. 5 6 CONTINUED BY MR. ROBERT CENTA: 7 MR. ROBERT CENTA: And when you say the 8 36th autopsy, the 36th autopsy of any type? 9 MS. MAXINE JOHNSON: Yes. 10 MR. ROBERT CENTA: Okay. And -- 11 COMMISSIONER STEPHEN GOUDGE: Medicolegal 12 is done under coroner's warrant? 13 MS. MAXINE JOHNSON: Yes, they are. 14 15 CONTINUED BY MR. ROBERT CENTA: 16 MR. ROBERT CENTA: And for what purpose 17 did the Hospital for Sick Children and the pathology 18 department create internal documents? 19 MS. MAXINE JOHNSON: When I started in the 20 department, this document was created on every autopsy. 21 For the medicolegal autopsies, this document would be 22 created within forty-eight (48) hours of completion of the 23 autopsy. It would just contain, you know, possibly a 24 heading, which in this case is, "Sudden and Unexpected 25 Death".

1 It would sometime have a clinical 2 diagnoses, which is usually a list of the clinical 3 information on the patient that -- that's available to 4 everyone. There -- there's an anatomical diagnosis, which 5 is -- would be the preliminary findings of the pathologist 6 at autopsy and the short history that is usually given to 7 -- you know, to everyone. 8 MR. ROBERT CENTA: And is there anything 9 on this document that indicates who typed this document 10 up? 11 MS. MAXINE JOHNSON: No, there is not. 12 MR. ROBERT CENTA: Okay. And would you 13 expect to see any indications on a document if someone 14 other than Dr. Smith had been involved in typing it up? 15 MS. MAXINE JOHNSON: Yes, there would be. 16 MR. ROBERT CENTA: Can you turn to Tab 4 17 in your binder? 18 COMMISSIONER STEPHEN GOUDGE: So I take it 19 you infer from that that Dr. Smith typed this up himself. 20 MS. MAXINE JOHNSON: It -- it's possible, 21 Mr. Commissioner. 22 23 CONTINUED BY MR. ROBERT CENTA: 24 MR. ROBERT CENTA: Can you turn to Tab 4, 25 PFP008780. What's this document?

1 MS. MAXINE JOHNSON: This is a central 2 nervous system procedure report for this autopsy. This 3 procedure report is created by the neuropathologist and 4 transcribed for inclusion in the final autopsy report. 5 MR. ROBERT CENTA: And if you'll look just 6 above the signature line on the left mar -- on the left 7 hand margin, in full caps is typed LEB/eld (phonetic). 8 MS. MAXINE JOHNSON: Right. 9 MR. ROBERT CENTA: What does that signify 10 to you? 11 MS. MAXINE JOHNSON: That tells me, the 12 pathologist, and the secretarial staff that had typed this 13 autopsy. 14 MR. ROBERT CENTA: And who -- based on 15 those initials, who would have been involved? 16 MS. MAXINE JOHNSON: This was Dr. Becker 17 and his secretary at the time, who was Etta Libbyduke 18 (phonetic). 19 MR. ROBERT CENTA: And are those the kind 20 -- that would be one (1) indication of who had typed this 21 particular report? 22 MS. MAXINE JOHNSON: Yes, it would be. 23 MR. ROBERT CENTA: Okay. If we can turn 24 back then to the internal tracking document at Tab 3, 25 PFP099990.

1 Who would normally receive copies of these 2 internal tracking documents? 3 MS. MAXINE JOHNSON: If we're talking 4 about the medicolegal autopsies -- 5 MR. ROBERT CENTA: Yes. 6 MS. MAXINE JOHNSON: -- the only person 7 that would get a signed copy of this would be the Office 8 of the Chief Coroner at that time. 9 MR. ROBERT CENTA: And if you'd look at 10 the stamp on the document, it's marked "Received March 11 12th, Trenton Police Department", and just to remind you, 12 that's the -- the day -- the day of the conversation 13 between Staff Sargent MacLellan and Dr. Smith regarding 14 the whereabouts of the report. 15 MS. MAXINE JOHNSON: Right. 16 MR. ROBERT CENTA: Do you recall ever 17 being asked to fax an internal tracking document to a 18 police service? 19 MS. MAXINE JOHNSON: No. 20 MR. ROBERT CENTA: And is there anything 21 else unusual about this report, given that it was faxed to 22 a police department? 23 MS. MAXINE JOHNSON: It doesn't have his 24 signature, which is huge. 25 MR. ROBERT CENTA: And when you say "it's

1 huge", what does that mean? 2 MS. MAXINE JOHNSON: Because technically 3 if the internal tracking document or preliminary report is 4 being sent out there is always a signature from the 5 pathologist on that document. 6 MR. ROBERT CENTA: And is it unusual that 7 this document was sent to the police? 8 MS. MAXINE JOHNSON: Yes, it is. 9 MR. ROBERT CENTA: And would secretaries 10 in the department in 1996 have been surpri -- in your 11 opinion, been surprised to be asked to fax out an unsigned 12 report? 13 MS. MAXINE JOHNSON: Of course. 14 MR. ROBERT CENTA: And would they have 15 known, or have been instructed, to do something about that 16 such a request? 17 MS. MAXINE JOHNSON: Yes. 18 MR. ROBERT CENTA: What would that be? 19 MS. MAXINE JOHNSON: We all knew that we 20 should not release any -- and when I say "release", I mean 21 fax out or send out from the department any report that 22 was not, or any part of a report, that was not signed out 23 by a pathologist. 24 MR. ROBERT CENTA: Okay. If we can turn 25 back to the overview report, and we're going to look at

1 the events of March 21st, 1996, which are set out at 2 PFP143053, at page 48 of the document, paragraph 126. 3 On Thursday, March 21st, 1996 at 8:35 in 4 the morning Staff Sargent MacLellan received a telephone 5 call from Dr. Smith. Sargent MacLellan's notes of that 6 conversation stated, "Received call from Dr. Smith". 7 It states that pulmonary hemorrhage exists, 8 but the patterns are different than what Dr. Dearborn is 9 talking about. It states: 10 "Dr. Dearborn does not understand how to 11 view this from a pathologist's point of 12 view. I asked for this in writing and 13 the fracture was healing in writing. He 14 states yes, when he gives me his final 15 report. He states it is done, waiting 16 to be typed, that he ha -- that he has 17 no secretary right now and he is the 18 only pathologist for the next few days, 19 so he is typing it at home at night. I 20 stated I really need it for the next 21 Tuesday as the CAS, if they got an 22 extension, would be back in Court next 23 Wednesday. He does not think it will be 24 ready by then." 25 Ms. Johnson, to the best of your

1 recollection, in March of 1996, assuming Dr. Smith's 2 secretary was away on vacation, or otherwise unavailable, 3 would Dr. Smith have had access to other secretarial 4 assistants? 5 MS. MAXINE JOHNSON: Always. 6 MR. ROBERT CENTA: And would he have been 7 required to type the report himself at home in the 8 evenings? 9 MS. MAXINE JOHNSON: No, he would not. 10 MR. ROBERT CENTA: If you could turn to 11 Tab 16 in your binder, PFP117050. And if you could look 12 at row 13 of this -- this chart. Just scroll to the top, 13 Mr. Registrar. This is a schedule. 14 COMMISSIONER STEPHEN GOUDGE: Sorry. What 15 tab, Mr. Centa? 16 MR. ROBERT CENTA: This is Tab 16. 17 COMMISSIONER STEPHEN GOUDGE: Thank you. 18 19 CONTINUED BY MR. ROBERT CENTA: 20 MR. ROBERT CENTA: And this is a document 21 provided to us by the Hospital for Sick Children. It sets 22 out the schedule for pathologists for 1996. And Row 13 23 deals with the time where we are right now. The 24 conversation between Dr. Smith and Staff Sergeant 25 MacLellan took place on March 21st, 1996. And that's

1 contained in Row 13 of that chart. 2 Now, Ms. Johnson, Dr. Smith had indicated 3 to the officer that he was the only pathologist on for the 4 next few days. Is that consistent with his schedule? 5 MS. MAXINE JOHNSON: No, it's not. 6 MR. ROBERT CENTA: And assuming Dr. Smith 7 was the only pathologist working, would that have affected 8 his ability to access secretarial services? 9 MS. MAXINE JOHNSON: No. 10 MR. ROBERT CENTA: And just clarify 11 information, what is the definition of "weekend" in Column 12 E? When does that start and finish? 13 MS. MAXINE JOHNSON: Weekend starts at 14 five o'clock on Friday and ends at eight o'clock on Monday 15 morning. 16 MR. ROBERT CENTA: Could you turn, with 17 me, in your binder of documents to Tab 6. This is the 18 report of -- the final signed copy of the report of post- 19 mortem examination, dated March 21st, 1996, in the Joshua 20 case. 21 And you've had a chance to review this 22 report? 23 MS. MAXINE JOHNSON: Yes, I have. 24 MR. ROBERT CENTA: Now assuming the report 25 was, as Dr. Smith described it to the officer, done and it

1 just needed to be typed up, how long would it take you to 2 type up this report of post-mortem examination if it was 3 otherwise completed? 4 MS. MAXINE JOHNSON: Less than an hour. 5 MR. ROBERT CENTA: And in your experience, 6 would other secretaries have been able to complete that 7 report in a similar length of time? 8 MS. MAXINE JOHNSON: Yes, they would be. 9 MR. ROBERT CENTA: If Dr. Smith had 10 indicated to you on Thursday -- a Thursday that the report 11 needed to be delivered to the police for a pending court 12 proceeding no later than the next Tuesday, is that the 13 kind of request that you would give priority to? 14 MS. MAXINE JOHNSON: Absolutely. 15 MR. ROBERT CENTA: And would you have been 16 able to arrange for the report to be completed by the next 17 Tuesday? 18 MS. MAXINE JOHNSON: Of course. 19 MR. ROBERT CENTA: And would you have been 20 able to ensure that the report was completed on the same 21 day that Dr. Smith made the request? 22 MS. MAXINE JOHNSON: Definitely. 23 MR. ROBERT CENTA: If we could just turn 24 back to the overview report at paragraph 127, which is 25 PFP143053, I believe at page 48 at the bottom:

1 "At 9:45, Staff Sergeant Mclellan spoke 2 with Ms. Walsh, who was the Crown 3 Counsel on the case in person, according 4 to Staff Sergeant Mclellan; advised 5 Sheila of conversation with Dr. Smith. 6 She states 'He did that last time; kept 7 saying another week'. 8 I asked if she could call John Cairns [I 9 think that should be Dr. Jim Cairns] or 10 make whatever call she could to get 11 Smith to get this report faster. She 12 agreed." 13 Ms. Johnson, do you ever -- not 14 specifically related to this case -- but do you ever 15 recall Dr. Cairns calling to speak to Dr. Smith? 16 MS. MAXINE JOHNSON: He does all the time. 17 MR. ROBERT CENTA: And do you personally 18 ever recall Dr. Cairns asking or saying that the call was 19 about a report that was not completed? 20 MS. MAXINE JOHNSON: Not specifically. 21 MR. ROBERT CENTA: If you could turn in 22 your binder of documents to Tab 5, PFP008556. This 23 appears to be a -- a -- an internal tracking document 24 related to the Joshua case; it has the has the ML file 25 number.

1 And this report looks slightly different 2 than the one (1) that is found at Tab 3 of your document 3 binder, correct? 4 MS. MAXINE JOHNSON: Mm-hm. Yes. 5 MR. ROBERT CENTA: And is there anything 6 unusual about this document? 7 MS. MAXINE JOHNSON: It has the central 8 nervous system gross description attached to this internal 9 tracking document. 10 MR. ROBERT CENTA: And why is that 11 unusual? 12 MS. MAXINE JOHNSON: Because a CNS report 13 is a separate document and not a part of this internal 14 tracking document. 15 MR. ROBERT CENTA: And would expect to see 16 that description contained in an internal tracking 17 document? 18 MS. MAXINE JOHNSON: No. 19 MR. ROBERT CENTA: And if you look in the 20 bottom right corner, this document appears to be a -- date 21 stamped in Dr. Bechard's office, who is the Regional 22 Coroner, and dated March 21, 1996? 23 MS. MAXINE JOHNSON: Yes, I see that. 24 MR. ROBERT CENTA: And give -- given that 25 this document was received by Dr. Bechard on March 21st,

1 according to the stamp, is there anything else unusual 2 about this -- the fact that this report was sent out? 3 MS. MAXINE JOHNSON: Sure. It doesn't 4 have a signature on it. 5 MR. ROBERT CENTA: And that for the same 6 reason -- 7 MS. MAXINE JOHNSON: For the same reason 8 as -- 9 MR. ROBERT CENTA: -- discussed earlier? 10 MS. MAXINE JOHNSON: Yes. 11 MR. ROBERT CENTA: Okay. And was it usual 12 to have a -- an internal tracking document faxed out to a 13 regional coroner? 14 MS. MAXINE JOHNSON: If it was signed out, 15 yes. It would not be unusual to -- to send it out because 16 they're the people who ultimately need to have it, so we 17 usually send it to the Coroner's Office. Sometimes we're 18 asked to send it directly to the Regional Coroner where 19 that autopsy came from, but it would be a signed document. 20 MR. ROBERT CENTA: And when we looked at 21 the report of post-mortem examination, which was PFP008486 22 at Tab 6, that report was dated March 21st, 1996? 23 MS. MAXINE JOHNSON: Right. 24 MR. ROBERT CENTA: And would it, in your 25 experience, have been unusual to send out an internal

1 tracking document the same day that the report of post- 2 mortem examination was signed and dated? 3 MS. MAXINE JOHNSON: Yes, it would be. 4 MR. ROBERT CENTA: So let's turn back to 5 the -- the report then, which is found at Tab 6, 6 PFP008486. 7 And just before we discuss it further, the 8 Joshua overview report, which is PFP143053 at page 49, 9 paragraph 128. 10 At 15:35, Staff Sergeant MacLellan spoke 11 with Dr. Bechard, the Regional Coroner. According to 12 Sergeant's MacLellan's notes 13 "Dr. Bechard advised that he has spoken 14 to Dr. Smith and requested his report by 15 Tuesday. He will attend a meeting with 16 Crown, Sheila Walsh. She agrees that 17 Dr. Smith must be pinned down on what 18 he's saying. Must be put in writing." 19 And that same Dr. Smith also issued an 20 invoice for his autopsy report in the amount of four 21 hundred and seventy-eight dollars ($478). And we'll come 22 back -- I'll ask you some questions about the invoicing 23 procedures. 24 MS. MAXINE JOHNSON: Okay. 25 MR. ROBERT CENTA: Now, the report of

1 post-mortem examination at Tab 6, PFP008486, this was a 2 standard form under the Coroner's Act? 3 MS. MAXINE JOHNSON: This -- yes, the Form 4 12 was. 5 MR. ROBERT CENTA: And would you describe 6 this as a standard Hospital for Sick Children's form? 7 MS. MAXINE JOHNSON: No. It was a -- what 8 we had in our computer was the reproduction of a very long 9 paper version of this coroner's Form 12 form, for the 10 Office of the Chief Coroner. 11 MR. ROBERT CENTA: And what about this 12 document tells you that it wasn't created on the standard 13 Hospital for Sick Children form? 14 MS. MAXINE JOHNSON: I can -- the font is 15 different; I can tell it's a Word document. 16 MR. ROBERT CENTA: Mm-hm. 17 MS. MAXINE JOHNSON: There's a table, very 18 nice table, in here. 19 MR. ROBERT CENTA: And you're looking at 20 image number 2 -- 21 MS. MAXINE JOHNSON: Yes. 22 MR. ROBERT CENTA: -- in that document and 23 the table at the top? 24 MS. MAXINE JOHNSON: Right. 25 MR. ROBERT CENTA: And what about that

1 table -- 2 MS. MAXINE JOHNSON: That -- 3 MR. ROBERT CENTA: -- suggests to you that 4 this document wasn't created on the standard Hospital for 5 Sick Children form? 6 MS. MAXINE JOHNSON: In our computer LIS 7 system, which was called 4th Dimension, we had a lot of 8 trouble trying to even get just the tabbed table into any 9 document. This is a table that's done in Word, and we 10 could never reproduce this into 4th Dimension. 11 So that's what -- that's a big indication 12 to me that this was done in a Word document as opposed to 13 on our LIS system. 14 MR. ROBERT CENTA: So it's -- it's to 15 attractive to have been produced in the LIS system? 16 MS. MAXINE JOHNSON: Definitely. 17 MR. ROBERT CENTA: Okay. And you are a -- 18 aware of how these reports of post-mortem examination are 19 distributed -- 20 MS. MAXINE JOHNSON: Yes. 21 MR. ROBERT CENTA: -- once they're signed 22 off? Could we have the Hospital for Sick Children 23 Institutional Report, which is PFP301353 at page 18, 24 please. 25

1 (BRIEF PAUSE) 2 3 MR. ROBERT CENTA: Perfect. Paragraph 49 4 describes the process of distribution for reports of post- 5 mortem examination, and this -- and the paragraph 49 6 reads: 7 "With regard to the reporting 8 accountability of individual 9 pathologists conducting forensic 10 autopsies, paragraph 4(c) of Schedule A 11 of the agreement [which is a defined 12 term] preserved the pathologist's 13 accountability to the requesting coroner 14 in order to maintain the independence of 15 the pathologist's professional opinion, 16 since at times, the pathologist might be 17 called upon to determine that a death 18 was the result of a medical error by a 19 peer. 20 The usual practice was that individual 21 pathologists provided the completed 22 post-mortem examination reports to an 23 administrative assistant in the Division 24 of Pathology who would then arrange for 25 copies to be provided to the Office of

1 the Chief Coroner. 2 Generally a copy would also be provided 3 to the coroner who had signed the 4 warrant authorizing the post-mortem 5 examination. A copy of the report was 6 retained for the Division of Pathology 7 records even if the case was referred in 8 from elsewhere. Copies of all post- 9 mortem examination reports for patients 10 who died at Sick Kids were and are 11 maintained as required by the hospital 12 management regulation enacted under the 13 Public Hospitals Act." 14 And you agree with that -- do you agree 15 with that paragraph? 16 MS. MAXINE JOHNSON: Yes. 17 MR. ROBERT CENTA: And as we discussed, 18 there are invoices created in connection with the services 19 provided to the Office of the Chief Coroner? 20 MS. MAXINE JOHNSON: Yes, there are. 21 MR. ROBERT CENTA: And was the normal 22 practice for you to create those invoices? 23 MS. MAXINE JOHNSON: Yes, it was. 24 MR. ROBERT CENTA: And who creat -- who 25 would create the invoices on cases where Dr. Smith

1 performed the post-mortem examination? 2 MS. MAXINE JOHNSON: He did them him -- 3 himself because he typed his own reports. So we didn't 4 actually see those forms. 5 MR. ROBERT CENTA: And how would he go 6 about creating those invoices? 7 MS. MAXINE JOHNSON: We had them on -- Dr. 8 -- Dr. Smith -- let me just back up for a minute. Dr. 9 Smith is very computer savvy, so he was able to -- we 10 could -- we'd create these forms on your computer, and you 11 just type the required information in into each section. 12 You print it out and sign it, and it's gone. 13 MR. ROBERT CENTA: And it was his practice 14 to do that himself? 15 MS. MAXINE JOHNSON: Yes. 16 MR. ROBERT CENTA: And would you then see 17 the invoice or the -- that had -- that had been prepared? 18 MS. MAXINE JOHNSON: No, we would not. 19 MR. ROBERT CENTA: And setting aside Dr. 20 Smith for the moment, when -- in a norm -- in another 21 case, when you would create the invoice, how then would 22 you deliver the invoice and the signed report of post- 23 mortem examination to the Chief Coroner's Office? 24 MS. MAXINE JOHNSON: Okay, after the 25 pathologist signs the case and signs the appropriate

1 invoices, we would photocopy the required copies of the 2 report along with any addended reports that might have 3 been mentioned in the -- in the CF12. 4 MR. ROBERT CENTA: Mm-hm. 5 MS. MAXINE JOHNSON: We would copy -- make 6 a copy of the invoice just for the folder so we knew that 7 that invoice had been sent. In an envelope, we would put 8 the four (4) copies of the autopsy report; the -- and -- 9 as well as the aut -- post-mortem invoice for performing 10 the autopsy, and a copy of the warrant; and any -- as I 11 said, any addended reports to get sent off to the 12 Coroner's Office. 13 MR. ROBERT CENTA: And how would you send 14 it off? 15 MS. MAXINE JOHNSON: We would send it by 16 mail. We'll take it to our mail room. 17 MR. ROBERT CENTA: You used the phrase, 18 "CF12"? 19 MS. MAXINE JOHNSON: Coroner's Form 12. 20 MR. ROBERT CENTA: Thank you. And 21 that's -- 22 MS. MAXINE JOHNSON: That's this form. 23 MR. ROBERT CENTA: Leaving aside the 24 Microsoft Word -- 25 MS. MAXINE JOHNSON: Right.

1 MR. ROBERT CENTA: -- easily described, 2 that's the CF12? 3 MS. MAXINE JOHNSON: Right. 4 MR. ROBERT CENTA: Okay. And how long 5 would it take the process from the time the report was 6 signed, the invoices were generated, until the time it 7 would be received by the Chief Coroner's Office? 8 MS. MAXINE JOHNSON: It took about three 9 (3) days; no more than three (3) days, and I know that, 10 because I did a tracking exercise just to see how well we 11 were doing; how efficient our mail service was. 12 If we got it down to the mail room at a 13 particular time during the day, we knew that we -- I could 14 track it, because we sent it to a specific person at the 15 Office of the Chief Coroner, and I could just simply make 16 a phone call and say, Did you receive that report? And 17 they could tell me, Yes, they had. 18 MR. ROBERT CENTA: And you investigated 19 how long that normally took? 20 MS. MAXINE JOHNSON: Yes. 21 MR. ROBERT CENTA: And what was the 22 answer? 23 MS. MAXINE JOHNSON: The answer was two 24 (2) to three (3) days. 25 MR. ROBERT CENTA: Okay. If you could go

1 -- turn up again, Tab 6, which is the Report of Post- 2 Mortem Examination, PFP008 -- 008486, and turn to page 6 3 of that document. It's dated March 21st, 1996 and signed. 4 MS. MAXINE JOHNSON: Right. 5 MR. ROBERT CENTA: And can you turn to 6 page 7, please? And you see here there are date stamps 7 from the Office of the Chief Coroner, dated April 23rd, 8 1996 for both the account and the report; are marked 9 "Received on April 23rd, 1996" which is over a month after 10 the report -- the date of the report. 11 Was that unusual? 12 MS. MAXINE JOHNSON: Very. 13 MR. ROBERT CENTA: And because this is a 14 report prepared by -- by Dr. Smith he would likely have 15 prepared the invoices? 16 MS. MAXINE JOHNSON: Yes, he would have. 17 MR. ROBERT CENTA: And how would he get 18 the reports from Sick Kids over to the Office of the Chief 19 Coroner? 20 MS. MAXINE JOHNSON: He usually walked 21 them over. 22 MR. ROBERT CENTA: If you could turn to 23 Tab 7 of your binder, PFP008507. This is a document 24 labelled "Final Autopsy Report." 25 MS. MAXINE JOHNSON: Right.

1 MR. ROBERT CENTA: And how are final 2 autopsy reports prepared? 3 MS. MAXINE JOHNSON: The final autopsy 4 report is usually what is on the internal tracking 5 document. So instead of copy -- instead of, you know, 6 copy-typing that internal tracking document -- because 7 they're two (2) separate documents -- we would cut that 8 document and paste it into a final report and simply edit 9 the final version of the report. 10 MR. ROBERT CENTA: And for what purpose 11 were these forms created? 12 MS. MAXINE JOHNSON: This form was created 13 mostly for our system just so that that would be the piece 14 that would say that the report has been signed out and it 15 simply just contains a demo -- demographics. This form 16 would not be sent. 17 For instance, in this case, the child was 18 not -- did not die at Sick Kids, this form would -- a copy 19 of this would go into our archive in the Division of 20 Pathology, on top of the CF-12 as the front page, is what 21 we used to refer to this as, and the original would stay 22 in the folder for the case pathologist. 23 MR. ROBERT CENTA: And, Commissioner, the 24 process of preparing the final autopsy report is described 25 at the Institutional Report, page 32, paragraphs 91 to 92.

1 I don't propose to turn them up right now, but for your 2 reference there's further information set out in PFP301353 3 on page 32. 4 Now, Ms. Johnson, if you could turn to Tab 5 8 in your binder, which is PFP152441. This is another 6 document also labelled, "Final Autopsy Report." 7 Can you describe this document and its 8 purpose. 9 MS. MAXINE JOHNSON: This document was 10 created in our -- or was in our old LIS system in 4th 11 Dimension. 12 When we got CoPath, our current system, the 13 documents in that database were transferred into the new 14 database and because of the transfer the format was 15 changed because we went from an Apple to a PC and so the 16 format -- and that's why it says "converted case" -- this 17 report may not match the original report format. The 18 format just simply changed when that information was 19 transferred over into the new system. 20 MR. ROBERT CENTA: And did you say it was 21 transferred from LIS to the new system? 22 MS. MAXINE JOHNSON: Yeah. From 4th 23 Dimension to CoPath. 24 MR. ROBERT CENTA: And you had explained 25 earlier that Dr. Smith did not prepare his reports of

1 post-mortem examination? 2 MS. MAXINE JOHNSON: Correct. 3 MR. ROBERT CENTA: So was there an initial 4 step of importing Dr. Smith's reports? 5 MS. MAXINE JOHNSON: Yes. 6 MR. ROBERT CENTA: And how would that be 7 done? 8 MS. MAXINE JOHNSON: That -- as I said 9 before, he would put it on a floppy, we would stick it in, 10 cut and past the report into 4th Dimension to ensure that 11 the report was signed out or was in our computer LIS 12 system and not just on someone's hard drive somewhere. 13 And once this report was transferred over and we made that 14 switch, the format of course, of all -- of all of the 15 reports in 4th -- that were in 4th Dimension changed once 16 it was transferred into -- in CoPath. 17 MR. ROBERT CENTA: And if you could turn 18 to -- 19 COMMISSIONER STEPHEN GOUDGE: When did 20 that change occur from -- 21 MS. MAXINE JOHNSON: 1998. 22 23 CONTINUED BY MR. ROBERT CENTA: 24 MR. ROBERT CENTA: If you could turn to 25 page 2 of that document, you'll see just below the halfway

1 point, below the number 4 "Internal Examination", there's 2 some data set out there -- 3 MS. MAXINE JOHNSON: Yes. 4 MR. ROBERT CENTA: -- and it's not an 5 attractive chart. 6 MS. MAXINE JOHNSON: No. 7 MR. ROBERT CENTA: And is that what you 8 were talking about before when you said that the LIS 9 System would not prepare -- not produce chart form? 10 MS. MAXINE JOHNSON: Exactly. 11 MR. ROBERT CENTA: Okay. Now, Ms... 12 13 (BRIEF PAUSE) 14 15 MR. ROBERT CENTA: Now, Ms. Johnson, I'd 16 now like to ask you some questions about your involvement 17 in locating certain slides relating to Valin's case. 18 MS. MAXINE JOHNSON: Okay. 19 MR. ROBERT CENTA: And, Commissioner, 20 Valin's overview report is found in Volume II, Tab 18, at 21 PFP144327, and the summary of facts in that case is found 22 at image Number 3 of that document. In brief compass, 23 because we've discussed this case at some length, Valin 24 was born in Sault St. Marie on February 11th, 1989. 25 She died four and a half (4 1/2) years

1 later in June -- on June 26th or 27th of '93 in Sault St. 2 Marie. Mr. Mullins-Johnson was arrested and charged with 3 first degree murder and aggravated sexual assault of 4 Valin. 5 He was convicted in September of 1994 and 6 unsuccessfully appealed his conviction to the Supreme 7 Court of Canada and which appe -- dismissed his appeal in 8 May of 1998. And if you could turn, Mr. Registrar, to 9 image 59 in that overview report, it describes it on 10 February 27th, 2003; page 59. 11 Paragraph 105 sets out the letter that Mr. 12 Lockyer, then on behalf of AIDWYC, wrote to Mr. Porter at 13 the Ministry of the Attorney General. And in the middle 14 paragraph that is set out on that page, Mr. Lockyer 15 describes that they are seeking to obtain the original 16 slides examined by Drs. Rasaiah and Smith so that they 17 could be provided to Dr. Bernard Knight, who they had 18 retained as a defence consultant. 19 Image 61, paragraph 114, sets out a letter 20 that jo -- Dr. Rasaiah sent to Staff Sergeant Carlucci on 21 June 4th, 2003. And if you could turn over the page, 22 please, Mr. Registrar. 23 The second full paragraph on that page: 24 "On the 22nd of June 1994, the slides 25 and tissue blocks were sent to Dr. Smith

1 at the Hospital for Sick Children at the 2 request of the Crown attorney. 3 Our records show that the microscopic 4 slides and tissue blocks were not 5 returned." 6 And then on page 63 of the overview report, 7 paragraph 119, this sets out a memo that Dr. -- or sorry, 8 that Mr. Downes prepared to file regarding a telephone 9 call he had with Dr. Smith on December 29th, 2003. 10 And the memo states: 11 "Spoke by telephone to Dr. Smith at 9:45 12 a.m. today. He had requested his 13 assistant to search the archive for the 14 material. Their first search had proved 15 fruitless. He thinks samples may not be 16 there. He will take another look when 17 his assistant returns next week." 18 Now, Ms. Johnson, you said earlier that as 19 of -- from 2001 onward, Dr. Smith often looked to you to 20 provide secretarial assistance? 21 MS. MAXINE JOHNSON: Yes, he did. 22 MR. ROBERT CENTA: And in December 2003, 23 who would Dr. Smith likely have asked to assist him with 24 this kind of task? 25 MS. MAXINE JOHNSON: Myself.

1 MR. ROBERT CENTA: And do you have any 2 recollection of Dr. Smith asking you to search the archive 3 for slides and blocks related from his consultation report 4 on Valin's case? 5 MS. MAXINE JOHNSON: No, I do not. 6 MR. ROBERT CENTA: And since this was a 7 referral case, as opposed to a case where there were -- 8 the post-mortem examination was performed at the Hospital 9 for Sick Children, where would you have expected such 10 slides and blocks to have been located? 11 MS. MAXINE JOHNSON: If he did have the 12 slides and the blocks, he would have them in his office; 13 we would not have filed them in our archival system 14 because they really don't belong to us, and they should go 15 back to the originating hospital with a copy of the report 16 once that report was completed. 17 MR. ROBERT CENTA: So they would not have 18 gone to the archive. 19 MS. MAXINE JOHNSON: No, they would not 20 have. 21 MR. ROBERT CENTA: And if Dr. Smith had 22 asked you in December 2003 to look for this material, 23 where would you have looked? 24 MS. MAXINE JOHNSON: In his office. 25 MR. ROBERT CENTA: And from that point,

1 Dr. -- Mr. Downes continues to correspond with Dr. Smith 2 in an attempt to track down the slides, and this goes on 3 for -- for some time until, as we know, Commissioner, on 4 page 70 of the overview report in November of 2004, Mr. 5 Downes eventually writes to Dr. McLellan, the Chief 6 Coroner of Ontario, to seek the Office of the Chief 7 Coroner's assistance in attempting to locate the slides. 8 And if you could turn the page, Registrar, 9 to image 71, on Friday, November 26th, 2004, at paragraph 10 139: 11 "Dr. Cairns and Dorothy Zwolakowski met 12 with Dr. Smith to discuss the missing 13 slides." 14 Now, Ms. Johnson, do you recall attending a 15 meeting among Dr. Cairns, Ms. Zwolakowski, and Dr. Smith 16 to discuss the Valin slides? 17 MS. MAXINE JOHNSON: Yes. The meeting had 18 started. 19 MR. ROBERT CENTA: Right. And how did you 20 first become involved? 21 MS. MAXINE JOHNSON: Dorothy came out of 22 the meeting to ask me -- to invite me into the meeting 23 with herself, and Dr. Cairns and Dr. Smith. 24 MR. ROBERT CENTA: And when you -- and you 25 went to the meeting?

1 MS. MAXINE JOHNSON: Yes, I did. 2 MR. ROBERT CENTA: And what was asked of 3 you? 4 MS. MAXINE JOHNSON: I was asked if I had 5 seen any slides on Valin's case and I said no. Dr. 6 Cairns, you know, asked if Dorothy and I -- if I mind 7 helping, you know, Dorothy to find these slides and I 8 said, No, I didn't mind. 9 MR. ROBERT CENTA: And what did you do 10 next? 11 MS. MAXINE JOHNSON: Dorothy and I -- 12 eventually we left the meeting and went to Dr. Smith's 13 office to try and find the slides. 14 MR. ROBERT CENTA: And how urgent a 15 request did you understand this to be? 16 MS. MAXINE JOHNSON: It was yesterday. 17 That's how urgent -- you know, like, it's not today, it's, 18 like, yesterday because obviously there had been a long 19 process happening prior to this conversation, so I knew 20 that, you know, we needed to find these slides. 21 MR. ROBERT CENTA: And when -- you -- you 22 went to his office on the -- the fist day, November the 23 26th. 24 MS. MAXINE JOHNSON: Right. 25 MR. ROBERT CENTA: Were you able to locate

1 any slides that day? 2 MS. MAXINE JOHNSON: We found a couple of 3 slides that day. 4 MR. ROBERT CENTA: And that was a Friday? 5 MS. MAXINE JOHNSON: Yes. 6 MR. ROBERT CENTA: And if you turn to 7 paragraph 139 in the overview report. 8 On Monday, which is the -- the next Monday, 9 November 29, 2004, twenty (20) slides were located in Dr. 10 Smith's office and the OCCO took possession of the slides 11 on November 30th. 12 On the Monday, who located those slides? 13 MS. MAXINE JOHNSON: I did. 14 MR. ROBERT CENTA: And where did you 15 locate them. 16 MS. MAXINE JOHNSON: On a shelf in Dr. 17 Smith's office. 18 MR. ROBERT CENTA: And how would describe 19 Dr. Smith's office on that day? 20 MS. MAXINE JOHNSON: It was fairly messy. 21 MR. ROBERT CENTA: And how long did you 22 spend looking for the slides before you found them? 23 MS. MAXINE JOHNSON: Not long at all 24 because Dorothy and I had spent a lot of time the day 25 prior -- the -- of the Friday prior, sorry -- and we

1 didn't find them, so I was really happy that all of a 2 sudden, you know, they were there. 3 MR. ROBERT CENTA: And I'd like to pause 4 at the story at this point and ask you some questions 5 about the state of Dr. Smith's office. 6 Registrar, if you could please pull the PDF 7 image of PFP137518. This is found at Tab 17 of your 8 binder. And if we go to image number 4, page 4 and -- 9 perfect. 10 Do you recognize these photos? 11 MS. MAXINE JOHNSON: Yes, I do. 12 MR. ROBERT CENTA: And who took these 13 pictures. 14 MS. MAXINE JOHNSON: I had someone take 15 them. 16 MR. ROBERT CENTA: And who did you have 17 take the photos? 18 MS. MAXINE JOHNSON: Jimmy Choi, one (1) 19 of our PAs. 20 MR. ROBERT CENTA: And what were you doing 21 when you asked Mr. Choi to take these photos? 22 MS. MAXINE JOHNSON: I was cleaning up Dr. 23 Smith's office again. 24 MR. ROBERT CENTA: And why did you ask him 25 to take the photos while you were cleaning up his office?

1 MS. MAXINE JOHNSON: I had cleaned up his 2 office quite a few times since I started in the -- in the 3 division and I thought -- this is -- this about an hour 4 into cleaning it, and I thought, Oh, you know, maybe I 5 should get Jimmy to take a photo so I could use it as a 6 motivating factor, you know, for -- for Dr. Smith, so that 7 I can just show him and say, see, this is what it looked 8 like then, now -- this is what it looks like now. You 9 know, just to try to encourage him to keep it fairly neat 10 once the cleanup was done. 11 MR. ROBERT CENTA: And did you show him 12 those photos? 13 MS. MAXINE JOHNSON: Yes. 14 MR. ROBERT CENTA: And did it have the 15 desired affect? 16 MS. MAXINE JOHNSON: No. 17 MR. ROBERT CENTA: And Dr. Smith ever ask 18 you to clean up his office? 19 MS. MAXINE JOHNSON: No. 20 MR. ROBERT CENTA: Did anyone ever ask you 21 to clean up his office? 22 MS. MAXINE JOHNSON: Yes. 23 MR. ROBERT CENTA: What reasons did those 24 people give? 25 MS. MAXINE JOHNSON: Usually it's because,

1 you know, we needed to find slides of cases that had not 2 been signed out by Dr. Smith and so now there was an 3 urgency to get those cases signed out. And someone else 4 was -- you know, another pathologist was willing to sign 5 the cases out, but of course you had to first find the 6 slides and the paperwork that went with the report in 7 order to do that. 8 MR. ROBERT CENTA: And do these photos 9 fairly depict how Dr. Smith's office looked at the end of 10 November 2004 when you were looking for Valin's -- the 11 slides from Valins' case? 12 MS. MAXINE JOHNSON: Yes. 13 MR. ROBERT CENTA: Okay. If we could go 14 back to the Valin overview report, PFP144327. And at page 15 90 of that report paragraph 167 indicates that in -- on 16 May 6th, 2005 an additional ten (10) glass slides and 17 twenty-eight (28) paraffin blocks were located in Dr. 18 Smith's office at the Hospital for Sick Children. 19 Who located these slides and blocks? 20 MS. MAXINE JOHNSON: I did. 21 MR. ROBERT CENTA: And where did you find 22 them? 23 MS. MAXINE JOHNSON: Again, on a shelf in 24 his office. 25 MR. ROBERT CENTA: And were you looking

1 for them at that time? 2 MS. MAXINE JOHNSON: Not specifically, but 3 I knew the case number because I had spent so much time 4 looking for it prior to that, and I knew that things were 5 still missing. 6 It was, again, you know, just another clean 7 up, and as you're cleaning up -- you know, when I -- when 8 I clean up, I try to make sure that I get the slides for, 9 like all the special stains, for instance, on a surgical. 10 I'd ensure that the special stains, as well as the H&Es 11 would be in the same folder wi -- along with a copy of the 12 report. And as I was doing that task, you know, the same 13 thing for the autopsies, I came across the stuff. 14 MR. ROBERT CENTA: And do you re -- do you 15 recall where you found them? 16 MS. MAXINE JOHNSON: It was just, sort of, 17 on -- on the left hand -- when you're going into his 18 office, on the left hand -- in a left hand cupboard, like 19 on the shelf -- on the first shelf in one (1) of the 20 cupboards. 21 MR. ROBERT CENTA: Okay. Later on that 22 year, in June 2005, the Office of the Chief Coroner 23 conducted a tissue audit at the Hospital for Sick 24 Children; do you recall that? 25 MS. MAXINE JOHNSON: Yes.

1 MR. ROBERT CENTA: And as part of that 2 process you, again, went through Dr. Smith's office? 3 MS. MAXINE JOHNSON: Yes. 4 MR. ROBERT CENTA: And at that time, a 5 fairly complete catalogue of material was created? 6 MS. MAXINE JOHNSON: Yes. 7 MR. ROBERT CENTA: And what kinds of 8 things did you locate in Dr. Smith's office that you would 9 not have expected, necessarily, to have found in -- in his 10 office? 11 MS. MAXINE JOHNSON: It was the -- Dorothy 12 and I were involved in trying to get the materials out of 13 his office. There were some tissues, you know, that were 14 dried out in plastic containers. There was some -- sort 15 of just some skeletal bones in another little dish. There 16 was a little, sort of, a wrist bead. 17 Those kids -- the children who were usually 18 sick; they make these beads for their wrists, so each time 19 they have a procedure, you add a bead; there was one (1) 20 of those. 21 You know, there were -- there was a -- you 22 know, blocks from police evidence that, you know, usually 23 is not in a pathologist's office, so those kinds of 24 things. 25 MR. ROBERT CENTA: And just on the block

1 then, where should those blocks have been? 2 MS. MAXINE JOHNSON: Actually, it was a 3 block. 4 MR. ROBERT CENTA: Oh, a block, I'm sorry. 5 MS. MAXINE JOHNSON: A block, sorry. 6 MR. ROBERT CENTA: All right. 7 MS. MAXINE JOHNSON: And, of course, yes, 8 there were tissue blocks, as well. 9 MR. ROBERT CENTA: There were tissue. 10 MS. MAXINE JOHNSON: Yes, sir. 11 MR. ROBERT CENTA: And was there 12 correspondence? 13 MS. MAXINE JOHNSON: Yes. 14 MR. ROBERT CENTA: And both opened and 15 unopened? 16 MS. MAXINE JOHNSON: Yes. 17 MR. ROBERT CENTA: I'd now like to ask you 18 a few questions about your handling of telephone calls for 19 Dr. Smith, because if we turn back to the job description, 20 which is found at Tab 1 of your binder, PFP137570. 21 And this is the Senior Secretary's job 22 description? 23 MS. MAXINE JOHNSON: Yes, it is. 24 MR. ROBERT CENTA: And under -- towards 25 the bottom, if you could just scroll down a little bit,

1 Mr. Registrar, under: 2 "Customer service responsible for main 3 telephone, i.e., incoming calls, 4 inquiries, voice mails, triage." 5 And then: 6 "Practices correct telephone etiquette 7 and demonstrates customer service and 8 satisfaction skills." 9 Now, did -- when you arrived in 1989, did 10 the Hospital for Sick Children have voice mail systems at 11 that time? 12 MS. MAXINE JOHNSON: No, we did not. 13 MR. ROBERT CENTA: And -- so let's talk a 14 little bit about the pre-voice mail era. 15 MS. MAXINE JOHNSON: Okay. 16 MR. ROBERT CENTA: At that time, did each 17 pathologist have a direct line -- 18 MS. MAXINE JOHNSON: Yes. 19 MR. ROBERT CENTA: -- into their office? 20 MS. MAXINE JOHNSON: Yes, they did. 21 MR. ROBERT CENTA: And how -- what would 22 happen to a call that went in -- on the -- on a 23 pathologist's direct line and was unanswered? 24 MS. MAXINE JOHNSON: If -- if the 25 pathologist wasn't in the office, the line would just

1 bounce to the secretary's -- the secretary's line. Of 2 course, the secretary was also able to pick up the 3 pathologist's line because you see that it -- it was 4 ringing in his office. 5 So, if he was there, you know, you don't -- 6 or you thought he was there, you would just ignore it 7 until it bounces. If you knew he wasn't there, then you 8 would just pick up that call. 9 MR. ROBERT CENTA: And if a call went into 10 the pathologist's office and was unanswered and it bounced 11 back out to the secretary's desk and the secretary was not 12 able to answer the phone, what was the practice? 13 MS. MAXINE JOHNSON: The way we were 14 situated, we all could just pick up each other's line, so 15 if I knew that the secretary who sat, you know, wasn't 16 there whose phone was ringing and I wasn't on the phone, I 17 would just simply press a call pick-up button on my phone 18 and pick up that person's calls. 19 MR. ROBERT CENTA: So you'd take steps to 20 ensure that no call was just unanswered? 21 MS. MAXINE JOHNSON: Right. 22 MR. ROBERT CENTA: And that was a 23 priority? 24 MS. MAXINE JOHNSON: Yes, it was. 25 MR. ROBERT CENTA: And what would you do

1 when you'd answer the phone? 2 MS. MAXINE JOHNSON: You'd take a message. 3 MR. ROBERT CENTA: And how would you do 4 that? 5 MS. MAXINE JOHNSON: We'd -- we had pink 6 message -- phone message pads that we would normally use 7 for those messages. 8 MR. ROBERT CENTA: And would you take 9 simply the name and the number or would you try to obtain 10 more information? 11 MS. MAXINE JOHNSON: You always try to 12 obtain more information as -- or as much information as 13 the caller would be willing to give. Of course, 14 sometimes, you know, nobody wants to tell you anything 15 other than to say, Just tell him to call me. 16 But you certainly would ensure -- it was 17 our practice, and again, it goes back to the customer 18 satisfaction; the best practices. We want to get as much 19 information so that the pathologist who is getting that 20 phone call is already aware of the reason for that call 21 and can prepare him or herself to return that phone call. 22 MR. ROBERT CENTA: So after you recorded 23 the information on the pink slip, what would you do with 24 it? 25 MS. MAXINE JOHNSON: We would normally

1 leave it in a designated spot. Wherever -- you know, that 2 pathologist might have decided that that's where their 3 messages should be left. 4 MR. ROBERT CENTA: And where did you put 5 Dr. Smith's messages? 6 MS. MAXINE JOHNSON: Usually on his 7 computer monitor or on his chair? 8 MR. ROBERT CENTA: How would you put them 9 on a monitor? 10 MS. MAXINE JOHNSON: Just with scotch 11 tape; you just tape them on. 12 MR. ROBERT CENTA: Okay. And why did you 13 do that? 14 MS. MAXINE JOHNSON: Because we -- the 15 secretaries always seem to, sort of, be blamed for him not 16 getting his messages. He would say, Oh, I didn't get the 17 message. So we developed a -- a system, whereas -- if you 18 put it on his computer; we always know that he's going to 19 sit in his chair and turn around to his computer screen, 20 so the message would be there. 21 And if the computer screen was full, which 22 sometimes it was, we would put it on his chair, because 23 he'd have to remove it to be able to sit, so he would 24 definitely get the message. 25 MR. ROBERT CENTA: Okay. And when you say

1 his computer screen was full, what do you mean... 2 MS. MAXINE JOHNSON: Oh, 'cause sometimes 3 we would leave multiple messages, and he would just move 4 them and stick them on a corner -- stick them on a corner. 5 MR. ROBERT CENTA: Now eventually email 6 arrived at The Hospital for Sick Children. And if you 7 could turn in your binder to Tab 9, PFP008796. 8 Do you recognize this -- this type of 9 message? 10 MS. MAXINE JOHNSON: Yes. 11 MR. ROBERT CENTA: And I notice it's from 12 Maxine Raymond? 13 MS. MAXINE JOHNSON: That was me. 14 MR. ROBERT CENTA: That was you then? 15 MS. MAXINE JOHNSON: That's me too. 16 MR. ROBERT CENTA: Okay. Also you? 17 MS. MAXINE JOHNSON: Yes. 18 MR. ROBERT CENTA: Okay. And to Dr. 19 Smith, and this is the type of form you would use to 20 record telephone messages and send them by email? 21 MS. MAXINE JOHNSON: Yes. 22 MR. ROBERT CENTA: And why would you send 23 them by email as opposed to using the pink slip? 24 MS. MAXINE JOHNSON: I would have a record 25 that I did, in fact, get that message and did in fact send

1 that message to Dr. Smith. 2 MR. ROBERT CENTA: Okay. And another type 3 of email message is found at Tab 10, PFP012151. Another 4 message sent, still by you? 5 MS. MAXINE JOHNSON: Yes. 6 MR. ROBERT CENTA: And this is on the -- 7 the Tyrell Case? 8 MS. MAXINE JOHNSON: Right. 9 MR. ROBERT CENTA: So you also used -- did 10 you just type the message into the email body? 11 MS. MAXINE JOHNSON: Yes. Sometimes it -- 12 you know, you would just type it into an email because the 13 telephone message pad required two more clicks on the 14 computer. 15 MR. ROBERT CENTA: Okay. And as -- as an 16 assistant in the department, did you ever receive phone 17 calls or emails from individuals who indicated that they 18 were waiting for Dr. Smith to deliver a report? 19 MS. MAXINE JOHNSON: Yes. 20 MR. ROBERT CENTA: And who would you 21 receive those calls and emails from? What kinds of 22 people? 23 MS. MAXINE JOHNSON: You know, in -- in- 24 house staff. You know, clinicians, their assistants, 25 genetics people. From outdoors, we would get police; the

1 Office of the Chief Coroner. 2 We'd get parents. We'd get grandparents. 3 You know, just any number of sources. 4 MR. ROBERT CENTA: And break that down a 5 little bit. You did -- you mentioned clinicians? 6 MS. MAXINE JOHNSON: Yes. 7 MR. ROBERT CENTA: So if you could turn in 8 your document binder to Tab 12, PFP137773. These are two 9 (2) emails that starting below the -- the -- I guess 10 beside that little symbol on the left, from Nina Baker to 11 Dr. Smith with a copy to you sent on February the 20th, 12 2002: 13 "Dr. Grant and his staff has been 14 calling several times to get results on 15 specimens since December. They state 16 that this is a, 'HAM/ONC Case'." 17 What -- what do you think that means? 18 MS. MAXINE JOHNSON: Hematology/Oncology. 19 MR. ROBERT CENTA: 20 "And this is very important. They need 21 the results in order to proceed for 22 possible radiation treatment. The cases 23 are..." 24 And then there are two (2) case numbers 25 there and that indicates that those were surgical

1 pathology? 2 MS. MAXINE JOHNSON: These indicate that 3 they were surgical pathology done in 2001. 4 MR. ROBERT CENTA: Okay. And you 5 forwarded this message on to Dr. Becker? 6 MS. MAXINE JOHNSON: Yes. 7 MR. ROBERT CENTA: And you write: 8 "I thought I would forward this message 9 on to you. I will look after getting 10 the slides together and maybe you can 11 make some suggestions about getting 12 these signed out." 13 And why did you send it to Dr. Becker? 14 MS. MAXINE JOHNSON: We were having -- you 15 know, there were ongoing issues in terms of Dr. Smith 16 getting his reports out in a timely manner. So if you 17 notice that Nina's email is actually blind copied to me, 18 so bas -- you know, she didn't really want Dr. Smith to 19 know that she had sort of let me know that she had sent me 20 this email. 21 So I sent it to Dr. -- to Dr. Becker 22 because he was always trying to facilitate getting those 23 reports of Charles' signed out when we found out -- when 24 we became aware. Because if this specimen was from 25 December -- we're now talking about February -- it's a

1 very long time for surgical specimens to still be on 2 signed-out. 3 So Dr. Becker would sometimes, you know, 4 just go to Dr. Smith and talk to him about it. Or we 5 would get another pathologist to sign the case out. 6 MR. ROBERT CENTA: You also mentioned that 7 you would sometimes get messages from colleagues. 8 If you could turn in your binder to Tab 11, 9 PFP137793. Now this is a message to Dr. Becker regarding 10 surgical autopsies sent on May the 30th, 2000. And the 11 message begins: 12 "The 1995 autopsies are now complete. 13 Charles gave me three (3) or four (4) on 14 Friday and the other was given to me 15 yesterday morning. He still has one (1) 16 incomplete case from 1998. I will find 17 out from him the status. Otherwise, his 18 outstanding 2000 autopsy cases are as 19 follows..." 20 And there's a list there, broken down -- or 21 an aged list there and also the surgical status. 22 Why did you send this message to Dr. 23 Becker? 24 MS. MAXINE JOHNSON: Again, you know, Dr. 25 Becker was always concerned that Dr. Smith's cases weren't

1 being signed out in a timely manner. Clinicians were 2 concerned as well. 3 We bind our reports each year, so this 4 being sent in 2000 -- and I said the 1995 autopsies are 5 now complete, which says that I -- you know, Dr. Smith has 6 now completed his 1995 cases. This was just to let Dr. 7 Becker know so he would have some real data as to what was 8 really outstanding and what he could do to help Dr. Smith 9 to get these cases out. 10 MR. ROBERT CENTA: And now turning from 11 inside the colleagues to -- to those who were calling from 12 outside the hospital. And you mentioned police officers-- 13 MS. MAXINE JOHNSON: Right. 14 MR. ROBERT CENTA: -- and coroners? 15 MS. MAXINE JOHNSON: Yes. 16 MR. ROBERT CENTA: How often would you 17 receive calls from outside Hospital for Sick Children from 18 someone looking for a report that they -- they described 19 as being overdue? 20 MS. MAXINE JOHNSON: If I had -- very 21 frequently specifically for Dr. Smith. I would say he 22 would be the person who we would handle the most calls for 23 these types of -- of reports. 24 MR. ROBERT CENTA: And when you would 25 receive calls for Dr. Smith, did anyone ever tell you that

1 they had previously left a message for Dr. Smith that had 2 not yet been returned? 3 MS. MAXINE JOHNSON: Of course. 4 MR. ROBERT CENTA: And did you mention 5 those occasions to Dr. Smith? 6 MS. MAXINE JOHNSON: Yes. 7 MR. ROBERT CENTA: What did he say? 8 MS. MAXINE JOHNSON: Oh, I'm going to get 9 to it soon. Don't worry about it. 10 And, you know, my response is usually, you 11 know, They've called before so let's try to do -- let's 12 try to get them out. And I always used to say "let's" so 13 -- just to remind him that, you know, we're here, so if 14 you can't get to it then we're more than happy -- if you 15 just dictate them, write -- you know, handwrite them, 16 whatever. Let's just get them out so we would alleviate 17 these types of phone calls all the time. 18 MR. ROBERT CENTA: And so you are aware 19 then that there was -- callers to the Department were 20 expressing concerns about delayed reports? 21 MS. MAXINE JOHNSON: Yes. 22 MR. ROBERT CENTA: Of Dr. Smith? 23 MS. MAXINE JOHNSON: Yes. 24 MR. ROBERT CENTA: And is it fair -- I'll 25 put it differently.

1 In your view, did Dr. Smith's access to 2 secretarial services meaningfully affect his -- the delay 3 in his cases? 4 MS. MAXINE JOHNSON: Did his access to us 5 affect his delay? 6 MR. ROBERT CENTA: Was that the reason for 7 the delay? 8 MS. MAXINE JOHNSON: We were always 9 available. And if Dr. Smith would simply give us the 10 work, he would not have these delays because we would get 11 them out; it's a part of what we do everyday. 12 MR. ROBERT CENTA: Now, from your 13 observations of how Dr. Smith worked, would -- if he had 14 access to greater secretarial services, would that have 15 affected the turnaround time on his reports? 16 MS. MAXINE JOHNSON: No. 17 MR. ROBERT CENTA: Why not. 18 MS. MAXINE JOHNSON: Because he loved to 19 type them himself. 20 COMMISSIONER STEPHEN GOUDGE: Sorry, 21 because he loved to type them? 22 MS. MAXINE JOHNSON: He liked to type them 23 himself. He didn't -- he just didn't give them to us. 24 COMMISSIONER STEPHEN GOUDGE: Did he 25 always type them himself?

1 MS. MAXINE JOHNSON: As fas as I know, 2 yes. 3 4 CONTINUED BY MR. ROBERT CENTA: 5 MR. ROBERT CENTA: And if he'd had 6 increased access to secretarial resources, would that 7 have, in your -- based on your observations, made him more 8 responsive to calls from individuals seeking to contact 9 him? 10 MS. MAXINE JOHNSON: I don't think it 11 would matter because, as I said, we were always available. 12 And, of course, we don't have a hundred (100) autopsies or 13 a hundred (100) surgicals everyday, so sometimes, you 14 know, especially during the holidays seasons the OR would 15 be more or less shut down, and it would only be emergency 16 cases and we were there. I mean, we had time to do these 17 things for him if he wanted us to do. 18 MR. ROBERT CENTA: And is it -- is it fair 19 to say though that -- that at -- from time to time there 20 were periods of increased work in the department? 21 MS. MAXINE JOHNSON: Oh, yeah. 22 MR. ROBERT CENTA: And there were times 23 when certain reports were taking some time to processed by 24 administrative assistants? 25 MS. MAXINE JOHNSON: Not usually because

1 again, as I said, the clinical work always took precedence 2 because the administrative staff -- we were always aware 3 because we're the ones who got the telephone calls, so we 4 understood the importance of getting these reports out and 5 also did not want to be the cause of -- of having a 6 backlog. We -- so each time we got them, we would get 7 them off of our desk. 8 MR. ROBERT CENTA: And -- and finally just 9 a -- a few questions about Dr. Smith as a -- as a 10 colleague. 11 You worked with Dr. Smith for many years? 12 MS. MAXINE JOHNSON: Yes, I did. 13 MR. ROBERT CENTA: Describe your views of 14 him as a colleague? 15 MS. MAXINE JOHNSON: You know, he's really 16 a great guy. He's got a great personality. If you wanted 17 to know something about the computer, the Mac, just ask 18 him because he was -- he was well versed. He -- he -- you 19 know, he's socialable and definitely not a difficult 20 person to -- to deal with, so secretaries actually liked 21 working for him because he was pleasant. So we would -- 22 you know, whatever he needed we were always available. 23 If you had to compare his personality type 24 to another pathologist, for instance, you would always 25 want to do Charles' work because he just made it -- you

1 know, if he wanted it done we were there. 2 MR. ROBERT CENTA: Thank you, Ms. Johnson. 3 Commissioner, those are my questions. It might make sense 4 to take an early break, so that we could use the break to 5 allocate the remaining time for cross-examination and to 6 establish an order? 7 COMMISSIONER STEPHEN GOUDGE: Yes. That 8 sounds sensible to me. We will come back then at 11:15. 9 10 --- Upon recessing at 10:51 a.m. 11 --- Upon resuming at 11:20 a.m. 12 13 COMMISSIONER STEPHEN GOUDGE: Mr. Centa, I 14 have the proposed cross-examination times. 15 I think Mr. Campbell, we begin with you, is 16 that right? 17 MR. ROBERT CENTA: Yes. 18 COMMISSIONER STEPHEN GOUDGE: Mr. 19 Campbell...? 20 21 CROSS-EXAMINATION BY MR. PHILLIP CAMPBELL: 22 MR. PHILLIP CAMPBELL: Good morning, Ms. 23 Johnson. My name is Phil Campbell, and I represent some 24 people who were convicted in cases where Dr. Smith was 25 involved.

1 The first two (2) areas I want to question 2 you in arise from consultations among the lawyers where I 3 found out that my confusion was shared and therefore I was 4 willing to admit it. 5 One (1) is about the nature of -- of 6 reporting and documentation following an autopsy. We've 7 heard, largely from you, but I think maybe from others as 8 well, about at least four (4) kinds of documentation. And 9 I'm -- I'm hopeful that you can clarify for us how the 10 results on an autopsy are documented from whenever it's 11 first documented after it happens till it's released to 12 the outside world. 13 We've heard of an internal tracking 14 document this morning, of something called preliminary 15 reports, of a post-mortem report and of -- we saw this 16 morning -- a short document called a Final Autopsy Report. 17 Can you just help all of us understand what 18 is the first document created at -- at the Hospital for 19 Sick Children in the aftermath of a -- of a forensic or 20 medicolegal autopsy? And we'll go from there. 21 MS. MAXINE JOHNSON: All right. Are you - 22 - do you want to know what we currently do? Because the 23 Coroner's Office has changed the rules a little bit over 24 the last few years. 25 So two (2) things -- there's something

1 that's little bit different that we currently do, based on 2 those recommendations from the Office of the Chief 3 Coroner. 4 So my question to you -- back to you is: 5 Do you want to hear what we were doing say, for instance, 6 in 1991? 7 MR. PHILLIP CAMPBELL: I think I primarily 8 want to know what we're doing now -- 9 MS. MAXINE JOHNSON: Now? 10 MR. PHILLIP CAMPBELL: -- because that 11 will be -- 12 MS. MAXINE JOHNSON: Okay. 13 MR. PHILLIP CAMPBELL: -- the starting 14 point for any -- any -- 15 MS. MAXINE JOHNSON: All right. 16 MR. PHILLIP CAMPBELL: -- reforms... 17 COMMISSIONER STEPHEN GOUDGE: I would like 18 to hear what was going on in the '90s as well, Mr. 19 Campbell. 20 So however you would like to answer that, 21 Ms. Johnson. 22 MR. PHILLIP CAMPBELL: All right. 23 MS. MAXINE JOHNSON: All right. So -- so 24 let's go back. In 1991, for instance -- 25 COMMISSIONER STEPHEN GOUDGE: Sorry. I

1 win. 2 MR. PHILLIP CAMPBELL: I noticed that. 3 4 CONTINUED BY MR. PHILLIP CAMPBELL: 5 MS. MAXINE JOHNSON: Okay. In 1991, Mr. 6 Commissioner, what was happening was an autopsy would come 7 in to the Department. And again, Mr. Campbell, you asked 8 specifically about medicolegal autopsies, so we'll focus 9 just on those. 10 Autopsy would come in. Autopsy is 11 performed. You know, the case is accessioned, which means 12 it's given an autopsy number, so it would be, in this case 13 of Joshua, for instance, ML36 of '96. Once the autopsy is 14 completed -- and I'm going to speak what happens 15 generally, not necessarily, you know, specifically, Dr. 16 Smith, but what our department does. 17 The autopsy comes in; the pathologist 18 performs the autopsies. Within forty-eight (48) hours, 19 the pathologist would either dictate or handwrites and 20 create -- we would create this internal tracking document. 21 And I know that you said "Internal Tracking Document 22 Preliminary"; they're the same things. 23 So an internal tracking document is really 24 the preliminary autopsy report. In that report, the 25 demographics have been entered. What's contained in this

1 internal tracking document, as I said before, would be a 2 title, -- is what we used to refer to it as -- a clinical 3 history and an anatomical diagnosis and a short history. 4 In the medicolegal report, within forty- 5 eight (48) hours, this is created. The secretaries 6 transcribe it. The pathologist gets it back. Eventually 7 it's signed out. We send it off -- fax it off usually -- 8 to the Office of the Chief Coroner. That would be the 9 only place that we would send that Internal Tracking 10 Document/Preliminary Report to. 11 MR. PHILLIP CAMPBELL: And that's a report 12 that is committed to print within forty-eight (48) hours 13 of the completion -- 14 MS. MAXINE JOHNSON: Right. And it's -- 15 MR. PHILLIP CAMPBELL: -- of the autopsy? 16 MS. MAXINE JOHNSON: -- and it's -- it's 17 totally preliminary findings because, of course, we 18 haven't seen the microscope slides yet. All of those 19 things haven't taken place as of yet. 20 Sometime later on, maybe two (2) weeks, we 21 have the brain cutting and that would be where the Central 22 Nervous System Procedure Report is created; where the 23 neuropathologist signs it out. 24 So there's a gross description of the 25 brain. Once the slides are cut and stained, the

1 pathologist -- the neuropathologist will get those slides. 2 He will read those slides; create a final Central Nervous 3 System Microscopic Report. So he'll say, you know, Slide 4 -- you know, block one (1), you know, Hippocampus: normal. 5 And he'll -- you know, he'll go through 6 those slides that he has on his desk that have been 7 created by the lab. Then he'll do a final diagnosis off 8 the central nervous system. 9 That report is signed by the 10 neuropathologist and given to the case pathologist. It 11 wouldn't go anywhere -- it would not -- it wouldn't leave 12 the department. It would just go to the case pathologist 13 in order for that pathologist to complete his reports. 14 At the time of autopsy, there might be 15 toxicology sent out. There might be virology or 16 bacteriology reports; different types of reports based on 17 -- which is case-specific. 18 So those would -- 19 COMMISSIONER STEPHEN GOUDGE: Is there a 20 CNS report on every medicolegal autopsy? 21 MS. MAXINE JOHNSON: Usually. Because -- 22 sometimes, however, we do have a limited autopsy. So, you 23 know, they might opt not to do the brain -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 MS. MAXINE JOHNSON: -- or, you know.

1 COMMISSIONER STEPHEN GOUDGE: But -- but 2 the usual practice -- 3 MS. MAXINE JOHNSON: Usual practice would 4 be -- 5 COMMISSIONER STEPHEN GOUDGE: -- would be 6 CAS report -- 7 MS. MAXINE JOHNSON: Yes. 8 COMMISSIONER STEPHEN GOUDGE: -- in 9 every -- 10 MS. MAXINE JOHNSON: In every -- 11 COMMISSIONER STEPHEN GOUDGE: -- medicolegal 12 aut -- 13 MS. MAXINE JOHNSON: -- medicolegal case. 14 COMMISSIONER STEPHEN GOUDGE: Yes. 15 MS. MAXINE JOHNSON: So once that -- once 16 the pathologist receives the brain microscopic -- in the 17 interim, the case pathologist -- the slides for the main 18 part of the autopsy; so the H&Es, all of those, you know, 19 findings from the various tissue samples that were taken, 20 those slides are made. 21 The case pathologist gets, you know, a 22 couple of folders with those slides; he looks at those 23 slides. He creates the coroner's Form 12 Report, so we do 24 a type up of that report. 25 MR. PHILLIP CAMPBELL: Is there anything

1 else that's called besides the CF 12? Is it called 2 preliminary -- 3 MS. MAXINE JOHNSON: No. 4 MR. PHILLIP CAMPBELL: -- post-mortem? 5 MS. MAXINE JOHNSON: There's no 6 preliminary on the CF 12. 7 MR. PHILLIP CAMPBELL: All right. 8 MS. MAXINE JOHNSON: It's -- it's usually 9 created as a final -- so you might put in initial data, 10 for instance, made upon the body of, you know, for 11 instance, Joshua in this case, at the Hospital for Sick 12 Children on the 24th day of whatever. 13 So those things can go in fairly early into 14 creating this procedure, but you're not doing anything 15 with it until you get the microscope glass slides, as well 16 as, you know, the central nervous system bacteriology 17 report, because all of those things will make up the final 18 coroner's Form 12 Autopsy Report. 19 COMMISSIONER STEPHEN GOUDGE: So you could 20 start it, but not complete it. 21 MS. MAXINE JOHNSON: He could start it, 22 but not complete it -- very, very basic -- but again, it's 23 not -- it's sent anywhere. 24 25 CONTINUED BY MR. PHILLIP CAMPBELL:

1 MR. PHILLIP CAMPBELL: So it's a work in 2 progress. 3 MS. MAXINE JOHNSON: It's a work in 4 progress, yes. 5 MR. PHILLIP CAMPBELL: All right. And it 6 is final that it's -- it is completed at the point when 7 all of the peripheral reports are in -- 8 MS. MAXINE JOHNSON: Exactly. 9 MR. PHILLIP CAMPBELL: -- and reviewed by 10 the pathologist and incorporated into the report. 11 MS. MAXINE JOHNSON: Exactly. 12 MR. PHILLIP CAMPBELL: Okay. And what is 13 this -- what is the circulation or distribution of the CF 14 12? 15 MS. MAXINE JOHNSON: Okay, so once the -- 16 we send the CF 12 only to the Office of the Chief Coron -- 17 Coroner, or in some specific cases, you know, we're asked 18 to send a copy to the Regional Coroner at the same time, 19 as well. 20 COMMISSIONER STEPHEN GOUDGE: By the 21 Office of the Chief -- 22 MS. MAXINE JOHNSON: By the Office of the 23 Chief Coroner. You know, as we progressed, the Office of 24 the Chief Coroner found that it was easier just to send 25 them the four (4) copies and they disseminated it.

1 We did not send out any of these reports, 2 other than to the Office of the Chief Coroner. If the 3 child died at Sick Kids in 1991, for instance, there used 4 to be a release of post -- post-mortem, so that form would 5 be sent to the Office of the Chief Coroner. That form 6 also came from the Office of the Chief Coroner. 7 It was a release, so you sent that along 8 with the final autopsy report and whatever else you needed 9 to send to them and they -- once they de -- determined 10 that you could release that report to the Sick Kids 11 medical records or to the Trenton Hospital medical 12 records, they would sign that form, send it back to us, 13 and at that point we would release this CF 12 to the 14 hospitals. 15 16 CONTINUED BY MR. PHILLIP CAMPBELL: 17 MR. PHILLIP CAMPBELL: Okay. And is it 18 your understanding, insofar as you perceive how the 19 justice system works, that it is the CF 12 that will get 20 released to the outside world -- 21 MS. MAXINE JOHNSON: Yes. 22 MR. PHILLIP CAMPBELL: -- the Crown 23 attorneys, police and Courts -- 24 MS. MAXINE JOHNSON: Yeah. 25 MR. PHILLIP CAMPBELL: -- ultimately?

1 Okay. 2 MS. MAXINE JOHNSON: That's how I perceive 3 it. 4 MR. PHILLIP CAMPBELL: But that CF 12 is 5 not what you would call the final autopsy report because 6 that's yet another document. 7 MS. MAXINE JOHNSON: No, this is the -- 8 okay, the final autopsy report, as I explained to you 9 before, that was just an internal -- or -- or should just 10 be an internal document. 11 MR. PHILLIP CAMPBELL: It's a Hospital for 12 Sick Children document -- 13 MS. MAXINE JOHNSON: It's -- 14 MR. PHILLIP CAMPBELL: -- not a coroner's 15 document? 16 MS. MAXINE JOHNSON: Right. It's a hosp - 17 - it's -- it's just the system -- it -- it's the way our 18 LIS system was set up. So if, for instance, in our 19 current system -- Commissioner, I'm just going to jump 20 forward a little bit. 21 In our current system, when you sign this 22 CF 12 procedure report out in the -- in the database, 23 because now we electronically sign them out, the report is 24 not signed out until you've signed out the final autopsy 25 report that's in our current system. So the final autopsy

1 report just has pre -- like now all it says on the final 2 diag -- autopsy report is, you know, For a complete copy 3 of the report contact the Office of the Chief Coroner, 4 416-314-4000; that's all that would be on that final 5 report document. Pre -- 6 COMMISSIONER STEPHEN GOUDGE: Do you keep 7 a copy of the CF 12? 8 MS. MAXINE JOHNSON: Yes. In our files, 9 yes. 10 COMMISSIONER STEPHEN GOUDGE: So there 11 would be two (2) things, there would be the CF 12 and on 12 top of it would be the final -- 13 MS. MAXINE JOHNSON: Would be the final 14 report, right. And that would be maintained in our -- a 15 copy of that would -- is maintained in our department -- 16 division. 17 18 CONTINUED BY MR. PHILLIP CAMPBELL: 19 MR. PHILLIP CAMPBELL: Okay, that -- 20 that's helpful, for me at least. 21 COMMISSIONER STEPHEN GOUDGE: Can I just 22 carry on? 23 MR. PHILLIP CAMPBELL: Certainly. 24 COMMISSIONER STEPHEN GOUDGE: This is my 25 time, not your time, okay.

1 But what you've described was the process 2 through the 1990s? 3 MS. MAXINE JOHNSON: Yes. 4 COMMISSIONER STEPHEN GOUDGE: And you say 5 now, but it's -- 6 MS. MAXINE JOHNSON: The -- the difference 7 now -- 8 COMMISSIONER STEPHEN GOUDGE: -- some new 9 changes -- some changes? 10 MS. MAXINE JOHNSON: -- the dif -- the 11 difference now is that final report that was created at -- 12 for instance, in -- in this Joshua case -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 MS. MAXINE JOHNSON: -- we no longer put 15 that information on that front sheet. All that's on that 16 final report is the demographics at the top and this bit 17 that just says, "For complete copy of the report please 18 contact the Office of the Chief Coroner." 19 COMMISSIONER STEPHEN GOUDGE: So it's more 20 summary than the final report used to be. 21 MS. MAXINE JOHNSON: It's the -- the one 22 (1) that we currently have doesn't have anything on there, 23 really. 24 COMMISSIONER STEPHEN GOUDGE: Whereas 25 the --

1 MS. MAXINE JOHNSON: But the previous one 2 (1) had -- 3 COMMISSIONER STEPHEN GOUDGE: -- one (1) 4 you used to have had -- 5 MS. MAXINE JOHNSON: -- a little -- like 6 it had the history -- 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 MS. MAXINE JOHNSON: -- and it had the 9 anatomical diagnosis. 10 COMMISSIONER STEPHEN GOUDGE: Okay. 11 MS. MAXINE JOHNSON: But that was it. So 12 the meat, if you would call it that, of the report -- of 13 the -- what was called the final report, is the Coroner's 14 Form 12. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 MS. MAXINE JOHNSON: That -- because that 17 would contain everything. 18 COMMISSIONER STEPHEN GOUDGE: Right. And 19 that's just -- I take it the change was made for ease of 20 record keeping, so you wouldn't have to put in the final 21 report a duplication of everything that was in the CF 12? 22 MS. MAXINE JOHNSON: Possibly. And it -- 23 and it wasn't everything that was there. It was just the 24 anatomical -- 25 COMMISSIONER STEPHEN GOUDGE: Okay.

1 MS. MAXINE JOHNSON: -- diagnosis from the 2 CF 12 that was in the -- 3 COMMISSIONER STEPHEN GOUDGE: Okay. 4 MS. MAXINE JOHNSON: -- the final report. 5 6 CONTINUED BY MR. PHILLIP CAMPBELL: 7 MR. PHILLIP CAMPBELL: And you answered 8 this, I think, and I've just forgotten. The preliminary 9 report, the original document created within forty-eight 10 (48) hours, goes to the Chief Coroner's Office? 11 MS. MAXINE JOHNSON: Internal tracking 12 document, yes. Yeah. You -- 13 MR. PHILLIP CAMPBELL: But you don't know 14 what use is made of it after that? 15 MS. MAXINE JOHNSON: No. I would imagine 16 that that would just be the preliminary findings being, 17 you know, put forth to them. That was their requirement 18 so... 19 MR. PHILLIP CAMPBELL: And -- and that's - 20 - that operated that way in the past and -- 21 MS. MAXINE JOHNSON: Yes. 22 MR. PHILLIP CAMPBELL: -- still does? 23 MS. MAXINE JOHNSON: No, it doesn't 24 operate -- we don't create any preliminary reports in our 25 system for the Coroner's Office anymore, no.

1 COMMISSIONER STEPHEN GOUDGE: So you don't 2 have the internal -- 3 MS. MAXINE JOHNSON: Internal, no. 4 COMMISSIONER STEPHEN GOUDGE: So what's 5 the first document you now have? 6 MS. MAXINE JOHNSON: So the first document 7 that we now create is the CF 12. 8 COMMISSIONER STEPHEN GOUDGE: Okay. 9 MS. MAXINE JOHNSON: And that's much 10 further along. 11 COMMISSIONER STEPHEN GOUDGE: When was 12 that change introduced? 13 MS. MAXINE JOHNSON: Probably in the -- 14 2000 sometime. 15 COMMISSIONER STEPHEN GOUDGE: Do you know 16 why? 17 COMMISSIONER STEPHEN GOUDGE: I'm not sure 18 what the reasoning was at the Coroner's Office. But as I 19 said, it didn't -- 20 COMMISSIONER STEPHEN GOUDGE: Did it have 21 anything to do with the preliminary reports -- the 22 tracking reports getting into the wrong place, places that 23 they weren't intended to go? 24 MS. MAXINE JOHNSON: I'm not sure. 25

1 CONTINUED BY MR. PHILLIP CAMPBELL: 2 MR. PHILLIP CAMPBELL: But the pathologist 3 then, as far as you can observe the system, does not 4 commit anything to writing in the immediate aftermath of 5 doing the post-mortem examination? 6 MS. MAXINE JOHNSON: Oh they have their 7 notes. 8 MR. PHILLIP CAMPBELL: Handwritten? 9 MS. MAXINE JOHNSON: They -- they hand 10 write their notes. Some pathologists will dictate 11 specific things that they can see right away. You know -- 12 and sometimes -- and then once they get the microscope 13 glass slides -- because there's parts of the report that 14 you can -- you know: liver, you know, 524 grams, normal. 15 You know, because you can see that -- they 16 can see that initially, so they can dictate that type of 17 information while it's still fresh in their minds. 18 MR. PHILLIP CAMPBELL: With a dictaphone 19 in the autopsy room or immediately afterwards? 20 MS. MAXINE JOHNSON: They usually go to 21 their offices and -- and just dictate it. Some 22 pathologists still have the -- the long Form 12, and they 23 would just hand write things and the secretaries 24 transcribe that. And we usually do that right away. 25 MR. PHILLIP CAMPBELL: But that creates

1 what you refer to as notes, rather than a report, is that 2 right? 3 MS. MAXINE JOHNSON: It's just notes. 4 It's not a report, because the report is not signed out -- 5 MR. PHILLIP CAMPBELL: Do -- 6 MS. MAXINE JOHNSON: -- and it's not 7 complete. 8 MR. PHILLIP CAMPBELL: -- do those notes, 9 in whatever form they take, whether dictated or 10 handwritten onto the form or anything else, do those notes 11 get forwarded to the Chief Coroner's Office? 12 MS. MAXINE JOHNSON: No. 13 MR. PHILLIP CAMPBELL: Do they get 14 preserved in the Hospital for Sick Children file? 15 MS. MAXINE JOHNSON: They -- no. It's 16 just in our database, that only pathology staff can 17 access. 18 MR. PHILLIP CAMPBELL: Well, in your data 19 -- if -- if they're made on a -- if they're made in ink on 20 a document -- 21 MS. MAXINE JOHNSON: Okay. 22 MR. PHILLIP CAMPBELL: -- what happens to 23 the document? 24 MS. MAXINE JOHNSON: If they're made in 25 ink on a document, those are kept with the pathologist in

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1 his working file. Each case has a file folder that the 2 pathologist keeps: you know, emails or phone messages, 3 you know, handwritten notes. 4 Those folders sometimes have just the -- 5 the tags that might have been attached to a toe; you know, 6 they might tape it on the inside, you know, of that 7 folder, because they're ultimately responsible for that 8 folder. 9 If they're going to court, that is the 10 folder that they take along with them with all of their 11 original notes, all of -- you know, all of the things 12 pertaining to that case. 13 MR. PHILLIP CAMPBELL: Where does that 14 document get retained? In the personal filing system of 15 the pathologist or in the Sick Kids filing system? 16 MS. MAXINE JOHNSON: It's kept with the 17 pathologist. 18 MR. PHILLIP CAMPBELL: And in perpetuity, 19 even after all -- say all court proceedings are done and 20 there's no more controversy about a case? 21 MS. MAXINE JOHNSON: That folder remains 22 with the case pathologist, or should remain with the case 23 pathologist. The -- the information on our database, the 24 report that's finalized and signed out, eventually, stays 25 on our database.

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1 We keep a copy of that report in our system 2 to be bound. You know, because we archive these reports. 3 But all of the original materials, all of the original, 4 you know, reports, microbiology report, all of those 5 things, the pathologist is responsible for maintaining 6 those with him. 7 MR. PHILLIP CAMPBELL: Do you know if 8 there's any requirement or practice about how long they're 9 retained? 10 MS. MAXINE JOHNSON: No, but I would 11 imagine for a very long time. 12 MR. PHILLIP CAMPBELL: And do you know 13 where they're retained? At home, at the hospital, or 14 wherever the pathologist wishes? 15 MS. MAXINE JOHNSON: Some of -- I know 16 that we -- we currently have -- some of the pathologists 17 will keep them, if they have space in their filing 18 cabinet, in their offices. 19 MR. PHILLIP CAMPBELL: And -- but they're 20 free to take them elsewhere as well? 21 MS. MAXINE JOHNSON: If they -- yes, 22 because it -- it really is their responsibility, as far as 23 I'm aware. 24 MR. PHILLIP CAMPBELL: Okay. 25 COMMISSIONER STEPHEN GOUDGE: So the

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1 hospital does not have any obligation or practice of 2 inventorying or archiving slides, tissue blocks -- 3 MS. MAXINE JOHNSON: Oh, no, we keep the 4 slides and the tissue blocks that are -- off the autopsies 5 that are performed. 6 COMMISSIONER STEPHEN GOUDGE: Okay. So 7 what is it that the individual case pathologist keeps as 8 his or her own? 9 MS. MAXINE JOHNSON: Just the -- the file 10 on that case. 11 COMMISSIONER STEPHEN GOUDGE: Just their 12 working file? 13 MS. MAXINE JOHNSON: Their working file 14 with a copy of the report -- you know, a copy of the final 15 report. And as I said, any correspondence that they might 16 have had pertaining to that case; they would normally keep 17 those in that file, as well. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 Thanks. 20 MS. MAXINE JOHNSON: You're welcome. 21 22 CONTINUED BY MR. PHILLIP CAMPBELL: 23 MR. PHILLIP CAMPBELL: Okay. We all 24 listened to your evidence about find -- beginning your 25 search on Friday the 29th (sic) of November for the slides

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1 once this had become the focus of everybody's attention 2 and then finding them on the morning of the 29th. 3 Again, I think some of us listening weren't 4 completely clear what your own perception of -- of that 5 was. You found the slides quickly and easily on the 6 Monday morning, is that right? 7 MS. MAXINE JOHNSON: Yes. 8 MR. PHILLIP CAMPBELL: Was it your own 9 appreciation of this, at that time, that -- on the Friday, 10 you had looked in the place where you found them on the 11 Monday? 12 MS. MAXINE JOHNSON: Yes. 13 MR. PHILLIP CAMPBELL: And did you draw 14 from that the inference that they had been placed in the 15 position where you found them between the Friday and the 16 Monday? 17 MS. MAXINE JOHNSON: Yes, I did because we 18 did spend a lot of time, and we did look everywhere for 19 those. 20 MR. PHILLIP CAMPBELL: Did you -- at the 21 time having formed that impression -- did you discuss it 22 with anybody else? With Dorothy or -- or anybody else who 23 was fam -- aware of this search in progress? 24 MS. MAXINE JOHNSON: Sure, I told Dorothy 25 that, you know, I thought it was kind of strange that we

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1 had looked, I mean, and we spent a lot of time looking and 2 then all of a sudden -- 3 COMMISSIONER STEPHEN GOUDGE: Did you look 4 in the same place on Friday -- 5 MS. MAXINE JOHNSON: Oh, yes. 6 COMMISSIONER STEPHEN GOUDGE: -- that you 7 found them on Monday? 8 MS. MAXINE JOHNSON: Yes, we did. I 9 looked. 10 COMMISSIONER STEPHEN GOUDGE: Okay. 11 12 CONTINUED BY MR. PHILLIP CAMPBELL: 13 MR. PHILLIP CAMPBELL: And I'm not 14 completely conversant with this history, but you found a 15 good deal more related to the case some months later? 16 MS. MAXINE JOHNSON: Yes. 17 MR. PHILLIP CAMPBELL: And had you -- 18 wherever you found that, had you looked in that location 19 on the November 26th and 29th searches? 20 MS. MAXINE JOHNSON: Yes, we did. 21 MR. PHILLIP CAMPBELL: And you formed the 22 same inference that between the end of the November 26th 23 to 29th search, and your later discovery of this material, 24 it had been put in the position where you finally found 25 it?

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1 MS. MAXINE JOHNSON: Yes. 2 MR. PHILLIP CAMPBELL: All right. Were 3 you aware, from your sort of insider's position in the 4 office, of other pathologists from around the province 5 frequently calling Dr. Smith for advice and second 6 opinions? 7 MS. MAXINE JOHNSON: Yes. 8 MR. PHILLIP CAMPBELL: When that happened, 9 as far as you were aware, was any documentary record 10 created of what he may have said to the other 11 pathologists? 12 MS. MAXINE JOHNSON: Not from our 13 perspective. If a case is not -- has not been 14 accessioned, we didn't always -- let me just back up for a 15 minute, we didn't open the pathologist's mail. The 16 preference was for them to do so themselves, so unless a 17 pathologist brought us some materials for accessioning, we 18 really didn't know that it existed. 19 MR. PHILLIP CAMPBELL: And he was not 20 under any obligation, as far as you knew, to create a 21 memorandum or open a file of his own about this kind of 22 informal advice from other pathologists -- with -- to 23 other pathologists? 24 MS. MAXINE JOHNSON: Well, I -- I know 25 that, from the others and from my own experience, that if

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1 -- if a pathologist gets a case where they're asking, you 2 know, for a consult -- 'cause really that's what it -- I 3 think it is. You look at the slides and you create a 4 report. 5 You accession the case. A report is 6 created, and you send that back. And the secretaries, you 7 know, will get the report, along with the materials that 8 the pathologist received, to return it. And we -- in our 9 current LIS system, we actually have the ability to go in 10 to the case and set a retrieval flag. 11 So we'll -- we'll get the materials; we 12 accession it. We can set a retrieval flag saying, 13 Materials to be returned and in a comment field, we'll 14 say, Ten (10) microscope slides plus five (5) paraffin 15 blocks to Trenton General Hospital, Department of 16 Pathology. 17 And -- for instance -- and if -- if -- once 18 that report has been signed out by the pathologist, the 19 pathologist will give it to a secretary along with the 20 materials. We make sure that all the blocks and all the 21 slides that we received are being returned. We -- we then 22 go into the system and put a Materials Returned Flag and 23 you say exactly what you returned and to whom. 24 MR. PHILLIP CAMPBELL: That -- and -- and 25 you may get some questions about that if I know what's

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1 coming. But my -- that presupposes that material comes in 2 to the -- into Sick Kids and at that point, your concern 3 is that it be properly documented and as -- accessioned, 4 correct? 5 MS. MAXINE JOHNSON: Sure. If we're aware 6 of it, yes. 7 MR. PHILLIP CAMPBELL: If advice is just 8 given informally say, over the telephone or in a corridor 9 consultation, as it's come to be called, there's no record 10 created of that. 11 Is that right? 12 MS. MAXINE JOHNSON: That would be on an 13 individual pathologist because some would do it anyway 14 just to be able to track the materials coming in. 15 Even though you might put in the system "No 16 report required," you have -- you have a documentation 17 that, Yes, we did get the materials. Yes, no formal 18 report was required but yes, we have sent back the 19 materials that were sent in -- 20 MR. PHILLIP CAMPBELL: But suppose no 21 materials come in at all. 22 MS. MAXINE JOHNSON: Okay. 23 MR. PHILLIP CAMPBELL: That the question 24 is just put over the phone based on whatever the 25 pathologist in -- in another town has observed --

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1 MS. MAXINE JOHNSON: Right. 2 MR. PHILLIP CAMPBELL: -- and wants help 3 in interpreting. That doesn't lead to any documentary 4 trail within the hospital, is that right? 5 MS. MAXINE JOHNSON: Well, we wouldn't -- 6 the secretaries wouldn't be involved at all. So that 7 would just be a phone call that, you know, we certainly 8 wouldn't know what discussions would have taken place. 9 MR. PHILLIP CAMPBELL: And any record that 10 is created would depend on the pathologist taking an 11 initiative to do his or her own memo? 12 MS. MAXINE JOHNSON: Or to -- to do it 13 and give it to a secretary to get out, yes. 14 MR. PHILLIP CAMPBELL: All right. And you 15 were aware though that Dr. Smith was frequently consulted 16 in that -- in an advisory capacity? 17 MS. MAXINE JOHNSON: Yes. 18 MR. PHILLIP CAMPBELL: All right. And 19 last question. Were you aware of him being -- frequently 20 seeking out advice from others? 21 MS. MAXINE JOHNSON: I'm not sure what he 22 did. I mean, he didn't come and report that he was going 23 off to seek advice so we -- you know, I certainly couldn't 24 answer that for you. 25 MR. PHILLIP CAMPBELL: Okay. And were Dr.

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1 Smith's own reports reviewed by anyone else insofar as you 2 were aware? 3 MS. MAXINE JOHNSON: Not in -- in-house. 4 I -- I understood that the person above him at the Chief 5 Coroner's Office would have reviewed his reports. 6 MR. PHILLIP CAMPBELL: But they weren't 7 reviewed within the confines of HSC? 8 MS. MAXINE JOHNSON: Not with -- not in 9 terms of -- I know that they would discuss their cases at 10 rounds but as far as any other sort of revision, I 11 couldn't tell you. 12 COMMISSIONER STEPHEN GOUDGE: There was no 13 practice for the CF12 to be reviewed by another 14 pathologist before it was signed out to the OCCO? 15 MS. MAXINE JOHNSON: Not for Dr. Smith. 16 But the other pathologists had to give theirs to Dr. Smith 17 because he was the Director of the Unit. So the 18 pathologists would, you know, do their case. We'll give 19 it to Dr. Smith. He would review it, you know, make any 20 suggestions to those pathologists -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 MS. MAXINE JOHNSON: -- and -- but as far 23 as Dr. Smith -- 24 COMMISSIONER STEPHEN GOUDGE: So the 25 practice was it would not be signed out by the case

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1 pathologist until the CF12 had been reviewed by Dr. Smith? 2 MS. MAXINE JOHNSON: Most of the times, 3 yes. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 6 CONTINUED BY MR. PHILLIP CAMPBELL: 7 MR. PHILLIP CAMPBELL: And this really is 8 the last question. 9 Did you ever hear -- have you heard in your 10 time at Sick Kids -- and perhaps, I'll back date this to 11 before this Inquiry began -- have you heard the expression 12 "think dirty"? 13 MS. MAXINE JOHNSON: Not really. 14 MR. PHILLIP CAMPBELL: It's not something 15 that was in the air at the hospital? 16 MS. MAXINE JOHNSON: No. 17 MR. PHILLIP CAMPBELL: Okay. Thanks very 18 much. 19 MS. MAXINE JOHNSON: You're welcome. 20 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 21 Campbell. 22 I have a list of those that requested 23 cross-examination time and it does not have everybody on 24 it, so I will not call everybody. I just assume that 25 these are the only requests.

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1 Ms. Simpson, for AIDWYC...? 2 3 CROSS-EXAMINATION BY MS. VANORA SIMPSON: 4 MS. VANORA SIMPSON: Thank you, 5 Commissioner. 6 My name is Vanora Simpson, I'm one (1) of 7 the lawyers acting for the Association in Defence of the 8 Wrongly Convicted. I'd like to focus my questions for you 9 this morning -- and I'll be very brief -- on the materials 10 that you located in Dr. Smith's office, both with respect 11 to the Valin case and then the 2005 tissue audit. 12 And I'm going to ask some questions to try 13 and understand how that happened. 14 My understanding of your evidence this 15 morning was that when you were looking for materials in 16 the Valin case, you didn't go into a storage area or an 17 archive because this was a consultation case. They 18 wouldn't -- the materials wouldn't have gone there. 19 Is that right? 20 MS. MAXINE JOHNSON: Right. 21 MS. VANORA SIMPSON: What is in that 22 storage area or archive? 23 MS. MAXINE JOHNSON: We have our slides -- 24 because obviously we have -- we have cases from the '50s, 25 so we cannot -- it's impossible to keep all of those in

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1 the -- in the physical space, you know -- that's the 2 division, just because of space issues. So we have some 3 storage elsewhere in the hospital that we access. So you 4 know, you'll find our old blocks or old slides. 5 We try to keep -- for the slides, for 6 instance, we try to keep two (2) years worth, the -- the 7 most current two (2) years upstairs so it's -- because you 8 -- those are the ones that people access more easily, and 9 the others are taken down to our storage area; the same 10 with our paraffin blocks, as well. 11 MS. VANORA SIMPSON: If a pathologist 12 needs to remove a slide from either the upstairs storage 13 or the downstairs storage in his or her work at the 14 hospital, is that recorded in any way that they borrowed 15 something? 16 MS. MAXINE JOHNSON: We used to have a 17 green -- a green rec -- record book that we used to put -- 18 that people were required to sign in. So you would take 19 the key, you sign the key out for the storage area, and 20 you would insert just a little -- a little strip of paper 21 into the slot saying that, you know, I've taken ten (10) 22 slides on SO-7555, just to name a case, and then they -- 23 once -- once they've finished with it, it should go back 24 into that spot. 25 Now, not everyone did that. Our current

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1 system allows us to actually go in and set a retrieval 2 flag saying that we've removed these slides and who has 3 them, so that it allows for people to find things more 4 quickly if someone else needs it in the interim until they 5 get refiled in our storage system. 6 MS. VANORA SIMPSON: Who sets the 7 retrieval flag? 8 MS. MAXINE JOHNSON: Usually the 9 administrative staff for the pathologist who's -- because 10 we're the ones who usually gets it. Of course, in the 11 past, pathologists have gone and gotten their own slides 12 and their own blocks without the secretaries being aware 13 of it. 14 MS. VANORA SIMPSON: Is there any problem 15 or any pragmatic difficulty with making that a 16 requirement, that if you take something out, you've got to 17 sign it out, and when it comes back, you've got to sign it 18 back in? 19 MS. MAXINE JOHNSON: We have a policy that 20 says that that -- you know, that that's what we're 21 supposed to be doing. Now, having said that, I've 22 discovered that human nature is such that people don't 23 always follow the rules, so it's a little frustrating for 24 me, personally, because if somebody can't find something, 25 they're usually in my space asking me to go and search for

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1 it, and that's not something that I enjoy doing because I 2 have other things to do. 3 So if -- if we all follow the rules, of 4 course, you know, things would be great because, you know, 5 the secretary of the pathologist isn't -- doesn't want to 6 do it, they'll bring it to the secretary and says, I've 7 pulled these slides out, can you set the flag for me? 8 You set it and you say, okay, when you're 9 finished with them can you bring them back to me, and you 10 set the retrieval flag as you're going off to re-file 11 them, is usually my personal practice. So if I'm not 12 going to file them until five o'clock this afternoon, I'm 13 not going to set the retrieval flag, but the slides have 14 been re-filed because they're still sitting my personal 15 space. 16 MS. VANORA SIMPSON: Can you think of any 17 ways to improve the system? 18 MS. MAXINE JOHNSON: Well, you know, what 19 we would really -- what I would really like to see if for 20 us to have a secured room that has barcode and only 21 specific individuals -- our badges are barcoded, so, you 22 know, if it's only ten (10) people who can have access to 23 that room, those are the only ten (10) people who can 24 access it. 25 Now, is that realistic? I don't know. But

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1 that would be good, it sounds like it. 2 MS. VANORA SIMPSON: I'd like to talk now 3 about the "B" cases, the -- the consultations, like 4 Valin's case. And this is when a pathologist is reviewing 5 sample -- samples or slides that are coming in to the 6 Hospital for Sick Kids. 7 MS. MAXINE JOHNSON: Right. 8 MS. VANORA SIMPSON: And I understand part 9 of the reason is that you rely on the pathologist to bring 10 the case to your attention, the fact it exists -- 11 MS. MAXINE JOHNSON: Right. 12 MS. VANORA SIMPSON: -- to be accessioned. 13 And when you did that 2005 tissue audit, you found 14 materials in there for cases that you had never heard 15 about and that hadn't been accessioned. 16 MS. MAXINE JOHNSON: Yes. 17 MS. VANORA SIMPSON: Is the system the 18 same now? 19 MS. MAXINE JOHNSON: No. 20 MS. VANORA SIMPSON: How is it -- 21 MS. MAXINE JOHNSON: And let me back up a 22 minute. It's not that there wasn't a system in place. 23 Individuals, you know, have to use that system. So you 24 can have ten (10) pathologists and nine (9) will do 25 exactly what you need to do: you get a case in, you bring

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1 it out, it gets accessioned, you, you know, put the slides 2 in a folder, attach the blocks, you know, in the zip lock 3 bag to that folder so everything is together, put an 4 elastic band around it with the paperwork, and you hand it 5 back to that pathologist. 6 Now, if someone chooses not to do that, I'm 7 not sure what an administrative person, like in my 8 capacity, can -- you know, can do. 9 MS. VANORA SIMPSON: Can you think of any 10 ways to improve the system so things slipping between the 11 cracks, like they did in 2005 and in Valin's case, doesn't 12 happen again? 13 MS. MAXINE JOHNSON: Well, I don't think 14 that there were many things slipping through the crack in 15 2005. We did find a lot of things, but they were old. So 16 let me just, you know, correct that. 17 MS. VANORA SIMPSON: Right. 18 MS. MAXINE JOHNSON: But what would be 19 really good is if the cases came in, the administrative 20 staff were, you know, authorized to open those packages 21 that showed up, and we see what it is. 22 Because ultimately you sort of elevate some 23 of these type of things where people are saying, you know, 24 It's a secretary who didn't. If we were able to do that, 25 then we have a better sense of what is coming in. We have

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1 accession it, and if someone calls, we know that we've 2 seen that, because we had to go in and accession it. Of 3 course, each time you accession a case, because you're 4 handling it, it's kind of stuck in your head. 5 So if somebody calls about it, it's in 6 here, you don't have to question whether or not it 7 actually showed up, because you had the responsibility of 8 accessioning that case coming into the department. 9 MS. VANORA SIMPSON: And there'd be no 10 difficulty in you creating a record of all the samples or 11 slides that come in, and when they go out again? 12 MS. MAXINE JOHNSON: No. 13 MS. VANORA SIMPSON: Thank you. 14 MS. MAXINE JOHNSON: You're welcome. 15 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 16 Simpson. Just one (1) thing I'm not quite clear on, Ms. 17 Johnson, with Valin's Case. 18 When you found the slides, you knew they 19 were the slides -- this is six (6) months later -- for 20 Valin's Case, because you knew the number? 21 MS. MAXINE JOHNSON: Yes. 22 COMMISSIONER STEPHEN GOUDGE: So I take it 23 that case at least, must have been brought to the 24 administrative assistant's attention when it came in as a 25 consultation?

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1 MS. MAXINE JOHNSON: Not necessarily, 2 because it could have -- 3 COMMISSIONER STEPHEN GOUDGE: How else 4 does it get a number? 5 MS. MAXINE JOHNSON: -- it -- it could 6 have been accessioned later on. The pathologist's 7 assistants also accession it. But again, I got back to 8 saying that Dr. Smith was also very computer savvy, so 9 there would be no -- he could accession that case. He had 10 the ability to do that himself. So -- 11 COMMISSIONER STEPHEN GOUDGE: And when you 12 say accession it, does that mean give it a -- 13 MS. MAXINE JOHNSON: Giving it a number. 14 COMMISSIONER STEPHEN GOUDGE: -- number 15 and do the filing according to -- 16 MS. MAXINE JOHNSON: Well, you wouldn't 17 file it, but you would give it a number. 18 COMMISSIONER STEPHEN GOUDGE: Yes. 19 MS. MAXINE JOHNSON: But, as I said, -- 20 COMMISSIONER STEPHEN GOUDGE: Do the 21 consultation cases have a different numbering system in 22 the hospital records then a case where the autopsy is done 23 at Sick Kids? 24 MS. MAXINE JOHNSON: In -- like prior to 25 our current system --

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1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 MS. MAXINE JOHNSON: -- we would call them 3 a "B" case. But it wasn't just, you know, it could be a - 4 - like, you know a cytology sample, an -- an immuno blood 5 sample. It didn't always have to be an autopsy that got a 6 "B" case. Anything -- "B" number -- anything that was 7 coming in that was not tissue. For instance, an entire 8 autopsy or you know, an appendix or placenta -- 9 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 10 MS. MAXINE JOHNSON: -- from, you know, 11 Mount Sinai, for instance. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 MS. MAXINE JOHNSON: You would accession 14 that -- you would give that a "B" number because it's 15 coming in. It wasn't the -- the biopsy or the autopsy was 16 not physically performed at Sick Kids. 17 COMMISSIONER STEPHEN GOUDGE: Okay. And 18 with samples or entire organs, does the hospital take 19 responsibility for storing them, or does that remain -- 20 MS. MAXINE JOHNSON: Well we -- 21 COMMISSIONER STEPHEN GOUDGE: -- with the 22 consulting pathologist? 23 MS. MAXINE JOHNSON: We -- storage is 24 always an issue for us. So, for instance, if a heart 25 comes in for a pathologist to look at --

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 MS. MAXINE JOHNSON: -- we usually send 3 back the heart that -- you know, what's left after we've 4 sampled it. So our -- our practice is not always to keep 5 other peoples stuff. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 MS. MAXINE JOHNSON: We want to get it 8 back to them so they can store it. We would certainly get 9 their blocks, you know, back to them, because that's -- 10 that's definitely their -- their permanent record of -- 11 COMMISSIONER STEPHEN GOUDGE: They need it 12 for their permanent records? 13 MS. MAXINE JOHNSON: Yes. 14 COMMISSIONER STEPHEN GOUDGE: Okay. 15 Thanks, Ms. Johnson. 16 MS. MAXINE JOHNSON: You're welcome, Mr. 17 Commissioner. 18 COMMISSIONER STEPHEN GOUDGE: Ms. 19 Ritacca...? 20 21 CROSS-EXAMINATION BY MS. LUISA RITACCA: 22 MS. LUISA RITACCA: Thank you, 23 Commissioner. Good morning, Ms. Johnson. My name is 24 Luisa Ritacca. I'm one (1) of the lawyers for the Office 25 of the Chief Coroner. I have just two (2) questions for

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1 you. 2 In answer to a question that Mr. Centa put 3 to you this morning, you indicated that at some point you 4 heard floating around, that the Office of the Chief 5 Coroner had raised concerns about Dr. Smith getting more 6 administrative support. 7 Do you remember answering that question 8 that way? 9 MS. MAXINE JOHNSON: Yes, I remember 10 answering. 11 MS. LUISA RITACCA: Could you help me 12 understand from whom you heard that information? 13 MS. MAXINE JOHNSON: I really can't tell 14 you specifically. I -- you just sort of hear rumblings in 15 the hallway, or just, you know, in passing. You know, 16 you'd hear, Oh, Dr. Smith went and told the Coroner's 17 Office that he didn't have any secretaries. 18 And, you know, that's how you hear about -- 19 we -- I heard about it. 20 MS. LUISA RITACCA: And would you have 21 heard about it from Dr. Becker? 22 MS. MAXINE JOHNSON: No, not necessarily. 23 MS. LUISA RITACCA: Dr. Phillips? 24 MS. MAXINE JOHNSON: Not necessarily. 25 MS. LUISA RITACCA: Did Dr. Smith tell you

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1 about it? 2 MS. MAXINE JOHNSON: Nope. 3 MS. LUISA RITACCA: Did you hear about it 4 from anybody at the Office of the Chief Coroner? 5 MS. MAXINE JOHNSON: Nope. 6 MS. LUISA RITACCA: It was just something 7 that was -- 8 MS. MAXINE JOHNSON: Yeah -- 9 MS. LUISA RITACCA: -- office gossip, is 10 that -- 11 MS. MAXINE JOHNSON: -- it wasn't -- it 12 wasn't -- and it wasn't so much gossip. It was -- you -- 13 you hear the blame game, and it's all what -- you know, 14 you hear, Oh, you know, apparently Dr. Smith went to the 15 Coroner's Office, and said that he didn't enough 16 secretaries or he didn't have any secretarial support. 17 And, you know, we would -- as -- as an 18 administrative group -- would be hurt because we knew that 19 that wasn't true. Let me -- and at that time, there were 20 -- in 1989, for instance, he's -- he had his own 21 secretary, until 1994, that was exclusively his. 22 And as well as all the other pathologists; 23 they had access to the other five (5) senior secretaries 24 that were in the div -- division at that point, as well. 25 MS. LUISA RITACCA: And did you ever have

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1 occasion to speak to anybody at the Coroner's Office about 2 how the secretaries at the -- at Sick Kids were feeling 3 about Dr. Smith's accusation that he didn't have enough 4 secretarial support? 5 MS. MAXINE JOHNSON: Well, I think later 6 on, much later on, once I got -- once Dorothy started 7 working there and I -- I -- you know, doing the job she -- 8 she was doing, and we got to talking, I'm sure that I 9 would have, you know, said to her, You know this just -- 10 MS. LUISA RITACCA: And so that would have 11 been after -- 12 COMMISSIONER STEPHEN GOUDGE: Sorry, you 13 would have said to her what? 14 MS. MAXINE JOHNSON: You know, this just 15 bites because it's not true. So -- 16 COMMISSIONER STEPHEN GOUDGE: How did that 17 square with the nice-guy sense you had of Dr. Smith? 18 MS. MAXINE JOHNSON: He is a nice guy. 19 No, he is -- you know, to answer your question, 20 Commissioner, Dr. Smith is very personable. It's very 21 hard to dislike Dr. Smith because he is -- you know, he 22 makes you feel at easy -- he's very inclusive when he's 23 having discussions, but, you know, the -- the downside to 24 that is -- is, you know, why would he say that he didn't 25 have enough secretarial support when he knew that that

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1 really wasn't true. 2 3 CONTINUED BY MS. LUISA RITACCA: 4 MS. LUISA RITACCA: And just to be clear, 5 Ms. Zwolakowski started working in the summer of 2002. So 6 this conversation that you think you may have had with her 7 would be after that point? 8 MS. MAXINE JOHNSON: It would -- yeah, if 9 I had with Dorothy because, you know, prior to that I 10 didn't really have, sort of, as much of a close tie with - 11 - with folks over at the Coroner's Office. You dealt with 12 them and -- and, you know, that was it. 13 MS. LUISA RITACCA: Fair enough. And I 14 think I got this right; it's Tab 6 of your documents, 15 PFP008486. This should be the form 12, right, in the 16 Joshua case, is that -- 17 MS. MAXINE JOHNSON: Yes. 18 MS. LUISA RITACCA: -- is that right, Ms. 19 Johnson? I just had a -- I -- now, if I understood your 20 evidence, you don't believe that you are one (1) of the 21 secretaries that typed this up, is that correct? 22 MS. MAXINE JOHNSON: I'm sure that one (1) 23 of us didn't. 24 MS. LUISA RITACCA: Right. But I have a 25 more general question about the form, so I think this can

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1 just assist us as an example. And my question is, were 2 you able, on the computer, to put in as much information 3 as necessary under each of the subheadings, as it were, on 4 the form? 5 MS. MAXINE JOHNSON: Oh, yeah. We -- I 6 mean, because some pathologists were more succinct; some 7 pathologists went on for a long time with their reports. 8 So putting in the -- the required information was not a 9 problem, at all. 10 MS. LUISA RITACCA: So the template didn't 11 limit how much room you had to -- 12 MS. MAXINE JOHNSON: No. 13 MS. LUISA RITACCA: Okay. And my last 14 question to you is -- and -- and I think you -- you may 15 have touched upon this in answer to a question earlier. 16 We've heard that there's a more -- I think it's fair to 17 say -- a more thorough review process in place now as a 18 result of changes made by both Dr. Chiasson and Dr. 19 Pollanen at the OCCO. 20 Does -- does that affect the timing of the 21 release of the reports at all from your perspective, 22 anyway? 23 MS. MAXINE JOHNSON: What do you mean by 24 release? 25 MS. LUISA RITACCA: Or the signing out of

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1 the reports, I guess is the...? 2 MS. MAXINE JOHNSON: If Dr. Chiasson is 3 not around, he has -- you know, Dr. Taylor, as a division 4 head, is designated to act on his behalf in terms of those 5 reports. 6 MS. LUISA RITACCA: So you're not able, 7 from your perspective, to see whether or not that really 8 makes a difference in term of how quickly the report gets 9 signed out? 10 MS. MAXINE JOHNSON: Our reports certainly 11 get signed out more quickly if pathologists, you know, get 12 an opportunity to do that. Obviously, currently, you 13 know, things are a little bit more -- a little slower 14 'cause we lost Dr. Smith and that position was never 15 replaced. 16 And there's been extenuating circumstances 17 like the Goudge Commission that sometimes takes away from 18 other people -- you know, from the time that people would 19 normally use to -- to prepare those reports, Mr. 20 Commissioner. 21 COMMISSIONER STEPHEN GOUDGE: I apologize, 22 Ms. Johnson. 23 MS. MAXINE JOHNSON: No, that's okay. 24 MS. LUISA RITACCA: Thank you, Ms. 25 Johnson. Those are my questions.

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1 COMMISSIONER STEPHEN GOUDGE: And, Ms. 2 Johnson, does -- in the current practice, does anybody at 3 the hospital review Dr. Chiasson's CF 12s before they're 4 signed out? 5 MS. MAXINE JOHNSON: Sometimes he will 6 give them to Dr. Taylor. I know that he sometimes take 7 them over -- he'll take them over to Dr. Pollanen as well. 8 COMMISSIONER STEPHEN GOUDGE: Thanks. 9 Then lastly, Mr. Carter...? 10 11 CROSS-EXAMINATION BY MR. WILLIAM CARTER: 12 MR. WILLIAM CARTER: I just want to go 13 over two (2) or three (3) points that came up in your 14 evidence, Ms. Johnson. 15 You talked about circumstances where the 16 workload of the secretarial assistance, including 17 yourself, was sometimes heavier than others; however, you 18 would generally give priority to those matters that were 19 clinical in nature and had patient impact. 20 Do you recall talking about that? 21 MS. MAXINE JOHNSON: Yes. 22 MR. WILLIAM CARTER: And in the context of 23 providing assistance to the pathologists, I take it that 24 you would take your cue, if you like, from the 25 pathologists as to what work had higher priority than

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1 other work? 2 MS. MAXINE JOHNSON: Of course. 3 Definitely. 4 MR. WILLIAM CARTER: And so the priority 5 that you and your colleagues gave to the work that you 6 were doing, you would derive from the pathologists who 7 were directing the work? 8 MS. MAXINE JOHNSON: Yes. 9 MR. WILLIAM CARTER: Okay. And at the 10 risk of not making this any more clear, I would like to 11 talk a little bit more about the management of autopsy 12 reports within the hospital. 13 As I understand it, there are several 14 different types of post-mortem examinations and reports 15 that get generated in the Division of Pathology. 16 First of all, there are the post-mortem 17 examinations that take place on the children who actually 18 die in the hospital -- who have been patients, and who are 19 not coroner's cases but whose parents -- are substitute 20 decision-makers -- provide authorization for post-mortem 21 examinations. 22 Is that right? 23 MS. MAXINE JOHNSON: Yes, it is. 24 MR. WILLIAM CARTER: And in those cases, 25 the post-mortem reports, I take it, go on to the hospital

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1 record of the patient and are kept in the hospital records 2 department with the other clinical records for the 3 patient? 4 MS. MAXINE JOHNSON: Yes. 5 MR. WILLIAM CARTER: Okay. So we're not 6 going to concern ourselves with those. I just want to 7 identify that there's that type of report that gets kept 8 in the hospital medical records. 9 MS. MAXINE JOHNSON: Correct. 10 MR. WILLIAM CARTER: Then there are the 11 reports that you've referred to as the "MLs", the 12 medicolegal reports, and those are coroner's autopsies, 13 are they not? 14 MS. MAXINE JOHNSON: Yes, they are. 15 MR. WILLIAM CARTER: And those reports get 16 generated in the manner you've described. They are -- 17 they result, ultimately, in a CF12 and those reports may 18 or may not be related to patients who died in the 19 hospital? 20 MS. MAXINE JOHNSON: Correct. 21 MR. WILLIAM CARTER: And if they relate to 22 patients who died in the hospital, the CF12 only goes on 23 the patient's clinical record in the Medical Records 24 Department with the consent of the coroner? 25 MS. MAXINE JOHNSON: Yes.

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1 MR. WILLIAM CARTER: And, of course, for 2 those patients who were not patients in the hospital and 3 do not have a clinical record, there's no clinic -- 4 there's no need to ask the coroner for them to be part of 5 the hospital record, is there? 6 MS. MAXINE JOHNSON: No, there isn't. 7 MR. WILLIAM CARTER: Okay. And as I 8 understand it, for all three (3) types of autopsies, the 9 Division of Pathology keeps a record for its archives or 10 annals. 11 Is that fair? 12 MS. MAXINE JOHNSON: Yes, it is. 13 MR. WILLIAM CARTER: But this -- these are 14 to be distinguished from the clinical records in the 15 medical record system of the hospital? 16 MS. MAXINE JOHNSON: Correct. 17 MR. WILLIAM CARTER: These are kept in a 18 locked room at the hospital and they go back to 1919, do 19 they not? 20 MS. MAXINE JOHNSON: Yes, they do. 21 MR. WILLIAM CARTER: Thank you. And 22 there's literally thousands of -- hundreds of volumes and 23 thousands of cases reported in there? 24 MS. MAXINE JOHNSON: Yes. 25 MR. WILLIAM CARTER: Okay. And I just,

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1 finally, would like to touch upon the management of cases 2 which we've referred to as "consulting cases" where the 3 pathologist is directed, personally, by others outside of 4 the hospital seeking assistance in respect of whatever 5 pathological advice is required. 6 As I understand it, the way contacts are 7 made to the pathologists in your division, it typically 8 goes directly to the pathologist either by phone or 9 written correspondence. 10 MS. MAXINE JOHNSON: Yes. 11 MR. WILLIAM CARTER: And you and your 12 colleagues are -- are not the gatekeepers; the -- it's the 13 pathologist themself who's the gatekeeper to the system. 14 MS. MAXINE JOHNSON: Yeah. 15 MR. WILLIAM CARTER: Is that fair? 16 MS. MAXINE JOHNSON: Yes. 17 MR. WILLIAM CARTER: And it always has 18 been, in your experience, the policy of the hospital that 19 cases that come in from the outside for pathological 20 consultation should, in fact, be accessioned by the 21 pathologist, is that fair? 22 MS. MAXINE JOHNSON: Yes. 23 MR. WILLIAM CARTER: But unfortunately, 24 it's been left in the hands of the pathologist, as opposed 25 to some other gatekeeper.

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1 MS. MAXINE JOHNSON: Yes. 2 MR. WILLIAM CARTER: Okay. And I 3 understand your answers to the Commissioner to relate to 4 how that -- that might change and that, you know, if -- if 5 there was appropriate method of affording you and your 6 colleagues the opportunity to be the ones who opened this 7 kind of correspondence, you might take the initiative to 8 do the accession -- 9 MS. MAXINE JOHNSON: Of course. 10 MR. WILLIAM CARTER: -- in this case. Of 11 course, there's also -- it is and -- and has been and 12 remains the -- the policy of the division that the 13 pathologists themselves are to exercise that 14 responsibility as gatekeepers. 15 MS. MAXINE JOHNSON: Yes, they should. 16 MR. WILLIAM CARTER: And of -- so, whether 17 it's you, or your colleagues, or the pathologists 18 themselves, it's really -- that responsibility rests with 19 people whose willingness to discharge it may be variable, 20 and in the case, I guess, of some pathologists, there may 21 not be perfect compliance with already existing rules. 22 MS. MAXINE JOHNSON: Right. 23 MR. WILLIAM CARTER: Okay. Now, was this 24 ever a matter of any discussion between you and Dr. Smith? 25 I'm -- I'm referring now to the accessioning of external

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1 consulting cases? 2 MS. MAXINE JOHNSON: Yes, I've -- I've 3 talked with Dr. Smith, only because with the amount of 4 telephone calls of people calling and not -- myself not 5 being aware -- and I can speak for myself when I get those 6 telephone calls -- not being aware that something had, in 7 fact, come in, you were left at a loss. 8 So I would say to Charles, You know, let me 9 open those packages for you when they come in so that, you 10 know, we can accession them so we know that they exist, so 11 that if he doesn't, in fact, get to it, somebody else 12 might take on that responsibility of looking at that case 13 for the person sending it in. 14 MR. WILLIAM CARTER: Okay. And what was 15 his reaction to that? 16 MS. MAXINE JOHNSON: Carry on as we 17 should. 18 MR. WILLIAM CARTER: Okay. Now, just 19 finally, Ms. Simpson raised the -- the question briefly of 20 the 2005 tissue audit. Can you just tell us, in a few 21 words, what that was about from your perspective? 22 MS. MAXINE JOHNSON: I know that there 23 were concerns that, you know, coming into the Office of 24 the Chief Coroner about just the findings of Dr. Smith, 25 and I -- and I think that that was the trigger for the

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1 audit, so -- so then I had to, along with Dorothy and Don, 2 start to try to find the -- the materials for the cases. 3 The -- the Coroner's Office sent us the 4 list of cases. 5 MR. WILLIAM CARTER: A list of cases for - 6 - for materials that -- that could not be obtained? 7 MS. MAXINE JOHNSON: No, materials that 8 they needed to review for the audit. 9 MR. WILLIAM CARTER: I see, okay. 10 MS. MAXINE JOHNSON: So, the -- it started 11 with that list, and then we would just look for the 12 materials to be sent over. 13 MR. WILLIAM CARTER: And where was it that 14 you were looking for these materials; where in the 15 hospital? 16 MS. MAXINE JOHNSON: Most of the -- most 17 of the cases on the list were autopsies that were 18 performed at -- at Sick Kids -- 19 MR. WILLIAM CARTER: Yes. 20 MS. MAXINE JOHNSON: -- so finding those 21 slides was fairly easy because they would be in our 22 archival files and our blocks were -- were also in that -- 23 in that area. 24 MR. WILLIAM CARTER: Okay. 25 MS. MAXINE JOHNSON: Now, the cases that

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1 were on that list that had been specifically referred to 2 Dr. Smith as a consult were definitely a little bit more 3 challenging to try and locate. 4 MR. WILLIAM CARTER: Well, for the cases 5 that were on the list that had been referred as coroner's 6 cases, the doc -- the materials had been properly 7 accessioned, I take it. 8 MS. MAXINE JOHNSON: They had been 9 properly accessioned because, of course, I mean they were 10 all older cases. 11 MR. WILLIAM CARTER: Yeah, and you were 12 able to find all of that material then. 13 MS. MAXINE JOHNSON: Pretty much. 14 MR. WILLIAM CARTER: Yeah. And now for 15 the material that had come in as external consults for Dr. 16 Smith, which may or may not have been -- I guess it hadn't 17 been accessioned, for the most part, how did you make out 18 with locating those materials? 19 MS. MAXINE JOHNSON: When Dr. Smith left, 20 he had a lot of stuff inside of his room, a lot -- you 21 know. So we had to move because we were -- the Cath lab 22 was doing some work so we had to move out of our space. 23 And eventually, Dorothy and an OPP officer came over and 24 actually went through Dr. -- what was Dr. Smith's office 25 to try to locate. And at that time, you know, they did --

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1 they did document what was actually in there and take the 2 materials that they needed. 3 MR. WILLIAM CARTER: And do you have any 4 understanding as to whether or not they were able to find 5 what they were looking for? 6 MS. MAXINE JOHNSON: I think mostly they - 7 - they did. 8 MR. WILLIAM CARTER: Okay. 9 COMMISSIONER STEPHEN GOUDGE: Did you help 10 with that? 11 MS. MAXINE JOHNSON: I -- I helped, in 12 terms of, you know, they would find the stuff, I would 13 type it up. Because we had created these sheets -- these 14 forms for each one (1) of the cases so we would -- we had 15 a section for the amount of slides to include routine 16 slides and the neuropath slides. We had a section for 17 Kodachromes, which were just the little -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 MS. MAXINE JOHNSON: -- photos. And if 20 they want -- and we had a section for blocks. 21 So we would pull the material; we'll flag 22 it in our system saying that we pulled it, but we also, 23 you know, added it on to the -- for this list for each of 24 these patients to say what it is that we pulled and what 25 was going out.

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1 MR. WILLIAM CARTER: Thank you. Those are 2 my questions. 3 COMMISSIONER STEPHEN GOUDGE: Was the 4 tissue audit exclusively Dr. Smith's cases? 5 MS. MAXINE JOHNSON: No, it wasn't. There 6 were a few cases from the other pathologists as well. 7 COMMISSIONER STEPHEN GOUDGE: Okay. 8 Thanks. Thanks, Mr. Carter. Mr. Centa...? 9 10 RE-DIRECT EXAMINATION BY MR. ROBERT CENTA: 11 MR. ROBERT CENTA: Just a few questions 12 arising. 13 First, with respect to the tissue audit. 14 If we could look at PFP033962, and these won't be in your 15 binder because -- yeah, his is the backgrounder released 16 by the Office of the Chief Coroner commenting on the 17 results of the tissue audit. And this document sets out 18 that the -- the audit was of seventy (70) cases from the 19 Hospital for Sick Children. 20 Does that seem about right to you? 21 MS. MAXINE JOHNSON: Yeah. 22 MR. ROBERT CENTA: And the paragraph -- 23 COMMISSIONER STEPHEN GOUDGE: Sorry. Did 24 you say "yes" to that? 25 MS. MAXINE JOHNSON: Yes.

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1 COMMISSIONER STEPHEN GOUDGE: Thanks. 2 3 4 CONTINUED BY MR. ROBERT CENTA: 5 MR. ROBERT CENTA: And the paragraph three 6 (3) from the bottom of the screen says that Dr. Smith was 7 the pathologist involved in forty (40) of the seventy (70) 8 cases audited. So he was involved in forty (40) and other 9 pathologists were involved in the -- the balance of the 10 thirty (30)? 11 MS. MAXINE JOHNSON: Yes. 12 MR. ROBERT CENTA: And just at the bottom 13 of the screen, I'll read from that: 14 "As a result of this audit, tissue 15 blocks arising..." 16 No, I'm sorry, up one (1) paragraph: 17 "Slides and tissue blocks arising from 18 the autopsy can be accounted for in all 19 seventy (70) cases reviewed. In a few 20 cases, a small number of microscopic 21 slides cannot be found but in all of 22 these cases, tissue blocks have been 23 identified which will allow new slides 24 to be prepared if required in the 25 future."

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1 And that accords with your recollection of 2 the results of the tissue audit? 3 MS. MAXINE JOHNSON: Yes. 4 MR. ROBERT CENTA: Arising out of some 5 questions that Ms. Simpson and I think, the Commissioner, 6 may have had for you relating to you finding the slides in 7 the Valin case. 8 And the question arose out of you finding 9 the second set of slides in May 2005, and you said that 10 you recalled the case number. And then that led us off 11 into a discussion of how that matter was -- was 12 accessioned, correct? 13 MS. MAXINE JOHNSON: Right. 14 MR. ROBERT CENTA: Okay. Can we look at 15 PFP036077? And this is the report of post-mortem 16 examination on Valin's case prepared in Sault Ste. Marie 17 by Dr. Rasaiah. And if you see just at the top, below the 18 -- beside the line that says "Form 14". It says "A-93- 19 51." 20 MS. MAXINE JOHNSON: Right. 21 MR. ROBERT CENTA: And that would be the 22 case file number from Sault Ste. Marie -- 23 MS. MAXINE JOHNSON: Yes. 24 MR. ROBERT CENTA: -- correct? Okay. 25 If you could now call up PFP116670. This

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1 is Dr. Pollanen's report that he prepared in January 2005, 2 having looked at the first set of slides that you located. 3 And if you could go to page 4 of that 4 document. Dr. Pollanen has helpfully catalogued the 5 slides that he reviewed and the slides that you found. 6 You'll see that they're labelled "A-93-51." And that's 7 the same file number that we see on Dr. Rasaiah's report 8 of post-mortem examination. 9 MS. MAXINE JOHNSON: Right. 10 MR. ROBERT CENTA: And is it possible that 11 that's the file number that you were remembering when you 12 found the slides six (6) months later; that it wasn't a 13 "B" accession number from the Hospital for Sick Children, 14 it was in fact an "A" file that had been created at Sault 15 Ste. Marie? 16 MS. MAXINE JOHNSON: Yes, that's exactly 17 the number that I remembered. 18 MR. ROBERT CENTA: And that would mean 19 that the -- would mean that the file -- the Valin's case 20 was not accessioned by Dr. Smith at the Hospital for Sick 21 Children? 22 MS. MAXINE JOHNSON: That's what I would 23 assume from that. 24 MR. ROBERT CENTA: Okay. And if we can 25 just -- to close this off, if we could look at PFP116853

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1 at page -- and this is Dr. Pollanen's supplementary 2 report and opinion on the death of Valin. And if you 3 could go to page 3 of that document. 4 This is the set of slides that you -- that 5 were found by you in May of 2005 and, again, they're 6 labelled "A-93-51" -- 7 MS. MAXINE JOHNSON: Right. 8 MR. ROBERT CENTA: -- right? And that's 9 the -- the file number that was created in Sault Ste. 10 Marie? 11 MS. MAXINE JOHNSON: Right. 12 MR. ROBERT CENTA: Okay. Finally, a 13 question arising out of Mr. Campbell's examination; you 14 told him that you found the slides in November, on 15 November 29th, 2004, in a spot of Dr. Smith's office where 16 you had already searched on November the 26th, the Friday 17 before? 18 MS. MAXINE JOHNSON: Yes. 19 MR. ROBERT CENTA: And that that surprised 20 you because you knew you had looked there before? 21 MS. MAXINE JOHNSON: Yes. 22 MR. ROBERT CENTA: Did you ever discuss 23 that observation with Dr. Smith? 24 MS. MAXINE JOHNSON: I don't remember. I 25 might have. I might have mentioned to him but I can't

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1 really recall fully. But if he was there, I would have -- 2 you know, I would have said, Do you know, I found these 3 slides up here. 4 MR. ROBERT CENTA: Do you have an 5 independent recollection of anything he said back to you? 6 MS. MAXINE JOHNSON: No. 7 MR. ROBERT CENTA: Okay. Those are my 8 questions, Commissioner. 9 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 10 Centa. 11 Well, Ms. Johnson, thank you very much. 12 You have been -- 13 MS. MAXINE JOHNSON: Thank you. 14 COMMISSIONER STEPHEN GOUDGE: -- very 15 helpful. You provided us with a very good picture of the 16 administrative side of the Department. So thank you for 17 coming. 18 MS. MAXINE JOHNSON: Thank you. 19 20 (WITNESS STANDS DOWN) 21 22 COMMISSIONER STEPHEN GOUDGE: Now, Mr. 23 Centa, what do you suggest? 24 MR. ROBERT CENTA: Commissioner, I propose 25 that we adjourn now and take -- and come back at the

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1 normal time, at two o'clock where -- 2 COMMISSIONER STEPHEN GOUDGE: Very well. 3 MR. ROBERT CENTA: -- we'll start with Dr. 4 Perrin. 5 COMMISSIONER STEPHEN GOUDGE: We will rise 6 then until two o'clock. 7 8 --- Upon recessing at 12:20 p.m. 9 --- Upon resuming at 2:01 p.m. 10 11 THE REGISTRAR: All rise. Please be 12 seated. 13 COMMISSIONER STEPHEN GOUDGE: Mr. 14 Centa...? 15 MR. ROBERT CENTA: Commissioner, this 16 afternoon we will be hearing from Dr. Donald Perrin from 17 the Hospital for Sick Children. His evidence will be 18 completed this afternoon and I hope to complete my 19 examination in forty (40) minutes. 20 21 DONALD PERRIN, Sworn 22 23 EXAMINATION-IN-CHIEF BY MR. ROBERT CENTA: 24 MR. ROBERT CENTA: Good afternoon, Dr. 25 Perrin. You should have a binder of documents before you.

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1 And if you could turn up Tab 1, please, that is PFP149418. 2 This is a copy of your curriculum vitae? 3 DR. DONALD PERRIN: Correct. 4 MR. ROBERT CENTA: And this was completed, 5 or updated in September 2007. 6 DR. DONALD PERRIN: Correct. 7 MR. ROBERT CENTA: I'd just like to start 8 with your academic background. 9 You completed three (3) degrees at the 10 University of Waterloo? 11 DR. DONALD PERRIN: Correct. 12 MR. ROBERT CENTA: A BSc in 1974 in 13 biology? 14 DR. DONALD PERRIN: Correct. 15 MR. ROBERT CENTA: A Masters of Science 16 degree in 1976 in physiology? 17 DR. DONALD PERRIN: Correct. 18 MR. ROBERT CENTA: And you completed your 19 PhD in 1979. 20 DR. DONALD PERRIN: Correct. 21 MR. ROBERT CENTA: And what was your PhD - 22 - did you do a PhD thesis? 23 DR. DONALD PERRIN: Yes. 24 MR. ROBERT CENTA: And what was that -- 25 what was the subject of that?

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1 DR. DONALD PERRIN: That was in 1979. I 2 think it was somewhere titled "Proestrogen Effects on the 3 Reproductive Cycle in Rhesus Monkeys." 4 MR. ROBERT CENTA: And after you completed 5 your PhD, under the -- employment in 1980, you commenced 6 employment at the Hospital for Sick Children. 7 DR. DONALD PERRIN: Correct. 8 MR. ROBERT CENTA: And what was the first 9 position you held at Sick Kids? 10 DR. DONALD PERRIN: Pathology Assistant. 11 MR. ROBERT CENTA: And how did you decide 12 -- or what made you want to become a pathology assistant? 13 DR. DONALD PERRIN: Well, there was an 14 interesting advertisement submitted from Sick Kids by Dr. 15 Kent Mancer that described things that I were interested 16 in. And it -- I didn't want to do a post- doctorate, and 17 this offered me at least a year of deciding what to do. 18 And twenty-seven (27) years later, I'm 19 still interested. 20 MR. ROBERT CENTA: And what aspects of the 21 posting attracted you? 22 DR. DONALD PERRIN: A lot of dissection. 23 There was also -- at that time, there was a part research 24 position, so that I could continued my research interested 25 -- without worrying too much about granting, which is a

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1 huge problem. And I could do research with the 2 pathologists in the department, clinical research and 3 basic science research part-time. 4 And there just -- it was a very well worded 5 advertisement, and I really wasn't wor -- for patha -- 6 pathologist assistants, at that time. It was a position 7 in States, but not in Canada. 8 MR. ROBERT CENTA: And when you started at 9 Sick Kids in 1980, how many pathology assistants were 10 there at that time? 11 DR. DONALD PERRIN: None. 12 MR. ROBERT CENTA: You were the first? 13 DR. DONALD PERRIN: Correct. 14 MR. ROBERT CENTA: And when you started 15 the position did it inbol -- involve both surgical 16 pathology and autopsy work? 17 DR. DONALD PERRIN: Correct. 18 MR. ROBERT CENTA: And just before we turn 19 to -- to the distinction a little bit between pathology 20 assistants and pathologist's assistant, if I could ask -- 21 one (1) of the binders you have in front of you is marked 22 the Sick Kids Institutional Report. 23 And that is PFP301353 -- I'm sorry, before 24 -- before we go there can we stay in your -- in the 25 original binder we were in -- I'm sorry -- and turn up Tab

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1 7, PFP177706. And this a document entitled, "A Five Year 2 Plan for the Department of Pathology." 3 DR. DONALD PERRIN: Okay. 4 MR. ROBERT CENTA: You're in the right 5 document. If you turn to page 5 in the -- if you look at 6 the numbers at the top of the middle of the page, 17 -- 7 117706. I'm sorry, that was probably my fault. And then 8 on page 5 of that document, under the heading, "Program 9 for Training of Residents, Fellows, and Others." 10 In the third paragraph -- and this is in 11 1989: 12 17"The reduction is resident numbers, 13 which has been felt in other areas of 14 the hospital, has been experienced by 15 this department. Ten (10) years ago 16 [which would be 1979] there was as many 17 as six (6) pathology residents. We now 18 average two (2) and the University 19 expects this number will remain stable. 20 One (1) pathologist assistant position 21 was added when our resident numbers were 22 reduced to four (4), and it is now time 23 to add a second." 24 And in your experience as a pathology 25 assistant at Sick Kids, do you recall the decline in the

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1 number of residents in the department? 2 DR. DONALD PERRIN: Yes. 3 MR. ROBERT CENTA: And a corresponding 4 increase in the number of the pathology assistants? 5 DR. DONALD PERRIN: I recall an increase 6 in the quality of the people called pathology assistants. 7 We had a very -- we had a foreign medical doctor, an older 8 lady, who -- we call -- I would call an autopsy assistant 9 and -- 10 MR. ROBERT CENTA: Mm-hm. 11 DR. DONALD PERRIN: -- she retired and we 12 replaced her with somebody more younger and a better 13 educational background, I guess, in Canada, as far as Can 14 -- Canadian education was concerned. 15 MR. ROBERT CENTA: Okay. And if you turn 16 over to page 7 in that same document, the first full 17 paragraph on page 7, it says: 18 "Pathology assistants are science 19 graduates MSc or PhD, who we train in a 20 specialized area of pathology to assist 21 with routine laboratory work. Work that 22 was previously handled by residents is 23 now commonly done by them [meaning the 24 pathology assistants]." 25 And -- and is that a fair description?

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1 DR. DONALD PERRIN: I think that's 2 somewhat of an exaggeration. In other words, pathology 3 assistants do not sign out any surgicals, for instance, 4 which residents do with the pathologist. I mean, we might 5 sit with a microscope and we might converse with the 6 pathologists, but we don't actually sign out with them. 7 Like, we don't sign anything. 8 MR. ROBERT CENTA: And is that because 9 signing something is tantamount to a -- to making a 10 diagnosis? 11 DR. DONALD PERRIN: Correct. 12 MR. ROBERT CENTA: And you need to be a 13 medical doctor to do that? 14 DR. DONALD PERRIN: Correct. 15 MR. ROBERT CENTA: Okay. So on -- on your 16 resume, Tab 1 of your binder, PFP149418, under the heading 17 of "Employment" it indicates that you are a fellow of the 18 American Association of Pathologist's Assistants. 19 DR. DONALD PERRIN: Correct. 20 MR. ROBERT CENTA: Okay. And let's see if 21 you agree with this definition of pathologist's assistant, 22 which is set out by the American Association, and that is: 23 "A pathologist's assistant is an 24 intensively trained allied health 25 profession who provides anatomic

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1 pathology services under the direction 2 and supervision of a pathologist. 3 Pathologist's assistants interact with 4 pathologists in the same manner that 5 physician's assistants carry out their 6 duties under the direction of physicians 7 in surgical medical practices. 8 Pathologist's assistant contribute to 9 the overall efficiency of a laboratory 10 or pathology practice in a cost- 11 effective manner by performing a variety 12 of tasks consisting primarily of gross 13 examination of surgical path -- 14 pathology specimens and performance of 15 autopsies." 16 DR. DONALD PERRIN: I agree with that 17 definition. 18 MR. ROBERT CENTA: Okay. 19 COMMISSIONER STEPHEN GOUDGE: That 20 organisation is the American Association of Pathologist's 21 Assistants? 22 DR. DONALD PERRIN: Correct. 23 MR. ROBERT CENTA: Correct. 24 COMMISSIONER STEPHEN GOUDGE: Okay, so is 25 that a misprint on your CV?

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1 DR. DONALD PERRIN: Oh, yeah, the last -- 2 COMMISSIONER STEPHEN GOUDGE: Okay. 3 DR. DONALD PERRIN: -- the last word 4 "Association", yes. Association HOYST (phonetic), sorry 5 about that. 6 7 CONTINUED BY DR. DONALD PERRIN: 8 MR. ROBERT CENTA: And as I understand it, 9 the AAPA is a not-for-profit organisation, that is, has 10 the objectives to benefit the profession by promoting and 11 maintaining high standards of ethical conduct among 12 pathologist's assistants. 13 DR. DONALD PERRIN: Correct. 14 MR. ROBERT CENTA: And it was established 15 in 1972? 16 DR. DONALD PERRIN: Correct. 17 MR. ROBERT CENTA: As I understand it, the 18 AAPA now has more than eleven hundred (1,100) members. 19 DR. DONALD PERRIN: That's correct. 20 MR. ROBERT CENTA: And there are currently 21 two (2) ways of becoming a fellow of the AAPA for about 22 another ten (10) days. 23 DR. DONALD PERRIN: That's correct. 24 MR. ROBERT CENTA: Okay. And can you 25 explain the two (2) different ways of becoming a fellow.

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1 DR. DONALD PERRIN: There is a number of 2 training institutions in the state -- I think there's now 3 eight (8) -- where they have a didactic lectures portion 4 and they also have on-the-job training at specific 5 hospitals. They rotate through hospitals something like a 6 resident would rotate, and it's a three (3) year course. 7 And then you have to write the exam, which is now 8 accredited by the ASCP, the American Society for Clinical 9 Pathology, now gives the exam, instead of the AAP, which 10 used to give the exam, until two (2) years ago. And 11 that's one (1) of the ways. 12 The other way is you -- you must have a BSc 13 just lis -- with the -- the school. You must have BSc -- 14 I forget to say, though, you must have a BSc before you 15 have the three (3) year program. On the job you must have 16 a BSc and then have at least three (3) years training in a 17 facility under a supervisor and pathologist. 18 MR. ROBERT CENTA: Okay. 19 DR. DONALD PERRIN: And then you must also 20 write the exam at the end of that. 21 MR. ROBERT CENTA: Okay, let's break that 22 down. So for both streams you eventually have to write a 23 board examination -- 24 DR. DONALD PERRIN: Correct. 25 MR. ROBERT CENTA: -- that is sponsored by

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1 who? 2 DR. DONALD PERRIN: It is now the American 3 Associa -- American Society for Clinic Pathology. 4 MR. ROBERT CENTA: Okay. And to qualify 5 to write that board examination there are -- for the 6 moment, there are two (2) streams to get there. 7 DR. DONALD PERRIN: Correct. 8 MR. ROBERT CENTA: The first stream is an 9 on-the-job experiential screen -- stream that requires you 10 to have a bachelor of science degree? 11 DR. DONALD PERRIN: Correct. 12 MR. ROBERT CENTA: And to have worked for 13 three (3) years under the direction of a certified 14 pathologist? 15 DR. DONALD PERRIN: Correct. 16 MR. ROBERT CENTA: The other stream is a 17 more academic stream where you take -- you have to have a 18 BSc to start with? 19 DR. DONALD PERRIN: Correct. 20 MR. ROBERT CENTA: You then have to take a 21 graduate program or a second degree from an accredited 22 institution like, for example, Duke University? 23 DR. DONALD PERRIN: Correct. 24 MR. ROBERT CENTA: And you take that 25 accrediting program, and that combi -- and that also has a

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1 residency-type component in it? 2 DR. DONALD PERRIN: Correct. 3 MR. ROBERT CENTA: Once you complete that 4 program you're then eligible to write the board 5 examination? 6 DR. DONALD PERRIN: Correct. 7 MR. ROBERT CENTA: But both streams 8 require you to write a board examination? 9 DR. DONALD PERRIN: Correct. 10 MR. ROBERT CENTA: And am I correct that 11 the on-the-job qualification stream is about to expire? 12 DR. DONALD PERRIN: That's true. 13 MR. ROBERT CENTA: And from this point 14 forward, in order to become an accredited pathologist's 15 assistant you'll have to take the graduate program at one 16 (1) of the accredited institutions. 17 DR. DONALD PERRIN: That's correct. 18 MR. ROBERT CENTA: And are there any post- 19 secondary institutions in Canada that are accredited to 20 offer that program? 21 DR. DONALD PERRIN: There's no 22 institutions in Canada that are accredited by ASCP or 23 AAPA. There is a program in -- in Manitoba that has 24 produced four (4) well qualified pathologist assistants. 25 MR. ROBERT CENTA: And are you familiar

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1 with the program in Manitoba? 2 DR. DONALD PERRIN: Not in details. 3 MR. ROBERT CENTA: Okay. As I understand 4 it, you qualified through on the job experience plus the 5 examination? 6 DR. DONALD PERRIN: Correct. 7 MR. ROBERT CENTA: And if you could look 8 in your binder at Tab 11, which is PFP117738. This is a 9 year end report for the Department of Pathology from 10 December 1993. 11 And if you look under paragraph 7, the 12 second-last bullet reads: 13 "Don Perrin PhD, FAAPA, our Senior 14 Pathologist Assistant, wrote and passed 15 the American Board Examinations for 16 Pathology Assistants. Don is one (1) of 17 only two (2) individuals in the country 18 who have attained this status [and 19 bracket] (and Don is the first to pass 20 the examinations on the first try)." 21 DR. DONALD PERRIN: I don't know whether 22 that's -- the last statement was true or not. I do know 23 the other -- the first PA, he's in Kingston right now. 24 MR. ROBERT CENTA: And you wrote the exam 25 then in 1993?

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1 DR. DONALD PERRIN: True. 2 MR. ROBERT CENTA: Okay. And did the 3 examination that you wrote to become accredited, did that 4 contain any forensic pathology component? 5 DR. DONALD PERRIN: I don't -- I don't 6 recall that. 7 MR. ROBERT CENTA: Okay. And in your 8 formal education background, do you have any formal 9 training in forensic pathology? 10 DR. DONALD PERRIN: No. 11 MR. ROBERT CENTA: So the forensic 12 pathology that you've learned, you've learned on the job? 13 DR. DONALD PERRIN: Correct. 14 MR. ROBERT CENTA: At Sick Kids? 15 DR. DONALD PERRIN: Correct. 16 MR. ROBERT CENTA: And is there a Canadian 17 equivalent organization to the AAPA? 18 DR. DONALD PERRIN: No. 19 MR. ROBERT CENTA: Is there a Canadian -- 20 some form of Canadian association of pathologist 21 assistants? 22 DR. DONALD PERRIN: It's trying to form 23 right now under CAP, Canadian Association of Pathologists, 24 but I don't know what the status is. 25 MR. ROBERT CENTA: And --

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1 DR. DONALD PERRIN: It hasn't achieved 2 very -- it has gone along very far yet. 3 MR. ROBERT CENTA: And does it have any 4 role in providing professional accreditation? 5 DR. DONALD PERRIN: Not as yet. 6 MR. ROBERT CENTA: Turning back to your 7 CV, Dr. Perrin, which is found at Tab 1 of your binder. 8 PFP149418. On page 2, it lists a number of committee 9 activities you were engaged in at the Hospital for Sick 10 Children. I'd like to ask you some questions about that. 11 From 1995 to 2001, you were involved in the 12 Sick Kids Autopsy Committee? 13 DR. DONALD PERRIN: Correct. 14 MR. ROBERT CENTA: What was the purpose of 15 the Autopsy Committee? 16 DR. DONALD PERRIN: Oh, in 1995. Reviewed 17 with Dr. Becker and Dr. Smith the outstanding autopsies 18 and any operations procedures that were going on and if 19 there was anything changing as far as operations. 20 I don't know specific things. I guess 21 anything to do with forensic -- if there was any changes 22 in forensic, for instance. If there was any change in 23 protocols, et cetera. 24 MR. ROBERT CENTA: When you say that it 25 dealt with outstanding autopsies, what did you mean by

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1 that? 2 DR. DONALD PERRIN: Well, I used to do the 3 statis -- some of the statistics for outstanding autopsies 4 to see -- monthly report to Dr. Becker to tell him what 5 case had not been signed out yet. 6 MR. ROBERT CENTA: So these would be -- 7 when you say "outstanding" you mean, post-mortem 8 examination reports; where the examination had been 9 completed but the report had not been signed out? 10 DR. DONALD PERRIN: Correct. And that 11 included hospital and medicolegal autopsies. 12 MR. ROBERT CENTA: And when you say 13 "medicolegal autopsy", just so we're clear, we're talking 14 about autopsies performed under coroner's warrant? 15 DR. DONALD PERRIN: Correct. 16 MR. ROBERT CENTA: And how often would 17 this committee meet? 18 DR. DONALD PERRIN: I don't recall exactly 19 how often. 20 MR. ROBERT CENTA: And how delayed would a 21 report have to be before it would be brought to the 22 Autopsy Committee? 23 DR. DONALD PERRIN: Well, we -- we -- we 24 tracked how long it took in days, so anything over three 25 (3) months was -- the standard that we wanted was three

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1 (3) months; 80 percent of the autopsies done in three (3) 2 months. So it didn't exactly split them that way. It 3 actually just recorded number of days outstanding -- the 4 time when the autopsy is still not signed out yet. 5 MR. ROBERT CENTA: So it would track all 6 of the autopsies that had not yet been signed out -- 7 DR. DONALD PERRIN: Correct. 8 MR. ROBERT CENTA: -- but an autopsy 9 wouldn't merit any particular attention until three (3) 10 months had passed? 11 DR. DONALD PERRIN: Correct. 12 MR. ROBERT CENTA: And -- I'm sorry, could 13 you repeat who is on the committee? 14 DR. DONALD PERRIN: As far as I can 15 remember, it's Dr. Smith, Dr. -- because Dr. Smith was in 16 charge of the autopsy facilities -- Dr. Becker and myself. 17 MR. ROBERT CENTA: And between the period 18 of 1995 to 2001, do you recall that the Autopsy Committee 19 dealt with delayed reports from Dr. Smith? 20 Were Dr. Smith's reports occasionally 21 discussed at the Autopsy Committee? 22 DR. DONALD PERRIN: Yes. 23 MR. ROBERT CENTA: Do you recall whether 24 any pathologist had a -- had a -- had more delayed reports 25 than any other pathologist in that period of time?

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1 DR. DONALD PERRIN: I think during that 2 period of time it was Dr. Smith that had more than anybody 3 else. 4 MR. ROBERT CENTA: And was the Autopsy 5 Committee responsible for suggesting recommendations on 6 how to get the reports signed off more quickly? 7 DR. DONALD PERRIN: That was between Dr. 8 Becker and Dr. Smith, not -- I wasn't really included in 9 those conversations. I mean I -- Dr. Becker asked me 10 whether I had any recommendations and I came up with a few 11 ideas that maybe I could assist Charles in trying to 12 facilitate reports. 13 MR. ROBERT CENTA: And what can you -- do 14 you recall what those suggestions were? 15 DR. DONALD PERRIN: Dr. Smith didn't want 16 me to facili -- or to help him. He said he would catch 17 up. 18 MR. ROBERT CENTA: And how did you offer 19 to assist? 20 DR. DONALD PERRIN: By bringing individual 21 cases to him to review together and I could assist him by 22 bringing the different parts together. 23 MR. ROBERT CENTA: And help me understand 24 what would go on at a Committee meeting. You would sit 25 down and there would be a -- you would pre -- present

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1 material that was sort of a data analysis of reports that 2 were outstanding? 3 DR. DONALD PERRIN: Yeah, that was one of 4 the things, but there was other things. There was day to 5 day operations. 6 MR. ROBERT CENTA: Right. 7 DR. DONALD PERRIN: You know, different 8 procedures, changes in -- in tissue collections or 9 changing archive -- all the day to day things as well. 10 MR. ROBERT CENTA: Was there an attempting 11 at the autopsy meeting to understand why the delays were 12 happening in the reports? 13 DR. DONALD PERRIN: We would ask Charles, 14 you know, why, and he didn't really give any satisfactory 15 answer -- that I know he was very busy with -- he did more 16 -- probably more -- I'm sure he did more autopsies than 17 anybody else. So, of course he could always say that he 18 had more work then anybody else, but other people had 19 other interests, which Charles didn't have. 20 But Charles is also, as you know, Director 21 of the Unit, so there was other responsibilities there. 22 And he also did the high profile cases. 23 MR. ROBERT CENTA: And we'd agree that the 24 complicated high profile cases might take more time then a 25 -- then a -- just a routine autopsy?

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1 DR. DONALD PERRIN: They would only -- not 2 only take more time, but the subsequent follow-up on these 3 cases is quite extensive, even after the report is 4 finished. He would have time commitments where he would 5 have to testify and so -- 6 MR. ROBERT CENTA: And those time -- those 7 time commitments following the completion of the report 8 could include meeting with police officers? 9 DR. DONALD PERRIN: Correct. 10 MR. ROBERT CENTA: Meeting with Crown 11 attorneys? 12 DR. DONALD PERRIN: Correct. 13 MR. ROBERT CENTA: Testifying in court? 14 DR. DONALD PERRIN: Correct. 15 MR. ROBERT CENTA: All of that would add 16 to the time taken for a report -- but most of that would 17 follow after a report was completed. 18 Is that correct? 19 DR. DONALD PERRIN: Or during -- 20 MR. ROBERT CENTA: Okay. 21 DR. DONALD PERRIN: -- often police came 22 during -- 23 MR. ROBERT CENTA: All right. 24 DR. DONALD PERRIN: -- in that time frame 25 where he hadn't signed out yet.

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1 MR. ROBERT CENTA: And did the autopsy 2 committee undertake any analysis to -- to try and 3 understand the -- what was -- what was slowing down the 4 completion of the autopsies? 5 DR. DONALD PERRIN: We did do some things. 6 There was a suggestion that one (1) time, that the 7 neuropathology was holding things up, so Dr. Becker 8 actually did a study where we did a very fast turnaround 9 time for neuropathology; recorded that and then looked at 10 the final sign out time. It really didn't change the 11 final sign out time on anybody's autopsies, including Dr. 12 Smiths. 13 We also did -- looked at the toxicology 14 turnaround time. There was a delay at one (1) time. I 15 don't remember what year it was that toxicology was taking 16 longer to get back to us, but still, it is usually back by 17 three (3) months. 18 MR. ROBERT CENTA: And from 1995 to 2001, 19 that post-dated the creation of the OPFPU at -- at The 20 Hospital for Sick Children? It -- 21 DR. DONALD PERRIN: Yes. 22 MR. ROBERT CENTA: -- was created in 1991. 23 And did any -- did the Autopsy Committee ever discuss 24 concerns that were being raised by the Office of the Chief 25 Coroner with respect to the delay in the turn -- or

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1 turnaround time concerns regarding the completion of 2 medicolegal post-mortem examinations? 3 DR. DONALD PERRIN: I'm not aware of that. 4 MR. ROBERT CENTA: Did the Autopsy 5 Committee ever meet with representatives of the OCCO to 6 discuss those matters? 7 DR. DONALD PERRIN: Not when I was present 8 anyway. 9 MR. ROBERT CENTA: And does the Autopsy 10 Committee exist today? 11 DR. DONALD PERRIN: There's a -- no, the 12 oper -- Autopsy Committee doesn't. There is a Operations 13 Committee -- 14 MR. ROBERT CENTA: Is that -- 15 DR. DONALD PERRIN: -- that still meets, 16 which includes autopsy issues. 17 MR. ROBERT CENTA: Did the functions form 18 -- that were performed by the Autopsy Committee are now 19 picked up by a different committee? 20 DR. DONALD PERRIN: They -- the Operations 21 Committee does not address turnaround time on autopsies. 22 MR. ROBERT CENTA: And currently, which 23 committee does address turnaround time for autopsies? 24 DR. DONALD PERRIN: I think many of Dr. 25 Taylor and Dr. Chiasson. Okay.

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1 I don't -- I don't know of a committee 2 actually, but I know that they are -- are looking at 3 turnaround times continually, especially Dr. Chiasson. 4 MR. ROBERT CENTA: Okay. They're ali -- 5 that's where the responsibility currently sits? 6 DR. DONALD PERRIN: Correct. 7 MR. ROBERT CENTA: Okay. And do you think 8 it would have been helpful between 1995 and 2001, for the 9 Autopsy Committee to have met formally with 10 representatives of the Office of the Chief Coroner to 11 discuss turnaround time concerns? 12 DR. DONALD PERRIN: I do. 13 MR. ROBERT CENTA: And did the Autopsy 14 Committee discuss Dr. Smith's request, dated January 25, 15 2001 -- and this is PFP127457, it's not in your binder, 16 but this is a -- Dr. Smith's request of Dr. Young where he 17 wrote: 18 "I am writing to request that you excuse 19 me from the performance of medicolegal 20 autopsies for the Office of the Chief 21 Coroner, having arranged for an external 22 review of my post-mortem examinations." 23 This was written on January 21st, 2001. 24 Do you recall whether the Autopsy Committee 25 spoke about this issue?

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1 DR. DONALD PERRIN: That was never 2 discussed. 3 MR. ROBERT CENTA: Was the questions -- 4 the question of whether or not Dr. Smith's request would 5 affect the delivery of that -- that service at Sick Kids 6 ever discussed at the Autopsy Committee? 7 DR. DONALD PERRIN: When we found the 8 pathologist assistants, and I found out, we did discuss 9 it. I said, Who is going to pick up the slack? And I was 10 informed by Dr. Becker that Dr. Cutz and Dr. Wilson would 11 be doing the -- the cases for Dr. Smith. 12 MR. ROBERT CENTA: And how did you learn 13 of -- 14 DR. DONALD PERRIN: From Dr. Becker. 15 MR. ROBERT CENTA: According to your CV, 16 from 1995 to '97, you also sat on the Pathology Management 17 Committee. 18 Do you recall what the Pathology Management 19 Committee -- 20 DR. DONALD PERRIN: That was met-- I can't 21 remember how often, probably once every two (2) weeks or 22 something like that, and it was to do with operations 23 again, and policy and procedures. And it was not -- it 24 was to do with surgical and autopsy and administrative 25 procedures and computerization of those procedures.

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1 MR. ROBERT CENTA: Okay. And who was on - 2 - who sat on the Pathology Management Committee? 3 DR. DONALD PERRIN: There was quite a few 4 people. The chief technologist at that time was on, Dr. 5 Becker was on, myself; those are the people I can 6 remember, but I'm sure that there were more. And there 7 was -- actually invited people at different times for 8 different procedures -- like policy and procedures. 9 MR. ROBERT CENTA: And did this committee 10 address policies and procedures that were in place at the 11 Ontario Pediatric Forensic Pathology Unit? 12 DR. DONALD PERRIN: No, not really. There 13 was more to do with the -- the lab, histology, electron 14 microscopy, those kind of things. 15 MR. ROBERT CENTA: Okay. And finally, the 16 third committee that you were listed as having been a 17 member of is the Pathology Senior Staff Committee, in 2000 18 and 2001. 19 Do you recall that committee? 20 DR. DONALD PERRIN: As a -- yeah, I guess 21 you could call it a committee. It was a -- it was a 22 meeting of everybody in the -- in department and current 23 issues. More to do with the pathologists than myself -- 24 or the technical support. 25 MR. ROBERT CENTA: And everyone was in --

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1 was able to attend this meeting. 2 DR. DONALD PERRIN: The pathologists and 3 senior scientists and myself. 4 MR. ROBERT CENTA: Okay. And what items 5 did it discuss -- just -- if you could explain that. 6 DR. DONALD PERRIN: They were more to do 7 with workload, different government issues that came down 8 to pathologists, and sometimes senior scientists. But it 9 really wasn't any to do with foren -- forensics were not 10 discussed usually on that -- in that forum. 11 MR. ROBERT CENTA: To the extent that it 12 discussed workload, did the Pathology Senior Staff 13 Committee discuss any implications arising from Dr. 14 Smith's request at the end of January, 2001, to be 15 relieved of performing medicolegal autopsies? 16 DR. DONALD PERRIN: I don't recall that. 17 I think that was -- that issue, as far as autopsies was 18 discussed with Dr. Wilson and Dr. Cutz and slightly with 19 myself, because it did affect how we were going to do 20 things. 21 I might have been a -- the small discussion 22 of the -- Charles -- Dr. Smith's surgical load, because 23 that would also have to be picked up to somewhat -- 24 extent, I think, because there was issues with his 25 surgical practice as well.

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1 MR. ROBERT CENTA: How -- can -- when you 2 say there were issues with his surgical practice, can you 3 elaborate on that? 4 DR. DONALD PERRIN: I don't know the exact 5 timing when that happened, but I know that there was a 6 review of his surgical performance. I wasn't involved in 7 that. I know -- but I know it did occur, because I had to 8 find some slides, et cetera. 9 MR. ROBERT CENTA: Can you put that in a 10 rough time frame? 11 DR. DONALD PERRIN: I'm afraid I don't 12 know exactly when that happened; it'd be in the 2000s. 13 COMMISSIONER STEPHEN GOUDGE: Were you on 14 the Autopsy Committee then? That is, was this a subject 15 of discussion? 16 DR. DONALD PERRIN: That wasn't discussed 17 at the Autopsy Committee, no. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 DR. DONALD PERRIN: That was, I think, 20 that was done privately with -- 21 COMMISSIONER STEPHEN GOUDGE: With Dr. 22 Becker? 23 DR. DONALD PERRIN: -- with Dr. Becker. I 24 think is the -- it's done very quietly. I don't think 25 most people knew about it in the department.

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1 CONTINUED BY MR. ROBERT CENTA: 2 MR. ROBERT CENTA: Would it -- would it 3 have been done as late as 2005 or -- I'm just trying to 4 get a sense of when you think -- 5 DR. DONALD PERRIN: No, I don't think it 6 was done before that. 7 MR. ROBERT CENTA: Okay. But you can't be 8 of more assistance than that? 9 DR. DONALD PERRIN: No. 10 MR. ROBERT CENTA: Do you recall who asked 11 you to be involved in that process? 12 DR. DONALD PERRIN: I was asked to pull 13 some slides and put some stuff together, but I really 14 don't remember anything more about it. 15 MR. ROBERT CENTA: Do you remember who 16 asked you? 17 DR. DONALD PERRIN: I think it was Dr. 18 Becker, but I'm not positive. 19 MR. ROBERT CENTA: Okay. Thank you. 20 DR. DONALD PERRIN: I assume it was. Or 21 it might have been Dr. -- even Dr. Taylor by then. 22 MR. ROBERT CENTA: Dr. Perrin, I'd like to 23 ask you some questions about your job duties as a senior 24 pathologist assistant. And your current job description 25 is found at Tab 2, PFP302212. And is this your current

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1 job description? 2 DR. DONALD PERRIN: No, this is actually 3 an older one. 4 MR. ROBERT CENTA: Okay. 5 DR. DONALD PERRIN: And the newer one 6 hasn't changed sig -- significantly, I don't think. 7 MR. ROBERT CENTA: So this is a fair 8 description of what you do at the -- at the Hospital for 9 Sick Children? 10 DR. DONALD PERRIN: What is the saying, at 11 30,000 feet? 12 MR. ROBERT CENTA: At 30,000 feet. Who 13 wrote this job description? 14 DR. DONALD PERRIN: I did. 15 MR. ROBERT CENTA: And am I correct that 16 it's based fairly carefully on the scope of practice for 17 pathologist assistants that is found -- that is 18 established by the AAPA? 19 DR. DONALD PERRIN: Correct. 20 MR. ROBERT CENTA: And that was the model 21 for this -- 22 DR. DONALD PERRIN: Correct. 23 MR. ROBERT CENTA: -- for this job 24 description? And as I see, the job description sets out 25 four (4) categories of duties for you. First, duties

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1 related to post-mortem services? 2 DR. DONALD PERRIN: Correct. 3 MR. ROBERT CENTA: Second, duties related 4 to surgical pathology? 5 DR. DONALD PERRIN: Correct. 6 MR. ROBERT CENTA: Third, duties related 7 to management responsibilities? 8 DR. DONALD PERRIN: Correct. 9 MR. ROBERT CENTA: And finally, duties 10 related to pediatric pathology research? 11 DR. DONALD PERRIN: Correct. 12 MR. ROBERT CENTA: Now, I want to deal 13 with your management responsibilities be -- quite quickly. 14 Whose performance do you oversee at the Hospital for Sick 15 Children? 16 DR. DONALD PERRIN: The pathology 17 assistants. 18 MR. ROBERT CENTA: And -- 19 DR. DONALD PERRIN: Or autopsy assistants, 20 whichever. 21 MR. ROBERT CENTA: And if we could look at 22 the Hospital for Sick Children Institutional Report, which 23 is PFP301353 at page 68. 24 25 (BRIEF PAUSE)

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1 That is a job posting for a pathologist's 2 assistant position? 3 DR. DONALD PERRIN: Correct. 4 MR. ROBERT CENTA: And you're familiar 5 with this job posting? 6 DR. DONALD PERRIN: Yes. 7 MR. ROBERT CENTA: Who currently holds the 8 position of pathologist's assistant at the Hospital for 9 Sick Children? 10 DR. DONALD PERRIN: Serge Robichaud is 11 being trained as a pathologist's assistant. 12 MR. ROBERT CENTA: And -- and what his 13 background? 14 DR. DONALD PERRIN: Former medical doctor. 15 MR. ROBERT CENTA: And are there any other 16 pathologist's assistants? 17 DR. DONALD PERRIN: That's -- depends on 18 how you classify the job, but I guess as far as 19 employment, Jimmy Choi is listed and Emily Pershaw 20 (phonetic) is also listed as a pathologist's assistant. 21 MR. ROBERT CENTA: And your -- your 22 hesitation is because neither Mr. Choi nor Ms. Renshaw 23 (sic) would qualify under the AAP definition of 24 pathologist assistant? 25 DR. DONALD PERRIN: Correct.

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1 MR. ROBERT CENTA: Okay. And that's 2 because either of a lack of formal education? 3 DR. DONALD PERRIN: Correct -- 4 MR. ROBERT CENTA: Or -- and neither of 5 them have written the board certified exams. 6 DR. DONALD PERRIN: Correct. 7 MR. ROBERT CENTA: But they both perform 8 duties that are set out as described in this job 9 description? 10 DR. DONALD PERRIN: Well, Emily Pershaw 11 has been there for just over a year so her training is 12 still in progress. 13 MR. ROBERT CENTA: Okay. And do either -- 14 do any of the people you supervise have any formal 15 forensic training? 16 DR. DONALD PERRIN: No. 17 MR. ROBERT CENTA: And if those 18 individuals were to continue on in their job duties for, 19 let's say, ten (10) or fifteen (15) years, if they were to 20 -- to make a -- a career of these positions, do you think 21 that obtaining formal training in forensic pathology would 22 be of assistance to them? 23 DR. DONALD PERRIN: Yes. 24 MR. ROBERT CENTA: So turning back to your 25 own job description which is found at Tab 2. The

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1 description of the duties there, am I correct, they're 2 quite broadly crafted? 3 DR. DONALD PERRIN: Yes. 4 MR. ROBERT CENTA: And they cover all 5 types of post-mortem examinations that you would conduct? 6 DR. DONALD PERRIN: Yes. 7 MR. ROBERT CENTA: And am I right that 8 roughly 50 percent of the autopsies conducted at the 9 Hospital for Sick Children would arise under coroner's 10 warrant? 11 DR. DONALD PERRIN: Yes. 12 MR. ROBERT CENTA: And the other half 13 would arise from a variety of other mechanisms? 14 DR. DONALD PERRIN: Correct. 15 MR. ROBERT CENTA: And the -- this job 16 description is designed to take into account all of the -- 17 the wide range of post-mortem examinations you would be 18 involved in? 19 DR. DONALD PERRIN: Yes. 20 MR. ROBERT CENTA: And it also addresses 21 surgical pathology but we're going to focus right now on 22 the post-mortem examinations. 23 And am I right, that the Hospital for Sick 24 Children, only a small fraction of the medicolegal cases 25 would actually be considered criminally suspicious or

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1 homicide cases? 2 DR. DONALD PERRIN: Yes, approximately 5 3 percent. 4 MR. ROBERT CENTA: And a number of people 5 have used that percentage of a 5 percent; do you have a 6 source for that data? 7 DR. DONALD PERRIN: I don't have it in 8 front of me but we've -- Dr. Smith actually looked at this 9 years ago and it was about the 5 percent level. We've 10 looked at it pre -- recently. I believe it's still around 11 the 5 percent. Maybe Dr. Taylor will be a better source 12 for this. 13 MR. ROBERT CENTA: And those numbers 14 remain fairly constant over time? 15 DR. DONALD PERRIN: It would appear so. 16 MR. ROBERT CENTA: Okay. And am I 17 correct -- 18 COMMISSIONER STEPHEN GOUDGE: That is 5 19 percent of the 50 percent? 20 DR. DONALD PERRIN: Correct. Correct. 21 COMMISSIONER STEPHEN GOUDGE: Do you 22 identify those as they come through the door or do you 23 identify that 5 percent at the end of the autopsy? 24 DR. DONALD PERRIN: That's at the end of 25 the autopsy.

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1 2 CONTINUED BY MR. ROBERT CENTA: 3 MR. ROBERT CENTA: So the number of case - 4 - am I correct that the number of cases that at the front 5 end look like they might be criminally suspicious or 6 homicide cases, would be larger than 5 percent? 7 DR. DONALD PERRIN: That can go both ways. 8 MR. ROBERT CENTA: Because it would -- 9 right. 10 DR. DONALD PERRIN: It can go the other 11 way as well. It could be it doesn't look criminally 12 suspicious but then becomes criminally suspicious. Or it 13 can look criminally suspicious and not become criminally 14 suspicious. 15 So it's not always easy to tell. Some 16 cases are very straightforward, you know. There's obvious 17 trauma seen in the emergency room, for instance. And 18 those are criminally suspicious, and they turn out to be 19 criminally suspicious. 20 MR. ROBERT CENTA: And I'm going -- as we 21 work through your job duties, I'm going to come back to 22 that question again. 23 All of the duties set out, though, just so 24 we're clear, you perform your duties at the direction of 25 the pathologist in the room?

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1 DR. DONALD PERRIN: Yes. 2 MR. ROBERT CENTA: And under the 3 supervision of that pathologist? 4 DR. DONALD PERRIN: Yes. 5 MR. ROBERT CENTA: And your job, at its 6 core, is to assist the pathologist to perform a competent 7 and efficient post-mortem examination? 8 DR. DONALD PERRIN: Yes. 9 MR. ROBERT CENTA: And the duties that you 10 perform in the autopsy room, would they be similar to the 11 duties performed by the people that you supervise? 12 With the exception of -- of the person 13 who's only been there for a year, do you all roughly do 14 the same kinds of things? 15 DR. DONALD PERRIN: For the most part. 16 MR. ROBERT CENTA: And you may have some 17 particular expertise in a number of areas, particularly 18 relating to your own research. 19 DR. DONALD PERRIN: Not on the foren -- 20 that doesn't apply to the high-profile forensic cases. 21 MR. ROBERT CENTA: Okay. And are you 22 involved in most of the high-profile forensic cases? 23 DR. DONALD PERRIN: If I'm available, I'm 24 involved in all the -- all the high-profile cases. 25 COMMISSIONER STEPHEN GOUDGE: What is a

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1 high-profile case? 2 DR. DONALD PERRIN: One (1) that is 3 criminally suspicious or could be criminally suspicious. 4 I'm pretty -- if I'm available, I'm involved in all the 5 autopsies, so it -- but I, particularly, make a point of 6 attending the autopsy at the quest -- usually at the 7 request of the pathologist to attend the autopsy if it's 8 criminally suspicious. 9 10 CONTINUED BY MR. ROBERT CENTA: 11 MR. ROBERT CENTA: Item number four (4) in 12 the job description is: 13 "Under the direction of pathologist in 14 charge, perform any post-mortem 15 examinations which may include external 16 examinations, in situ examination, 17 evisceration, dissection and 18 documentation." 19 Am I correct that the examinations that you 20 would personally perform, in any particular case, would 21 vary with the pathologist you were working with? 22 DR. DONALD PERRIN: I don't like the way 23 you phrased that. 24 I don't do the examination. I do -- I 25 would delegate work by -- for the pathologist and it does

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1 vary. The delegation varies with the pathologist and with 2 the case. 3 MR. ROBERT CENTA: Thank you for 4 clarifying that. 5 DR. DONALD PERRIN: Sorry. 6 MR. ROBERT CENTA: And when you were 7 working with Dr. Smith, did he tend to delegate more or 8 less of those kinds of examinations to you than other 9 pathologists? 10 DR. DONALD PERRIN: Probably somewhat less 11 but it would depend on the case. 12 MR. ROBERT CENTA: And he was quite 13 involved in doing his own work at the table? 14 DR. DONALD PERRIN: He was quite involved 15 in prosecting; he was a very good prosector. 16 MR. ROBERT CENTA: Let's talk about that. 17 How -- how did his skills at the table compare, in your 18 view, to the other pathologists you were working with? 19 DR. DONALD PERRIN: Charles had done some 20 surgery and so he was a very good prosector. 21 MR. ROBERT CENTA: And one (1) of your job 22 duties involves photography during the -- during the 23 examination? 24 DR. DONALD PERRIN: Yeah, all the 25 pathologist assistants, they're involved in photography.

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1 MR. ROBERT CENTA: And was there a time at 2 the Hospital for Sick Children where there was a full time 3 photographer? 4 DR. DONALD PERRIN: Correct. 5 MR. ROBERT CENTA: And that position has 6 been lost? 7 DR. DONALD PERRIN: Correct. 8 MR. ROBERT CENTA: And in your opinion, 9 given the improvements in digital photography, do you 10 think there would be a benefit to having a full time 11 photographer? 12 DR. DONALD PERRIN: I don't think so. 13 MR. ROBERT CENTA: And why not? 14 DR. DONALD PERRIN: What has changed is 15 that on any high profile case, and almost all 16 medicolegals, a police photographer attends now, which 17 that did not happen in the old days, so we have a double 18 coverage. 19 We have not only the pathologist's 20 assistant taking digital photographs -- and many digital 21 photographs -- and we also have the police photographer 22 taking photographs. 23 MR. ROBERT CENTA: And am -- am I correct 24 that now, at the Hospital for Sick Children, if it's a 25 criminally suspicious case where the police are in

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1 attendance, if you take photographs during the autopsy is 2 there a record kept of that fact? 3 DR. DONALD PERRIN: Yes. 4 MR. ROBERT CENTA: And that is written 5 down now on the autopsy form itself? 6 DR. DONALD PERRIN: No, we have a archival 7 system called Apollo where all images taken during the 8 autopsy are downloaded and can not be deleted. 9 MR. ROBERT CENTA: And is the fact that 10 you've taken photographs alongside a police photographer, 11 would that fact be disclosed? 12 DR. DONALD PERRIN: Yes. 13 MR. ROBERT CENTA: And how is that 14 disclosed? 15 DR. DONALD PERRIN: It's disclosed in the 16 C 12 form, or the -- I don't know exactly the term, but 17 it's what everybody calls it, the C 12 form. 18 MR. ROBERT CENTA: And during the post- 19 mortem examination, I have a question about note taking. 20 Do you take any notes during the examination? 21 DR. DONALD PERRIN: I don't take any notes 22 for my personal use, but I do take some notes for the 23 pathologist. 24 MR. ROBERT CENTA: And when you were 25 working with Dr. Smith, how -- what was his practice for

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1 taking notes; how did he take notes? 2 DR. DONALD PERRIN: Dr. Smith's practice 3 was quite variable. He tried a number of different 4 systems, from writing his own notes, to dictating his own 5 notes, to typing his own notes on a laptop. 6 MR. ROBERT CENTA: And was there a 7 particular kind of case where he would employ one (1) 8 method or the other? 9 DR. DONALD PERRIN: I think the more 10 complicated cases he was ty -- typing his own for awhile 11 because he was afraid of losing stuff and, I don't know, I 12 think he just wanted to try and see whether that worked -- 13 facilitated his reports more quickly. 14 MR. ROBERT CENTA: And do you have any 15 role in authoring an autopsy report? 16 DR. DONALD PERRIN: No. 17 MR. ROBERT CENTA: If you could turn to 18 Tab 3 in your binder, PFP044130. This is a letter written 19 by Dr. Smith to Dr. Becker relating -- 20 COMMISSIONER STEPHEN GOUDGE: Sorry, the 21 tab number? 22 MR. ROBERT CENTA: Sorry, Tab 3, 23 Commissioner. 24 COMMISSIONER STEPHEN GOUDGE: Thank you. 25

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1 CONTINUED BY MR. ROBERT CENTA: 2 MR. ROBERT CENTA: And it's a document 3 that was written in January of 1995 concerning the HSC 4 Standardized Autopsy Protocol. Now, before this Inquiry 5 had you seen a copy of this letter? 6 DR. DONALD PERRIN: No. 7 MR. ROBERT CENTA: The letter raises at 8 the bottom of the first page a concern by Dr. Smith and it 9 re -- reads: 10 "The completion of a pro -- of the 11 protocol by an autopsy assistants..." 12 Sorry. 13 "...by autopsy assistants draws 14 attention to the matter of how much 15 reporting should be performed by a non 16 MD. It is clear that apart from 17 recording observations such as weights 18 and measurements, pathology assistants 19 are not to be participating in the 20 authoring of medicolegal reports. The 21 Chief Coroner and the Chief Forensic 22 Pathologist are aware of the practices 23 at HSC where Don Perrin writes much, if 24 not all, of a report for at least one 25 (1) of the pathologists. The Office of

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1 the Chief Coroner has indicated that, 2 effective immediately, they wish this 3 practice to stop." 4 And in 1995, Dr. Perrin, were -- were you 5 writing much, if not all, of a report for at least one (1) 6 of the pathologists? 7 DR. DONALD PERRIN: I was transcribing a 8 significant portion from Dr. -- one (1) of the doctor's C 9 12 forms. 10 MR. ROBERT CENTA: And which doctor was 11 that? 12 DR. DONALD PERRIN: Dr. Wilson. 13 MR. ROBERT CENTA: And when you say 14 "transcribing", can you just explain what you mean by 15 that? 16 DR. DONALD PERRIN: Dr. scri -- Wilson is 17 of the old school; he writes everything longhand on the 18 copy of the old C 12 form. And he would -- he's a very -- 19 sometimes verbose and he would fill the -- the sides of 20 the pages, the backs of the pages, and I would transcribe 21 them; make out his notes. And then I would meet with him 22 to see if that was okay; what he -- what he had written 23 down was adequate. 24 MR. ROBERT CENTA: And did Dr. Smith ever 25 address this concern directly with you?

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1 DR. DONALD PERRIN: No. 2 MR. ROBERT CENTA: Did anyone ever tell 3 you to stop the practice that you had -- that had grown 4 up? 5 DR. DONALD PERRIN: No. 6 MR. ROBERT CENTA: And in your view, was 7 the practice that had developed, was it in any way 8 inappropriate? 9 DR. DONALD PERRIN: No. 10 COMMISSIONER STEPHEN GOUDGE: Did you 11 continue it? 12 DR. DONALD PERRIN: Yes. Well, I didn't 13 know about this -- this letter, so I'm still doing it to 14 this day. I still facilitate a number of the pathologists 15 autopsies. I do bring their cases to them and say, We 16 need to show this at rounds. We need to photograph 17 microscopic slides, things like that. 18 COMMISSIONER STEPHEN GOUDGE: So you work 19 up the presentation for them? 20 DR. DONALD PERRIN: We work together. We 21 do look at them -- we have a double headed microscope for 22 instance, and we -- we'll decide what he wants to have 23 shown, and I will go back to my office and photograph 24 whatever he tells me -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. DONALD PERRIN: -- is appropriate. 2 MR. ROBERT CENTA: Commissioner, I'm a 3 little past my time, but I think if I could have five (5) 4 more minutes, I can wrap this examination up. 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 Thanks. 7 8 CONTINUED BY MR. ROBERT CENTA: 9 MR. ROBERT CENTA: And now I'd like to ask 10 you just a -- finally about -- some questions about the 11 autopsy guidelines for homicidal and criminally suspicious 12 deaths in infants and children. 13 This is found at Tab 9 of your binder, 14 PFP137602. And am I correct that this first edition, 15 which was released in April 2007, is it -- it's now been 16 implemented at The Hospital for Sick Children? 17 DR. DONALD PERRIN: I -- I must admit, I 18 didn't know this was actually effective. I have seen the 19 drafts of this, but I didn't know -- we -- we -- we're 20 practising most of these -- I believe, most of the things 21 in here. 22 MR. ROBERT CENTA: And these guidelines 23 are also reproduced largely in the document you'll find at 24 Tab 10, which is the Guidelines on Autopsy Practice for 25 Forensic Pathologists in Criminally Suspicious Cases and

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1 Homicides. 2 DR. DONALD PERRIN: Okay. 3 MR. ROBERT CENTA: It's a subset of that. 4 And you're familiar with this document? 5 DR. DONALD PERRIN: Yes, both -- 6 MR. ROBERT CENTA: Okay. 7 DR. DONALD PERRIN: -- of them, yes. 8 MR. ROBERT CENTA: And I've a question for 9 you about -- if we could look at Tab 9, PFP137602, page 4. 10 And this is a document that delineates the role of the 11 pathologist in a case of a criminally -- of a homicide and 12 criminally suspicious death. 13 And you see on page 4, there's an 14 indication of when these guidelines are to be used; a 15 whole list of cases that will trigger the application of 16 these guidelines. Known history -- and this is set out in 17 2.2: 18 "Known history of child abuse, unusual 19 suspicious appearance of the death 20 scene, history of an unusual fall or 21 accident, poor hygiene, lice 22 infestations or other evidence of 23 neglect." 24 And then down through a number of other 25 factors. And if these -- if these guidelines are to be --

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1 I take it they're to be applied at the beginning of the 2 autopsy? 3 DR. DONALD PERRIN: Correct. 4 MR. ROBERT CENTA: How do the pathology 5 assistant and the pathologist know whether this is a case 6 to which these guidelines apply? How's that information 7 communicated to you? 8 DR. DONALD PERRIN: From the pathologist. 9 MR. ROBERT CENTA: And how does the 10 pathologist learn that this is a case that might attract 11 these guidelines? 12 DR. DONALD PERRIN: Well, it depends on 13 the specific issue. Sometimes abuse is known upfront. 14 Sometimes they're picked up in emergency; the unit. 15 Sometimes the police actually inform us. Sometimes the 16 coroner informs us. Sometimes when we get the body, we 17 actually get suspicious and find -- and phone back to the 18 police and back to the coroner. 19 MR. ROBERT CENTA: Okay. So the possible 20 source of information include the coroner's warrant, 21 correct? 22 DR. DONALD PERRIN: Correct. 23 MR. ROBERT CENTA: Reports from the 24 police? 25 DR. DONALD PERRIN: Correct. Or else --

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1 MR. ROBERT CENTA: Clinical history -- 2 DR. DONALD PERRIN: -- police verbal 3 reports, not necessarily a written report. 4 MR. ROBERT CENTA: At the time? 5 DR. DONALD PERRIN: Correct. 6 MR. ROBERT CENTA: And clinical history? 7 DR. DONALD PERRIN: Correct. 8 MR. ROBERT CENTA: Okay. So let's assume 9 that this is the kind of case that would attract these 10 guidelines. 11 COMMISSIONER STEPHEN GOUDGE: Can I just 12 ask first -- is it your understanding of the guidelines, 13 Dr. Perrin, that -- how many of the criteria do you have 14 to meet for inclusion in the protocol? 15 DR. DONALD PERRIN: I think -- 16 COMMISSIONER STEPHEN GOUDGE: Any of them? 17 DR. DONALD PERRIN: -- I think any of 18 them. 19 COMMISSIONER STEPHEN GOUDGE: One's 20 enough? 21 DR. DONALD PERRIN: One's enough to raise 22 suspicion, and then it goes from there. 23 COMMISSIONER STEPHEN GOUDGE: Okay. 24 DR. DONALD PERRIN: And you -- you know, 25 you -- as you progress with the autopsy, you might be able

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1 to ignore this one (1) -- or not ignore, but -- 2 COMMISSIONER STEPHEN GOUDGE: Go back to 3 your normal -- 4 DR. DONALD PERRIN: -- there's -- the 5 significance of it might not be -- 6 COMMISSIONER STEPHEN GOUDGE: But your 7 starting point -- 8 DR. DONALD PERRIN: Yeah. 9 COMMISSIONER STEPHEN GOUDGE: -- would be 10 this special process? 11 DR. DONALD PERRIN: Correct. 12 COMMISSIONER STEPHEN GOUDGE: And if I 13 said to you -- maybe Dr. Taylors the better one (1) to ask 14 this question of -- but we've got the 5 percent of the 50 15 percent being criminally suspicious at the end of the 16 autopsy. This is the front end of that? 17 DR. DONALD PERRIN: Correct. 18 COMMISSIONER STEPHEN GOUDGE: What would 19 the number be if -- 20 DR. DONALD PERRIN: I'm not aware of -- 21 COMMISSIONER STEPHEN GOUDGE: -- compared 22 to 5 percent? That's for Dr. Taylor? 23 DR. DONALD PERRIN: It's -- it's probably 24 for Dr. Taylor. 25 COMMISSIONER STEPHEN GOUDGE: Okay.

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1 2 CONTINUED BY MR. ROBERT CENTA: 3 MR. ROBERT CENTA: And would it -- would 4 you agree that now that these guidelines are in place, it 5 -- it would be easy to track somehow, whether these 6 guidelines were applied to a particular case or not, so 7 that in the future, you could have a better sense of how 8 often these -- these guidelines are being triggered? 9 DR. DONALD PERRIN: Yeah, you could do 10 that. 11 MR. ROBERT CENTA: We look at section 4, 12 that delineates the role of the pathologist when these 13 guidelines do apply. Section 4.2 reads: 14 "The pathologist is responsible for 15 performing the post-mortem examination. 16 Pathologist assistants will perform 17 technical tasks only under the direct 18 supervision of the pathologist." 19 Can you help me understand what you 20 understand to be a technical task that you can perform 21 under these guidelines. 22 DR. DONALD PERRIN: I'm not quite clear on 23 this statement. I would assume that a technical staff is 24 -- his technical task would be include taking photo mics 25 (phonetics) under the direction of the pathologist, but

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1 I'm not sure they -- they include that. Typing whatever 2 the pathologist has written down or as a joint venture was 3 -- sometimes Dr. Wilson and myself will discuss the case 4 and he'll then write what he thinks are the pre -- 5 diagnosis. I will type those. 6 MR. ROBERT CENTA: And have you had the 7 opportunity to sit down with representatives of the 8 Hospital for Sick Children and the Office of the Chief 9 Coroner to discuss how to implement these guidelines? 10 DR. DONALD PERRIN: No. 11 MR. ROBERT CENTA: Do you think that would 12 be of assistance to interpreting these guidelines? 13 DR. DONALD PERRIN: Yes. 14 MR. ROBERT CENTA: And do you think it 15 would be helpful to try and more clearly delineate the 16 appropriate role of the pathologist assistant in a 17 criminally suspicious or homicide case beyond that 18 sentence in -- 19 DR. DONALD PERRIN: Yes. 20 MR. ROBERT CENTA: -- Section 4.2? 21 DR. DONALD PERRIN: Yes. 22 MR. ROBERT CENTA: And in light of the -- 23 I take it that the duties that you would perform during a 24 post-mortem examination, we talked about them being 25 influenced by the pathologist you're working with, that

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1 the pathologist will assign you certain duties and will 2 not -- 3 DR. DONALD PERRIN: He will delegate 4 certain -- 5 MR. ROBERT CENTA: -- dele -- 6 DR. DONALD PERRIN: -- acts. 7 MR. ROBERT CENTA: And I take it these 8 guidelines also will affect the work that you can do in a 9 criminally suspicious or homicide case? 10 DR. DONALD PERRIN: Yes. 11 MR. ROBERT CENTA: And I take it -- would 12 you agree with me that some training and a shared 13 understanding with the Office of the Chief Coroner and the 14 Hospital for Sick Children would be of assistance to 15 making sure that these guidelines are implemented 16 effectively going forward? 17 DR. DONALD PERRIN: I think it's need to 18 be delineated a little more clearly. 19 MR. ROBERT CENTA: Okay. Thank you for 20 your indulgence, Commissioner. Those are -- those are my 21 questions. 22 COMMISSIONER STEPHEN GOUDGE: Okay, 23 thanks, Mr. Centa. 24 What do you suggest? Do you want to do 25 what we did this morning and I will break now for fifteen

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1 (15) minutes and we can come back with the batting order-- 2 MR. ROBERT CENTA: That would be -- 3 COMMISSIONER STEPHEN GOUDGE: -- and then 4 wrap up the day? 5 MR. ROBERT CENTA: That would be very 6 helpful. 7 COMMISSIONER STEPHEN GOUDGE: Thanks. We 8 will rise then until about ten (10) past 3:00. 9 10 --- Upon recessing at 2:51 p.m. 11 --- Upon resuming at 3:11 p.m. 12 13 MR. REGISTRAR: All Rise. Please be 14 seated. 15 COMMISSIONER STEPHEN GOUDGE: Okay. Mr. 16 Ortved...? 17 18 CROSS-EXAMINATION BY MR. NIELS ORTVED: 19 MR. NIELS ORTVED: Thank you, Mr. 20 Commissioner. So, Dr. Perrin, my names is Niels Ortved. 21 I act for Dr. Smith. 22 DR. DONALD PERRIN: Good morning. 23 MR. NIELS ORTVED: Just a couple of very 24 short questions, I think. You referred to the job 25 description that you find at Tab number 2 of your binder,

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1 Dr. Perrin. And -- and Mr. Centa took you to 1(4) of that 2 job description, which refers to the fact that as 3 delegated by the particular pathologist with whom you're 4 working, you'll do certain duties including the 5 dissection, correctly... 6 DR. DONALD PERRIN: Correct. 7 MR. NIELS ORTVED: And -- and can you just 8 assist the Commissioner as to the extent to which you 9 engage in dissection, depending on -- on the pathologist 10 in question? 11 DR. DONALD PERRIN: Dissection actually 12 varies from pathologist to pathologist and from case to 13 case. There are really two (2) types, I guess, of cases, 14 as far as dissection. There's the high profile forensic 15 type case, and then there's the more medical type case 16 where there's a medical disease underlying the -- the 17 cause of death and different types of dissections are done 18 in each case. 19 In the high profile forensic case, Dr. 20 Smith implemented the 631 Memo, which involved extensive 21 dissection of the body, front and back. And he also 22 preferred a posterior neck dissection, a dry neck 23 dissection anteriorly. 24 MR. NIELS ORTVED: Okay. So I'm going to 25 actually ask you about those in a little bit more detail,

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1 but just -- just dealing with the -- the dissection which 2 you perform personally depending on the pathologist, would 3 it -- it would include, I take it, the "Y" incision? 4 DR. DONALD PERRIN: Correct. 5 MR. NIELS ORTVED: And -- and other 6 dissections, depending on what the pathologist requests of 7 you, I take it? 8 DR. DONALD PERRIN: Correct. 9 MR. NIELS ORTVED: And would that be the 10 case in both medical cases and autop -- and -- and 11 medicolegal cases? 12 DR. DONALD PERRIN: It would depend. If 13 there was trauma, the pathologist might prefer to do the 14 dissection at certain -- at a certain stage himself where 15 the trauma was involved. 16 MR. NIELS ORTVED: All right. And then 17 what you've mentioned to us was that back in 1995, there 18 was this 631 memo that you've referred to? 19 DR. DONALD PERRIN: Correct. 20 MR. NIELS ORTVED: And that was a memo 21 that was circulated by Dr. Smith that set in place certain 22 procedures for criminally suspicious cases? 23 DR. DONALD PERRIN: That was drafted 24 partly by Dr. Smith, signed by Dr. Young. But Dr. Smith 25 had sig -- I know how he had significant involvement in

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1 writing that -- 2 MR. NIELS ORTVED: Right. 3 DR. DONALD PERRIN: -- memo. 4 MR. NIELS ORTVED: And what that entailed, 5 in part, was that there were to be full skeletal surveys, 6 is one (1) aspect? 7 DR. DONALD PERRIN: Correct. 8 MR. NIELS ORTVED: Of infants under five 9 (5)? 10 DR. DONALD PERRIN: Under two (2). 11 MR. NIELS ORTVED: Under two (2) at the 12 time. 13 Now I think it's extended to infants under 14 five (5), is it not? 15 DR. DONALD PERRIN: Correct. 16 MR. NIELS ORTVED: And it also included 17 this dry neck dissection that you made reference to, 18 correct? 19 DR. DONALD PERRIN: Correct. 20 MR. NIELS ORTVED: And maybe you could 21 just tell -- tell the Commissioner what this dry neck 22 dissection is all about. 23 DR. DONALD PERRIN: In cases where there's 24 suspected an asphyxial mode of death -- in other, a 25 smothering or a compression over the mouth or those kinds

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1 of cases -- a dry neck dissection would be done. 2 In that case, the Y incision -- the 3 evisceration -- would include all organs below the 4 clavicles. That would be the abdomina and thoracic 5 viscera but not the neck until after the brain had been 6 removed, and the thoracic and abdomina viscera had been 7 removed. 8 The idea behind that was to drain blood 9 from the body before dissecting the neck tissues for 10 evidence of trauma. 11 MR. NIELS ORTVED: And just explain to the 12 Commissioner what the -- how -- how draining the blood 13 from the neck makes a difference. 14 DR. DONALD PERRIN: The idea behind that 15 is you don't contaminate any tissues with blood from blood 16 vessels because a lot of the blood will be drained out of 17 those blood vessels. So you would not confuse post-mortem 18 bleeding from vessels with actual pre-mortem hemorrhages. 19 And also to document that you'd like to 20 take photographs, so you want to make sure your 21 photographs do not show artifacts as far as contamination 22 by blood, you want to have actual -- true documentation of 23 the lesions. 24 MR. NIELS ORTVED: Right. And then the 25 only other thing I wanted to canvass with you was you

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1 mentioned that you'd been involved in collecting some 2 slides for a -- for a review of Dr. Smith's surgical work. 3 And we know that that -- we know that one (1) of those was 4 undertaken at the insistence of Dr. Taylor and you allowed 5 -- you think it may have -- it may have been Dr. Taylor 6 that told you to do that? 7 DR. DONALD PERRIN: It probably was Dr. 8 Taylor, I expect. Now I think about it, it was probably 9 Maxine Johnson had told Dr. Taylor that we should find 10 these slides and put them together for something to send 11 out for a review of -- 12 MR. NIELS ORTVED: Right. 13 DR. DONALD PERRIN: -- Dr. Smith's work. 14 MR. NIELS ORTVED: Okay. Thank you. 15 Those are my questions, Mr. Commissioner. 16 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 17 Ortved. 18 Mr. Campbell...? 19 20 CROSS-EXAMINATION BY MR. PHILLIP CAMPBELL: 21 MR. PHILLIP CAMPBELL: Good afternoon, Dr. 22 Perrin. 23 DR. DONALD PERRIN: Hello 24 MR. PHILLIP CAMPBELL: I'm Phillip 25 Campbell and I represent a group of persons who were

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1 convicted of offences in cases where Dr. Smith was 2 involved, and I just have a few areas to touch on. 3 You've had the opportunity, because of your 4 own long service at Sick Kids' Hospital, to observe Dr. 5 Smith's career, I think, since its inception and -- and 6 I'm wondering about this. 7 We know that from sometime in the early to 8 mid-'90s and onward, Dr. Smith had an exceptional 9 reputation, at least in public and judicial and criminal 10 justice circles as a -- as a pediatric pathologist -- or 11 forensic pathologist. I'd like to ask if, in the more 12 specialized circles that you moved in and were aware of in 13 the hospital, if he also had an elevated reputation as a - 14 - as a really distinctively superior pathologist? 15 DR. DONALD PERRIN: No, I don't think so. 16 There's a -- the pathologists at Sick Kids are world- 17 renowned as far as pediatric pathology. There's people 18 like Dr. Becker, who is world-wide reputation; Dr. Ernest 19 Cutz, again, a leading person in his field; Dr. Gregory 20 Wilson, another leading person in his field; and then 21 there's Dr. Taylor, who's also another leading person in 22 his field, pediatric pathology. These are all expert 23 pediatric pathologists. 24 Dr. Charles Smith wasn't world renowned as 25 a pediatric pathologist, but he was known as a forensic

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1 pediatric pathologist, I believe. 2 MR. PHILLIP CAMPBELL: Yeah, I think 3 that's probably true. His -- his work did not include a 4 lot of original research insofar as I can understand the 5 evidence we've heard, is that fair to say? 6 DR. DONALD PERRIN: As far as I know, 7 that's true. 8 MR. PHILLIP CAMPBELL: Were you able -- 9 watching his career with whatever level of attention you 10 devoted to it -- were you able to -- to identify the 11 source of that reputation and when it -- when it 12 crystallized, because it -- it had an affect on a -- on a 13 -- quite a large number of people connected with this 14 case? 15 DR. DONALD PERRIN: I think it was very 16 gradual. I mean, I think once he became Director of the - 17 - the Unit, I think, his reputation had increased. He -- 18 don't forget, once he was -- the unit was formed, he did 19 most of the hoe -- high profile medicolegal cases, 20 forensic cases, or criminally suspicious cases, so the 21 number of criminally suspicious cases that Dr. Smith did 22 increased in that time frame. 23 The other pathologists tended not to do 24 those cases. 25 MR. PHILLIP CAMPBELL: You were aware --

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1 COMMISSIONER STEPHEN GOUDGE: Was that a 2 matter of interest or -- in other things or how did that - 3 - 4 DR. DONALD PERRIN: That was a matter of 5 selection by Dr. Smith, I believe, or -- and the coroner's 6 office, who thought that he should do these cases. 7 COMMISSIONER STEPHEN GOUDGE: Sorry, Mr. 8 Campbell. 9 10 CONTINUED BY MR. PHILLIP CAMPBELL: 11 MR. PHILLIP CAMPBELL: Were you also aware 12 of Dr. Smith frequently doing consultations with other 13 forensic pathologists who would just solicit his opinion 14 on a case of their own? 15 DR. DONALD PERRIN: I'm aware that tissues 16 in -- in reports and blocks were sent in for consultation 17 to Dr. Smith. 18 MR. PHILLIP CAMPBELL: And also sometimes 19 consultations that didn't involve actually looking at the 20 raw material of the autopsy? 21 DR. DONALD PERRIN: I'm less aware of 22 that. I think I do know there were -- that he was doing 23 some, [quote], 'informal consults', but we really had no 24 record of that, so we didn't know, whereas the tissues -- 25 some of the tissues were blo -- brought in, we did know

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1 about. 2 MR. PHILLIP CAMPBELL: As a pathologist's 3 assistant, were you invited or expected to lend a voice to 4 the formation of the crucial opinions in the autopsy 5 report? 6 DR. DONALD PERRIN: No. 7 MR. PHILLIP CAMPBELL: And did you avoid 8 doing that? 9 DR. DONALD PERRIN: As much as possible, 10 yes. 11 MR. PHILLIP CAMPBELL: You must sometimes 12 had it -- 13 DR. DONALD PERRIN: I mean, we did discuss 14 some medical cases. I shouldn't say, you know, as far as 15 criminally suspicious, no, tha -- those things are not 16 usually decided upfront where -- where -- at the part 17 where I'm involved in; they usually decide it much later 18 or -- or in conference in the conference room. 19 What happened in the high profile 20 criminally suspicious cases, Dr. Smith or the pathologist 21 would meet with the police after the autopsy, often in the 22 conference room at the -- at Sick Kids on the third floor, 23 but I wasn't in -- part of that conversation. 24 MR. PHILLIP CAMPBELL: You would not be 25 invited to that?

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1 DR. DONALD PERRIN: No, no. 2 MR. PHILLIP CAMPBELL: And you wouldn't -- 3 or you wouldn't seek to go, either. 4 DR. DONALD PERRIN: No. 5 MR. PHILLIP CAMPBELL: And would you have 6 delivered an opinion privately to Dr. Smith of your own 7 before that? 8 DR. DONALD PERRIN: No. 9 MR. PHILLIP CAMPBELL: You must have come 10 across the name of Mr. Blenkinsop in the course of your 11 career at Sick Kids. 12 DR. DONALD PERRIN: Yes. 13 MR. PHILLIP CAMPBELL: You -- you began 14 your evidence this afternoon with a description of the 15 levels of accreditation available to a pathologist's 16 assistant. Was Mr. Blenkinsop an -- a board credited 17 pathologist's assistant? 18 DR. DONALD PERRIN: No. 19 MR. PHILLIP CAMPBELL: Did you have any 20 opportunity to evaluate his work? 21 DR. DONALD PERRIN: No. 22 23 (BRIEF PAUSE) 24 25 MR. PHILLIP CAMPBELL: I understand from

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1 background material in connection with the Inquiry that 2 you have an opinion on a subject that I've touched on with 3 a few witnesses, and that is the recording by some means 4 or another of what goes on before and during an autopsy. 5 DR. DONALD PERRIN: Before and during? 6 MR. PHILLIP CAMPBELL: Pardon me? 7 DR. DONALD PERRIN: You -- if you could 8 repeat that, before and during? 9 MR. PHILLIP CAMPBELL: Well, before and 10 during, although I use the word "recording" in it's 11 loosest sense, keep -- keeping a record of. 12 Having sat in on a large number of 13 autopsies, including those where there were clearly 14 criminal law issues, would you agree with me that it is 15 common for there to be a -- a continuing dialogue between 16 the police and the pathologist about facts in the case and 17 facts emerging from the autopsy? 18 DR. DONALD PERRIN: I think that depends 19 with the pathologist. But I think that's not true in most 20 cases nowadays, at least that -- the -- the actual feeling 21 is the pathologists do not want to discuss the fin -- the 22 particular case they're working on until the -- at the end 23 of the autopsy because they're -- things change as the 24 autopsy goes on. And I do believe that most the 25 pathologists now do not want to make judgments until the

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1 end of the autopsy. 2 MR. PHILLIP CAMPBELL: Do you hear them 3 asking questions of the police? 4 DR. DONALD PERRIN: Of -- the -- the 5 police asked -- oh, of the police? 6 MR. PHILLIP CAMPBELL: Yes. 7 DR. DONALD PERRIN: Usually that 8 discussion is pretty well taken care before we start the 9 autopsy. Sometimes there'll be a question like when was 10 the -- for instance, I'll give you a simple example: When 11 was the child last fed? Because when you open the stomach 12 and the child is supposed to have been fed fifteen (15) 13 minutes before he was found dead and there -- you know, 14 eith -- you want to know whether he had been fed or not 15 been fed, so they might ask that kind of question. 16 MR. PHILLIP CAMPBELL: Mm-hm. All right. 17 And there is, in advance of the autopsy, usually a 18 considerable amount of exchange between the police and the 19 pathologist? 20 DR. DONALD PERRIN: Correct. 21 MR. PHILLIP CAMPBELL: And no record is 22 made of that, I take it? 23 DR. DONALD PERRIN: The pathologist keeps 24 notes, selective notes, I believe. I don't know -- I 25 think that varies with pathologists and -- from case to

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1 case. 2 MR. PHILLIP CAMPBELL: And at the -- at 3 the case conference that follows the autopsy, you're not 4 usually present, so do you know if any record is made of 5 what's said there? 6 DR. DONALD PERRIN: I'm not aware of what 7 goes on exactly. I know now, since Dr. Chiasson's 8 implemented this, there is a -- a preliminary autopsy 9 findings form that is filled out, okay. It's just been 10 done in the last six (6) months maybe. 11 MR. PHILLIP CAMPBELL: Sorry, on whose 12 imple -- who's -- who -- 13 DR. DONALD PERRIN: At the end of the 14 autopsy, there is a preliminary autopsy findings form 15 that's filled out by the pathologist that is sent to Dr. 16 Chiasson or Dr. Pollanen. 17 And what it does is summarize briefly what 18 the findings were, just to give a heads up if this is a 19 high profile case or a criminally suspicious case, so that 20 Dr. Pollanen is aware of it and Dr. Chiasson is aware of 21 it, If he doesn't do it himself. And that form often has 22 a summary of the pertinent findings -- 23 MR. PHILLIP CAMPBELL: And that goes out 24 the -- on the day of the autopsy? 25 DR. DONALD PERRIN: That goes to Dr.

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1 Chiasson. And Dr. Chiasson, if he feels warranted, will 2 fax that to Dr. Pollanen. 3 MR. PHILLIP CAMPBELL: And is it something 4 that the pathologist just handwrites out and faxes over? 5 DR. DONALD PERRIN: Correct. 6 MR. PHILLIP CAMPBELL: Okay. 7 COMMISSIONER STEPHEN GOUDGE: Is that in 8 addition to the forms we heard about from Ms. Johnson this 9 morning? 10 DR. DONALD PERRIN: Correct. This is a 11 brand new form. Any idea, I believe, behind that is to 12 pro -- alert Dr. Pollanen and Dr. Chiasson that this is a 13 high profile case in case they -- Dr. Pollanen is not ware 14 -- aware of it, and whether it should be -- the body 15 should be held. 16 In this kind of case, a body would be held 17 for twenty-four (24) hours. It would be released from 18 Sick Kids until twenty-four (24) hours and then it would 19 be decided whether to release the body or not. 20 COMMISSIONER STEPHEN GOUDGE: And would 21 these be cases to which coming in the 2007 guidelines we 22 looked at before the break, would have applied or might 23 they be any case that is done under coroner's warrant -- 24 DR. DONALD PERRIN: No, these are the 25 cases that the pathologist feel that could become

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1 criminally -- a criminal investigation could ensue. 2 COMMISSIONER STEPHEN GOUDGE: Whether or 3 not the guidelines were implemented from the start of that 4 autopsy? 5 DR. DONALD PERRIN: Correct. 6 COMMISSIONER STEPHEN GOUDGE: Something 7 might have turned up during the autopsy that would require 8 the filling in of this form? 9 DR. DONALD PERRIN: If something -- if Dr. 10 Chiasson was not doing the autopsy -- 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. DONALD PERRIN: -- and something 13 turned up during the autopsy, he would be consulted if 14 possible or Dr. Pollanen would be consulted. This autopsy 15 would be stall -- stopped and we would say we need to talk 16 to Dr. Chiasson, Dr. Pollanen and discuss the case. 17 Because sometimes -- it has happened in the past where 18 we'll -- the case will stop and the decision will that 19 maybe Dr. Chiasson should take this case over. 20 And this can sometimes happen right at the 21 very beginning where the x-rays are performed and there 22 are fractures. And Dr. Wilson might say this is not the 23 kind of case I want to be involved in any longer. It 24 should be either Dr. Pollanen or Dr. Chiasson doing the 25 case.

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1 COMMISSIONER STEPHEN GOUDGE: Okay. 2 3 CONTINUED BY MR. PHILLIP CAMPBELL: 4 MR. PHILLIP CAMPBELL: You were, I think, 5 invited to express an opinion on the value of -- of video 6 and audio taping autopsies and I understand that you're -- 7 that -- that you weren't a -- a fan of that proposal. 8 And I just wondered if you could -- as somebody who's been 9 in this system a long time and attended a lot of 10 autopsies, if you could flesh out why you feel that way 11 and I may follow up with some questions 12 DR. DONALD PERRIN: I feel that it would 13 inhibit -- it's a work in progress, the autopsy. You 14 have a clinical -- you have clinical input or police input 15 before you start and then you -- you start doing the 16 autopsy. And you might find certain things and you want 17 to discuss freely with the pathologist and -- and the 18 pathologist may want to discuss things with you. 19 MR. PHILLIP CAMPBELL: "With you" meaning 20 you the pathologist's assistant. 21 DR. DONALD PERRIN: Myself and -- as a 22 prosector at that time, and we need to decide what we're 23 going to do, whether we should need to take samples. And 24 I -- I -- there's a lot of discussion that goes on during 25 the autopsy between the pathologist's assistant and the

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1 pathologist of what -- what samples need to be taken and 2 what this means and the significance of this. 3 And I don't think that -- we don't like the 4 police to actually record all these things. It like 5 seeing blood somewhere on the -- and -- which means 6 nothing, but the police take a photograph of it and then 7 you are left explaining that this really isn't anything 8 significant, this is just blood that dripped from 9 somewhere else. It's not a significant -- I mean so we 10 try not to have the police take pictures randomly. We 11 actually tell them exactly what pictures should be taken. 12 MR. PHILLIP CAMPBELL: Okay. 13 DR. DONALD PERRIN: And so I think it 14 would inhibit that kind of back and forth dol -- dialogue. 15 MR. PHILLIP CAMPBELL: Have you attended 16 an autopsy that was being taped? 17 DR. DONALD PERRIN: Yes. 18 MR. PHILLIP CAMPBELL: Including audio 19 taped? 20 DR. DONALD PERRIN: Yes. I -- well, I'm 21 not so sure about audiotape, but I've attended a number of 22 -- we actually did a study of this quite a few years ago 23 where we videoed autopsies, five (5) or six (6) I 24 remember, and we reviewed them and it's interesting that 25 the pathologists all left after about two (2) minutes;

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1 they did not like watching themselves in an autopsy. 2 COMMISSIONER STEPHEN GOUDGE: Why not? 3 DR. DONALD PERRIN: I think it's a -- it's 4 a -- it must be very hard for the police to attend an 5 autopsy because they -- when you're doing the autopsy you 6 are -- you are mentally involved in the case, you're 7 involved in trying to figure out what's go -- what is 8 going on and the lesions, but when you're actually 9 watching it and have nothing to occupy your mind, I 10 think -- 11 COMMISSIONER STEPHEN GOUDGE: So who 12 left -- 13 DR. DONALD PERRIN: It's not a -- 14 COMMISSIONER STEPHEN GOUDGE: -- who left 15 after a couple of minutes of watching? 16 DR. DONALD PERRIN: Well we videotaped 17 this -- 18 COMMISSIONER STEPHEN GOUDGE: Was it the 19 police? 20 DR. DONALD PERRIN: No, we videotaped 21 these and then we all went down to the room in the dark 22 and watched the autopsy and the -- 23 24 CONTINUED BY MR. PHILLIP CAMPBELL: 25 MR. PHILLIP CAMPBELL: "We" meaning a

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1 group of pathologists? 2 DR. DONALD PERRIN: Pathologists and 3 myself. And Dr. Phillips left first and then shortly 4 after, everybody left, and I was left alone in the dark. 5 But that -- that just shows you that it's not a pleasant 6 procedure, as everybody knows and it's not pleasant to 7 watch somebody else doing it. 8 MR. PHILLIP CAMPBELL: But it's worse on 9 TV than in person. 10 DR. DONALD PERRIN: Well, that's -- I 11 think this happened long before -- I think now we've been 12 -- we see this a lot on television, this kind of pro -- 13 procedures, which we didn't twenty (20) years ago. 14 MR. PHILLIP CAMPBELL: Would you accept 15 that thing -- that in the course of an autopsy, decisions 16 are made about what to investigate or not to investigate 17 that can affect the course of the conclusion of the 18 autopsy? 19 I -- I'm speaking here from the perspective 20 of a jury who has to think about the -- the significance 21 of this autopsy a year or two (2) after it occurs and -- 22 and wants to know maybe what went on. 23 DR. DONALD PERRIN: I think now we 24 investigate these kids much more -- in a much more 25 standardised fashion. I mean, that started with Dr. Smith

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1 when he brought up the see -- the 631 Form. In other 2 words, a dry neck would be done on all cases. Toxicology 3 we submitted it in all cases. 4 The -- in -- this is kind of that -- that 5 standard has actually advanced more with these new for -- 6 these new protocols, where the -- the back and the neck, 7 for instance, will be examined in detail on all cases. So 8 -- and what that does is actually allow you to evaluate 9 findings on cases that are significant, versus the cases 10 you don't -- you might find lesions on all these cases 11 from the resuscitation, for instance, right? By -- by 12 doing it on a routine case, by case, by case, by case, you 13 get a background knowledge of what the -- what you'd 14 expect to find, so you can better evaluate significant 15 cases. 16 MR. PHILLIP CAMPBELL: That's a sort of 17 checklist approach to -- to standardisation. 18 DR. DONALD PERRIN: Yeah. It's kind of -- 19 you can think of it the same way as taking histology 20 samples on -- on normal kids. Why do you do that? 21 Well, you get -- do that because you get 22 used to the variation, especially in children where 23 children -- you're looking at children from newborns all 24 the way up to sixteen (16) years of age. They say the -- 25 the long -- change a great deal and I think the -- that --

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1 it's a stained approach. By doing a standardised approach 2 you get a background knowledge of what to expect. 3 MR. PHILLIP CAMPBELL: Mm-hm. Another 4 observation I think you made of -- of Dr. Smith was a 5 tendency on his part to defer to the opinions of -- of 6 child abuse experts, child abuse medical staff, when they 7 were in the autopsy room? 8 DR. DONALD PERRIN: I don't know if I said 9 before, but I did consult with the SCAN Team. I think Dr. 10 Smith felt that the SCAN Team had actually more experience 11 in looking at those types of lesions then he did. 12 MR. PHILLIP CAMPBELL: Were you aware, as 13 a pathologist's assistant, and -- and obviously a very 14 experienced figure in the autopsy room, were you aware of 15 differences in the interpretation of the anogenital area 16 of children before and after death. 17 Were you aware that -- that death can 18 affect observations in that area, relevant to sexual 19 assault? 20 DR. DONALD PERRIN: I assume you're 21 talking the anal dilatation and that kind of lesion? 22 MR. PHILLIP CAMPBELL: Yes. 23 DR. DONALD PERRIN: Yeah, I was aware of 24 that. 25 MR. PHILLIP CAMPBELL: When did you become

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1 aware of that, can you think back in your career? 2 DR. DONALD PERRIN: We started -- when I 3 first started, we'd do indi -- we did forensic cases 4 there, so I guess -- but I don't know exactly when. I 5 knew that this could happen. 6 I think that those examinations are always 7 very difficult because, you know, you can get -- somebody 8 can manipulate those areas and not leave any evidence of 9 trauma. So -- and I think clinicians are somewhat -- 10 sometimes better at this kind of thing, because they see a 11 lot of these. 12 MR. PHILLIP CAMPBELL: But on the other 13 hand, death can cause a dilation that is -- that is 14 clinically insignificant? 15 DR. DONALD PERRIN: Correct. 16 MR. PHILLIP CAMPBELL: And you've been 17 aware of that I take it, for most of your career? 18 DR. DONALD PERRIN: Correct. 19 MR. PHILLIP CAMPBELL: And it was a thing 20 you were -- alert to from early on in your own pathology 21 assistant's practice? 22 DR. DONALD PERRIN: Correct. 23 MR. PHILLIP CAMPBELL: I have nothing 24 further, thanks very much, Dr. Perrin. 25 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr.

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1 Campbell. 2 One (1) of the things you said in answer to 3 Mr. Campbell, Dr. Perrin, was that the modern practice 4 seems to be less, sort of -- let me put it another way, 5 the pathologist is less interested in dialoguing with the 6 police until the conclusion of the autopsy once it starts? 7 DR. DONALD PERRIN: Correct. 8 COMMISSIONER STEPHEN GOUDGE: How would 9 you contrast, or compare at least, that aspect of the 10 autopsy today with the same aspect of the autopsy to, let 11 us say, fifteen (15) years ago, ten (10) years ago? 12 Is that a change? 13 DR. DONALD PERRIN: That is a change. I 14 don't know if I should attribute it to Michael Pollanen, 15 but I know Michael Pollanen, and I've done cases with 16 Michael at Sick Kids, and Dr. Pollanen is quite adamant 17 that the police not take notes until the end of the 18 autopsy. I've even heard -- 19 COMMISSIONER STEPHEN GOUDGE: And then 20 others have followed that example, I take it? 21 DR. DONALD PERRIN: I think Dr. Chiasson 22 tends not to do that as well. 23 COMMISSIONER STEPHEN GOUDGE: But it -- 24 DR. DONALD PERRIN: Charles was -- I -- 25 seemed to be much more willing to talk to the police --

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1 COMMISSIONER STEPHEN GOUDGE: During the 2 autopsy? 3 DR. DONALD PERRIN: -- during the autopsy. 4 But often it was for educational purposes. He was showing 5 them -- 6 COMMISSIONER STEPHEN GOUDGE: That is 7 explaining things to them? 8 DR. DONALD PERRIN: Correct. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 Thanks. 11 Mr. Di Luca...? 12 MR. JOSEPH DI LUCA: I have no questions, 13 Mr. Commissioner. 14 COMMISSIONER STEPHEN GOUDGE: I had you 15 down for ten (10) minutes, Mr. Di Luca. 16 MR. JOSEPH DI LUCA: I'll take a pass, 17 thank you very much. 18 COMMISSIONER STEPHEN GOUDGE: Take a pass, 19 you'll bank it? Are you on the list Mr. Wardle? 20 MR. PETER WARDLE: That was my ten (10) 21 minutes. 22 COMMISSIONER STEPHEN GOUDGE: Oh, that's 23 your ten (10) minutes, okay. We have you on another team 24 jersey here. Come on, it's you now. I just had the 25 Criminal Lawyer's Association down.

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1 2 CROSS-EXAMINATION BY MR. PETER WARDLE: 3 MR. PETER WARDLE: Dr. Perrin, my name's 4 Peter Wardle, and I act for a number of families who were 5 affected by some of Dr. Smith's findings and I just have a 6 few questions for you. 7 You started at Sick Kids in 1980, 8 approximately? 9 DR. DONALD PERRIN: Correct. 10 MR. PETER WARDLE: And so you overlapped 11 for your entire period until Dr. Smith left, with Dr. 12 Smith, and also with Dr. Cutz, correct? 13 DR. DONALD PERRIN: Correct. 14 MR. PETER WARDLE: In fact Dr. Cutz, was 15 he at Sick Kids before you arrived? 16 DR. DONALD PERRIN: Correct. 17 MR. PETER WARDLE: And when did he -- when 18 did he retire? 19 DR. DONALD PERRIN: Dr. Cutz did not 20 retire. 21 MR. PETER WARDLE: He hasn't retired, but 22 he's not doing medicolegal cases anymore? 23 DR. DONALD PERRIN: Correct. 24 MR. PETER WARDLE: When did he stop doing 25 them?

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1 DR. DONALD PERRIN: I think you'll have to 2 ask Dr. Cutz that. It's probably been in -- less than a 3 year. 4 COMMISSIONER STEPHEN GOUDGE: Sorry, in? 5 DR. DONALD PERRIN: Less than a year he's 6 -- in the last year he's retire -- I think into 2006, but 7 I don't know for sure. 8 9 CONTINUED BY MR. PETER WARDLE: 10 MR. PETER WARDLE: And is it fair to say 11 that, you know, from 1980 until recently you worked 12 extensively with both Dr. Cutz and Dr. Smith? 13 DR. DONALD PERRIN: Correct. 14 MR. PETER WARDLE: And just -- I 15 understand that they did not have a particularly good 16 working relationship. 17 Is that fair? 18 DR. DONALD PERRIN: That's -- that's true. 19 MR. PETER WARDLE: And as I understand it, 20 Dr. Smith had fairly strong views that there were a number 21 of child deaths that were not attributable to natural 22 causes. 23 Is that -- is that fair? 24 DR. DONALD PERRIN: I think Dr. Smith 25 thought that these cases weren't being investigated

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1 sufficiently in the old days, and that they needed to be 2 investigated much more thoroughly to rule out criminally 3 suspicious -- criminal trauma, criminal events. 4 MR. PETER WARDLE: And so in the old days 5 we'd be talking about the late -- 6 DR. DONALD PERRIN: Pre -- 7 MR. PETER WARDLE: -- '80s and the early 8 '90s? 9 DR. DONALD PERRIN: Pre '90 -- pre -- pre- 10 unit times. 11 MR. PETER WARDLE: Okay. And I understand 12 he told you that Dr. Cutz did not pursue the possibility 13 of criminal injury strongly enough in some of his cases, 14 is that correct? 15 DR. DONALD PERRIN: That was a rough 16 paraphrasing of what Dr. Smith expressed to me. 17 MR. PETER WARDLE: Okay. So that's your 18 recollection today about -- more or less what he would 19 have told you at some point in the past? 20 DR. DONALD PERRIN: Correct. 21 MR. PETER WARDLE: And this came up, as I 22 understand it, in the context of SIDS deaths, correct? 23 DR. DONALD PERRIN: Well, I think it came 24 up in the context of sudden unexpected deaths, and in that 25 -- less than year -- year of age, but I think it implied,

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1 in general, to any that -- sudden deaths outside the 2 hospital that occurred, not necessarily SIDS deaths. 3 MR. PETER WARDLE: And -- and Dr. Cutz, as 4 I understand it, had a strong interest in -- and strong 5 research background in SIDS, correct? 6 DR. DONALD PERRIN: Correct. 7 MR. PETER WARDLE: Okay. And am I right 8 that -- from your observation of the two (2) of them in 9 the autopsy room -- that Dr. Cutz was more cautious in his 10 dealings with the police? 11 DR. DONALD PERRIN: Yes, I would -- I 12 would say that. 13 MR. PETER WARDLE: And Dr. Smith was 14 inclined to have more interaction with the police? 15 DR. DONALD PERRIN: Correct. 16 MR. PETER WARDLE: And he was more 17 inclined to, as you said it, you know, give informational 18 material, educational material to the police during an 19 autopsy? 20 DR. DONALD PERRIN: Dr. Smith was, yes. 21 MR. PETER WARDLE: And was he more 22 inclined to give information in the nature of opinions 23 during the autopsy process? 24 DR. DONALD PERRIN: I don't think that's 25 true. I don't know -- he didn't -- again, he did not give

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1 information on the final cause of death during the 2 autopsy. That would be something I wasn't priv -- privile 3 -- privileged -- or wasn't present. 4 They would actually go back to -- to the 5 conference room or his office, so I really wasn't present 6 on that kind of discussion. 7 COMMISSIONER STEPHEN GOUDGE: Who would go 8 back there? 9 DR. DONALD PERRIN: Dr. Smith and the 10 police. 11 12 CONTINUED BY MR. PETER WARDLE: 13 MR. PETER WARDLE: And did Dr. Smith ask 14 more questions of the police than Dr. Cutz about the 15 background of the case, the history, the circumstances 16 that lead to the body coming in -- all that sort of thing? 17 DR. DONALD PERRIN: I don't know if it was 18 more questions. It would be different type of questions, 19 different -- for instance, Dr. Cutz would be more 20 concerned about the perinatal history, the medical 21 history, than probably Dr. Smith. 22 MR. PETER WARDLE: Thank you. Those are 23 all my questions for you, sir. 24 DR. DONALD PERRIN: Okay. 25 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr.

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1 Wardle. 2 Would other pathologists doing medicolegal 3 autopsies meet with the police after the autopsy? 4 DR. DONALD PERRIN: Yes. 5 COMMISSIONER STEPHEN GOUDGE: Is that 6 common practice? 7 DR. DONALD PERRIN: It's -- they -- they 8 could -- they might just go into the corner of the autopsy 9 area and -- and discuss if it was a straightforward quote, 10 "no anatomical findings" or they -- 11 COMMISSIONER STEPHEN GOUDGE: Sorry, 12 no...? 13 DR. DONALD PERRIN: -- they -- there was 14 no significant anatomical findings at the end -- 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 DR. DONALD PERRIN: -- they might just say 17 there's no significant anatomical findings, no evidence of 18 trauma, radiology is negative, and we have to wait for 19 microscope and technolo -- toxicology. That kind of 20 straightforward case, they might just meet in the autopsy 21 room. 22 Any kind of case where there was trauma, 23 they would actually leave and there would be quite a long 24 -- usually a fairly long discussion in -- in their office 25 or in the conference room.

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1 COMMISSIONER STEPHEN GOUDGE: And that 2 would usually be right at the conclusion of the autopsy? 3 DR. DONALD PERRIN: Correct. And that was 4 -- again, that was usually Dr. Smith's cases because those 5 are the kind of cases he did. 6 COMMISSIONER STEPHEN GOUDGE: But if those 7 cases were done by other pathologists, they would do it 8 too? 9 DR. DONALD PERRIN: Correct. 10 COMMISSIONER STEPHEN GOUDGE: Is that a 11 practice that is carried on today in the unit? 12 DR. DONALD PERRIN: Yes. 13 COMMISSIONER STEPHEN GOUDGE: Thanks, Dr. 14 Perrin. 15 Ms. Ritacca...? 16 17 CROSS-EXAMINATION BY MS. LUISA RITACCA: 18 MS. LUISA RITACCA: Good afternoon, Dr. 19 Perrin. My name is Luisa Ritacca. I'm one (1) of the 20 lawyers here for the Office of the Chief Coroner. 21 DR. DONALD PERRIN: Good afternoon. 22 MS. LUISA RITACCA: Dr. Perrin, in your 23 career as a pathologist's assistant, have you ever had the 24 opportunity to work in another morgue? 25 DR. DONALD PERRIN: Autopsy suite.

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1 MS. LUISA RITACCA: Autopsy suite, sorry. 2 DR. DONALD PERRIN: No, I've only done -- 3 I think I've done two (2) cases over at the Coroner's 4 Office, but they were -- they were unusual cases, and the 5 fact that there was high publicity and the families did 6 not want the autopsy. 7 So it had nothing to do with being -- being 8 high profile forensic. It was more to do with family not 9 wanting an autopsy even though the coroner had ordered an 10 autopsy. So the decision was to do them over at the 11 Coroner's Office. 12 MS. LUISA RITACCA: And sorry, you said 13 they weren't forensic, so they were not criminally -- 14 DR. DONALD PERRIN: Well, they weren't -- 15 MS. LUISA RITACCA: -- suspicious, is 16 that -- 17 DR. DONALD PERRIN: -- high-profile 18 criminally suspicious cases. They were medicolegal -- or 19 coroner's autopsies, but they weren't -- wasn't a 20 criminally suspicious case. It was just that the family 21 did not want the autopsy; they were protesting. And the 22 pathologist felt that it would be better done over at the 23 Coroner's Office, and he asked me to go with him. 24 MS. LUISA RITACCA: And who was that 25 pathologist?

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1 DR. DONALD PERRIN: Dr. Cutz. 2 MS. LUISA RITACCA: And do you remember 3 when that was? 4 DR. DONALD PERRIN: No. 5 MS. LUISA RITACCA: Do you -- 6 COMMISSIONER STEPHEN GOUDGE: How 7 different is it with that experience -- doing it there 8 than doing it at Sick Kids? 9 DR. DONALD PERRIN: I don't think it's 10 anything signifig -- difference. We do have -- well, I 11 think we still have better facilities for pediatrics. We 12 have better photography system. 13 We do have our own x-ray facilities there. 14 We do have a pediatric radiologist interpret the results. 15 Things like that. So I think -- 16 COMMISSIONER STEPHEN GOUDGE: That sounds 17 like some significant difference. 18 DR. DONALD PERRIN: Well, they can always 19 -- the Coroner's Office can take radi -- x-rays and they 20 will have a -- they can send them to a pediatric 21 radiologist to be examined. 22 But the upfront -- I agree, there is some 23 significant differences because the -- what the -- what 24 happens in our institution is that the radiologist will 25 often ask for additional x-rays, especially if there is a

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1 -- any evidence of trauma. So we might do an upfront x- 2 rays and if we see trauma or evidence of trauma -- 3 COMMISSIONER STEPHEN GOUDGE: And then 4 when they come back, the radiologist would say, I'd like 5 to take some more pictures? 6 DR. DONALD PERRIN: Correct. 7 8 CONTINUED BY MS. LUISA RITACCA: 9 MS. LUISA RITACCA: And just to follow up 10 from the Commissioner's question, Dr. Perrin. 11 We've heard from Dr. Chiasson that he keeps 12 up his -- well, he said that he keeps up his forensic 13 skills as they are, by doing some work at the OCCO on 14 adult cases. 15 Do you see any value for pathologist's 16 assistants to be exposed to forensic adult cases even 17 though you're primarily working in the pediatric setting? 18 DR. DONALD PERRIN: There might be some 19 small advantage to that but the trauma that we see in 20 pediatrics is much different from those in adults. 21 Gun shot wounds, we don't see. I mean, I 22 assume -- I've never done a shotgun wound in a kid. The 23 only one (1) I know that we were going to do was actually 24 sent to the Coroner's Office to be done. 25 So that kind of trauma we don't see. We

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1 don't -- so yeah, there would be an advantage, I think, 2 for certain things such as sexual assault kits. We don't 3 do them very often in pediatrics, where I assume, probably 4 in forensic, over at the Coroner's Office, they do them 5 much more frequently. 6 So yeah, I think there would be some 7 advantage to having some training. 8 MS. LUISA RITACCA: And what about with 9 regard to evidence collection? I don't -- I'm not sure 10 what role the pathologist's assistant plays in that. And 11 would that be something that it would be helpful if you 12 have experience in the adult setting to be able to apply 13 that to the pediatric setting? 14 DR. DONALD PERRIN: I don't think so. For 15 the most -- there might be the odd very, very rare case. 16 But for trace evidence, you're talking about? 17 MS. LUISA RITACCA: Yes. 18 DR. DONALD PERRIN: Trace evidence cases 19 don't usually come to our institution. They're usually 20 done at the Coroner's Office by Dr. Pollanen now. So if - 21 - if there is a case where they need trace evidence with 22 UV light, for instance, those cases tend to be done at the 23 Cor -- they go directly to the Coroner's Office. 24 COMMISSIONER STEPHEN GOUDGE: Why? 25 DR. DONALD PERRIN: Because we're not set

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1 up for that. We don't have a UV light, for one (1) thing. 2 They're -- those cases tend to be very high-profile, and 3 Dr. Pollanen wants to do them at the Coroner's Office. 4 COMMISSIONER STEPHEN GOUDGE: And you'd be 5 looking for trace evidence of...? 6 DR. DONALD PERRIN: Semen, blood stains. 7 COMMISSIONER STEPHEN GOUDGE: Bodily 8 fluids? 9 DR. DONALD PERRIN: Yes. Most of the 10 cases we receive have been resuscitated and extensively 11 handled by paramedics, resuscitation team, many EMRs. So 12 those kind of cases don't usually get that kind of trace 13 evidence analysis. 14 15 CONTINUED BY MS. LUISA RITACCA: 16 MS. LUISA RITACCA: And if we could put up 17 PFP137602; those are the Coroner's Office Guidelines for 18 Homicidal and Criminally Suspicious Deaths in Infants and 19 Children. And I'm sorry, Dr. Perrin, I don't know the tab 20 number. 21 Tab 9. Thank you, Mr. Centa. Mr. 22 Registrar, if we could flip to Section 2.2; I'm not sure 23 of the page number. 24 COMMISSIONER STEPHEN GOUDGE: Page 4. 25 MS. LUISA RITACCA: Four (4). Page 4.

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1 Dr. Perrin, is it fair to say if we look at 2 the inclusion criteria in Section 2.2, there's a fairly 3 low threshold for these guidelines to kick in? 4 DR. DONALD PERRIN: I guess you could say 5 that. There's some of them that are; you know, history of 6 a accidental fall. 7 MS. LUISA RITACCA: Well, I was looking 8 more, for example, at poor hygiene or lice infestation. 9 In an answer to a question from the Commissioner, you 10 indicated that only one of these had to be present, so, it 11 seems to me that it's a fairly low threshold before these 12 guidelines are meant to apply. Is that fair? 13 DR. DONALD PERRIN: Yes. 14 MS. LUISA RITACCA: And are you able to 15 comment at all what you as a pathologist's assistant, or 16 what you observed the pathologists doing in a case where 17 these guidelines apply, that's different than what they 18 would do when the guidelines do not apply? Or what you 19 would do? 20 DR. DONALD PERRIN: I -- I only do what 21 the pathologist tells me and delegates to me to do, so 22 that -- I don't think that really affects me directly. 23 The pathologist might ask for more history. 24 He had asked for, you know, background information more -- 25 maybe more extensively.

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1 MS. LUISA RITACCA: Ask whom that? 2 DR. DONALD PERRIN: The police. 3 MS. LUISA RITACCA: And anything about the 4 autopsy procedure that would be different? 5 DR. DONALD PERRIN: That's more defined by 6 what we find during the autopsy. For instance, 7 examination of a fa -- of the face, internally, is not 8 usually done on a -- on a autopsy. But if you find a -- 9 now, if you find bruises on the face, there is actual aff 10 -- there is actually a facial dissection performed. 11 MS. LUISA RITACCA: All right. 12 COMMISSIONER STEPHEN GOUDGE: Is there a 13 counter-part guideline for medicolegal autopsies that 14 clearly are not criminally suspicious? That would show 15 the difference in level of investigation, if you like. 16 DR. DONALD PERRIN: I believe that we are 17 treating all these cases now, almost the same. In other 18 words, all sudden deaths that come in to -- for autopsy, 19 have the same prosection or dissection techniques. 20 COMMISSIONER STEPHEN GOUDGE: But I assume 21 you -- you know, you get 150 cases under coroner's warrant 22 in a year. Am I right about that, Mr. Carter? 23 DR. DONALD PERRIN: I don't know. 24 MR. WILLIAM CARTER: I think about 130. 25 COMMISSIONER STEPHEN GOUDGE: 130. And

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1 half of those are criminally suspicious or half -- sorry - 2 - 50 percent of the 50 percent that are -- are done by -- 3 MR. WILLIAM CARTER: Five percent. 4 DR. DONALD PERRIN: Five percent. 5 COMMISSIONER STEPHEN GOUDGE: Five 6 percent. What I'm getting at is, for those that are 7 clearly not criminally suspicious, but are there under 8 coroner's warrant. 9 DR. DONALD PERRIN: For those I -- 10 COMMISSIONER STEPHEN GOUDGE: Is this 11 procedure used? 12 DR. DONALD PERRIN: No. For certain -- 13 there's a -- there's a percentage that are neonatal 14 deaths. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. DONALD PERRIN: They won't be -- they 17 won't be done. This -- under this pro -- they will be 18 dissected the same way. But any sudden death under 5, 19 that's a -- dies at home, with no known medical condition 20 in the background, will probably follow this type of 21 procedure. 22 COMMISSIONER STEPHEN GOUDGE: Right. For 23 those that don't get this procedure, how different is the 24 procedure they get? 25 DR. DONALD PERRIN: They -- for instance,

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1 they would nev -- they wouldn't get any back incisions. 2 They wouldn't have a cervical -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. DONALD PERRIN: -- posterior neck 5 incision. They might -- they wouldn't have a dry neck 6 dissection. 7 8 CONTINUED BY MS. LUISA RITACCA: 9 MS. LUISA RITACCA: Dr. Perrin, perhaps it 10 would be of assistance to you in answering the 11 Commissioner's question if you turn one (1) tab ahead to 12 Tab 8; looks to be the hospital's autopsy guidelines in 13 Sudden Unexpected Deaths of Infants and Children Under 5. 14 And that applies to all autopsies, not just 15 the criminally suspicious? Is that correct? 16 DR. DONALD PERRIN: That applies to all 17 sudden deaths under 5, not necessarily -- for instance, 18 there's -- there are coroner's cases of medicolegal 19 autopsies that are not sudden deaths. For instance, you 20 could have birth asphyxia. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DONALD PERRIN: A significant number 23 reported cases with birth asphyxia that are not sudden 24 deaths. So they wouldn't not be included in this 25 protocol.

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1 2 CONTINUED BY MS. LUISA RITACCA: 3 MS. LUISA RITACCA: All right. But the 4 difference between these two protocols is that the Sick 5 Kids one would apply to sudden unexpected deaths and the 6 one at Tab 9 from the Coroner's Office, applies to those 7 deaths that are homicidal or criminally suspicious. 8 DR. DONALD PERRIN: Criminally suspicious. 9 MS. LUISA RITACCA: All right. Those are 10 my questions, thank you. 11 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 12 Ritacca. Mr. Carter�? 13 MR. WILLIAM CARTER: I have no questions. 14 COMMISSIONER STEPHEN GOUDGE: Thank you. 15 Then Mr. Centa...? 16 17 RE-DIRECT EXAMINATION BY MR. ROBERT CENTA: 18 MR. ROBERT CENTA: Dr. Perrin, just one 19 set of questions arising out of some questions that Mr. 20 Campbell posed to you. He asked you whether or not Mr. 21 Blenkinsop was a board certified pathologists assistant or 22 a member of the AAPA, and you said he was not? 23 DR. DONALD PERRIN: Correct. 24 MR. ROBERT CENTA: And am I correct that 25 to be a board certified pathologist assistant you must

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1 fulfil a experience requirement? 2 DR. DONALD PERRIN: Correct. 3 MR. ROBERT CENTA: And that experience 4 requirement requires a candidate to have experience in a - 5 - in the prior number of years in the preparation, gross 6 description, and dissection of human tissue, surgical 7 specimens? 8 DR. DONALD PERRIN: Correct. 9 MR. ROBERT CENTA: And to the best of your 10 knowledge, did Mr. Blenkinsop do surgical pathology in his 11 position at the Chief Coroner's Office? 12 DR. DONALD PERRIN: At the Chief Coroner's 13 Office he would not have done surgeon material. 14 MR. ROBERT CENTA: Right. And thus he 15 would have been eligible for membership as a -- as a 16 person who was doing exclusively autopsy pathology? 17 DR. DONALD PERRIN: No, but this is only 18 the AAPA and the pathologist is only recognized in the 19 states -- 20 MR. ROBERT CENTA: Right. 21 DR. DONALD PERRIN: -- okay. I don't want 22 to -- Barry Blenkinsop, his reputation is quite well known 23 as an excellent assistant. 24 MR. ROBERT CENTA: But he would -- and as 25 an -- as an excellent assistant, he still wouldn't have

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1 met the very paticul -- that particular criteria for -- in 2 order to qualify to write the examination because he 3 didn't do surgical pathology? 4 DR. DONALD PERRIN: Correct. 5 MR. ROBERT CENTA: Thank you. Those are 6 my questions, Commissioner. 7 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 8 Centa. Well, Dr. Perrin, thank you very much. You also 9 have been of great assistance to us, and we are grateful 10 for the time you spent preparing and attending to help us. 11 12 DR. DONALD PERRIN: You're welcome. 13 14 (WITNESS STANDS DOWN) 15 16 COMMISSIONER STEPHEN GOUDGE: We will rise 17 now until 9:30 tomorrow morning. 18 19 --- Upon adjourning at 3:53 p.m. 20 21 Certified correct, 22 23 24 ______________________ 25 Rolanda Lokey, Ms.