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 18th, 2007 25

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

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  
  7  James Lockyer        (np) )     William Mullins-Johnson, 
  8  Alison Craig              )     Sherry Sherret-Robinson and
  9  Phillip Campbell          )     seven unnamed persons
 10  Peter Wardle              )     Affected Families Group
 11  Julie Kirkpatrick     (np) )
 12  Daniel Bernstein          )
 13  
 14  Louis Sokolov        (np) )     Association in Defence of
 15  Vanora Simpson            )     the Wrongly Convicted
 16  Elizabeth Widner      (np) )
 17  Paul Copeland         (np) )
 18  
 19  Jackie Esmonde        (np) )     Aboriginal Legal Services 
 20  Kimberly Murray           )     of Toronto and Nishnawbe
 21  Sheila Cuthbertson    (np) )      Aski-Nation
 22  Julian Falconer      (np) )
 23  
 24  
 25

4
  1                 APPEARANCES (cont'd)
  2  Suzan Fraser              )     Defence for Children 
  3                             )     International - Canada
  4  
  5  William Manuel            )     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 Exhibit List 4 5 ERNEST CUTZ, Sworn 6 GLENN PAUL TAYLOR, Sworn 7 8 Examination-In-Chief by Ms. Jennifer McAleer 8 9 10 11 12 Certificate of transcript 312 13 14 15 16 17 18 19 20 21 22 23 24 25

1 LIST OF EXHIBITS 2 EXHIBIT NO. DESCRIPTION PAGE NO. 3 1 Glenn Phillips' interview summary 8 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon commencing at 9:30 a.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Good 6 morning. 7 Ms. McAleer...? 8 MS. JENNIFER MCALEER: Good morning, Mr. 9 Commissioner. 10 Mr. Commissioner, this morning we have two 11 (2) pediatric pathologists from the Hospital for Sick 12 Kids. They will be testifying in-chief today and 13 available for cross-examination tomorrow. We have Dr. 14 Cutz and Dr. Taylor. 15 16 ERNEST CUTZ, Sworn 17 GLENN PAUL TAYLOR, Sworn 18 19 MS. JENNIFER MCALEER: And Mr. 20 Commissioner, before we begin with Doctors Cutz and Dr. 21 Taylor, I would like to file with the Commission the 22 interview summary for Dr. Phillips. 23 Dr. Phillips could not participate on the 24 panel today for health reasons, but we have previously 25 circulated his interview summary to all counsel and I

1 understand that no counsel have any followup questions 2 and as a result we will simply file Dr. Phillips' 3 interview summary as evidence in these proceedings. 4 COMMISSIONER STEPHEN GOUDGE: That is 5 fine. Thanks. Mark that as Exhibit 1. 6 7 --- EXHIBIT NO. 1: Glenn Phillips' interview 8 summary 9 10 EXAMINATION-IN-CHIEF BY MS. JENNIFER MCALEER: 11 MS. JENNIFER MCALEER: Dr. Cutz, we begin 12 by reviewing your resume, which is at Tab 1 of the 13 binders before you, in Volume I. And Mr. Registrar, that 14 is PFP302300. 15 Dr. Cutz, looking at your resume we see 16 that you obtained your medical degree from Charles 17 University in Prague in 1966? 18 DR. ERNEST CUTZ: That's correct. 19 MS. JENNIFER MCALEER: And you then did a 20 Research Fellow in the Department of Pathology at the 21 Hospital for Sick Kids from 1968 to 1969? 22 DR. ERNEST CUTZ: That's correct. 23 MS. JENNIFER MCALEER: And then you 24 completed your residency at the Department of Pathology 25 at the University of Toronto, Banting Institute, and also

1 with the Department of Pathology at the Wellesley and 2 Princess Margaret Hospitals between 1969 and 1971? 3 DR. ERNEST CUTZ: That is correct, yes. 4 MS. JENNIFER MCALEER: And then in 1972 5 you obtained your specialty certification in anatomical 6 pathology from the Royal College of Physicians and 7 Surgeons? 8 DR. ERNEST CUTZ: That's correct, yes. 9 MS. JENNIFER MCALEER: And you then 10 obtained a position as a senior staff pathologist at the 11 Hospital for Sick Children starting in 1971? 12 DR. ERNEST CUTZ: Yes, that's correct. 13 MS. JENNIFER MCALEER: And you have been 14 there since 1971? 15 DR. ERNEST CUTZ: That's correct, yes. 16 MS. JENNIFER MCALEER: And you are also a 17 -- currently a professor with the Department of 18 Laboratory Medicine and Pathobiology for the University 19 of Toronto? 20 DR. ERNEST CUTZ: That's correct, yes. 21 MS. JENNIFER MCALEER: And then if we 22 turn to page 3 of your resume, under "Committees", we see 23 that you are currently on the Advisory Committee on SIDS 24 Research; that you are the Chairman of that Committee? 25 DR. ERNEST CUTZ: That's correct, yes.

1 MS. JENNIFER MCALEER: And what is the 2 Advisory Committee on SIDS Research? 3 DR. ERNEST CUTZ: Well, this -- this 4 Committee was established by the Research Institute of 5 the Hospital for Sick Children and it was to deal with 6 matters related to academic research into sudden infant 7 deaths, including Sudden Infant Death Syndrome. And it 8 also distributed funding from a private donation; from 9 parents who had children died of SIDS and wanted research 10 into this condition. 11 And so the Committee was assessing various 12 projects and grants submitted to -- to the Committee for 13 -- for consideration and funds have been distributed to 14 do this research. 15 MS. JENNIFER MCALEER: And if we turn to 16 page 8 of your resume -- actually I think it's page 6, 17 under "Research Awards Current." 18 Do you have that, Dr. Cutz? 19 DR. ERNEST CUTZ: Yes. 20 MS. JENNIFER MCALEER: And can you please 21 explain to the Commissioner your current research 22 projects? 23 DR. ERNEST CUTZ: Well, I have two (2) 24 research projects which are funded by the Canadian 25 Institute of Health Research or CIHR, and they both

1 relate to aspects of pulmonary -- or respiratory system, 2 which has a component which -- which may be relevant to 3 Sudden Infant Death Syndrome and -- and conditions 4 related to it. One (1) is more concerned with -- with 5 developmental aspects and -- and -- the -- the second one 6 is more concerned with molecular aspects of oxygen 7 sensing which is a biological function as to how the body 8 detects lack of oxygen in the body. 9 So these -- these funds are for a three 10 (3) year period and it's a sort of continuation of 11 projects I've been carrying out at the hospital for the 12 last twenty-five/thirty (25/30) years. 13 MS. JENNIFER MCALEER: You've done a 14 considerable amount of research into the area of SIDS, 15 have you not, over the course of your career? 16 DR. ERNEST CUTZ: That's correct, yes. 17 MS. JENNIFER MCALEER: And in -- in 18 addition to specializing in the area of SIDS research, I 19 also understand that you have a particular expertise in 20 gastrointestinal matters and pulmonary disease. 21 Is that correct? 22 DR. ERNEST CUTZ: That's correct, yes. 23 MS. JENNIFER MCALEER: And if we turn to 24 -- further on your resume we see that you have published 25 quite a few articles over the course of your thirty-six

1 (36) years as a staff pathologist at The Hospital for 2 Sick Children? 3 DR. ERNEST CUTZ: That's correct, yes. 4 MS. JENNIFER MCALEER: Okay. And now, 5 Dr. Taylor, if we could briefly review your resume, which 6 is at Tab 2 -- 7 DR. GLENN TAYLOR: Yes. 8 MS. JENNIFER MCALEER: -- of the 9 document. And, Mr. Registrar, that is PFP302261. 10 Dr. Taylor, you obtained your medical 11 degree from the University of British Columbia in June of 12 1976? 13 DR. GLENN TAYLOR: Yes, I did. 14 MS. JENNIFER MCALEER: And you then did 15 an intern -- internship at the Toronto General Hospital 16 between 1976 and 1977? 17 DR. GLENN TAYLOR: Yes. 18 MS. JENNIFER MCALEER: Followed by 19 residency at the University of British Columbia and the 20 University of Toronto between 1977 and 1981? 21 DR. GLENN TAYLOR: That's correct. 22 MS. JENNIFER MCALEER: You then obtained 23 your sub-speciality in anatomical pathology from the 24 Royal College of Physicians and Surgeons in December of 25 1981?

1 DR. GLENN TAYLOR: Yes. 2 MS. JENNIFER MCALEER: And you then 3 obtained your first staff position with the Vancouver 4 General Hospital in July of 1981, and we see that at the 5 top of page 2 of your resume? 6 DR. GLENN TAYLOR: That's correct. 7 MS. JENNIFER MCALEER: And I understand 8 that you were only at the Vancouver General Hospital for 9 one (1) year, and then starting in 1982, you obtained a 10 position as a Staff Pathologist at the British Columbia 11 Children's Hospital? 12 DR. GLENN TAYLOR: That's correct. 13 MS. JENNIFER MCALEER: And you were there 14 until September of 1995? 15 DR. GLENN TAYLOR: Correct. 16 MS. JENNIFER MCALEER: And in September 17 of 1995 you then came back to Toronto and you obtained a 18 position as a Staff Pathologist at the Hospital for Sick 19 Children? 20 DR. GLENN TAYLOR: Yes. 21 MS. JENNIFER MCALEER: And you also, in 22 1992, before coming back to Toronto, you obtained a 23 special qualification in pediatric pathology from the 24 American Board of Pathology? 25 DR. GLENN TAYLOR: Yes, I did.

1 MS. JENNIFER MCALEER: Can you explain, 2 what is the special qualification of pediatric pathology? 3 DR. GLENN TAYLOR: It's a sub-speciality 4 discipline in pathology. The qualification is awarded on 5 -- on the basis of appropriate, at that time, clinical 6 experience or fellowship training, and completion of an 7 examination held by the American Board of Pathology in 8 pediatric pathology topics. 9 MS. JENNIFER MCALEER: And then in 1999, 10 you then moved back to British Columbia again. 11 Is that correct? 12 DR. GLENN TAYLOR: That's correct. 13 MS. JENNIFER MCALEER: Okay. So -- and 14 you held the position as the Head of Autopsy and Fetal 15 Pathology Services in the Department of Pathology and 16 Laboratory Medicine at the Children and Women's Health 17 Centre of British Columbia, between October of 1999 and 18 April of 2003? 19 DR. GLENN TAYLOR: Yes. 20 MS. JENNIFER MCALEER: And you then 21 stayed there until, as I understand it, this -- the late 22 Spring/early Summer of 2003 and then came back to Toronto 23 again and took over as the head of the division of 24 pathology at the Hospital for Sick Kids in 2003. 25 DR. GLENN TAYLOR: That's right, yes.

1 MS. JENNIFER MCALEER: All right. And 2 you've -- you -- you've stayed in that position since 3 July of 2003. 4 DR. GLENN TAYLOR: I haven't moved yet, 5 correct. 6 COMMISSIONER STEPHEN GOUDGE: Haven't 7 moved back yet. 8 9 CONTINUED BY MS. JENNIFER MCALEER: 10 MS. JENNIFER MCALEER: And in addition to 11 being the head of the division I also understand that you 12 are also an associate professor at the University of 13 Toronto. 14 DR. GLENN TAYLOR: Yes. 15 MS. JENNIFER MCALEER: Okay. And again, 16 like Dr. Cutz, you have listed the numerous publications 17 and committee work in academic matters that you've been 18 involved with over the course of your career in your 19 resume. 20 DR. GLENN TAYLOR: Yes, I have. 21 MS. JENNIFER MCALEER: And do you have a 22 particular area of expertise, Dr. Taylor. 23 DR. GLENN TAYLOR: I have a general 24 interest in pediatric pathology, but I got a special 25 interests in pediatric cardiovascular pathology.

1 MS. JENNIFER MCALEER: And then if we 2 could -- now that we've reviewed your backgrounds, as I 3 understand it, Dr. Taylor, you weren't at the Hospital 4 for Sick Kids until 1995, so I'm going to start my 5 questions with respect to the background at the Hospital 6 for Sick Children and their work in forensic pathology by 7 addressing my questions to Dr. Cutz, to begin with. 8 Mr. Commissioner, if we could turn up the 9 HSC Institutional Report, which is PFP301353, and we're 10 going to look at page 7 of the document. 11 12 (BRIEF PAUSE) 13 14 MS. JENNIFER MCALEER: And as I 15 understand it, Dr. Cutz -- do you have that document in 16 front of you, Dr. Cutz? 17 DR. ERNEST CUTZ: I'm looking at the 18 screen. 19 MS. JENNIFER MCALEER: You're looking at 20 the screen. All right. 21 DR. ERNEST CUTZ: Yeah. 22 MS. JENNIFER MCALEER: It's -- I believe 23 it's also the small binder that's just in front of you. 24 DR. ERNEST CUTZ: Okay. 25 MS. JENNIFER MCALEER: If you want to

1 open that up and turn to page 7. 2 3 (BRIEF PAUSE) 4 5 DR. ERNEST CUTZ: Yes, I'm looking there. 6 MS. JENNIFER MCALEER: All right. And 7 looking at paragraph 10 of the HSC institutional report, 8 I understand that the HSC has over sixty (60) years of 9 experience doing medicolegal autopsies on behalf of the 10 Coroner's Office. 11 And if you look at paragraph 13 of that 12 document, it indicates that in 1979 Dr. Phillips accepted 13 the position of Pathologist and Chief at Sick Kids and it 14 indicates that at the time Dr. Phillips, Dr. Becker, Dr. 15 Mancer and yourself, Dr. Cutz, were the individuals who 16 were performing medicolegal autopsies. 17 Is that correct? 18 DR. ERNEST CUTZ: That is correct, yes. 19 MS. JENNIFER MCALEER: All right. And 20 then if we turn the page and look at the top of page 8, 21 we also see in the last sentence that prior to 1981 the 22 majority of the -- the coroner's cases were -- were a 23 shared responsibility between Dr. Phillips, Dr. Becker, 24 Dr. Mancer, and you, Dr. Cutz. 25 DR. ERNEST CUTZ: That is correct, but

1 the distribution was quite different in that Dr. Mancer, 2 who had training and background in forensic -- adult 3 forensic pathology, did a larger share than, for example, 4 Dr. Phillips, who, you know, really didn't do many -- 5 much autopsy work. You know, he did much less. So it 6 was basically Mancer, me, and Dr. Becker. 7 MS. JENNIFER MCALEER: All right. And 8 among the three (3) of you, how were cases assigned to 9 the individual HSC pathologists from the Coroner's 10 Office? 11 DR. ERNEST CUTZ: Yeah. Now my -- my 12 understanding when I came on staff at the Hospital for 13 Sick Children was that the reason for doing the autopsies 14 for the Coroner's Office was to provide pediatric 15 expertise, which was lacking at the Coroner's Office. It 16 was not asked for us to provide forensic expertise. 17 So that the majority of cases which were 18 received at the Hospital for Sick Children, the -- that 19 was pediatric disease and such. There's a small 20 proportion of cases which may -- may have been due to 21 child abuse or suspected child abuse, which is also part 22 of pediatric medicine. And those cases -- in those, that 23 Dr. Mancer who was trained, so he would take, in 24 preference, those cases, but at the same time, he would 25 also have the other staff to deal with the cases.

1 So there wasn't any specific assignment. 2 It was -- you know, we were cover -- we -- we had the 3 coverage on a monthly or weekly basis and then whoever 4 covered it which -- whichever cases came along. If there 5 were some problems in terms of forensic aspects then, you 6 know, we make consult with Dr. Mancer or -- or ask Dr. 7 Mancer to do it. 8 MS. JENNIFER MCALEER: So do I 9 understand, Dr. Cutz, that a schedule was set up and a 10 particular pathologist would be assigned to do 11 medicolegal autopsy work on a particular week or a 12 particular month? 13 DR. ERNEST CUTZ: That's correct, yes. 14 MS. JENNIFER MCALEER: And if that 15 particular pathologist, as you've just indicated, wasn't 16 comfortable with a particular case -- 17 DR. ERNEST CUTZ: Yes. 18 MS. JENNIFER MCALEER: -- that they might 19 then ask Dr. Mancer to take over the case? 20 DR. ERNEST CUTZ: Yes. Or -- or return 21 it back to the Coroner's Office which -- which had the 22 option of refusing to do the -- do the case if we felt 23 uncomfortable. 24 MS. JENNIFER MCALEER: And -- 25 COMMISSIONER STEPHEN GOUDGE: Dr. Cutz,

1 do you know what Dr. Mancer's forensic training was? 2 DR. ERNEST CUTZ: Dr. Mancer, he was a -- 3 I think one of the first trained pediatric pathologists. 4 He -- he trained in -- in some large centres in the 5 United States including in Seattle with Dr. Bruce 6 Beckwith, who is the person who -- who designated the 7 name Sudden Infant Death Syndrome. So he had a great 8 deal of experience. 9 COMMISSIONER STEPHEN GOUDGE: Did he have 10 forensic experience? 11 DR. ERNEST CUTZ: Yes. 12 COMMISSIONER STEPHEN GOUDGE: Where did 13 he get that? 14 DR. ERNEST CUTZ: I think in Seattle. 15 But Dr. Mancer also took courses at the Armed Forces 16 Institute in -- in Washington in -- in forensic 17 pathology. And he was also carrying on on the weekends 18 and -- and in the evening at -- at the Coroner's Office 19 doing adult -- adult forensic autopsies. 20 COMMISSIONER STEPHEN GOUDGE: Thank you. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: And, Dr. Cutz, 24 what was your own training in forensic pathology when you 25 started doing medicolegal autopsies at the Hospital for

1 Sick Children? 2 DR. ERNEST CUTZ: I had some experience 3 from the medical school where it was part of our training 4 in pathology and that included forensic pathology over -- 5 over several months including hands-on experience doing 6 autopsies. And we had an examination. 7 So that I had a good idea forensic 8 pathology covered and what -- what were the -- but I 9 wouldn't consider myself to be a forensic pathologist. 10 MS. JENNIFER MCALEER: And as I 11 understand it, Dr. Cutz, in Canada at the time, while 12 there may have been individual lectures on forensic 13 pathology that one might sit through as part of doing 14 your medical degree, the European system was a little bit 15 different, in that you actually took courses in forensic 16 pathology as part of your medical degree. 17 Is that correct? 18 DR. ERNEST CUTZ: That is correct, yes. 19 MS. JENNIFER MCALEER: Okay. And I had 20 asked you how the cases were assigned and you had 21 indicated that basely -- basically it was a monthly 22 rotation, but you had Dr. Mancer that you could ask for 23 assistance. And you also indicated that there was some 24 cases that you actually decided not to do and those cases 25 were sent back to the Office of the Chief Coroner.

1 DR. ERNEST CUTZ: That's correct, yes 2 MS. JENNIFER MCALEER: Who -- who would 3 make that decision? 4 DR. ERNEST CUTZ: Well, it -- it's 5 individual pathologists can make the decision because the 6 arrangement was -- was between the coroner who refers the 7 case and the pathologist, so that the coroner would call 8 in and -- and explain or gives the history and explain 9 the situation. 10 And through this discussion if things came 11 up which were not really within the expertise of that 12 particular pathologist then he would just say that, you 13 know, it would be better if the case is handled by the 14 Coroner's Office rather than Sick Childrens. 15 MS. JENNIFER MCALEER: And what kinds of 16 cases were sent to the Coroner's Office as opposed to the 17 Hospital for Sick Children? 18 DR. ERNEST CUTZ: I -- I would say that 19 the triage was reasonably good, so this actually would -- 20 would happen quite infrequently. But, you know, 21 occasionally -- I remember one (1) situation where there 22 was a kind of a family tragedy where, you know, the -- 23 there was a sort of a murder/suicide situation, which 24 also involved children and -- and so they wanted the 25 children to be done at Sick Kids, and we just said, you

1 know, we would not be handling that. 2 MS. JENNIFER MCALEER: Okay. 3 DR. ERNEST CUTZ: And -- and so this is 4 how -- in any sort of a clear cut case, which you are -- 5 knew, there was, you know, homicide, requiring expertise 6 of the forensic pathology, we would not in principle do. 7 MS. JENNIFER MCALEER: And was that the 8 general practice right up until 1991 when the OPFPU was 9 established? 10 DR. ERNEST CUTZ: Yes it was the 11 practice, but even with OPAP the -- the Schedule "A" 12 includes a proviso that the pathologists still have a -- 13 an option of sort of declining to do a case. 14 MS. JENNIFER MCALEER: All right. And 15 we'll look at that schedule a little -- 16 DR. ERNEST CUTZ: Yes. 17 MS. JENNIFER MCALEER: -- bit more 18 closely later. 19 Before the OPFPU was set up, what internal 20 oversight was there within the Department of Pathology, 21 with respect to medicolegal work? 22 DR. ERNEST CUTZ: Well, the oversight was 23 similar to, you know, other hospital work. And, you 24 know, since 90 percent of cases were medical disease we 25 would report to or be responsible to the Department Head.

1 2 And at the beginning, the Head of 3 Department was Dr. William Donahue and he, himself, did 4 the medicolegal autopsies. And after him, Dr. Huber, he 5 also fully participated in the schedule and did the 6 autopsies, so that, you know, any issues would be sort of 7 a departmental subject. 8 But in terms of the specific oversight, 9 the individual cases were handled between the pathologist 10 and -- and the responsible coroner and -- and I don't 11 know if there was any oversight over that part. 12 MS. JENNIFER MCALEER: All right. So 13 when Dr. Phillips became the Head of the Department of 14 Pathology, and -- between 1981 and 1991 once you had 15 completed a post-mortem examination report, would it be 16 reviewed by anybody within your department before it was 17 sent to the Coroner's Office or to the local coroner? 18 DR. ERNEST CUTZ: No, it was the 19 responsibility of individual pathologists to ensure that 20 the report is accurate and it's, you know, well -- well 21 prepared. 22 MS. JENNIFER MCALEER: And once you had 23 sent your report to the local coroner did you receive any 24 feedback from the Coroner's Office or from the Chief 25 Forensic Pathologist?

1 Was there any kind of external oversight 2 with respect to your report, that you were aware of? 3 DR. ERNEST CUTZ: Well, in most cases one 4 wouldn't hear back because these were natural deaths. 5 Now, occasionally, if the case came to an 6 inquest or came to some judicial proceedings then, you 7 know, the pathologist would be invited to a, sort of a 8 case conference, and -- and then depending on the -- on 9 the subject or -- or the case, will then participate in 10 this component. And I've gone to, you know, many 11 inquests and preliminary trial -- hearings, et cetera. 12 MS. JENNIFER MCALEER: So you may -- you 13 might receive some feedback about your work as part of a 14 discussion at a case conference. But apart from the case 15 conferences, would you receive any feedback from the 16 local coroner or the Coroner's Office? 17 DR. ERNEST CUTZ: No, we -- I don't 18 recall that there was any -- any feedback. 19 MS. JENNIFER MCALEER: All right. And 20 between 1981 and 1991, did you take any continuing 21 medical education with respect to forensic pathology? 22 You've told us a little bit about what 23 forensic pathology experience you had from university, 24 but between 1981 and 1991, did you take any other courses 25 in forensic pathology?

1 DR. ERNEST CUTZ: Yeah, actually, the 2 Coroner's Office, and this goes back to '72, there were 3 yearly courses for pathologists doing medicolegal work, 4 organized by the Coroner's Office. It's sort of a three 5 (3) day course and these were on a yearly basis and I 6 attended, I think most of these, since '72. 7 MS. JENNIFER MCALEER: And who would put 8 those courses on at the Coroner's Office? 9 DR. ERNEST CUTZ: Well, I think at the 10 time it was Dr. Hillsdon Smith who organized these. 11 MS. JENNIFER MCALEER: And you indicated 12 they were three (3) day courses? 13 DR. ERNEST CUTZ: Well, I can't remember; 14 two (2) or three (3) days. Because it involved also 15 lawyers, police investigators, and the pathologists. I 16 think the pathologist was about two (2) days. 17 MS. JENNIFER MCALEER: And who from the 18 Hospital from Sick Kids -- for Sick Kids would attend 19 those conferences put on by the Office of the Chief 20 Coroner? 21 DR. ERNEST CUTZ: Well, all -- all of the 22 staff who did the medicolegal autopsies would -- would 23 attend. 24 MS. JENNIFER MCALEER: All right. So 25 then between 1981 and 1991, that would be you, Dr. Smith?

1 DR. ERNEST CUTZ: Yes. 2 MS. JENNIFER MCALEER: Dr. Wilson? 3 DR. ERNEST CUTZ: Yes. 4 MS. JENNIFER MCALEER: Dr. Becker? 5 DR. ERNEST CUTZ: Yes. 6 MS. JENNIFER MCALEER: Anyone else? 7 DR. ERNEST CUTZ: I think there -- Dr. 8 Silver. I can't remember whether she was there; maybe 9 late -- she came on later on. 10 MS. JENNIFER MCALEER: What about Dr. 11 Mancer? How long was he there? 12 DR. ERNEST CUTZ: Well, Mancer, I'm not 13 quite sure the date where he -- where he left the 14 hospital. 15 MS. JENNIFER MCALEER: All right. 16 DR. ERNEST CUTZ: But, you know, he 17 attended prior to that, you know. 18 MS. JENNIFER MCALEER: And if we look at 19 paragraph 26 of the Institutional Reports -- sorry, the 20 Institutional Report, we see that while the Hospital for 21 Sick Children doesn't have historic data available to 22 indicate the breakdown of the respective workloads, that 23 it's the hospital's understanding that between -- prior 24 to 1991 was primarily you, Dr. Wilson, Dr. Smith, Dr. 25 Silver and Dr. Becker who were doing the medicolegal

1 work. 2 DR. ERNEST CUTZ: That's correct. 3 MS. JENNIFER MCALEER: Okay. Now, we 4 know that Dr. Smith came to the department around 1981, 5 can you describe for the Commission your impression of 6 Dr. Smith's role in the department between 1981 and 1991? 7 DR. ERNEST CUTZ: Dr. Smith was hired 8 when -- when Dr. Phillips took over, together with two 9 (2) pathologists; was Dr. Wilson and Dr. Baumal. And all 10 three (3) were sort of recent graduates of the Toronto 11 Anatomic Pathology Program and they just completed their 12 fellowship in -- in anatomic pathology. 13 Dr. Wilson and Dr. Baumal, they had a 14 strong research background with research grants and 15 experience in publications, but Dr. Smith didn't have any 16 sort of, either research or specialty interest, and I 17 think he started to work with Dr. Phillips as a -- as a 18 PhD student and I believe he discontinued when he became 19 the staff. 20 MS. JENNIFER MCALEER: He -- he 21 discontinued his PhD? 22 DR. ERNEST CUTZ: PhD, yes. 23 MS. JENNIFER MCALEER: I see. And over 24 the -- those ten (10) years, 1981 to 1991, did you 25 observe Dr. Smith to develop an interest in any

1 particular field? 2 DR. ERNEST CUTZ: Oh, I think he was in a 3 general rotation, doing -- doing, you know, surgical 4 pathology in the general hospital autopsies, including -- 5 including the medicolegals. 6 And, well, you know, initially I don't 7 think, you know, he seemed to be especially interested in 8 -- in the medicolegal, because you see it was evenly 9 distributed between the staff, so, you know, we -- we 10 dealt with the cases as they came along and so they 11 wasn't re -- assignment of cases in those -- those early 12 days. 13 MS. JENNIFER MCALEER: Well, we know at 14 one (1) point he -- he did express a strong interest in 15 medicolegal autopsy work, and do you know how that 16 interest progressed or how he came to have an interest in 17 that area? 18 DR. ERNEST CUTZ: I'm not -- I'm not sure 19 of the, you know, dates or -- or details, but I think it 20 sort of gradually -- when he reported this is what his 21 interest was. 22 MS. JENNIFER MCALEER: All right. And we 23 know from our review of the documents that in 1988 the 24 Paediatric Death Review Committee was formed and that Dr. 25 Smith was a member of that committee.

1 Were you aware of that, in or about 1988? 2 DR. ERNEST CUTZ: No, I was not aware 3 that there was a committee. 4 MS. JENNIFER MCALEER: Okay. And can you 5 describe Dr. Smith's relationship with the Coroner's 6 Office before the OPFPU was established? 7 DR. ERNEST CUTZ: Well, my understanding 8 was that Dr. Phillips relied on Dr. Smith to liaise with 9 the Coroner's Office, because I understand that Dr. Smith 10 was a friend of Dr. Young and so this facilitated the 11 interactions, and I -- I think, you know, then the things 12 evolved from that. 13 MS. JENNIFER MCALEER: All right. If we 14 could turn to Tab 9 of Volume I, which is PFP11704 -- 15 sorry, 117704. 16 DR. ERNEST CUTZ: Yes. 17 18 (BRIEF PAUSE) 19 20 MS. JENNIFER MCALEER: And this is a memo 21 of March 9th, 1990 and it indicates that at that point 22 Dr. Paul Thorner is assuming the position of staff 23 pathologist in charge of surgical pathology, and that Dr. 24 Smith is assuming the position of staff pathologist in 25 charge of autopsy service.

1 Now, do you know, Dr. Cutz, how it went 2 that Dr. Smith was appointed the staff pathologist in 3 charge of autopsy services in or about March of 1990? 4 DR. ERNEST CUTZ: Yes, I think we had a 5 departmental meeting discussing plans for the future and 6 so both Dr. Thorner and Smith were sort of young and 7 upcoming pathologists, so it was logical to give them 8 responsibility for certain areas within the department so 9 that they can, you know, develop and -- and acquire 10 experience. 11 And so I think -- so this division -- 12 because these are two (2) main clinical responsibilities 13 of the department, is the surgical and pathology and the 14 autopsy service. 15 MS. JENNIFER MCALEER: And Dr. Thorner 16 was also a young staff pathologist, at that point? 17 DR. ERNEST CUTZ: That's correct, yes. 18 MS. JENNIFER MCALEER: Now, if we could 19 turn to Tab 11 of Volume I, which is PFP129902. It's Tab 20 11 of Volume I. 21 You have that, Dr. Cutz? 22 DR. ERNEST CUTZ: Yes, yes. 23 MS. JENNIFER MCALEER: And that is a 24 letter of Dr. Phillips to the Chief Coroner at the time, 25 Dr. Bennett, in which he attaches a proposal for a

1 forensic pathology service at the Hospital for Sick 2 Children. And actually he calls it a proposal for an 3 Ontario Centre for the Study of Infant Deaths. 4 Do you see that, Dr. Cutz? 5 DR. ERNEST CUTZ: Yes. Yes, I do. 6 MS. JENNIFER MCALEER: Now, have you 7 reviewed this document before? 8 DR. ERNEST CUTZ: I've just seen it last 9 week. I don't recall seeing it before. 10 MS. JENNIFER MCALEER: Okay. Did you 11 discuss with Dr. Phillips his expectations or his 12 proposal, with respect to setting up this centre for the 13 study of infant deaths? 14 DR. ERNEST CUTZ: I don't recall 15 discussing the particulars, but what I have a 16 recollection of is that Dr. Phillips realized that, you 17 know, all this work we were doing for the Coroner's 18 Office has been costing a lot of resources to the 19 hospital. And in order to get some funding from -- from 20 the Coroner's Office, this would have been one (1) way of 21 perhaps getting more resources from -- from them. 22 MS. JENNIFER MCALEER: All right. If we 23 turn to the second page of the document under the 24 heading, "Workload" -- 25 DR. ERNEST CUTZ: Yeah.

1 MS. JENNIFER MCALEER: -- Dr. Phillips 2 outlines that there are three (3) sources of cases that 3 come to the Hospital for Sick Children. He -- he 4 indicates in the first paragraph that: 5 "Sixty (60) or more forensic pathology 6 examinations each year on children are 7 from those who die outside the Hospital 8 for Sick Children, but within the 9 boundaries of the Metro Toronto area." 10 Does that accord with your recollection? 11 DR. ERNEST CUTZ: That's correct. That 12 was the initial arrangement we had when I came to the 13 hospital. 14 MS. JENNIFER MCALEER: All right. And 15 then in the second paragraph he says: 16 "In addition, almost sixty (60) more 17 forensic autopsy examinations are 18 undertaken on infants and children who 19 die at the Hospital for Sick Kids." 20 DR. ERNEST CUTZ: That's correct, yes. 21 MS. JENNIFER MCALEER: And then in the 22 third paragraph he says: 23 "The third source of those cases, which 24 are transferred into this department, 25 outside the Metropolitan Toronto

1 region, this number is steadily 2 increasing and could grow as high as 3 forty (40) a year." 4 Does that also accord with your 5 recollection? 6 DR. ERNEST CUTZ: Yes. 7 MS. JENNIFER MCALEER: And then he 8 provides numbers below that with respect to the number of 9 medicolegal autopsies that are being performed at the 10 Hospital for Sick Kids between 1987 and 1999. 11 And in the first year -- I'll -- I'll do 12 the math for you -- but it -- it comes to a hundred and 13 thirty-two (132) autopsies. The second year is a hundred 14 and thirteen (113) and the third year is a hundred and 15 forty-three (143). 16 And again, that accords with your 17 recollection, Dr. Cutz? 18 DR. ERNEST CUTZ: Yes. 19 MS. JENNIFER MCALEER: All right. And 20 then on the last page of the proposal there's a reference 21 to the financial issue that you had raised. Dr. Phillips 22 has done some accounting and indicates the technical 23 component of an autopsy at the Hospital for Sick Children 24 costs two thousand, one hundred and sixty-five dollars 25 ($2,165) in 1980 dollars -- sorry, 1989 dollars, based

1 on Stats Can workload units, and that the hospital was 2 then receiving a hospital -- hospital fee of fifty 3 dollars ($50) per case. 4 Again, does that accord with your 5 recollection? 6 DR. ERNEST CUTZ: That's correct, yes. 7 MS. JENNIFER MCALEER: All right. And 8 then as a result, the proposal we'll see in the 9 recommendation at the very bottom of the page, is for an 10 amount of funding of two hundred thousand dollars 11 ($200,000) a year. 12 DR. ERNEST CUTZ: Yes. 13 MS. JENNIFER MCALEER: All right. And 14 flipping ahead then to Tab 17. 15 I'm sorry, before we do that, just of that 16 -- of that number of cases that you're doing -- that the 17 department is doing between 1987 and 1989, do you have 18 any idea, Dr. Cutz, how many, if any, of those cases 19 would be of the criminally suspicious or homicide nature? 20 DR. ERNEST CUTZ: Well, I think the 21 statistics over the years are pretty consistent in that 22 one sees that, you know, 90 to 95 percent would be 23 natural deaths, and then between 5 to 10 or 12 percent 24 would be either suspicious or criminally confirmed -- 25 confirmed cases.

1 And I think in -- in Toronto area, it has 2 been pretty, you know, even sort of numbers. I don't 3 think they are big -- big variations. 4 MS. JENNIFER MCALEER: Sorry. There are 5 big variations or -- 6 DR. ERNEST CUTZ: They are not -- 7 MS. JENNIFER MCALEER: -- they're not? 8 DR. ERNEST CUTZ: They are as far as I 9 remember. You know, these are sort of the usual 10 percentages one sees. 11 MS. JENNIFER MCALEER: So approximately 5 12 percent? 13 DR. ERNEST CUTZ: Between 5 and 10 14 percent. 15 MS. JENNIFER MCALEER: All right. 16 And then again, we should point out the 17 two thousand one hundred and sixty-five dollars ($2,165) 18 Dr. Phillips indicates does not include pathologist's 19 time, right? These are just -- 20 DR. ERNEST CUTZ: No -- 21 MS. JENNIFER MCALEER: -- fees? 22 DR. ERNEST CUTZ: -- these are technical 23 components. 24 MS. JENNIFER MCALEER: All right. And 25 those technical components are listed on the second page

1 of the proposal in the chart. 2 Is that correct? 3 DR. ERNEST CUTZ: Yes. 4 MS. JENNIFER MCALEER: All right. So 5 then turning to Tab 17, which is PFP057354. 6 DR. ERNEST CUTZ: Yes. 7 MS. JENNIFER MCALEER: All right. Now 8 this is a letter from Dr. Phillips to Dr. Young that 9 attaches the -- the first agreement, the 1991 agreement. 10 And as I understand it, Dr. Cutz, you had not seen the 11 agreement at the time but you had seen Schedule "A." 12 Is that correct? 13 DR. ERNEST CUTZ: That's correct, yes. 14 MS. JENNIFER MCALEER: All right. And 15 what, if anything, did you find significant about 16 Schedule "A" to the agreement? 17 DR. ERNEST CUTZ: The Schedule "A" I 18 considered was a de facto recognition of putting of -- 19 putting on paper the arrangement which was informally in 20 place prior to -- to the formation of the unit, and just 21 basically spelling out again in terms of reference, 22 again, you know, asking us to do cases of natural disease 23 as a predominant component our work. It -- it says that 24 the arrangement is still between the coroner and the 25 pathologist and it's a fee-for-service arrangement.

1 The thing it emphasized under point 2 is - 2 - is to also enhance research and other special 3 investigative activities. 4 MS. JENNIFER MCALEER: So you're looking 5 at paragraph 2, sub (d)? 6 DR. ERNEST CUTZ: (d) Eg., Sudden Infant 7 Death Syndrome. And at that time, Dr. Becker and I had a 8 very active research program funded by National Institute 9 of Health, which was based on examining tissues and 10 things from -- from infants who died of Sudden Infant 11 Death Syndrome. So that this for us was -- you know, we 12 thought was a reassurance that we will be able to 13 continue in this work. 14 MS. JENNIFER MCALEER: And did you have 15 some expectation that the OPFPU would in some way assist 16 you in that research? 17 DR. ERNEST CUTZ: Yes. 18 MS. JENNIFER MCALEER: And can you 19 elaborate on that. 20 DR. ERNEST CUTZ: Yes. I think, you 21 know, we -- we said that part of this funding could be 22 used to establish a Sudden Infant Deaths database. And - 23 - and we had one (1) nurse who worked in the department 24 who had already worked with us, you know, setting up a 25 SIDS database tissue bank and so we thought that may be

1 good. And she could provide statistics, she could 2 provide demographics to the Coroner's Office. And so we 3 thought that maybe, you know, one (1) -- one (1) part of 4 the funding which could be used for this. 5 MS. JENNIFER MCALEER: And that's an 6 expectation that you and Dr. Becker shared. Is that -- 7 DR. ERNEST CUTZ: Yes, that's correct. 8 Yes. 9 MS. JENNIFER MCALEER: And was that 10 communicated to Dr. Phillips? 11 DR. ERNEST CUTZ: I understand, yes. 12 MS. JENNIFER MCALEER: All right. And 13 then if we look above that in paragraph 1 of the terms of 14 reference, sub (f), we see that: 15 "Pathologists who are members of the 16 unit may ask so that some post-mortem 17 examinations be performed using the 18 special facilities of the Coroner's 19 building. For example, use of 20 firearms, identification of remains, 21 exhumations." 22 DR. ERNEST CUTZ: That's correct. That's 23 the exclusionary component, yes. 24 MS. JENNIFER MCALEER: This is the 25 component that you were discussing earlier that would

1 still provide you with the discretion -- 2 DR. ERNEST CUTZ: That's correct. 3 MS. JENNIFER MCALEER: -- to decide not 4 to perform certain autopsies? 5 DR. ERNEST CUTZ: That's correct, yes. 6 MS. JENNIFER MCALEER: All right. Now 7 when this unit was set up, did you have any concerns with 8 respect to the unit being established at the Hospital for 9 Sick Kids? 10 DR. ERNEST CUTZ: Well, it wasn't quite 11 clear as to what -- what -- how it's going to function 12 and I -- I think I looked at it as a way of Coroner 13 Office justifying this expense so that, you know, it's -- 14 it's some sort of a different entity which -- which 15 receives funding. 16 MS. JENNIFER MCALEER: I see, that 17 because the Coroner's Office or the Ministry of -- 18 DR. ERNEST CUTZ: Yes. 19 MS. JENNIFER MCALEER: -- the Solicitor 20 General would be providing funding -- 21 DR. ERNEST CUTZ: Yes. 22 MS. JENNIFER MCALEER: -- that this 23 document did what -- did that -- 24 DR. ERNEST CUTZ: Well, it established 25 some kind of an administrative entity to which funds

1 could be distru -- disbursed. 2 MS. JENNIFER MCALEER: All right. 3 COMMISSIONER STEPHEN GOUDGE: It didn't 4 change the functions you were performing for the -- 5 DR. ERNEST CUTZ: That -- that was my 6 understanding. It's basically recognizing, because you 7 know, Hospital for Sick Children is the major academic 8 centre. We are not a forensic centre. 9 So if 90 percent of cases are natural 10 deaths, it's just to me, is a natural thing that we would 11 carry out and provide the expertise in pediatric 12 pathology. That's what -- that's what we do. 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: And -- 16 COMMISSIONER STEPHEN GOUDGE: Were all 17 SIDS cases -- sorry, Ms. McAleer. Were all SIDS cases 18 done under coroner's warrant? 19 DR. ERNEST CUTZ: That's correct, yes. 20 COMMISSIONER STEPHEN GOUDGE: And what, 21 in numbers, would we talking about that back then, Dr. 22 Cutz? 23 DR. ERNEST CUTZ: SIDS cases actually 24 accounted for anywhere between 25 to 30 percent of -- of 25 these natural deaths.

1 COMMISSIONER STEPHEN GOUDGE: And did 2 that number stay relatively static? Did that percentage 3 stay relatively static over the years? 4 DR. ERNEST CUTZ: It -- there's some 5 variation of course. Some years went up, some years is 6 way down, but it kind of depends in terms of what 7 terminology people use. I think in the '90s, the 8 terminology has been changed, so instead of calling it 9 SIDS it's called undetermined. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. ERNEST CUTZ: So then, you know, if 12 you look at statistics, it's been difficult to trace. 13 But I think the trend has been to -- to decrease but by - 14 - it hasn't gone away. I mean, SIDS still exist and is 15 still a big problem. 16 COMMISSIONER STEPHEN GOUDGE: You may be 17 brought to that in due course, I'm sure. 18 DR. ERNEST CUTZ: Right. 19 COMMISSIONER STEPHEN GOUDGE: Okay. 20 Thanks, Ms. McAleer. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: And if we could 24 have PFP118078. I don't believe this is in the binders. 25 118078.

1 DR. ERNEST CUTZ: Yes. 2 MS. JENNIFER MCALEER: Sorry, it may be 3 in the binders. Sorry, Tab 87 of Volume II. 4 5 (BRIEF PAUSE) 6 7 MS. JENNIFER MCALEER: Do you have that, 8 Dr. Cutz? 9 DR. ERNEST CUTZ: Yes, I do. 10 MS. JENNIFER MCALEER: And do you 11 recognize that document? 12 DR. ERNEST CUTZ: No, I have never seen 13 it, but I know for a fact that we received funding the 14 first year the unit was -- unit was formed, and we -- you 15 know, I thought it was twenty-five thousand (25,000) but 16 it's twenty-three thousand nine thirty-eight (23,938) -- 17 MS. JENNIFER MCALEER: All right. 18 DR. ERNEST CUTZ: -- was provided for 19 SIDS, Dr. Becker and Dr. Cutz research support. 20 MS. JENNIFER MCALEER: All right. So 21 it's my understanding that this is a -- a coroner's 22 reconciliation for the year 1991/92, of the funds that 23 were provided to the OPFPU. 24 And you indicated that you had an 25 understanding that twenty-five thousand (25,000) had been

1 allocated to SIDS research and on reviewing this 2 document, you think that's probably the figure of twenty 3 three thousand nine hundred and thirty-eight dollars 4 ($23,938) that we see? 5 DR. ERNEST CUTZ: That's correct, yes. 6 MS. JENNIFER MCALEER: All right. And 7 that was in, -- as far as you're concerned, you had been 8 informed that there was a certain amount of money that 9 was being attributed to SIDS research. 10 Is that correct? 11 DR. ERNEST CUTZ: That's correct. 12 MS. JENNIFER MCALEER: Okay. Now you can 13 put that document away, Dr. Cutz. 14 We know that eventually Dr. Smith was 15 appointed the Director of the unit. What was your 16 understanding, Dr. Cutz, as to why Dr. Smith was chosen 17 as the Director of the unit? 18 DR. ERNEST CUTZ: Well, I think at that 19 time Dr. Smith was, you know, showed interest in 20 medicolegal work and since it was part of the autopsy 21 service which he was in charge of, right, so my 22 understanding was that this was an administrative sort of 23 title. Not really in a sense, that is, somebody who 24 liases with the Coroner's Office and who ensures some of 25 the components of the agreement -- or on this education

1 of police officers, defence, and you know, Crown lawyers, 2 et cetera, which was part of the thing. Plus it was -- 3 also covered the cases which would be sent out from -- 4 from other parts of Ontario. 5 MS. JENNIFER MCALEER: All right. So 6 first of all you understood there would be an educational 7 component -- component -- component of -- 8 DR. ERNEST CUTZ: But all -- 9 MS. JENNIFER MCALEER: -- as well as 10 Director? 11 DR. ERNEST CUTZ: Of -- yeah, that would 12 be the role of the Director to -- to ensure the 13 educational component. 14 MS. JENNIFER MCALEER: All right, and -- 15 and who would he be educating? 16 DR. ERNEST CUTZ: This is for police 17 officers, for Crown -- Crown lawyers, and -- and any 18 other -- you know, any other law enforcement agencies. 19 MS. JENNIFER MCALEER: All right. And 20 then, sir, you said the second part of that is that he 21 would be doing something with respect to outside the 22 Toronto area or something throughout the Province. I 23 didn't quite understand your answer. 24 DR. ERNEST CUTZ: Well, that -- that he 25 would be assigned cases which come from the usual

1 catchment area -- you know, other parts of province, or 2 even outside the Province, if -- if necessary. 3 MS. JENNIFER MCALEER: And was it your 4 understanding that the workload would be redistributed as 5 a result of the OPFPU being set up or were people going 6 to continue to do the same kind of medicolegal work as 7 they had prior to the unit being established? 8 DR. ERNEST CUTZ: No, I think when -- 9 when the schedules -- my understanding is when the 10 schedules were made, it was -- it was to balance between 11 the various responsibilities the staff had. 12 Like for example, I had quite a heavy 13 research component. I also had heavy clinical component, 14 and so I -- and on top of it, I was doing the medicolegal 15 work. So, you know, I had sort of served, served, 16 served, whereas Dr. Smith only was doing one (1) with, 17 you know, some -- some surgical, but no research -- 18 MS. JENNIFER MCALEER: Right. 19 DR. ERNEST CUTZ: -- so that -- so that 20 the time distribution was adjusted to -- to accommodate 21 these and -- and, for example, Doc -- Dr. Wilson, who was 22 75 percent research, so he -- his component was 23 relatively small. 24 MS. JENNIFER MCALEER: All right. And 25 when you say "clinical", Dr. Cutz, is that the same as

1 surgical work? 2 DR. ERNEST CUTZ: That's correct. 3 MS. JENNIFER MCALEER: All right. And so 4 essentially, the schedule was drafted in such a way as to 5 accommodate people's interests? 6 DR. ERNEST CUTZ: Well, their interest in 7 the actual work they were doing. 8 MS. JENNIFER MCALEER: But who decided 9 what work they were doing? 10 DR. ERNEST CUTZ: I think it's between 11 department Chief and -- and the individual pathologists. 12 MS. JENNIFER MCALEER: And did you have 13 any concerns with respect to the choice of Dr. Smith to 14 be the Director of the OPFPU? 15 DR. ERNEST CUTZ: Well, the terms of 16 reference when -- when it seemed to include some, you 17 know, forensic work, which means the usual type of 18 forensic medicine, which I thought requires special 19 training and ec -- experience to do it well. 20 And, you know, I didn't know if Dr. Smith 21 was qualified, but I didn't think that, you know, he had 22 the appropriate training to assume that, to do those 23 kinds of cases, but it was his choice. 24 I think it -- you know, it wasn't -- I -- 25 I wouldn't have recommended him to do it.

1 MS. JENNIFER MCALEER: To -- to be the 2 Director or to do forensic work? 3 DR. ERNEST CUTZ: To do the forensic work 4 without having the appropriate training. 5 COMMISSIONER STEPHEN GOUDGE: Had he been 6 doing forensic work before he became the Director? 7 DR. ERNEST CUTZ: Well, he was doing as 8 the rest of us, which -- 9 COMMISSIONER STEPHEN GOUDGE: So he would 10 take his turn. 11 DR. ERNEST CUTZ: He would take his turn, 12 and you know, those would be predominantly the type of 13 cases I -- I was mentioning earlier, which were 90 14 percent natural deaths, and then one (1) which was 15 suspicious or -- these would be mostly cases related to 16 child abuse, which, you know, could come to attention. 17 And a lot of the child abuse patients 18 actually are -- are alive and they are seen in these 19 clinics, and occasionally, if the child dies, then, you 20 know, he's subject of -- of coroner's investigation. 21 And -- and so I think it's still better -- 22 best for the pediatric pathologist to do this case 23 because often it's difficult to differentiate between 24 violence and natural disease. Especially in cases of -- 25 you know, there's neglect, there may be some underlying

1 medical conditions which could mimic violence, for 2 example. 3 So -- so I think still that -- that I can 4 see, you know, a significant role for -- for a pediatric 5 pathologist to get involved in, and you know, that, I 6 don't think you can take special training, except, you 7 know, all -- experience -- you know, work experience 8 actually doing it and reading the literature and 9 consulting with more experienced colleagues, and this is 10 how you build up your experience. 11 But I don't know of any specific training 12 in that part of pathology. Whereas in forensic 13 pathology, it's -- it's a very complex discipline with, 14 you know, totally different thing than you learn in 15 medical school and including working with the courts, 16 presenting evidence to the courts, documentation of 17 things, you know, which are not really part of the 18 regular pathologist's work. 19 COMMISSIONER STEPHEN GOUDGE: Thanks. 20 Sorry, Ms. McAleer. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: That's fine. 24 So just to clarify then, Dr. Cutz. You 25 didn't see any problem with the Hospital for Sick

1 Children doing work with child abuse -- suspected child 2 abuse or suspected neglect cases, but there was another 3 category of cases that you thought should not be done at 4 the Hospital -- 5 DR. ERNEST CUTZ: That -- 6 MS. JENNIFER MCALEER: -- for Sick 7 Children? 8 DR. ERNEST CUTZ: That's correct. 9 MS. JENNIFER MCALEER: And just to 10 clarify, what cases are those? 11 DR. ERNEST CUTZ: Well, these would be 12 like homicide where, you know, you are doing wound 13 assessment; you know, bullet wounds, knife wounds, any 14 kind of act of violence, rape and those kind of things, 15 which are -- things which the forensic pathologists do on 16 a daily basis so they have a lot of experiences; whereas 17 we practically never do it, and so we have no experience. 18 MS. JENNIFER MCALEER: And was it your 19 understanding that you would -- "you" being the 20 department, would -- or the division, would start to do 21 more of these cases as a result of the OPFPU being 22 established? 23 DR. ERNEST CUTZ: Well, I understand that 24 that's what was to happen but individual pathologists 25 still had the option of declining. And, you know, I

1 always declined if I would have been faced with it. And 2 I guess Dr. Smith took -- took it up on doing it, so... 3 MS. JENNIFER MCALEER: Have you actually 4 declined to do cases like that, Dr. Cutz? 5 DR. ERNEST CUTZ: Yes. I'm -- I cannot 6 recall any specifics but, you know, I -- I would. As I 7 said, you know, after discussion with the coroner and 8 then finding out what the case is about and if I felt 9 it's something I'm not comfortable in handling, I would 10 just tell the coroner to assign somebody else. 11 MS. JENNIFER MCALEER: And is it your 12 understanding that those cases would be assigned to Dr. 13 Smith? 14 DR. ERNEST CUTZ: It might have been, or 15 it might have been sent to the Coroner's Office. 16 MS. JENNIFER MCALEER: You don't know? 17 DR. ERNEST CUTZ: I don't know. Yes. 18 MS. JENNIFER MCALEER: All right. 19 COMMISSIONER STEPHEN GOUDGE: The cases 20 you are concerned about or were concerned about, Dr. 21 Cutz, is it fair to say that they are captured by the 5 22 percent that are criminally suspicious? 23 Is that really the core cases that you 24 were concerned about; not having the experience at Sick 25 Kids to continue to do?

1 DR. ERNEST CUTZ: That -- that's correct, 2 yes. 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: And once the unit 6 was up and running - the Commissioner asked you this but 7 I'll ask you again - were there any changes, with respect 8 to how cases were being handled within the unit, as to 9 what you'd been doing previously? 10 DR. ERNEST CUTZ: Well, the only 11 difference, maybe, is because Dr. Smith was more 12 frequently on call for those kinds of cases, so he would 13 do more cases than the rest of it -- rest of us. 14 And, you know, looking at the numbers, for 15 example, Dr. Smith was doing about 50 percent, and I 16 would do 25 percent of cases, and the other twenty-five 17 (25) would be divided between other pathologists. 18 MS. JENNIFER MCALEER: All right. So you 19 noticed an increase in the amount of medicolegal work 20 that Dr. Smith was doing? 21 DR. ERNEST CUTZ: That's correct, yes. 22 COMMISSIONER STEPHEN GOUDGE: And would 23 he have begun to do almost all of the 5 percent? 24 DR. ERNEST CUTZ: Yes, he would have to 25 because, you know, I personally would not get involved

1 and so would not the other pathologists, as far as I 2 know. 3 And so if Coroner's Office reassigned it, 4 it was up to -- up to the Coroner's Office to decide who 5 should be doing it. 6 7 CONTINUED BY MS. JENNIFER MCALEER: 8 MS. JENNIFER MCALEER: Dr. Cutz, did you 9 ever have any discussions with Dr. Becker or Dr. Phillips 10 about this concern that this type of work -- the 11 criminally suspicious work, the 5 percent -- really 12 shouldn't be done at the Hospital for Sick Kids? 13 DR. ERNEST CUTZ: Yes, I had discussion 14 with Dr. Becker and the other staff and we, sort of, just 15 reiterated what I just said; that, you know, we didn't 16 think it was appropriate for the hospital to get involved 17 in handling those kind of cases. 18 MS. JENNIFER MCALEER: Do you know if Dr. 19 Becker or Dr. Phillips shared your concern? 20 DR. ERNEST CUTZ: Dr. Becker definitely 21 shared my -- and, you know, we -- we -- I think Dr. 22 Phillips was also concerned that, you know, seeing armed 23 policemen in the Department, you know, and having the 24 autopsy room closed to even the Chief cannot go in, you 25 know, he found it was sort of inappropriate.

1 MS. JENNIFER MCALEER: Well, apart from 2 having armed police officers in the hospital, was there a 3 concern that perhaps this was just beyond the expertise 4 of the Division -- or the Department? 5 DR. ERNEST CUTZ: Well, I think it's 6 both. 7 MS. JENNIFER MCALEER: And as far as you 8 know, were those concerns ever communicated to the Office 9 of the Chief Coroner? 10 DR. ERNEST CUTZ: I -- I'm not sure, I -- 11 you know. 12 MS. JENNIFER MCALEER: Did you ever 13 discuss your concerns with Dr. Smith? 14 DR. ERNEST CUTZ: We -- we raised these 15 at our staff meetings. Yeah, we -- we discussed issues 16 related to the coroner's work at -- at staff meetings. 17 MS. JENNIFER MCALEER: But this 18 particular concern that perhaps this was beyond the 19 expertise of the department? 20 DR. ERNEST CUTZ: Yes, we did. 21 MS. JENNIFER MCALEER: And what was Dr. 22 Smith's response? 23 DR. ERNEST CUTZ: He seemed to, you know, 24 not be overly concerned. He seemed to say that he's be - 25 - he will be able to handle it.

1 MS. JENNIFER MCALEER: If we could turn 2 to Tab 31, please, of Volume I, PFP134495. 134495. 3 Now, these -- these are not your notes, 4 Dr. Cutz. 5 DR. ERNEST CUTZ: Yeah. 6 MS. JENNIFER MCALEER: As I understand 7 it, these are notes by Dr. Chiasson. I just want to use 8 them as a bit of a -- a guide. 9 You -- you'll recall that Dr. Chiasson was 10 appointed the Chief Forensic Pathologist in 1994? 11 DR. ERNEST CUTZ: That's correct, yes. 12 MS. JENNIFER MCALEER: All right. And as 13 I understand it, there were series of discussions of 14 meetings between Dr. Becker and Dr. Chiasson and 15 sometimes Dr. Young, with respect to the role of the 16 OPFPU in those initial years after it was first formed. 17 Do you -- do you recall being aware that 18 there was some discussions between Dr. Becker and the 19 Office of the Chief Coroner about the role of OPFPU? 20 DR. ERNEST CUTZ: Yes, I was in -- 21 actually Dr. Becker confided in me as to what was 22 discussed and also asked my advice as to what -- what -- 23 how should we proceed and what -- what areas we should 24 emphasize. 25 MS. JENNIFER MCALEER: All right. And if

1 we look at these notes -- and again, these are Dr. 2 Chiasson's notes -- but they seem the reflect a -- a 3 concern by Dr. Becker, with respect to three (3) areas 4 which are listed at the top: academic, administrative 5 and communicative. 6 And then you'll see that number 1: 7 "Wants strong academic focus to unit, 8 including use of case materials, data 9 for research projects, especially 10 related to SIDS." 11 DR. ERNEST CUTZ: That's correct. That 12 was -- 13 MS. JENNIFER MCALEER: Now, what -- what 14 do you recall, Dr. Cutz, about this issue? 15 DR. ERNEST CUTZ: Well, we discussed it 16 with Dr. Becker, you know, that -- you know, we can -- we 17 had some work which we wanted to -- to continue in and we 18 saw no reason why it should stop. And -- and 19 understanding of Dr. Becker was that, you know, we are 20 doing these autopsies to advance knowledge in pediatric 21 disease. And this is just because these babies happen to 22 die at home and -- and are investigated by the coroner. 23 You know, this is a very valuable source 24 of information for -- for people who are interested in -- 25 in what are the mechanism, what are the disease

1 processes, et cetera. So this is part of pediatric 2 medicine and understanding. And so we saw that -- what 3 our role should be actually to -- to help these families 4 and to advance the knowledge in -- in pediatrics. 5 MS. JENNIFER MCALEER: And was it your 6 understanding that -- that somehow that research was 7 going to be impacted or that the Coroner's Office didn't 8 agree? Or what was the concern? 9 DR. ERNEST CUTZ: No, I think their 10 feeling was that this is not within the mandate of the 11 Coroner's Office. And their mandate is to investigate 12 violent deaths and they are not really involved in 13 supporting or advancing or interested in medical 14 conditions. 15 MS. JENNIFER MCALEER: That was your 16 understanding? 17 DR. ERNEST CUTZ: Or I think that's what 18 -- you know, it's well understood missions. 19 MS. JENNIFER MCALEER: And was that 20 communicated to you or to Dr. Becker in some way, as far 21 as you know? 22 DR. ERNEST CUTZ: Well, I understand that 23 was a feedback from -- from these meetings with the -- 24 the coroner's officials, that -- you know, that that's 25 not in their mandate to -- and -- and they raised some

1 other issues in terms of, you -- you know, use of tissues 2 for research, which previously it was possible to -- to 3 get a -- permission from the Coroner's Office, but that 4 this was no longer possible and one would require consent 5 from -- from the parents or next of kin. 6 MS. JENNIFER MCALEER: All right. So 7 prior to the OPFPU being set up, your understanding was 8 that the Coroner's Office would provide consent if you 9 wanted to use tissues from medicolegal autopsies to do 10 SIDS research? 11 DR. ERNEST CUTZ: That's correct. We, in 12 fact -- I wrote to Dr. Bennett at the time, telling him 13 about our project with the National Institute of Health 14 and he -- he approved it, and he gave us the permission 15 to use tissues for SIDS research. 16 MS. JENNIFER MCALEER: Okay. And -- and 17 it was your understanding that this was no longer the 18 coroner's position, or that your -- your studies were 19 going to be impacted in some way? 20 DR. ERNEST CUTZ: Well, we were -- that 21 was no longer the position of the Coroner's Office. 22 MS. JENNIFER MCALEER: And did it in fact 23 impact the research work that you and Dr. Becker had been 24 doing? 25 DR. ERNEST CUTZ: Well, it in effect

1 stopped. 2 COMMISSIONER STEPHEN GOUDGE: Can I just 3 understand -- sorry, Ms. McAleer. 4 Can I just understand that -- at least in 5 '91/'92, there was funding out of the two hundred 6 thousand dollars ($200,000) directed to the SIDS 7 database. 8 DR. ERNEST CUTZ: Yes. 9 COMMISSIONER STEPHEN GOUDGE: At that 10 point in time had you been prevented from using slides 11 from these cases for your research, or did that happen 12 subsequently? 13 DR. ERNEST CUTZ: This happened 14 subsequently, yeah. 15 COMMISSIONER STEPHEN GOUDGE: And so in 16 subsequent years after '91/'92, did you lose both the 17 database component of the funding and your right to use 18 the tissues? 19 DR. ERNEST CUTZ: Yes. 20 COMMISSIONER STEPHEN GOUDGE: Okay. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: Now the -- the 24 second -- unless, Mr. Commissioner, if you have any more 25 questions?

1 COMMISSIONER STEPHEN GOUDGE: No, that's 2 fine, sorry, Ms. McAleer, thank you. 3 DR. ERNEST CUTZ: Well there were some 4 other developments which perhaps influenced this 5 attitude, is that there were some instances and cases in 6 Europe where there was a misuse of tissues. And there 7 were these commissions -- you know, the pathologists 8 keeping tissues and things. So -- so there were some 9 changes in attitude, in terms of -- 10 COMMISSIONER STEPHEN GOUDGE: Being free 11 to give permission -- 12 DR. ERNEST CUTZ: That's right. 13 COMMISSIONER STEPHEN GOUDGE: -- for you 14 to use -- 15 DR. ERNEST CUTZ: Yeah. 16 COMMISSIONER STEPHEN GOUDGE: -- the 17 tissues? 18 DR. ERNEST CUTZ: Right. 19 COMMISSIONER STEPHEN GOUDGE: Okay, 20 thanks. Sorry, Ms. McAleer. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: Did you discuss 24 this issue with Dr. Smith, Dr. Cutz? 25 DR. ERNEST CUTZ: Yes.

1 MS. JENNIFER MCALEER: And what was Dr. 2 Smith's view? 3 DR. ERNEST CUTZ: Well his -- he 4 maintains that this is in purview of the Coroner's Office 5 and we have to abide by it and there's nothing -- you 6 know, they're not willing to change it and you know, he - 7 - he can do nothing about it. 8 MS. JENNIFER MCALEER: Did Dr. Smith have 9 a different approach, with respect to SIDS research than 10 you and Dr. Becker? 11 DR. ERNEST CUTZ: Well, I don't know 12 whether he had any, you know, specific interest that I 13 know of. But I think in -- in the '90's, the -- the 14 prevalent view was or had seemed to have emerged, that 15 SIDS and the Sudden Infant Death in fact may not be 16 natural disease, but it -- it may be, you know, result of 17 foul play, either accidental or intentional. 18 Now there was -- all the anecdotal 19 evidence to suggest that there was no scientific evid -- 20 evidence to say this is what -- what's happening and 21 since then the -- the view have changed now. You know, 22 now it's pretty well established that this is a view 23 which is, you know, outdated and -- and is not 24 substantiated by any kind of evidence. 25 So that, you know, there was a period

1 where people were -- the thinking was that, you know, 2 these -- these kind of cases would need a much -- much 3 higher scrutiny to -- to ensure that, you know, these 4 children were not -- not subject to criminal activities. 5 MS. JENNIFER MCALEER: And did you 6 discuss that difference in -- in view or perspective with 7 Dr. Smith? 8 DR. ERNEST CUTZ: Well that's become 9 clear in the memo 631. 10 MS. JENNIFER MCALEER: All right. With 11 respect to the second issue that's identified on this 12 memo: 13 "Would like a dedicated forensic 14 pathology assistant to help C. Smith. 15 Apparent backlog of? [question mark] 16 sixty (60) plus cases as far back as 17 1992." 18 Now, do you remember speaking to Dr. 19 Becker about this request for a dedicated forensic 20 pathology assistant? 21 DR. ERNEST CUTZ: I -- I don't know the 22 specifics. I might have heard about it, but you know, 23 don't recollect it specifically, discussing this. 24 MS. JENNIFER MCALEER: All right. With 25 respect to the third point:

1 "Problems of communication between 2 members of Department performing 3 medicolegal and Coroner's Office, all 4 directed through CS. Would want more 5 direct contact." 6 Do you recall that being an issue, Dr. 7 Cutz. 8 DR. ERNEST CUTZ: Well, all I recall -- I 9 mean, I don't know this particular one, but you know, all 10 I recall that there was repeated complaints in Coroner's 11 Office and even we -- we bend backwards, it wasn't good 12 enough. And -- and so that might be one (1) of those 13 kind of complaints, because you see the official 14 understanding and setup was that pathologists directly 15 communicates with the coroner and -- and so that's as far 16 as communication go. 17 Now in -- if you insert a cert -- person 18 into it, I don't see how it's -- you know, how it -- how 19 it makes things better -- or unless if there's some 20 specific policy. You know, there -- there was no policy 21 to -- to tell, you know, this is how things should work, 22 but we -- we thought that the arrangement of the 23 pathologist communicating directly with the investigating 24 coroner is the best way to, you know, pass on the 25 information.

1 MS. JENNIFER MCALEER: All right, and had 2 that changed? Were you no longer communicating directly 3 with the local coroners or was the communication all 4 directed through Dr. Smith? 5 DR. ERNEST CUTZ: No, I -- I think I 6 always did the, you know, coroner communication or if 7 there was an issue which, you know, Dr. Smith may know 8 through the Coroner's Office that, you know, he heard 9 about the case or heard something about it, then he would 10 ask about it. 11 MS. JENNIFER MCALEER: Sorry, if it was a 12 case that had been assigned to you, but he had heard -- 13 DR. ERNEST CUTZ: That's right. 14 MS. JENNIFER MCALEER: -- something 15 through the Coroner's Office -- 16 DR. ERNEST CUTZ: That's correct, yes. 17 MS. JENNIFER MCALEER: -- he might speak 18 to you about the case? 19 DR. ERNEST CUTZ: Yes, yes. 20 MS. JENNIFER MCALEER: All right. But 21 you were continuing to have direct contact with the local 22 coroner on the medicolegal cases that you were assigned 23 to. 24 DR. ERNEST CUTZ: Yes. 25 MS. JENNIFER MCALEER: And then looking

1 at the second page where it says "Our response" -- 2 DR. ERNEST CUTZ: Yeah. 3 MS. JENNIFER MCALEER: -- and I won't 4 take you through all of this, but down at the bottom, 5 there's a reference by Dr. -- and again, these are Dr. 6 Chiasson's notes -- but there's a reference to a 7 possibility of monthly forensic pathology working rounds 8 and he says, "We'll explore", and then there's a little 9 arrow that says, "Monitoring of cases; discussion of 10 cases". 11 Do you have any recollection, Dr. Cutz, as 12 to there being a suggestion, in or around the summer of 13 1994, that there should be forensic pathology rounds? 14 DR. ERNEST CUTZ: Yes. I heard about it, 15 yes. 16 MS. JENNIFER MCALEER: Okay, and what was 17 your understanding as to who wanted the rounds and -- and 18 what purpose they would serve? 19 DR. ERNEST CUTZ: Well, I think we 20 presented practically every case which came through the 21 department at our regular weekly autopsy rounds. You 22 know, regardless whether they were coroner's cases or 23 not, we obtained permission from the coroner to show the 24 case. And so to have a special round, you know, I guess 25 it's okay to have a -- to have a special round just

1 dedicated to certain types of cases, but, you know, we -- 2 we've seen these cases before. 3 MS. JENNIFER MCALEER: Were all 4 medicolegal cases discussed at the general pathology 5 rounds? 6 DR. ERNEST CUTZ: Pretty well, except, 7 you know, some high profile cases where there may be a 8 question of malpractice, or a question of homicide, or, 9 you know, some highly suspicious case which was under 10 police investigation, so... 11 And, you know, since we checked with the 12 coroner, he would tell us, you know, it can be shown or 13 it cannot be shown, so... 14 MS. JENNIFER MCALEER: And if the case 15 was not shown, was it your understanding that it was 16 shown somewhere else, or that there were rounds at the 17 Coroner's Office, or did you know? 18 DR. ERNEST CUTZ: It doesn't necessarily 19 have to be shown; it -- it, you know, wouldn't name -- 20 most likely not be shown. 21 MS. JENNIFER MCALEER: Okay. Turning to 22 Tab 32, which is the next document in binder, PFP056441. 23 And this is a letter from Dr. Becker to Dr. Chiasson and 24 you are cc'd on it, if we look at the next page at the 25 top.

1 DR. ERNEST CUTZ: Yes. 2 MS. JENNIFER MCALEER: And it seems to be 3 a letter from Dr. Becker to Dr. Chiasson, further to the 4 meeting on July 11th; the notes of which we just 5 reviewed. And you'll see that the last paragraph: 6 "As I indicated at the meeting of July 7 11th, the pathologist's participating 8 in the medicolegal cases at the 9 Hospital for Sick Children would 10 appreciate an opportunity of talking 11 directly with Jim Young at a mutually 12 convenient time." 13 Now, do you recall, Dr. Cutz, whether or 14 not you had an interest in speaking to Dr. Young 15 directly? 16 DR. ERNEST CUTZ: I -- I think this was 17 brought up because one was getting mixed messages from 18 different people; like Dr. Chiasson was talking on one 19 (1) thing, Dr. Cairns was talking on something else, and 20 Dr. Smith was -- and still another version, so we -- we 21 wanted to know, you know, what -- what actually they 22 want, what is the -- and to have some discussion with the 23 top official. 24 MS. JENNIFER MCALEER: Mixed messages 25 about what, Dr. Cutz?

1 DR. ERNEST CUTZ: Well, about these 2 different procedures -- you know, who -- who communicated 3 with whom, and, you know, how -- how to -- these things 4 kept changing. 5 MS. JENNIFER MCALEER: Well, did -- did 6 you have that meeting with Dr. Young, as far as you 7 recall? 8 DR. ERNEST CUTZ: I kind of recall that, 9 you know, we might have had, but, you know, I can't 10 recall a specific meeting. 11 MS. JENNIFER MCALEER: All right. If we 12 look at the next tab, Tab 33, which is PFP056861, there 13 is a ref -- this is a letter from Dr. Chiasson to Dr. 14 Becker in response to his letter, but there is a 15 reference to trying to set up a meeting in September. 16 DR. ERNEST CUTZ: Yes. 17 MS. JENNIFER MCALEER: But you don't 18 recall, Dr. Cutz, whether or not you were at that 19 meeting -- 20 DR. ERNEST CUTZ: No -- 21 MS. JENNIFER MCALEER: -- or whether -- 22 DR. ERNEST CUTZ: -- I have no specific 23 recollection, no. 24 MS. JENNIFER MCALEER: Okay. And then in 25 the documents that I had asked you to review, Dr. Cutz,

69
  1  there are a series of letters regarding a discussion
  2  about autopsy protocols and what autopsy protocols should
  3  be used, and the impact with respect to SIDS research.  
  4                 Without reviewing each one of those
  5  documents individually, Dr. Cutz, do you recall that the
  6  issue regarding autopsy protocols and which autopsy
  7  protocol to use?  We can look at the documents.  
  8                 DR. ERNEST CUTZ:   Yeah, I...
  9                 MS. JENNIFER MCALEER:   We can look at Tab
 10  34, which if PFP056438.  That's Tab 34 of your binder.
 11                 DR. ERNEST CUTZ:   Yes.
 12                 MS. JENNIFER MCALEER:   I'll just give you
 13  a moment to review that briefly, Dr. Cutz.
 14                 DR. ERNEST CUTZ:   Yeah, I think this is a
 15  letter from Dr. Smith to Dr. Becker.
 16                 MS. JENNIFER MCALEER:   Right.  And you'll
 17  see that you're cc'd on it again?
 18                 DR. ERNEST CUTZ:   Yes, I think because
 19  this -- this was to let the staff know any changes in,
 20  you know, procedures.  
 21                 MS. JENNIFER MCALEER:   And do you recall
 22  what the issue was about the autopsy protocol?
 23                 DR. ERNEST CUTZ:   This is the point 5 you
 24  mean or which -- which one?
 25                 MS. JENNIFER MCALEER:   Well, let -- let's

1 actually just look at the first, number 1, for a moment. 2 DR. ERNEST CUTZ: Yeah. 3 MS. JENNIFER MCALEER: It says: 4 "All coroner's autopsies may be 5 discussed within the hospital, provided 6 that the death did not result from 7 medical malpractice on the part of the 8 staff member at the hospital." 9 DR. ERNEST CUTZ: Yes. 10 MS. JENNIFER MCALEER: Now, that would 11 indicate to me, Dr. Cutz -- it says "all coroner's 12 autopsies". It says that would include the criminally 13 suspicious autopsies. 14 But is it your understanding that those 15 cases weren't discussed? 16 DR. ERNEST CUTZ: No, as I mentioned 17 earlier, each time if we going to present, we check with 18 the coroner to ensure that we can present it. 19 MS. JENNIFER MCALEER: Mm-hm. 20 DR. ERNEST CUTZ: And so, you know, if he 21 said there's a malpractice, you know, we -- we would not 22 present it. 23 MS. JENNIFER MCALEER: All right. But 24 apart from it being malpractice, if it were a criminally 25 suspicious case did you ever -- was it your understanding

1 that those cases were or were not discussed? 2 DR. ERNEST CUTZ: Those would not be 3 discussed. 4 MS. JENNIFER MCALEER: All right. And if 5 we could turn to the -- to the next document, I think, 6 which will address this other issue, which is Tab 35, 7 PFP056436. 8 DR. ERNEST CUTZ: Yeah. 9 MS. JENNIFER MCALEER: And in the middle 10 of the -- this is a letter from Dr. Smith to Dr. Young 11 referring to some communication with Dr. Phillips -- 12 second -- third paragraph referring to a -- a memo about 13 medicolegal tissues, was written at Dr. Phillips' 14 request. Dr -- he: 15 "Dr. Phillips was concerned that it 16 would significantly impact the SIDS 17 research program in the Department and 18 did not act on the memo for several 19 months. It was not welcomed by Dr. 20 Cutz and Becker. A final act of Dr. 21 Phillips in his capac -- capacity of 22 pathologist and Chief was to have this 23 memo adopted at -- a departmental 24 policy. This was done at the 25 departmental staff meeting on June

1 24th, 1994." 2 And if we turn the page you'll see the 3 memo from Dr. Smith to Dr. Phillips about tissue for 4 medicolegal autopsies. 5 DR. ERNEST CUTZ: Yes. 6 MS. JENNIFER MCALEER: And does this 7 accord with your recollection, Dr. Cutz, about the issues 8 surrounding the use of medical -- tissue obtained from 9 medicolegal autopsies for SIDS research? 10 DR. ERNEST CUTZ: Well, it's one (1) of 11 the issues. I think the second issue in this memo is 12 that Dr. Smith thought that all kind of special 13 investigation, which means like research -- results of 14 research, they should be included in -- in a medicolegal 15 report. 16 And, you know, this would be, you know, 17 something totally -- not only impractical, but totally 18 useless because anybody doing research knows that a 19 single result is -- is insignificant. You have to look 20 at the whole, you know, series of cases and -- and 21 results from one (1) case means nothing. And it would -- 22 it would only draw -- confuse, so we didn't think that. 23 And that was on the so-called disclosure, you know, which 24 I don't think disclosure refers to any research activity. 25 MS. JENNIFER MCALEER: So it was your

1 understanding that Dr. Smith wanted you to list on the 2 medicolegal report -- 3 DR. ERNEST CUTZ: Right. 4 MS. JENNIFER MCALEER: -- that you were 5 completing whether or not any tissues had been taken to 6 do this research? 7 DR. ERNEST CUTZ: No, no, he wanted us to 8 put results of our research studies on it. 9 MS. JENNIFER MCALEER: I see. 10 DR. ERNEST CUTZ: Like, you know, some 11 values. When -- let's say measurements. For example, 12 Dr. Becker was doing work in the neuropathology and he 13 was measuring or counting neurons in the brainstem and -- 14 and so he wanted to have result from each case what -- 15 what those findings were. 16 MS. JENNIFER MCALEER: Would that 17 research not be ongoing, though, Dr. Cutz? 18 Would it be possible to have research 19 results completed in time, when the post-mortem 20 examination report was completed? 21 DR. ERNEST CUTZ: No, but I think the 22 issue here is not -- was that both Dr. Becker and me, we 23 thought it was useless and inappropriate. Like it was 24 totally unnecessary to -- 25 COMMISSIONER STEPHEN GOUDGE: It had

1 nothing to do with the cause of death -- 2 DR. ERNEST CUTZ: That's correct. 3 COMMISSIONER STEPHEN GOUDGE: -- report-- 4 DR. ERNEST CUTZ: Yeah. 5 COMMISSIONER STEPHEN GOUDGE: -- it was a 6 piece of data you were accumulating for ongoing research? 7 DR. ERNEST CUTZ: For -- that's correct. 8 9 CONTINUED BY MS. JENNIFER MCALEER: 10 MS. JENNIFER MCALEER: Now, Dr. Taylor... 11 DR. GLENN TAYLOR: Yes. 12 MS. JENNIFER MCALEER: Still with us? 13 DR. GLENN TAYLOR: Yes. 14 MS. JENNIFER MCALEER: You joined the 15 Department in 1995. When you -- and I should, before we 16 -- I start asking you questions, -- the -- the HSC 17 Institutional Report that's before you, Commissioner -- 18 it's my understanding, Dr. Taylor, that you have 19 participated in the preparation of that report and that 20 you are prepared to adopt that report as part of your 21 evidence here today? 22 DR. GLENN TAYLOR: Yes, I am. 23 MS. JENNIFER MCALEER: All right. And 24 that report indicates that you joined the department in 25 1995 as we discussed reviewing your resume.

1 What was your understanding as to the role 2 of the OPFPU when you joined the department? 3 DR. GLENN TAYLOR: Similar to Ernest, it 4 was mostly an administrative agent within the Department 5 of Pathology that was involved with handling the 6 coroner's cases; coroner's autopsies. 7 Charles was the Director, and as such, had 8 administrative direction to provide the unit. Also was - 9 - Dr. Smith was involved with, generally, overseeing the 10 quality -- as far as I was concerned, quality of the 11 unit. And I guess the direct example of that was he 12 reviewed all of the autopsy reports that were generated 13 through the coroner's autopsies. 14 Other than that, it was just a part of 15 pathology and it related to the coroner's autopsies; 16 functioned as a staff pathologist doing those cases when 17 I was on the rota. 18 MS. JENNIFER MCALEER: Right. We'll talk 19 about the review process that Dr. Smith engaged in with 20 respect to the post-mortem reports that were being 21 generated by the staff pathologists. 22 But before we talk about that, as you just 23 indicated, you had had some prior experience doing 24 coroner's work when you in British -- you were in British 25 Columbia, correct?

1 DR. GLENN TAYLOR: That's true, yes. 2 MS. JENNIFER MCALEER: And can you 3 elaborate on the nature of your experience in British 4 Columbia? 5 DR. GLENN TAYLOR: In many ways, it was 6 similar to what was being done at Sick Kids in that there 7 was an autopsy rotation as part of the general service 8 rotation or service requirements of the pathologist. 9 There were a selected group of 10 pathologists; three (3) or four (4), of the staff that 11 would be -- that were willing to do the coroner's cases, 12 so that if a coroner's case come up -- came up as part of 13 the autopsy rotation and one (1) of those pathologists 14 was on that week, they would do the case. 15 If cases came through when another 16 pathologist who was not involved with the coroner's cases 17 was on, then it would be deferred to one (1) of the 18 people that were, kind of, willing to do them. 19 These people were not necessarily approved 20 by the Office of the Chief Coroner of British Colombia 21 through a formal process like they were in Ontario, but 22 they certainly were recognized by the coroners in British 23 Columbia as pediatric pathologists who would be able to 24 do those kind of cases. 25 MS. JENNIFER MCALEER: All right. And if

1 we look at your CV again, which is at Tab 2 of Volume I, 2 and we look at page 4. That document again, Mr. 3 Registrar, is PFP302261 page 4, under "Professional 4 Consultant Activities". We see there that you've -- 5 you've listed your previous experience with the Office of 6 the Chief Coroner in British Columbia. 7 DR. GLENN TAYLOR: Yes. 8 MS. JENNIFER MCALEER: All right. And 9 were you doing all medicolegal autopsies, or all types of 10 medicolegal autopsies? Or were there certain categories 11 that you -- you did not do? 12 DR. GLENN TAYLOR: We did basically what 13 came to us. I think there was probably some streaming of 14 certain cases bef -- prior to the Pathology Department at 15 BC Children's Hospital being considered. So if -- if it 16 was an obvious homicide case, generally I think they went 17 to the Vancouver General Hospital or to the Royal 18 Columbian Hospital in New Westminster. 19 Occasionally some child abuse cases came 20 through and occasionally some cases which would be 21 considered, sort of hardcore forensic homicide cases came 22 through, but they were very rare. 23 MS. JENNIFER MCALEER: And -- 24 COMMISSIONER STEPHEN GOUDGE: SIDS cases? 25 DR. GLENN TAYLOR: We had many, many SIDS

1 cases. In fact, through Margaret Norman, who was one (1) 2 of my mentors, with regards to pediatric forensic 3 pathology during those years, there was an arrangement 4 for several years that all of the SIDS cases for the 5 Province of British Columbia would come to BC Children's 6 Hospital. 7 MS. JENNIFER MCALEER: And what was Dr. 8 Norman's background; we've -- we've heard her name 9 before? 10 DR. GLENN TAYLOR: She was a pediatric 11 pathologist; pediatric neuropathologist. She -- I -- I 12 can't remember the -- where exactly she trained, but 13 certainly she spent some time at the Hospital for Sick 14 Children, then she was, I think, Chief of Pathology at 15 Children's Hospital of Eastern Ontario and then in about 16 19 -- I guess it was 1980 or '79 she came to Vancouver to 17 be a staff pathologist, neuropathologist, at the soon to 18 be BC Children's Hospital. 19 MS. JENNIFER MCALEER: And was it your 20 understanding that she had any formal forensic training? 21 DR. GLENN TAYLOR: I'm not sure what you 22 mean by formal. I don't think she did a fellowship in 23 forensic pathology. I'm not sure what courses she took 24 or other kind of formal activities with regards to her 25 education in forensic pathology, but she certainly had a

1 lot of experience. 2 MS. JENNIFER MCALEER: And had you taken 3 any forensic pathology courses, or seminars, or had any 4 formal forensic pathology training? 5 DR. GLENN TAYLOR: As part of my 6 entopathology (phonetic) residency through the University 7 of Toronto, I had a re -- a regular rotation in forensic 8 pathology that was required during the -- those years. 9 Subsequently I've taken courses and 10 workshops in forensic pathology, pedia -- focussing on 11 pediatric forensic pathology over the years. There's an 12 -- off the top of my head, I think I took the AFIP, Armed 13 Forces Institute of Pathology, workshop one (1) year. 14 I've -- I -- 15 COMMISSIONER STEPHEN GOUDGE: Is that the 16 one in Washington? 17 DR. GLENN TAYLOR: Yes. I took a multi- 18 day course through the Institute for Pediatric Medical 19 Education. I think that was around 1989 or so, 1990; it 20 may have been later. And I've taken workshops at the 21 Canadian Association of Pathology annual meetings and 22 through the United States/ Canadian Association of 23 Pathology meetings over the years. 24 In addition, I have attended some of the 25 coroner's educational opportunities that the Office of

1 the Chief Coroner of Ontario has provided. And I have 2 been involved more in teaching, rather than taking, 3 through educational activities of the Office of the Chief 4 Coroner for British Columbia. 5 6 CONTINUED BY MS. JENNIFER MCALEER: 7 MS. JENNIFER MCALEER: All right. Going 8 back to your -- your resident -- 9 COMMISSIONER STEPHEN GOUDGE: Can I just 10 ask -- sorry, Ms. McAleer. 11 MS. JENNIFER MCALEER: Sorry, go ahead. 12 COMMISSIONER STEPHEN GOUDGE: Just in a 13 general way, Dr. Taylor, those courses directed at what 14 you might comfortably label "forensic training", did they 15 deal mostly with the interface of the pathologist with 16 the legal system, the giving of evidence -- 17 DR. GLENN TAYLOR: Yeah. 18 COMMISSIONER STEPHEN GOUDGE: -- the 19 dealing with Crowns, and the dealing with police? Or was 20 there an element that also dealt with, if you like, 21 injury investigation of the kinds of injuries you might 22 not commonly see unless they were the 5 percent of 23 obviously criminal cases? 24 DR. GLENN TAYLOR: You know, they involve 25 both aspects, but primarily they involved looking at the

1 types of causes of sudden unexpected death in children. 2 And many of them had a greater focus on natural disease 3 causes than on inflicted causes or accidental causes, 4 although that always was a part. So child abuse was 5 always a consideration at these. 6 And there were -- there were components as 7 well, about interaction with the court system and with -- 8 COMMISSIONER STEPHEN GOUDGE: But so far 9 as they have focussed on SIDS and SIDS related scientific 10 investigation, -- 11 DR. GLENN TAYLOR: Yeah. 12 COMMISSIONER STEPHEN GOUDGE: -- it is 13 interesting they would put that under the label of 14 forensic, because it is, sort of, right on the borderline 15 between what might be pediatric pathology and what might 16 be considered -- I mean, Dr. Cutz, you would consider it 17 pediatric pathology? 18 DR. ERNEST CUTZ: That's correct, yes. 19 DR. GLENN TAYLOR: Well, these were 20 pediatric forensic pathology -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. GLENN TAYLOR: -- events, usually. 23 COMMISSIONER STEPHEN GOUDGE: Because 24 they are under warrant. 25 DR. GLENN TAYLOR: Yes.

1 COMMISSIONER STEPHEN GOUDGE: But 2 different from the 5 percent, which I think Dr. Cutz 3 would -- 4 DR. GLENN TAYLOR: Generally different 5 from -- 6 COMMISSIONER STEPHEN GOUDGE: -- describe 7 as cases where the injuries are obviously inflicted 8 through criminal activity? 9 DR. ERNEST CUTZ: That's correct. 10 DR. GLENN TAYLOR: So for -- I use the 11 word hard core forensic pathology education that was a -- 12 it was a minority of my -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. GLENN TAYLOR: -- educational 15 activities. 16 COMMISSIONER STEPHEN GOUDGE: Okay. 17 Thanks. Thanks, Ms. McAleer. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: You mentioned that 21 as part of your residency, you had done a regular 22 forensic rotation. What -- what did that rotation 23 consist of? 24 DR. GLENN TAYLOR: It was attending at 25 the autopsy facility at the Office of the Chief Coroner;

1 watching and performing autopsies under supervision of 2 the staff pathologist. I can recall attending a couple 3 of scene investigations, and I can recall going to court 4 with one (1) of the staff pathologists who happened to 5 have a court date during my rotation period. 6 MS. JENNIFER MCALEER: And that rotation 7 was -- was it a month long at the Office of the Chief 8 Coroner? 9 DR. GLENN TAYLOR: Yes, it was a month or 10 two (2) months. I can't recall. 11 MS. JENNIFER MCALEER: And you would -- 12 you would have done that between 1979 and 1981 when 13 you -- 14 DR. GLENN TAYLOR: It would have between 15 1979 and 1981, correct. 16 MS. JENNIFER MCALEER: Okay. And, Dr. 17 Taylor, you've explained some of the continuing medical 18 education courses that you've taken that are related to 19 forensic pathology. 20 Dr. Cutz, have you also taken some CME 21 training or courses over the last number of years with 22 respect to forensic pathology issues? 23 DR. ERNEST CUTZ: Yes, similar to what 24 Dr. Taylor mentioned. You know, these are usually 25 courses or seminars in conjunction with meetings of

1 pediatric pathologists. And, you know, at Sick 2 Children's, you know, we are one of the few places which 3 actually does this kind of work. But, you know, there 4 are other places where -- where they have this sort of 5 experience and they would makes courses which sort of 6 covers the spectrum of -- of sort of type of cases which 7 one sees. 8 And, you know, it reflects, you know, 90 9 percent natural deaths and this -- this 10 percent of -- 10 of various types of activities or criminal activities. 11 So I took seminar courses with the US/Canadian 12 Association of Pathology with the Pediatric Pathologist 13 Society. 14 And I also took a course, which was part 15 of the International SIDS Symposium was -- was held in 16 Edmonton as it was 2003 or '04. It was -- was a course 17 on investigation of sudden deaths in infancy. 18 MS. JENNIFER MCALEER: So -- so as Dr. 19 Taylor indicated, your experience as well, the CME 20 courses you've taken, have been largely within the 21 category of pediatric pathology issues that arise doing 22 coroner's work as opposed to, as Dr. Taylor has said, 23 that the hard core forensic's courses? 24 DR. ERNEST CUTZ: That's correct. 25 MS. JENNIFER MCALEER: Okay. And, Dr.

1 Taylor, just finally, you had indicated that when you 2 were in British Columbia doing coroner's work that some 3 of the cases, you had the impression, may have been 4 triaged out before they even came to the hospital, but 5 that some of the criminally suspicious homicide cases 6 actually did end up coming into your hospital? 7 DR. GLENN TAYLOR: Yes, they did. 8 MS. JENNIFER MCALEER: And -- and did you 9 participate in those autopsies? 10 DR. GLENN TAYLOR: Yes, I did. 11 MS. JENNIFER MCALEER: And generally 12 speaking, how many of those autopsies would you do in a 13 year? 14 DR. GLENN TAYLOR: In a year? Oh, 15 probably less than one (1) a year. 16 MS. JENNIFER MCALEER: I see. So over 17 the course of your experience, out there in British 18 Columbia, do you have any idea how many of those cases 19 you may have done before you came to the Hospital for 20 Sick Kids? 21 DR. GLENN TAYLOR: I think I added them 22 up recently. I think there were only six (6). 23 MS. JENNIFER MCALEER: Okay. So when you 24 joined the department then, in 1995, Dr. Taylor, did you 25 ask to do medicolegal work or was it expected of you?

1 How did you come to be part of the team doing medicolegal 2 autopsies? 3 DR. GLENN TAYLOR: I didn't specifically 4 ask. I just assumed that it would be part of my 5 responsibilities on the autopsy service. 6 MS. JENNIFER MCALEER: And you mentioned 7 earlier that it was your understanding that Dr. Smith as 8 -- in his role as Director of the Unit was reviewing the 9 post-mortem examination reports that you would prepare. 10 Is that correct? 11 DR. GLENN TAYLOR: Yes. 12 MS. JENNIFER MCALEER: All right. And 13 starting with you, Dr. Taylor. What was your experience 14 with respect to how that process worked? Would you 15 submit the form and just get it back or would you sit 16 down and discuss it? What was the process? 17 DR. GLENN TAYLOR: I would complete the 18 report. It would be typed out. It would be given to Dr. 19 Smith for his review. I can't recall if there were any 20 that were brought back to me. Generally, they just 21 seemed to be reviewed, checked, stamped and sent off to 22 the Coroner's Service. 23 I can't recall any specific discussion I 24 had with Dr. Smith about one (1) of my reports. 25 MS. JENNIFER MCALEER: Would they

1 physically get stamped by Dr. Smith? 2 DR. GLENN TAYLOR: I -- yeah, if I 3 remember. If I remember right, yes. 4 MS. JENNIFER MCALEER: And then would Dr. 5 Smith forward them on to the local coroner or the Crown 6 attorney or would you do that -- 7 DR. GLENN TAYLOR: Mm. 8 MS. JENNIFER MCALEER: -- or would 9 somebody else? 10 DR. GLENN TAYLOR: This I can't remember; 11 maybe Ernest can help me here. I can't remember if he 12 sent them directly or they came back to my secretary for 13 sending out. I -- I think it was the latter. 14 MS. JENNIFER MCALEER: All right. 15 Dr. Cutz, do you recall? Was the process 16 as Dr. Taylor has explained it -- 17 DR. ERNEST CUTZ: Yes, pre -- 18 MS. JENNIFER MCALEER: -- or was your 19 experience different? 20 DR. ERNEST CUTZ: -- pretty well. Yes, 21 pretty well as Dr. Taylor described. 22 The stamping was on the invoice. The 23 invoice where we, sort of, bill for the -- for the 24 autopsy. And if it didn't have Dr. Smith's signature or 25 stamp, then we won't get paid and so -- but the report,

1 after it was stamped, it was given back to the 2 secretaries to send wherever, you know, was the 3 instruction to send it. 4 MS. JENNIFER MCALEER: All right. So you 5 would submit -- would you actually sign your report 6 before submitting it to Dr. Smith or would it be a draft 7 report? 8 DR. ERNEST CUTZ: No, well, I don't -- 9 DR. GLENN TAYLOR: No, it was a signed -- 10 it was a signed report, yes. 11 DR. ERNEST CUTZ: Yeah, it was completed, 12 signed. So as far as we were concerned, it was finished; 13 like it was a final, finished report. 14 MS. JENNIFER MCALEER: All right. And do 15 you recall, Dr. Cutz, ever sitting down and discussing 16 any of your reports with Dr. Smith? 17 DR. ERNEST CUTZ: There -- I think one 18 (1) of -- one (1) of the reason or -- for looking at 19 these reports was, one (1) was to check for spelling 20 mistakes, you know, there's some -- some embarrassing 21 spelling mistakes. And the other one (1) was so that -- 22 so that the wording which is used as the cause of death, 23 that's in accordance with the Coroner's Office, sort of, 24 wishes. 25 And in terms of some disagreement in the

1 diagnosis, I had some -- some experience with that. 2 MS. JENNIFER MCALEER: And what was your 3 experience? 4 DR. ERNEST CUTZ: Where some of my 5 diagnoses may be questioned or the diagnoses may be -- 6 wanted to be more different. 7 MS. JENNIFER MCALEER: Can you recall a 8 specific experience where you submitted a post-mortem 9 examination report to Dr. Smith, and he disagreed with 10 the diagnosis that you had reached? 11 DR. ERNEST CUTZ: Yes, I do. 12 MS. JENNIFER MCALEER: And can you 13 provide us with any particulars about that difference in 14 diagnosis? 15 DR. ERNEST CUTZ: Yes. I think I listed 16 four (4) -- four (4) instances which -- and I don't know 17 where it is in this binder but, you know, at least four 18 (4) instances of -- of -- 19 MS. JENNIFER MCALEER: It's not in the 20 binder. 21 DR. ERNEST CUTZ: Oh, it is not? 22 MS. JENNIFER MCALEER: What do you 23 recall, Dr. Cutz? 24 DR. ERNEST CUTZ: Well, the four (4) -- 25 like the one (1) case was -- was a child who was two (2)

1 weeks past one (1) year. And my diagnosis, based on the 2 circumstances, based on the pathology and all the 3 findings, I made a diagnosis of Sudden Infant Death 4 Syndrome or SIDS. 5 And this is fairly consistent with what -- 6 what is known about the age distribution of SIDS. It's a 7 sort of Gaussian distribution. There is a predominant 8 age group that this occurs, but there are outliers at 9 both less than this age and also over this age. So I 10 didn't think a two (2) week -- extra two (2) week of life 11 would disqualify the case from being called SIDS. 12 Because, you know, the official -- official cutoff was 13 like twelve (12) months, you know; death under one (1) 14 year of age, which defines it at twelve (12) months. 15 But having worked on the National 16 Institute of Health's expert panel on SIDS definition and 17 also reading the literature, knowing what -- you know, 18 how they should be classified, including a large review 19 of SIDS cases at the Armed Forces Institute of Pathology, 20 it lists this Gaussian distribution showing that, in 21 fact, you know, there is at least 7 percent of cases 22 which are over one (1) year of age. 23 MS. JENNIFER MCALEER: Sorry, did you say 24 -- 25 COMMISSIONER STEPHEN GOUDGE: What

1 percentage? 2 DR. ERNEST CUTZ: About 7 percent would 3 be over one (1) -- you know, it gives weeks by weeks, so 4 I don't remember what is the -- well beyond the, you 5 know, twelve (12) -- 6 COMMISSIONER STEPHEN GOUDGE: And -- 7 DR. ERNEST CUTZ: -- months and two (2) 8 weeks -- 9 COMMISSIONER STEPHEN GOUDGE: Yeah. 10 DR. ERNEST CUTZ: -- okay. And -- and so 11 I say, you know, to generate the proper statistics and 12 actually define the specific subgroups of SIDS, because 13 these would be different from the most common, which is 14 between, you know, two (2) and three (3) months, so 15 that's one (1) group which are subgroup. 16 And we used a different approach to, sort 17 of, characterize these cases, and we called them like 18 SIDS Group A, which would be classical SIDS cases which 19 had all the features of what's described "age et cetera." 20 And then SIDS Group B, which had some feature which was 21 outside; these are outside of the usual age. You know, 22 some feature but it still was in... 23 And then when you started these subgroups, 24 you know, you can understand better. Because it's not a 25 uniform disease. It's -- it's probably a multi-

1 factorial. So you need this kind of a... 2 And so I felt that, you know, if we put it 3 into "undetermined" category, this case will get lost in 4 terms of, you know, if everything else would be, you 5 know, indicating this is a SIDS death by all this 6 definition. But because, you know, there's a twelve (12) 7 month cutoff and therefore. 8 So I tried to make this argument to Dr. 9 Smith and I didn't change it. I stick with my -- stick 10 with my diagnosis. 11 MS. JENNIFER MCALEER: And when you say 12 "gets lost", you -- you meant as -- 13 DR. ERNEST CUTZ: Well, it would work 14 from the statistics. 15 MS. JENNIFER MCALEER: From the 16 statistics -- 17 DR. ERNEST CUTZ: Yeah. 18 MS. JENNIFER MCALEER: -- on SIDS 19 research? 20 DR. ERNEST CUTZ: And -- and from -- and 21 then when you look in the subgroups. 22 MS. JENNIFER MCALEER: All right. And 23 then you briefly mention that you were on the National -- 24 the Committee that determined the definition of SIDS. 25 Can you --

1 DR. ERNEST CUTZ: Yes, this was a -- 2 MS. JENNIFER MCALEER: -- explain that? 3 DR. ERNEST CUTZ: -- expert committee 4 which was called in 19 -- '90/'91. This was published in 5 '90/'91 and which is the world-wide recognized definition 6 of SIDS. 7 This was called by the National Institute 8 of Health, the branch of Child Health and Development or 9 so-called SIDS -- SIDS Office of the National Institute 10 of Health. And there were two (2) pediatric 11 pathologists, Dr. Bruce Beckwith, myself; Dr. John 12 Smialek, who is the Chief Medical Officer -- Chief 13 Medical Examiner for Baltimore, a forensic pathologist, a 14 well-known pediatrician; and two (2) researchers. 15 And the purpose of this definition was 16 ahead of a major funding initiative by the National 17 Institute of Health to ensure that the cases which are 18 being studied are well-defined cases. 19 So that was the primary role for coming up 20 with the definition. And so this is the definition 21 which, you know, appear -- appear everywhere. And it's 22 not just this three (3) paragraph of the definition, but 23 there's a whole article which describe these various 24 features and variables, et cetera. So one is to read the 25 whole article to actually appreciate the problem.

1 MS. JENNIFER MCALEER: And ultimately, 2 did Dr. Smith agree with you and did the cause of death 3 remain SIDS? 4 DR. ERNEST CUTZ: I -- I insisted to keep 5 it that way. Yeah, I think it remained that way, yeah. 6 COMMISSIONER STEPHEN GOUDGE: What was 7 his alternative: unascertained or -- 8 DR. ERNEST CUTZ: Yeah, un -- 9 COMMISSIONER STEPHEN GOUDGE: -- 10 undetermined? 11 DR. ERNEST CUTZ: Undetermined, yeah. 12 13 CONTINUED BY MS. JENNIFER MCALEER: 14 MS. JENNIFER MCALEER: And do you recall 15 having any other differences of opinion with Dr. Smith 16 regarding your classification of a cause of death on a 17 post-mortem examination? 18 DR. ERNEST CUTZ: Yes, I recall some 19 additional cases. One (1) which is listed was sort of 20 unusual case of -- can't recall exact age of the child -- 21 but it was anywhere between one (1) and three (3) years, 22 who developed croup which is a severe upper respiratory 23 infection and had -- had breathing difficulties. And -- 24 and to relieve this problem, he went to a hot shower, you 25 know, for -- to generate some steam to relieve his -- his

1 breathing difficulty and apparently collapsed in -- in 2 the shower. 3 And so he was -- he was resuscitated but 4 he subsequently died because of, you know, brain damage 5 sustained in it. And -- 6 MS. JENNIFER MCALEER: So this was a 7 young child, so apparently a -- 8 DR. ERNEST CUTZ: Right, young child. 9 MS. JENNIFER MCALEER: -- parent or 10 caregiver had suggested the shower. 11 DR. ERNEST CUTZ: That's right. That's 12 right, yeah. 13 MS. JENNIFER MCALEER: Oh. And -- and 14 what happened, the child died? 15 DR. ERNEST CUTZ: The child died and then 16 at autopsy we found a foreign object in his -- in his 17 airway, which was actually, you know, it was fungus ball, 18 but it's something which develops as part of the croup of 19 this inflammation in his throat, which detached and -- 20 and obstructed his airway. 21 MS. JENNIFER MCALEER: So it was a 22 natural cause, in your view? 23 DR. ERNEST CUTZ: It was -- it was a 24 natural cause and Dr. Smith thought that this was 25 artifact of intubation. In other words, the object has

1 been pushed in during the intubation and that somehow 2 the -- 3 MS. JENNIFER MCALEER: During -- 4 DR. ERNEST CUTZ: -- mother was 5 responsible for this. 6 MS. JENNIFER MCALEER: Sorry, it -- it 7 had been pushed in during intubation during efforts to 8 revive the child? 9 DR. ERNEST CUTZ: That's right, yeah. 10 MS. JENNIFER MCALEER: And the -- the 11 mother was responsible -- 12 DR. ERNEST CUTZ: Well, somehow he -- he 13 seemed to imply that maybe this is a case of Munchausen 14 By Proxy. 15 COMMISSIONER STEPHEN GOUDGE: Of what? 16 MS. JENNIFER MCALEER: Munchausen By 17 Proxy. 18 COMMISSIONER STEPHEN GOUDGE: I see. 19 20 CONTINUED BY MS. JENNIFER MCALEER: 21 MS. JENNIFER MCALEER: Sorry, not that 22 the mother hadn't done this as results of trying to 23 revive the child, but that something else more sinister-- 24 DR. ERNEST CUTZ: That's right. 25 MS. JENNIFER MCALEER: -- had happened?

1 DR. ERNEST CUTZ: That's right, yeah. 2 MS. JENNIFER MCALEER: And what -- 3 DR. ERNEST CUTZ: In other words, the -- 4 the fungus ball or the obstruction was a red herring. 5 MS. JENNIFER MCALEER: He thought it was 6 a red herring? 7 DR. ERNEST CUTZ: Yeah. 8 MS. JENNIFER MCALEER: And what in his 9 view had happened, as -- as he described to you? 10 DR. ERNEST CUTZ: Well, I -- no, he 11 didn't describe exactly, but, you know, he thought it may 12 not be a natural cause. And -- so then I talked to the 13 people who looked after the patient in the ICU to give 14 their opinion, and this is how I arrived to my opinion, 15 was after discussing it with them, and it was totally 16 consistent with -- with what I -- as I was interpreting 17 it. 18 In other words, the child had airway 19 obstruction, which was reasonable ex -- explanation. 20 They don't recall any case where intubation would push 21 something down -- down the airway and so that was totally 22 plausible and I don't think there was any -- any further 23 discussion of this. 24 MS. JENNIFER MCALEER: So -- just so that 25 I understand then, your understanding was that Dr.

1 Smith's view that this might be Munchausen By Proxy was 2 based on the fact that he didn't believe that this -- I'm 3 sorry, what did you call it -- a -- 4 DR. ERNEST CUTZ: Well, obstruction. 5 MS. JENNIFER MCALEER: -- fungus ball -- 6 DR. ERNEST CUTZ: Fungus ball, yeah. 7 MS. JENNIFER MCALEER: -- would -- would 8 be present? 9 DR. ERNEST CUTZ: Well, that -- that may 10 be ex -- extraneous, like not really significant. 11 MS. JENNIFER MCALEER: Okay, did -- did 12 he have any other basis for his opinion, as far as you 13 knew? 14 DR. ERNEST CUTZ: No, I -- I did not know 15 what -- what his basis was. 16 MS. JENNIFER MCALEER: And -- and 17 ultimately you said you had a discussion with the 18 clinicians. And how was that case concluded? 19 DR. ERNEST CUTZ: Well, I wrote to Dr. 20 Smith and I gave the letter written or the opinion of the 21 clinician who looked after the patient, and so I think 22 this probably ended the -- ended the controversy. But, 23 you know, I don't know of any further -- I -- I think 24 I'll stick with my diagnosis and that's what it was 25 reported as and I -- I heard nothing to the contrary.

1 MS. JENNIFER MCALEER: All right. 2 Commissioner, that might be a convenient time to break -- 3 COMMISSIONER STEPHEN GOUDGE: Sure. 4 MS. JENNIFER MCALEER: -- for the morning 5 break. 6 COMMISSIONER STEPHEN GOUDGE: That' fine. 7 We'll come back then at 11:30. 8 9 --- Upon recessing at 11:15 a.m. 10 --- Upon resuming at 11::32 a.m. 11 12 THE REGISTRAR: All rise. Please be 13 seated. 14 COMMISSIONER STEPHEN GOUDGE: Ms. 15 McAleer...? 16 17 CONTINUED BY MS. JENNIFER MCALEER: 18 MS. JENNIFER MCALEER: Thank you, 19 Commissioner. 20 Dr. Cutz, before the break we were 21 reviewing some cases that you had in which your diagnosis 22 had differed from that of Dr. Smith. 23 Do you recall any other cases in which you 24 had -- had a different view with respect to the cause of 25 death, then Dr. Smith?

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1 DR. ERNEST CUTZ: Yes, there's two (2) 2 other cases which I recall. The -- the third case was -- 3 again, it was a small infant, I can't recall the age, who 4 was -- who was found tangled into venetian blind cord 5 with the crib being too close to the -- the -- the 6 venetian blinds. 7 MS. JENNIFER MCALEER: The crib was too 8 close? 9 DR. ERNEST CUTZ: Yes. And so I -- I 10 listed this as a -- as an accidental -- accidental 11 hanging, as a cause of death. And this -- this was 12 presented at the rounds and -- and Dr. Smith raised the 13 issue that, you know, he -- to him it looked suspicious 14 and some of the parents may be involved. 15 I found that, you know, quite ridiculous, 16 especially knowing that this is a recognized hazzard 17 which has been, you know, has been documented in the 18 literature and it has even been subject of -- of 19 television reporting, bringing attention of the -- of the 20 hazzards of venetian blind cords with infants. 21 MS. JENNIFER MCALEER: Did Dr. Smith 22 inform you as to why he thought that perhaps there was 23 another cause and it wasn't accidental? 24 DR. ERNEST CUTZ: Well that's what he 25 raised, but you know, I don't think there was any

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1 evidence to substantiate it. And -- 2 MS. JENNIFER MCALEER: Did he tell you 3 why he thought? 4 DR. ERNEST CUTZ: He didn't explain, no. 5 MS. JENNIFER MCALEER: And ultimately 6 what happened with respect to that case? 7 DR. ERNEST CUTZ: I don't think any -- I 8 think, you know, there was no evidence from police or 9 other investigations that anything untowards has happened 10 and it -- you know, I -- I presumed that's how it was 11 ended up classified. 12 MS. JENNIFER MCALEER: What -- what cause 13 of death would you put? 14 DR. ERNEST CUTZ: Accidental -- 15 accidental hanging. 16 MS. JENNIFER MCALEER: And then were 17 there any other cases in which you -- 18 DR. ERNEST CUTZ: Yes, there was -- 19 MS. JENNIFER MCALEER: -- had a different 20 view than Dr. Smith? 21 DR. ERNEST CUTZ: Yeah, there was another 22 case where -- it was -- again, the exact age escapes me, 23 but it was a, you know, a child between one (1) and two 24 (2) or over two (2) years of age, who -- who had a cold 25 and was given some medi -- some cold medication and

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1 subsequently was found lifeless. 2 And so we did -- we did autopsy on -- on - 3 - I mean, I did the autopsy on the case, and as part of 4 the toxicology screen we found an increase -- I mean, 5 hundred (100) times value for Dextromethorphan, which is 6 one (1) of the components of the cough medicine. 7 MS. JENNIFER MCALEER: Dextromethorphan? 8 DR. ERNEST CUTZ: Yes. 9 MS. JENNIFER MCALEER: All right. 10 DR. ERNEST CUTZ: It's -- it's an anti- 11 cough medication. And so this kind of result is -- is, 12 you know, totally unusual or out of -- out of the 13 ordinary and my interpretation, knowing the literature on 14 this kind of medication issues, is that, you know, 15 certain patients may have metabolic defect, what -- what 16 is called slow metabolizer. 17 In other words, they have enzyme which 18 break down the drug it's missing or it's -- has a 19 decreased activity and therefore even a small amount of 20 medication can result in high levels. 21 The other evidence I had is that the 22 bottle of -- with the medication was recovered and there 23 was hardly anything missing. Now, the child was 24 supposedly given one (1) -- one (1) spoonful of -- of the 25 medicine.

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1 So this was discussed at the Coroner's 2 Office as a sort of a case -- case conference and Dr. 3 Smith was present. And he advanced theory or hypothesis, 4 is that there was a sib present with -- with this child-- 5 MS. JENNIFER MCALEER: Sorry, there was a 6 what? 7 DR. ERNEST CUTZ: An older -- 8 MS. JENNIFER MCALEER: Sibling? 9 DR. ERNEST CUTZ: -- older sibling, yeah. 10 And he raised the issue that it's -- maybe it's the older 11 sib -- sibling who -- who gave him overdose of 12 medication. 13 MS. JENNIFER MCALEER: And what was -- 14 did he explain the basis for that proposition? 15 DR. ERNEST CUTZ: Not -- not especially. 16 Just, you know, said that this kind of situation could 17 happen. But it would be inconsistent with the fact that 18 the medication volume was -- was maintained, plus the 19 fact that there is a clinical condition which was slow 20 metabolizer. 21 Now, what subsequently happened, there was 22 quite extensive police investigation, which didn't 23 substantiate any wrongdoing. And, in fact, some further 24 work in pharmacology at Sick Kids actually confirmed that 25 the child did have a defect, there's a small -- slow

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1 metabolizer. 2 MS. JENNIFER MCALEER: And -- and that's 3 what ultimately caused the death of the child? 4 DR. ERNEST CUTZ: That's correct -- 5 that's -- well, that's -- that's correct, yes. 6 MS. JENNIFER MCALEER: All right. And if 7 we look at Tab 79 of Volume II, which is PFP056409. So 8 Tab 79. 9 DR. ERNEST CUTZ: Tab 79. 10 MS. JENNIFER MCALEER: I'll just give you 11 a moment to look at that. 79 of Volume II. 12 And is this the case to which you were 13 referring, Dr. Cutz? 14 DR. ERNEST CUTZ: Yes. 15 MS. JENNIFER MCALEER: And it makes 16 reference to the police investigation that you refer to? 17 DR. ERNEST CUTZ: That's correct, yes. 18 MS. JENNIFER MCALEER: And the fact that 19 there were additional studies done by the Hospital for 20 Sick Children? 21 DR. ERNEST CUTZ: That's correct. 22 MS. JENNIFER MCALEER: Confirming that 23 the child was, in fact, a -- a slow metabolizer, as you 24 put it. 25 DR. ERNEST CUTZ: That's correct, yes.

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1 MS. JENNIFER MCALEER: And ultimately, 2 did -- did Dr. Smith agree with your diagnosis? 3 DR. ERNEST CUTZ: Well, I think this was 4 then the decision of Dr. Cairns. And it says: 5 "I'm now satisfied that we have a full 6 explanation for this boy's death and 7 that is not related in any way to foul 8 play." 9 MS. JENNIFER MCALEER: Do you recall 10 anything else about discussions with Dr. Smith about that 11 case? 12 DR. ERNEST CUTZ: No. 13 MS. JENNIFER MCALEER: Now, do you recall 14 any other cases where you and Dr. Smith had a difference 15 in view -- with respect to what the diagnosis should be 16 on a particular case? 17 DR. ERNEST CUTZ: Not any specific cases. 18 Only to say that, you know, I tried to use a more 19 balanced approach. In other words, look at all options 20 and all -- and base my opinion on factual evidence, which 21 can be verified. And I do literature research to back it 22 up. 23 MS. JENNIFER MCALEER: And you said 24 more -- 25 DR. ERNEST CUTZ: So that -- that's my

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1 approach. And so if -- if, you know, as this would I say 2 --usually stick with and I think it -- it served me well 3 to get -- stay out of trouble. 4 MS. JENNIFER MCALEER: Well, did you have 5 the impression that Dr. Smith was using a different 6 approach? 7 DR. ERNEST CUTZ: Well, I don't know what 8 -- the approach he said, but, you know, if there was 9 differences of opinion, it might have been because of -- 10 of, you know, using different set of parameters. 11 MS. JENNIFER MCALEER: And, Dr. Taylor, I 12 think you indicated that you -- you've not had an -- an 13 experience where you and Dr. Smith differed on what the 14 diagnosis should be in medicolegal work? 15 DR. GLENN TAYLOR: I -- I can't recall a 16 specific incident, no. 17 MS. JENNIFER MCALEER: All right. Now, 18 with Dr. Smith reviewing your post-mortem examination 19 reports, was anybody reviewing Dr. Smith's post-mortem 20 examination reports, internally, at the Hospital for Sick 21 Children, as far as you're aware, Dr. Taylor? 22 DR. GLENN TAYLOR: Not as far as I was 23 aware. 24 MS. JENNIFER MCALEER: Dr. Cutz, as far 25 as you were aware?

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1 DR. ERNEST CUTZ: No, I don't -- I don't 2 --I'm not aware anybody was reviewing them. 3 MS. JENNIFER MCALEER: Would Dr. Smith 4 ever consult with you or seek your opinion with respect 5 to medicolegal autopsies? Dr. Taylor? 6 DR. GLENN TAYLOR: Yeah. I think, 7 informally, I probably had been asked to look at some 8 slides or something like that on more than one (1) 9 occasion. Not often, but I -- I can vaguely recall 10 having done that with him, yes. 11 MS. JENNIFER MCALEER: And was Dr. Smith 12 reluctant to seek consultations from his colleagues or 13 was he open to consultations with his colleagues? 14 DR. GLENN TAYLOR: I can't speak for my 15 other colleagues. I just know that on -- on occasion, I 16 think pretty infrequently -- he came and asked me to have 17 a look at his file. 18 MS. JENNIFER MCALEER: Did he come more 19 or less frequently than your other colleagues? 20 DR. GLENN TAYLOR: Some colleagues came 21 not at all. Some colleagues came very frequently, so it 22 was a spectrum. He was -- he was in the spectrum. 23 MS. JENNIFER MCALEER: All right. And, 24 Dr. Cutz, did Dr. Smith ever consult with you with 25 respect to his own work on medicolegal autopsies?

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1 DR. ERNEST CUTZ: Yes, he did. He would 2 show me, occasionally, slides of some lesions he wanted 3 opinion on or he was not familiar with. Usually in the 4 areas, you know, of my interest, such as respiratory 5 system -- lungs or -- or liver -- intestinal organs. 6 MS. JENNIFER MCALEER: And in your 7 experience, did he consult with you or with your 8 colleagues more frequently or less frequently or 9 approximately the same as -- as your colleagues? 10 DR. ERNEST CUTZ: I would say it -- it 11 was relative infrequent, but, you know, comparatively, I 12 can't say whether it was more or less. 13 MS. JENNIFER MCALEER: All right. 14 COMMISSIONER STEPHEN GOUDGE: Can I ask 15 about peer review generally at the hospital to both of 16 you? I have formed a general impression that peer review 17 is an important aspect of sound medical practice. Would 18 you both agree with that? 19 DR. GLENN TAYLOR: Yes, I would. 20 DR. ERNEST CUTZ: Yes. 21 COMMISSIONER STEPHEN GOUDGE: And 22 generally speaking, Dr. Taylor, speaking in your present 23 role as the head of a department, is the head of the 24 department in the general work of the hospital subject to 25 the same kind of peer review of his or her work as those

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1 who work in the department? 2 DR. GLENN TAYLOR: Well, in my division, 3 I believe that I am -- I am subject to the same kind of 4 peer review as anybody else is. I can't speak for other 5 divisions -- 6 COMMISSIONER STEPHEN GOUDGE: And that 7 would be peer review by your colleagues in the 8 department? 9 DR. GLENN TAYLOR: Correct. 10 COMMISSIONER STEPHEN GOUDGE: Why was the 11 head of the unit not subjected to peer review within the 12 hospital? 13 DR. GLENN TAYLOR: Within the hospital? 14 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 15 DR. GLENN TAYLOR: I think that gets into 16 the distinction between the coroner service functions and 17 the hospital functions. And in -- I think the philosophy 18 should -- should apply to both, but as far as mandated 19 peer review coming from a hospital employee such as a 20 division head, to -- there is -- there is a lot of 21 overlap in -- in the thing, but my approach would be to 22 try to keep the arms-length arrangement of the coroner 23 service from the hospital -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. GLENN TAYLOR: -- with that regard.

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1 COMMISSIONER STEPHEN GOUDGE: Without 2 worrying about the institutional arrangement too much, do 3 I hear you saying that the reason -- or one (1) reason 4 why his post-mortem reports might not have been peer 5 reviewed within the hospital is not that he's head -- 6 held a director's position, but that it was a director's 7 position for a service being performed for the Coroner's 8 Office? 9 DR. GLENN TAYLOR: Hmm, I'm not sure I 10 would say that. I think -- I just have to work through 11 this a bit. 12 I think the philosophy of peer review 13 would hold in either situation; whether you're working 14 for the hospital; working for the coroner's service. How 15 you arrange that could be subjected to different 16 administrative rules and regulations perhaps, but I think 17 the philosophy is the same. 18 COMMISSIONER STEPHEN GOUDGE: It is part 19 of quality assurance, is it not? 20 DR. GLENN TAYLOR: Yes. Yes. 21 And I think as head of the unit, even 22 though there is an arm's length relationship between -- 23 or supposed to be between the hospital and the coroner's 24 service, you still have colleagues present. 25 And I think that the principle of peer

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1 review could easily be implemented. In a sense, it was 2 but it was sort of going towards the top -- at least, 3 from what it appeared to me at the time -- was going to 4 the top and then it stopped. But it certainly could 5 include having the -- 6 COMMISSIONER STEPHEN GOUDGE: Yeah. 7 DR. GLENN TAYLOR: -- person at the top 8 be peer reviewed which is what we do -- 9 COMMISSIONER STEPHEN GOUDGE: Well it 10 does in your case -- 11 DR. GLENN TAYLOR: -- now. 12 COMMISSIONER STEPHEN GOUDGE: -- for 13 example. 14 DR. GLENN TAYLOR: Yeah, it does in my 15 case, in my -- my hospital clinical work, but it also is 16 what's being done now in the unit under Dr. Chiasson. 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 Right. But I am curious to try to understand why it was 19 that, prior to Dr. Chiasson introducing this, it was not 20 done. 21 Because I take it, it was clearly the case 22 that being the head of a department, being the head of a 23 unit elsewhere in the hospital did not exclude you from 24 peer review of your own work. 25 DR. GLENN TAYLOR: That would be my take

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1 on it. No, I mean, I -- 2 COMMISSIONER STEPHEN GOUDGE: Would you 3 agree with what I said? 4 DR. GLENN TAYLOR: Yes, I agree. I 5 subject myself to peer review and I think it's -- 6 COMMISSIONER STEPHEN GOUDGE: And 7 accounta -- 8 DR. GLENN TAYLOR: -- good for me. 9 COMMISSIONER STEPHEN GOUDGE: Well, but 10 back in the '90s, that would have happened if you had 11 been the Chair or the head of a department. 12 DR. GLENN TAYLOR: I'm not sure whether 13 we -- yeah. 14 COMMISSIONER STEPHEN GOUDGE: Or was it a 15 more hierarchal world there when -- 16 DR. GLENN TAYLOR: I -- you know, I can't 17 really -- I can't really say what the reason for that 18 state of affairs was. 19 COMMISSIONER STEPHEN GOUDGE: What do you 20 say, Dr. Cutz? 21 I mean, how much of it had to do with this 22 being a service that, in some fashion, was provided for 23 another institution as opposed to, Well that's just the 24 way peer review worked in the '90s, where the head of the 25 unit didn't get peer reviewed the same way that those

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1 worked in it did. 2 DR. ERNEST CUTZ: Yeah, I think the 3 difference here is that, for example, the clinical work, 4 it -- it gets constantly peer reviewed by our clinical 5 colleagues so there is no -- if one renders a diagnosis 6 and it doesn't correspond to what they -- that we hear 7 about it right away, and so this -- this is -- or we get 8 clinicians coming to our offices -- even slides are not 9 ready yet, for example, you know, before the diagnosis is 10 rendered. 11 So there is a constant peer review and 12 back and forth communication to give the best possible 13 diagnosis for the patient. 14 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 15 DR. ERNEST CUTZ: Now in case of the 16 forensic autopsies, the -- the basic communication is 17 between the pathologist and the coroner. So there's -- 18 there's nobody else, kind of, in -- in that, you know, to 19 oversee what happens between the two (2). 20 Like -- like the pathologist provides a 21 professional service by doing the autopsy, interpretation 22 and forwards it to the Coroner's Office, okay, and this 23 is part of the investigation the coroner does. 24 COMMISSIONER STEPHEN GOUDGE: Right. But 25 your peer review --

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1 DR. ERNEST CUTZ: And there it is -- 2 like I think there wasn't even initially to put any kind 3 of a peer review; the only peer review is if, let's say, 4 the coroner doesn't like something. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. ERNEST CUTZ: Or the Coroner's Office 7 says, you know, this doesn't correspond to, you know, our 8 -- our finding. Something like that. 9 But because the information is restricted 10 to -- to certain groups of people, so -- so it's hard to 11 do peer review. I mean, you can do peer review in terms 12 of: Is the report complete? Are there no mistakes? Are 13 there no typing errors? And is the formulation of 14 diagnosis appropriate? 15 But in -- the peer review is not such that 16 you would review the whole case, you know, every slide 17 and -- and think like that. That -- that would be, you 18 know, extremely time consuming. 19 And so in our situation -- the clinical 20 situation -- we present the whole case and so then 21 everything what's known is -- is look -- and this is 22 implication for the patient's diagnosis. 23 COMMISSIONER STEPHEN GOUDGE: And so it 24 is helpful part of peer review -- 25 DR. ERNEST CUTZ: That's right. So it's

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1 for -- 2 COMMISSIONER STEPHEN GOUDGE: -- for your 3 clinical work? 4 DR. ERNEST CUTZ: -- clinical. It's -- 5 it's very rigorous -- 6 COMMISSIONER STEPHEN GOUDGE: Yeah. 7 DR. ERNEST CUTZ: -- and it's in place. 8 But for this -- this kind of activity, because it's 9 segregated, it doesn't -- doesn't use the same kind of a 10 review system. 11 COMMISSIONER STEPHEN GOUDGE: For your 12 clinical work, the work you do that we've labelled 13 "surgical pathology", is there any kind of peer review 14 that is intra-department as opposed to the kind of peer 15 review you were describing, Dr. Cutz, which is a peer 16 review by the clinician and user of your diagnosis? 17 Is there any kind of intra-department peer 18 review, Dr. Taylor? 19 DR. GLENN TAYLOR: Yes, there is. We 20 have a presentation of difficult cases at weekly rounds 21 where ideas are bounced back and forth and directions are 22 perhaps given. 23 We have a policy that for any new 24 diagnosis of cancer or any significant disease condition 25 that may have a major impact on patient care, that that

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1 be reviewed by a second person -- either by a second 2 person or at our weekly rounds formally by the group 3 there, and this is documented and marked off in the 4 computer as being peer reviewed. 5 There certainly is pretty free and open 6 interchange of ideas with regards to cases, if there are 7 difficulties walking a case down the hall a few 8 doorsteps. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. GLENN TAYLOR: It happens fairly 11 frequently. And we also have -- so that's intra. We 12 also have -- 13 COMMISSIONER STEPHEN GOUDGE: Now, can I 14 just stop you there. Is that different than when you 15 first joined the department in the mid '90s? Is there 16 more scrutiny or was it something in existence then? 17 DR. GLENN TAYLOR: It was -- it's more 18 formalised now, in the sense that we have an actual form 19 that is filled out when a -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. GLENN TAYLOR: -- specific request -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. GLENN TAYLOR: -- for a review is 24 made and it's now what we call "flagged" and the case is 25 flagged in the computer as being peer reviewed. The

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1 interaction between the pathologist with regards to 2 reviewing slides -- What do you think this is, kind of 3 thing -- that went on before, as well. 4 COMMISSIONER STEPHEN GOUDGE: A second 5 look at a serious diagnosis for patient care? 6 DR. GLENN TAYLOR: That didn't happen by 7 policy, it happened by choice of the pathologist, so 8 there wasn't any standard operating procedure for doing 9 that. 10 COMMISSIONER STEPHEN GOUDGE: Was it 11 common on the surgical side in the mid '90s? 12 DR. GLENN TAYLOR: It was reasonably 13 common, yes. And -- and then there was inter- 14 departmental scrutiny, as Dr. Cutz mentioned, plus for 15 the -- for the neoplastic cases or the cancer cases, they 16 would be reviewed at another set of rounds with the 17 oncologist present and the radiologist present. 18 And if there were problems with the 19 pathology diagnosis, the pathologist would definitely 20 hear about it at those rounds. 21 COMMISSIONER STEPHEN GOUDGE: Okay, 22 that's all very helpful. Thanks, Ms. McAleer. 23 24 CONTINUED BY MS. JENNIFER MCALEER: 25 MS. JENNIFER MCALEER: Thank you, Mr.

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1 Commissioner. 2 Just following up from the Commissioner's 3 question, there were also, as I understand it, morbidity 4 and mortality rounds, as well, in the 1990s. 5 DR. GLENN TAYLOR: Yes. 6 MS. JENNIFER MCALEER: And would surgical 7 or clinical pathology cases sometimes be discussed at the 8 morbidity and mortality rounds? 9 DR. GLENN TAYLOR: Yes, they would. 10 MS. JENNIFER MCALEER: All right. And 11 would the medicolegal cases be discussed at the morbidity 12 and mortality rounds? 13 DR. GLENN TAYLOR: The medicolegal cases 14 overall, or those that were of a criminally suspicious 15 nature? 16 MS. JENNIFER MCALEER: Would -- would any 17 be discussed? 18 DR. GLENN TAYLOR: Yes. Some would be 19 discussed, yeah. 20 MS. JENNIFER MCALEER: Would the 21 criminally suspicious cases be discussed? 22 DR. GLENN TAYLOR: Now, I can't recall 23 being involved in any direct set of rounds with a 24 criminally suspicious case, but that's not to say that 25 they might have been presented by other people.

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1 MS. JENNIFER MCALEER: Dr. Cutz, do you 2 recall presenting any criminally suspicious cases at 3 morbidity and mortality rounds? 4 DR. ERNEST CUTZ: Yes, as I mentioned 5 before, that, you know, that -- what case is presented 6 depending on the authorisation from the coroner, so that 7 if the coroner said it's okay to show it, it was -- it 8 was presented. Now, if he said there's some proceedings 9 going and don't show it, then it won't be shown. 10 And so I don't recall if, you know, 11 anybody breached this sort of agreement or showing it, in 12 spite of being -- the interdiction of showing it. 13 MS. JENNIFER MCALEER: Right. But -- but 14 do you recall presenting any criminally suspicious cases 15 at morbidity and mortality rounds? 16 DR. ERNEST CUTZ: No, I -- no, I would 17 not, no. 18 MS. JENNIFER MCALEER: All right. If we 19 could turn to Tab 37 of Volume I, which is PFP056425. 20 And I just pull up this document, gentlemen, because the 21 bottom of the memo makes reference to monthly pediatric 22 forensic rounds. And this is January of 1995. 23 Dr. Taylor, you wouldn't have been at the 24 hospital yet. But Dr. Cutz -- 25 DR. ERNEST CUTZ: Yes?

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1 MS. JENNIFER MCALEER: -- do you recall 2 monthly pediatric forensic rounds in or around January of 3 1995? Or start any time in 1995? 4 DR. ERNEST CUTZ: Yes. I think what this 5 refers to is Dr. Chiasson wanted to have some forensic 6 rounds or having -- having cases of the pediatric cases 7 shown at the Coroner's Office. 8 As far as -- that's what this refers to, 9 is to -- to set up rounds so that the medicolegal or the 10 coroner's case is done at Sick Kids; are shown at the 11 Coroner's Office to the -- for Coroner's Office 12 pathologists. 13 MS. JENNIFER MCALEER: Okay. Your, if I 14 could call them, normal pathology rounds -- what you call 15 them your general pathology rounds, do they have a 16 specific name? 17 DR. GLENN TAYLOR: Clinical Pathologic 18 Conferences. 19 MS. JENNIFER MCALEER: Your Clinical 20 Patholo -- Pathology Conferences -- 21 DR. GLENN TAYLOR: Conferences. 22 MS. JENNIFER MCALEER: -- they were 23 normally held on Fridays as well, were they not? 24 DR. GLENN TAYLOR: Yes. 25 DR. ERNEST CUTZ: Friday morning, yeah.

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1 MS. JENNIFER MCALEER: All right. Is it 2 -- is it possible that they rounds were at the Hospital 3 for Sick Kids, or is it your recollection, Dr. Cutz, they 4 were actually at the Office of the Chief Coroner? 5 DR. ERNEST CUTZ: No, I believe it's at 6 the Office of the Chief Coroner. They -- they put two 7 (2) days one -- no, I think, it's not just Friday, but it 8 -- it could not have been because it would have 9 interfered with -- with our rounds. 10 MS. JENNIFER MCALEER: Right. Which is 11 why I'm suggesting perhaps -- 12 DR. ERNEST CUTZ: Yeah. 13 MS. JENNIFER MCALEER: -- they were 14 actually held at the Hospital for Sick Kids as opposed to 15 the Office of the Chief Coroner. 16 DR. ERNEST CUTZ: It's -- it's possible 17 that they would be special rounds, maybe once or twice a 18 month, which would be just dedicated to these cases, and 19 then pathologists from the Coroner's Office would have to 20 come to Sick Kids. 21 MS. JENNIFER MCALEER: All right. 22 DR. ERNEST CUTZ: So that would be one 23 (1) area. But one (1) -- the -- the second arrangement 24 which was for us going there, I recall having gone at 25 least twice to Coroner's Office to show cases.

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1 MS. JENNIFER MCALEER: All right. With 2 respect to -- you said there might have been special 3 rounds at the Hospital for Sick Kids? 4 DR. ERNEST CUTZ: Yes. 5 MS. JENNIFER MCALEER: Dr. Taylor, do you 6 recall there ever being forensic pathology rounds at the 7 Hospital for Sick Kids? 8 DR. GLENN TAYLOR: I recall there being 9 forensic pathology rounds. I seem to be getting mixed up 10 if they were always at Sick Kids or if there were some at 11 the Coroner's Office, because I -- my vague recollection 12 is that I was at the Coroner's Office on a couple of 13 occasions. 14 But I also have a recollection that there 15 were some at Sick Kids as well, so sorry. 16 MS. JENNIFER MCALEER: All right. 17 COMMISSIONER STEPHEN GOUDGE: I think 18 we've heard from others there were both. 19 DR. ERNEST CUTZ: Yeah, there could be. 20 DR. GLENN TAYLOR: Okay, then I don't 21 feel so bad. 22 23 CONTINUED BY MS. JENNIFER MCALEER: 24 MS. JENNIFER MCALEER: All right. If we 25 could turn to Tab 53. And Tab 53 is a collection of a

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1 number of different documents that are found in different 2 locations in the database. We've put them all together 3 because they are a series of documents that speak to 4 forensic pathology rounds. If we could just go to the 5 first one (1), Mr. Registrar, which is PFP056459. 6 7 (BRIEF PAUSE) 8 9 MS. JENNIFER MCALEER: And this document 10 is a little bit difficult to read, although if you -- 11 yeah, it's a little difficult to read, but it -- it seems 12 to be a memorandum announcing forensic pathology rounds 13 on Friday, May 10th -- I guess that's 1996 -- at 11:00 14 a.m. 15 Would that correspond with the clinical 16 pathology rounds that were held at the Hospital for Sick 17 Kids, Dr. Taylor? 18 DR. GLENN TAYLOR: Current rounds are at 19 10:30. I can't recall, were they always at 10:30? 20 DR. ERNEST CUTZ: No, I think it might 21 have been 11:00. 22 MS. JENNIFER MCALEER: So it's possible 23 that this is in fact -- 24 DR. ERNEST CUTZ: Yes. 25 MS. JENNIFER MCALEER: -- a reference to

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1 what Dr. Cutz eluded to that there'd be a -- a specific 2 exception perhaps -- 3 DR. ERNEST CUTZ: Right. 4 MS. JENNIFER MCALEER: -- on occasion, 5 and you would discuss forensic cases? 6 DR. ERNEST CUTZ: That's correct. 7 MS. JENNIFER MCALEER: Okay. And then as 8 we look at -- without naming any of the names, but if we 9 look at the pathologists that associated with those 10 cases, we you, Mr. -- Dr. Taylor, we see Dr. Wilson and 11 we see Dr. Smith. 12 Given that neither of you have really very 13 much recollection of these rounds at the Hospital for 14 Sick Children, I won't ask you more about what may have 15 transpired at those rounds, but perhaps we could look at 16 the next document which is PFP056456. 17 And again, this is still in 1996. It's 18 from September 17th of 1996. And again, it's announcing 19 forensic pathology rounds Friday, September 20th at 11:00 20 a.m. These are all of the documents we have, with 21 respect to forensic pathology rounds in 1995 or 1996. 22 Again, it's -- you're listed, Dr. Taylor. Dr. Cutz, 23 you're listed as well there. 24 Do you see that? 25 DR. ERNEST CUTZ: Yes. Mm-hm.

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1 MS. JENNIFER MCALEER: And again, Dr. 2 Smith. So again, this is possibly a forensic pathology 3 round that may have taken place at the Hospital for Sick 4 Kids. 5 Is that correct? 6 DR. ERNEST CUTZ: I think in fact 7 probably it did because it lists copy to the pediatric 8 intensive unit staff, which would be at the hospital and 9 they would unlikely go to the Coroner's Office. So these 10 rounds must have been held at Sick Kids. 11 MS. JENNIFER MCALEER: Okay. And then if 12 we can just jump ahead a little bit. If we look at 13 PFP05641. Again, this is a memo to Dr. Chiasson from Dr. 14 Smith with respect to pediatric forensic pathology 15 rounds. There are a number of cases listed. It's from 16 May 5th, 1999, so we've jumped ahead three (3) years. 17 And again, we see you, Dr. Taylor, we see Dr. Cutz, we 18 see Dr. Smith and we see Dr. Wilson. 19 Is it your understanding that these 20 rounds, starting in 1999, were actually held at the 21 Office of the Chief Coroner? 22 DR. ERNEST CUTZ: Well, it doesn't -- it 23 doesn't include a copy to intensive care unit staff, so I 24 presume that -- that those might have been the one at the 25 Coroner's Office.

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1 MS. JENNIFER MCALEER: All right. And I 2 believe these, if we had a calendar, would be on 3 Wednesdays. 4 DR. ERNEST CUTZ: Right. 5 MS. JENNIFER MCALEER: So that's not a 6 normal round -- 7 DR. ERNEST CUTZ: Yeah, that's right. 8 MS. JENNIFER MCALEER: -- day at -- 9 DR. ERNEST CUTZ: Yes. 10 MS. JENNIFER MCALEER: -- Hospital for 11 Sick Kids, is it? 12 DR. ERNEST CUTZ: That's correct, yes. 13 MS. JENNIFER MCALEER: All right. And -- 14 COMMISSIONER STEPHEN GOUDGE: Can I just 15 ask -- sorry -- 16 MS. JENNIFER MCALEER: Sorry, go ahead. 17 COMMISSIONER STEPHEN GOUDGE: -- Ms. 18 McAleer. Can I just ask a general question; it may not be 19 one (1) capable of answer by either of you. 20 But could you compare the level of 21 scrutiny given by those who attended the forensic 22 pathology rounds to those -- to the level of scrutiny 23 that was received by those presenting it, the clinical 24 pathology consultation that are your regular rounds. 25 DR. GLENN TAYLOR: Mm-hm.

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1 COMMISSIONER STEPHEN GOUDGE: I mean, let 2 me tell you what -- 3 DR. GLENN TAYLOR: Yeah, it's not -- 4 COMMISSIONER STEPHEN GOUDGE: Let me put 5 a postulate to you. 6 I have no idea whether it is true or not, 7 but from some of the things Dr. Cutz said earlier this 8 morning, forensic work was clearly not being done by 9 everybody in the department. Some were doing far more 10 than others. Some felt they were not really suited to do 11 the work and weren't trained in it. 12 I guess what I am getting at is whether 13 that resulted in a lesser level of scrutiny, given the 14 audience then one might find in the clinical pathology 15 consultations you have regularly? 16 DR. GLENN TAYLOR: I'm just trying to 17 compare now and take that back ten (10) years ago and -- 18 COMMISSIONER STEPHEN GOUDGE: Yeah, 19 because we have constantly got to do -- 20 DR. GLENN TAYLOR: Right. 21 COMMISSIONER STEPHEN GOUDGE: -- that Dr. 22 Taylor because -- 23 DR. GLENN TAYLOR: Right. 24 COMMISSIONER STEPHEN GOUDGE: -- the 25 world has changed, I know.

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1 DR. GLENN TAYLOR: Right. And I think 2 our level of scrutiny now is pretty equivalent between 3 the two (2) types of autopsy cases. 4 In those days, especially if there was 5 involvement by some of the clinicians from the intensive 6 care unit, I suspect that the level would be similar. My 7 con -- I guess the -- my -- a question might be generated 8 by looking at the number of cases that are being listed 9 for the 5th of May, 1999 here, if it's the same time 10 period then there's going to be less time to discuss and, 11 therefore, you could argue, Okay -- 12 COMMISSIONER STEPHEN GOUDGE: Yeah, 13 that -- 14 DR. GLENN TAYLOR: -- it's not -- 15 COMMISSIONER STEPHEN GOUDGE: Yeah. 16 DR. GLENN TAYLOR: -- going to be 17 scrutinized as much. On the hand, I don't know how -- I 18 can't remember how long the rounds -- what, maybe they 19 were three (3) hours, I don't know. 20 COMMISSIONER STEPHEN GOUDGE: Yes. What 21 do you say, Dr. Cutz? I mean, I can understand the 22 limitation of time. 23 What I was postulating was whether the 24 limitation on comfort, familiarity, training -- 25 DR. ERNEST CUTZ: Yes.

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1 COMMISSIONER STEPHEN GOUDGE: -- reduced 2 the level of scrutiny provided by forensic rounds. And I 3 just do not know the answer to that or whether it is 4 possible to make a comparison. 5 DR. ERNEST CUTZ: No, I think in terms of 6 scrutiny, actually both type of rounds they are sort of 7 show and tell. You know, you present it but is not 8 scrutinized, if somebody is going to be verifying what 9 you are showing. 10 COMMISSIONER STEPHEN GOUDGE: I see. So 11 neither -- 12 DR. ERNEST CUTZ: So -- so these would be 13 different audiences. For example, these forensic rounds 14 at the Coroner's Office would be pediatric pathologists 15 presenting their pathology which one sees in cases of 16 Sudden Infant Death Syndrome. So it's more or less us 17 educating them -- 18 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 19 DR. ERNEST CUTZ: -- and their -- their 20 feedback would be they may some questions about, you 21 know, some forensic aspect, which may or may not have 22 been considered. So -- so that those -- those are the 23 kind of level of scrutiny, but it wouldn't be that, you 24 know, you would go in -- in great detail of each case. 25 Basically, just showing the main findings

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1 and then giving sort of an open discussion on a case -- 2 you know, what the pediatric pathologist thought and then 3 what -- what the forensic pathologist -- there were any 4 comments they wanted to add, because there's no way your 5 could handle all these cases in a -- 6 COMMISSIONER STEPHEN GOUDGE: Okay. 7 DR. ERNEST CUTZ: -- reasonable -- so 8 our -- 9 COMMISSIONER STEPHEN GOUDGE: But in that 10 respect, are your departmental rounds any more effective 11 at peer review? 12 DR. GLENN TAYLOR: Well, Mr. 13 Commissioner, I -- these aren't an in-depth review of all 14 of the slides and all of the circumstantial evidence and 15 so on related to the cases, but they do -- at least, I 16 personally find them very valuable in maybe confirming 17 that the person is on the right track or saying, You're 18 not on the right track, why don't you think of this. 19 And certainly we do discuss alternate 20 interpretations and raise alternate -- or additional 21 areas of study with regards to the case. So they are 22 peer reviewed, it's not simply just an education -- 23 COMMISSIONER STEPHEN GOUDGE: You 24 wouldn't buy quite -- it is not entirely show and tell. 25 DR. GLENN TAYLOR: It's not entirely. I

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1 mean, it is -- there is a lot of show and tell. There is 2 an educational activity -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. GLENN TAYLOR: -- for these -- 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. GLENN TAYLOR: -- rounds, as well as 7 the peer review. But certainly if -- if I'm -- if I've 8 gone off the rails a little bit on a case -- 9 COMMISSIONER STEPHEN GOUDGE: On a 10 surgical case, you are -- 11 DR. GLENN TAYLOR: Yeah. 12 COMMISSIONER STEPHEN GOUDGE: -- 13 clinician friends will have no trouble -- 14 DR. GLENN TAYLOR: And my pathology peers 15 would have no trouble telling me that, as well. 16 COMMISSIONER STEPHEN GOUDGE: Okay, 17 thanks. Thanks, Ms. McAleer. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: Now, the rounds 21 that took place at the Coroner's Office, would you always 22 present your own cases, or on occasion would one (1) of 23 your colleagues present the case for you? 24 Dr. Taylor, what was your experience? 25 DR. GLENN TAYLOR: I think there may have

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1 been one (1) or two (2) cases that I did not present 2 because of not being available, but generally I present 3 my own cases. 4 MS. JENNIFER MCALEER: And, Dr. Cutz, 5 what was your experience? 6 DR. ERNEST CUTZ: Yes. No, I think, as I 7 mentioned, I went a couple of times, but I think the 8 rounds were at an very inconvenient time for us. I mean, 9 they interfere with our other hospital activity. And so 10 then Dr. Smith volunteered that he -- he will present the 11 cases. And so we would give him the slides and the -- or 12 photographs to show and -- and so then -- the he would -- 13 he would show these case -- you know, cases for us. 14 MS. JENNIFER MCALEER: And would you 15 receive feedback from Dr. Smith after he had shown your 16 cases at forensic rounds at the Coroner's Office? 17 DR. ERNEST CUTZ: I can't recall any 18 specific feedback, but you know, I suppose if the issue 19 came up he might have might have -- he -- he may raise 20 it. But, you know, I don't know of a specific instance. 21 MS. JENNIFER MCALEER: Okay. So apart 22 from the -- the rounds that were taking place at the 23 Coroner's Office, did you receive any other external 24 feedback or was there any other external oversight of the 25 medicolegal work that you were preparing?

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1 And I might try and refresh your memory a 2 little bit by asking you to turn to Tab 45 of the 3 documents. 4 COMMISSIONER STEPHEN GOUDGE: This is 5 Volume I? 6 7 CONTINUED BY MS. JENNIFER MCALEER: 8 MS. JENNIFER MCALEER: Volume I, Tab 45, 9 PFP129358. It's a memo from Dr. Chiasson and Dr. Young 10 to all pathologists and coroners regarding: 11 "Effective immediately, all reports of 12 post-mortem examinations on cases which 13 the manner of death is either homicide 14 or undetermined and form -- and 15 possibly homicide are to be forwarded 16 directly to the appropriate regional 17 coroner for referral and to the Office 18 of the Chief Coroner for review." 19 Do you both recall this policy being 20 implemented in or about September of 1995? 21 Dr. Taylor, do you recall? You would have 22 been at -- newly arrived at HSC. 23 DR. GLENN TAYLOR: Well, in October -- 24 MS. JENNIFER MCALEER: Right. Not quite 25 there yet.

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1 DR. GLENN TAYLOR: -- but I knew of -- I 2 knew of this policy, yes. 3 MS. JENNIFER MCALEER: All right. And is 4 it -- was it your understanding that the policy was 5 followed, that these cases were, in fact, sent to Dr. 6 Chiasson for review? 7 DR. GLENN TAYLOR: That's my 8 understanding there, yes. 9 MS. JENNIFER MCALEER: Okay. Dr. 10 Cutz...? 11 DR. ERNEST CUTZ: Well, since I didn't 12 have any cases of homicide then, you know, I wouldn't be 13 really directly involved and if anybody else followed 14 this policy, you know, I -- I wouldn't know. 15 MS. JENNIFER MCALEER: All right. And I 16 just want to draw your attention to something in the HSC 17 Institutional Report, which is at page 33 of the report. 18 And again, that's PFP301353, page 33, paragraph 97. 19 And the report is talking about oversight 20 of coroner's autopsies. And the last sentence indicates: 21 "It is Sick Kids' understanding during 22 that time, [that is the time above] 23 following the establishment of the 24 OPFPU in 1991, that the Chief Forensic 25 Pathologist at the OCCO reviewed Dr.

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1 Smith's reports." 2 Now, is it your understanding that the 3 Chief Forensic Pathologist reviewed all of Dr. Smith's 4 post-mortem examination reports? 5 DR. GLENN TAYLOR: That -- that was my 6 interpretation of that, yes. 7 MS. JENNIFER MCALEER: All right. And -- 8 and not simply those that were being submitted because 9 they were criminally suspicious or homicide cases? 10 DR. GLENN TAYLOR: My understanding was 11 all of the reports. 12 MS. JENNIFER MCALEER: Okay. And what 13 was the basis of your understanding, Dr. Taylor? 14 DR. GLENN TAYLOR: The -- my 15 understanding was that the members of the units had their 16 reports reviewed by the Director of the Unit and the 17 Director of the Unit had his or her reports reviewed by 18 the Chief Forensic Pathologist. 19 MS. JENNIFER MCALEER: Is that your 20 understanding as well, Dr. Cutz? 21 DR. ERNEST CUTZ: Yes. 22 MS. JENNIFER MCALEER: All right. If we 23 could turn to Tab 43, please. Actually, we can look at 24 Tab 42 first, which is PFP118146. It's a short memo from 25 Dr. Young to:

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1 "All coroners and pathologists with 2 respect to the new protocol to be used 3 in the investigation of Sudden 4 Unexpected Death in any child under two 5 (2) years of age." 6 And then if we turn -- which is memo 631. 7 And then if we turn to Tab 43. And I 8 believe, Commissioner, you have this in a couple of 9 places already. But if we turn to Tab 43, there is a 10 copy of the Protocol for the Investigation of Sudden 11 Unexpected Deaths in Children Under 2 Years of Age. 12 PFP032280. 13 Now, Dr. Cutz, are you familiar with this 14 protocol? 15 DR. ERNEST CUTZ: Yes, I am. 16 MS. JENNIFER MCALEER: And with respect 17 to the second page of the protocol, three-quarters (3/4s) 18 of the way down the page, the paragraph that reads: 19 "Unfortunately, in this day and age, 20 child abuse is a real issue and it is 21 extremely important that all members of 22 the investigation team 'think dirty'." 23 You're familiar with that -- 24 DR. ERNEST CUTZ: Yes. 25 MS. JENNIFER MCALEER: -- concept, Dr.

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1 Cutz? 2 DR. ERNEST CUTZ: Yes, I am. 3 MS. JENNIFER MCALEER: And what was your 4 understanding as to what the concept "think dirty" meant? 5 DR. ERNEST CUTZ: Well, to me, in the 6 protocol talking about SIDS using this word, I found it 7 was inappropriate. 8 MS. JENNIFER MCALEER: Sorry, I couldn't 9 quite hear you. 10 DR. ERNEST CUTZ: I mean, to use this 11 terminology when discussing SIDS, I -- I found -- I found 12 it's inappropriate. 13 MS. JENNIFER MCALEER: All right. Well, 14 what was your understanding as to the -- the import of 15 this memo? What was this memo supposed to accomplish? 16 DR. ERNEST CUTZ: Well, I think it was to 17 raise awareness of that there may be cases where, you 18 know, more thorough investigation is needed to, you know, 19 rule out foul play. And I think it's -- it's maybe okay 20 in, you know, speaking to a colleague or something, but 21 in an official document, I find that it is not 22 appropriate to use such -- such motto. 23 MS. JENNIFER MCALEER: What did you 24 understand the concept to mean, "to think dirty"? 25 DR. ERNEST CUTZ: Well, the concept to

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1 me, means that you are -- you are sus -- you know, you 2 are implying guilt up front, and, you know, until proven 3 otherwise. 4 MS. JENNIFER MCALEER: That's how you 5 interpreted -- 6 DR. ERNEST CUTZ: That's -- 7 MS. JENNIFER MCALEER: -- this document? 8 DR. ERNEST CUTZ: That's how -- that's 9 how I interpreted, yes. 10 MS. JENNIFER MCALEER: And did you apply 11 that method of thinking when you approached these cases 12 after receiving this protocol? 13 DR. ERNEST CUTZ: Well, I -- as I 14 mentioned before, I use the balance approach; looking at 15 the facts and evidence, you know, regardless of what the 16 motto is. You know, I was aware that there are cases 17 where there is a concealed trauma or there's a concealed 18 wrong-doing. 19 And, you know, those have to be vigorously 20 handled in prosecuting. You need to protect the children 21 from harm. So I'm fully aware of that, but in the 22 majority of cases, you know, this doesn't -- shouldn't 23 apply. 24 MS. JENNIFER MCALEER: And did you -- if 25 you didn't think it was appropriate, and I understand

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1 that's what you said, -- 2 DR. ERNEST CUTZ: Yes. 3 MS. JENNIFER MCALEER: -- did you -- did 4 you voice that concern to Dr. Becker or Dr. Phillips or 5 any of your colleagues? 6 DR. ERNEST CUTZ: Yes, I voiced to Dr. 7 Becker, and he actually agreed with me on it. He -- he 8 also thought it was not appropriate. 9 MS. JENNIFER MCALEER: And do you know if 10 anybody drew that to the attention of the Office -- 11 DR. ERNEST CUTZ: No. 12 MS. JENNIFER MCALEER: -- of the Chief 13 Coroner? 14 DR. ERNEST CUTZ: Well, what we found 15 about this memo is that, you know, in addition to that 16 motto was -- was the cover letter, which actually says -- 17 and this is Tab -- whatever it is -- 43. 18 MS. JENNIFER MCALEER: 42, I believe. 19 COMMISSIONER STEPHEN GOUDGE: 42. 20 DR. ERNEST CUTZ: Oh, 42, which is second 21 paragraph, which it says: 22 "After much consultation with many 23 experts in Ontario and other parts of 24 Canada..." 25 Et cetera. I find it curious that, you

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1 know, Dr. Becker is of all the expert in SIDS, and I was 2 on all these NIH panels defining SIDS. Not only we were, 3 you know, not consulted, but we didn't even know about 4 this protocol. 5 In other words, had we seen this protocol, 6 we would have suggested -- you know, we found that the 7 protocol was heavily on the forensic side and very thin 8 on the -- on the natural disease side, -- 9 MS. JENNIFER MCALEER: And -- and do you 10 know -- 11 DR. ERNEST CUTZ: -- investigation of 12 natural disease. 13 MS. JENNIFER MCALEER: And -- 14 DR. ERNEST CUTZ: Yes. 15 MS. JENNIFER MCALEER: Sorry. Do you -- 16 do you know if Dr. Becker ever raised those concerns with 17 the Office of the Chief Coroner? 18 DR. ERNEST CUTZ: Yes, I believe so. 19 MS. JENNIFER MCALEER: And -- 20 DR. ERNEST CUTZ: When -- when he 21 actually took over, and I think he raised this and also 22 raised the issue of the academic work being jeopardized. 23 MS. JENNIFER MCALEER: And did Dr. Becker 24 ever report back to you what the response had been from 25 the Office of the Chief Coroner?

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1 DR. ERNEST CUTZ: Well, we had 2 discussions and, you know -- and this was sort of an 3 evolving situation. And I know Dr. Becker has a lot of 4 problems dealing with this issue. And so we were not 5 very successful to either convince or -- 6 MS. JENNIFER MCALEER: But you had -- 7 DR. ERNEST CUTZ: -- anyway, so things 8 just progressed the way the -- you know, the Coroner's 9 Office see fit. 10 MS. JENNIFER MCALEER: All right. But, 11 today, Dr. Cutz, -- 12 DR. ERNEST CUTZ: Yeah. 13 MS. JENNIFER MCALEER: -- you don't have 14 any specific recall as to who Dr. Becker may have spoken 15 to at the Office of the Chief Coroner or what the 16 specific response may have been? 17 DR. ERNEST CUTZ: No, I think it was 18 partially covered in -- in some correspondence earlier 19 where there was meeting between Dr. Becker, Dr. Cairns, 20 Dr. Chiasson, and Dr. Young on some occasion. So I know 21 that Dr. Becker would raise this, repeatedly, to -- to 22 say, you know, like, This is -- research is important if 23 we want to continue in it, and how could you facilitate 24 this? 25 MS. JENNIFER MCALEER: But, specifically,

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1 with respect to the concept of "think dirty" and that 2 that concept was being articulated in a protocol, -- 3 DR. ERNEST CUTZ: Yeah. 4 MS. JENNIFER MCALEER: -- do you know if 5 Dr. Becker raised that specific issue with the Office of 6 the Chief Coroner? 7 DR. ERNEST CUTZ: They -- I think he did 8 and -- and the answer was that to cover -- or -- or to 9 address the issue of wrong-doing and -- any concealed 10 wrong-doing. There are publications and there are -- 11 there are -- there's a literature on how to assess risk 12 factors for these kind of conditions, okay. 13 And instead of using that -- like, you 14 know, we're using precise pointers as to what these 15 things are which point to a possible foul play. And -- 16 and so I would have recommended to use those kind of 17 usings -- using criteria where you decide how -- how does 18 it become a foul play; rather than giving a general, you 19 know, "think dirty" sort of -- which -- which doesn't 20 tell you what you're supposed to do. 21 MS. JENNIFER MCALEER: Okay. 22 COMMISSIONER STEPHEN GOUDGE: Using the 23 pointers, would you have accepted the "think dirty" -- 24 DR. ERNEST CUTZ: Well, I still think -- 25 COMMISSIONER STEPHEN GOUDGE: --

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1 phraseology? 2 DR. ERNEST CUTZ: -- "think dirty" would 3 not be the right -- you know, would not be the right 4 thing in that setting, if you're talking 90 percent of 5 cases. If you're talking the 10 percent, then it may be 6 appropriate. 7 COMMISSIONER STEPHEN GOUDGE: In the 10 8 percent? 9 DR. ERNEST CUTZ: Yeah. 10 COMMISSIONER STEPHEN GOUDGE: All right. 11 Using the pointers that you have referred to to identify 12 the 10 percent? 13 DR. ERNEST CUTZ: That's correct. 14 COMMISSIONER STEPHEN GOUDGE: Okay. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: And, Dr. Taylor, 18 you, over the course of your work at Hospital for Sick 19 Kids doing medicolegal autopsies, had occasion to become 20 familiar with memo 631 -- 21 DR. GLENN TAYLOR: Yes, I did. 22 MS. JENNIFER MCALEER: -- or to resort to 23 it? 24 DR. GLENN TAYLOR: Yes. 25 MS. JENNIFER MCALEER: And what was your

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1 understanding as to the purpose of this memo? 2 DR. GLENN TAYLOR: I thought it was more 3 of a flag to remind the pathologist investigating the 4 case to keep in mind that the one (1) pos -- a 5 possibility that there might have been injury done to the 6 child. 7 I didn't think of it as a mandate to 8 approach the autopsy prejudging the situation that injury 9 had been done to the child. I thought it was a reminder 10 to not forget that you should look for evidence of 11 injury, along with all of the other causes of sudden 12 unexpected death in a child. 13 I guess I don't have the same overall view 14 of the situation as Dr. Cutz does. I think the protocol 15 actually is not bad, taking away some of the inflammatory 16 items in it. 17 I think having a standardized thorough 18 approach to the investigation of the sonnen -- sudden 19 unexpected death of a -- of an infant is a good thing, 20 and having this as a start, because there really was 21 nothing -- as far as I can recall -- before this, is -- 22 is good. 23 I certainly didn't think that every child 24 that came to autopsy had been murdered. I considered 25 this, kind of, a reminder that this is one (1) of the

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1 possibilities for explaining the death of a child, but 2 it's -- to me, it's only one (1), and I knew -- I know 3 that statistics; 95 percent of the time, it's going to be 4 something other than a deliberate injury done to a child. 5 MS. JENNIFER MCALEER: You referred to 6 the memo containing inflammatory items. Are you 7 referring to the "think dirty"? 8 DR. GLENN TAYLOR: I think the -- yeah, I 9 think the "think dirty" is -- it's a pretty powerful 10 statement, and it could be, easily, taken the way that 11 Ernest and Dr. Becker took it. 12 I didn't give it that weight. I 13 considered it a reminder that when we're doing these 14 cases, we need to do a complete autopsy, including 15 excluding those signs that may suggest the child received 16 some injuries. 17 COMMISSIONER STEPHEN GOUDGE: I hear Dr. 18 Cutz saying, Dr. Taylor, that for the 10 percent, a 19 slightly different approach might be warranted in terms 20 of scrutiny, perhaps, even in terms of background concern 21 about the possibility of criminal act -- do you agree 22 with that or do you think all deaths under -- 23 DR. GLENN TAYLOR: No, no. No, Mr. 24 Commissioner. 25 COMMISSIONER STEPHEN GOUDGE: -- two (2)

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1 shou -- 2 DR. GLENN TAYLOR: I'm -- I'm not -- I'm 3 not -- I agree with what you're saying, but it -- 4 COMMISSIONER STEPHEN GOUDGE: I was just 5 really quoting Dr. Cutz, so it's not me. 6 DR. GLENN TAYLOR: We have slightly 7 different approaches, and I -- I admit to that. 8 COMMISSIONER STEPHEN GOUDGE: Well, you 9 read the memo differently. 10 DR. GLENN TAYLOR: Yes. 11 COMMISSIONER STEPHEN GOUDGE: But what 12 I'm getting at is one could, as Dr. Cutz does, suggest 13 that pointers that might suggest they are markers for 14 possible criminal activity would warrant a slightly 15 different kind of approach that this memo, or at least, 16 the language "think dirty", might be appropriate for, 17 where it wouldn't be appropriate for the other 90 18 percent. 19 You, on the other hand, approach this memo 20 as if the same level of scrutiny is appropriate for every 21 death under two (2), or am I misreading it? 22 DR. GLENN TAYLOR: No. No, I think this 23 is a baseline that there should be a level of willingness 24 to entertain all possibilities when you start. Now 25 that's modified --

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1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 DR. GLENN TAYLOR: -- as you go along 3 with the circumstantial evidence that's presented to 4 you -- 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 DR. GLENN TAYLOR: -- and with what you 7 find at autopsy, so things do change. The problem with - 8 - without -- with not having a standardized approach, as 9 the baseline, is that things can be missed in both 10 directions because with children -- 11 COMMISSIONER STEPHEN GOUDGE: Both false 12 positive and false negative. 13 DR. GLENN TAYLOR: There are false 14 positive and false negatives -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. GLENN TAYLOR: -- so I think you need 17 a -- you need a solid baseline to start with; you modify 18 things as you go along by what you find, and by what the 19 circumstantial evidence -- evidence is. 20 I consider this statement to be a little 21 bit unfortunate because of its sort of connotations -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. GLENN TAYLOR: -- but as a reminder 24 that this is one (1) of the possibilities -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. GLENN TAYLOR: -- as causing the 2 death of a -- of a child. You should have that as part 3 of your overview of the case, along with all of the 4 infectious diseases, the congenital anomalies, the 5 accidental causes, and so on that may be the reason why 6 the child died. 7 COMMISSIONER STEPHEN GOUDGE: Okay. Can 8 you give me an exam -- do you want to say something, 9 because -- 10 DR. ERNEST CUTZ: What I'd like just to 11 add is that, you know, if fact, all what's in this 12 protocol we've been already been doing for years. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. ERNEST CUTZ: The only two (2) 15 differences is that there is a "think dirty". And the 16 other difference is the way the diagnosis of SIDS is -- 17 is, you know. Before we just said Sudden Infant Death 18 Syndrome; now there is like three (3) paragraphs. 19 COMMISSIONER STEPHEN GOUDGE: Okay. 20 Okay. 21 DR. ERNEST CUTZ: So -- so that we were 22 following this at Sick Children for, you know, many years 23 before, and there was a protocol which we used. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. ERNEST CUTZ: So that -- that's --

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1 but I find that the protocol is too heavy on the part of 2 forensic, and -- you know, so, I mean, it's not to say 3 that I would suggest that you -- you sort of disregard 4 possible foul play. 5 It's to say that, you know, you should do 6 all those things, but on the other hand, you also be 7 should -- should be looking what is the cause of death 8 and what are the -- what are the diseases and mechanism 9 underlying it. 10 Now the coroner's warrant, it does not 11 mandate you to do that. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. ERNEST CUTZ: Right. And -- and so, 14 it doesn't -- for example, this memorandum 631, doesn't 15 include either tests for natural disease which you need 16 to use to rule out or -- or rule in natural disease. So 17 it's -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. ERNEST CUTZ: -- too regularly -- one 20 (1) sided, that's what I try to say. 21 COMMISSIONER STEPHEN GOUDGE: Okay. Give 22 me an example of, Dr. Cutz, of a pointer that might point 23 to the kind of case within the 10 percent where this 24 approach in this memo might conceivably be warranted? 25 What would a pointer be?

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1 DR. ERNEST CUTZ: Well, those would 2 usually come from the history. 3 COMMISSIONER STEPHEN GOUDGE: Okay. 4 DR. ERNEST CUTZ: Like what's -- what is 5 the family history; what are the circumstances? 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. ERNEST CUTZ: Is there previous 8 history of involvement with Sick Children's Aid Society? 9 Was there involvement with -- with law enforcement? 10 COMMISSIONER STEPHEN GOUDGE: Okay. 11 DR. ERNEST CUTZ: Is -- is there drug 12 abuse? 13 COMMISSIONER STEPHEN GOUDGE: That might 14 trigger a different approach to -- 15 DR. ERNEST CUTZ: That's correct, yeah. 16 There's a high -- 17 COMMISSIONER STEPHEN GOUDGE: Do you 18 agree with that, Dr. Taylor? 19 DR. GLENN TAYLOR: I agree, if the 20 history is reliable. But I've certainly had the 21 unfortunate experience of having the story change in 22 time. So my approach is to try to do as complete and 23 thorough autopsy as I can at -- at the time. 24 And hopefully all bases are covered if 25 surprising information comes out a year or so later.

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1 COMMISSIONER STEPHEN GOUDGE: Okay. 2 Thanks. I mean, you obviously have slightly different 3 approaches. Frankly, it's very helpful for me to hear 4 them elaborated. It was my pleasure. 5 6 CONTINUED BY MS. JENNIFER MCALEER: 7 MS. JENNIFER MCALEER: Thank you, Mr. 8 Commissioner. Doctors, if I could have you change 9 subjects now to Tab 55 please, which is PFP115898. 10 Now we understand from Dr. Chiasson's 11 evidence that at one (1) point, Dr. Chiasson decided that 12 he would request pathologists to submit applications for 13 a limited number of Regional Coroner's Pathologist 14 positions. 15 And, Dr. Cutz, we know that you filled out 16 the questionnaire that accompanied this memo and 17 submitted an application, and that's at Tab 57 -- 18 DR. ERNEST CUTZ: Yes. 19 MS. JENNIFER MCALEER: -- of the 20 document. It's PFP056972. Dr. Cutz, what was your 21 recollection or your understanding as to the request by 22 the Chief Forensic Pathologist and your application? 23 DR. ERNEST CUTZ: Yes. My -- my reading 24 of the memo from Dr. Chiasson was that this is an 25 application for pathologists working at, you know,

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1 outside -- units throughout Ontario who would like to 2 participate in -- in coroner's autopsies. 3 MS. JENNIFER MCALEER: So outside of 4 metropolitan Toronto or outside of the forensic units? 5 DR. ERNEST CUTZ: Outside -- that's 6 right, because, you know, my understanding was that 7 people working for the forensic units, they are already 8 included in it, and they don't need to -- to apply. 9 And it's specifically said for -- for 10 carrying cases of homicide, right; so which wasn't really 11 something which I was going to apply for. And I -- I 12 filled it out, and as you see, this is quite late after 13 the deadline. 14 MS. JENNIFER MCALEER: Right. 15 DR. ERNEST CUTZ: I -- I didn't -- didn't 16 think it was -- it was appropriate for me to -- but Dr. 17 Smith told me I have to sub -- I had to submit it. 18 MS. JENNIFER MCALEER: All right, so the 19 deadline was August 31st, 1996? 20 DR. ERNEST CUTZ: Yeah. 21 MS. JENNIFER MCALEER: -- you're 22 application is October 18th, 1996? 23 DR. ERNEST CUTZ: Yes, right. 24 MS. JENNIFER MCALEER: Initially you 25 didn't think you were going to apply because you didn't

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1 think it applied to those outside of forensic units, and 2 also you weren't interested in doing criminally 3 suspicious or homicide cases. 4 DR. ERNEST CUTZ: That's correct, yes. 5 MS. JENNIFER MCALEER: Is that correct? 6 DR. ERNEST CUTZ: Yes. 7 MS. JENNIFER MCALEER: All right. And 8 then ultimately, you did apply. And -- and why did you 9 apply? 10 DR. ERNEST CUTZ: Because Dr. Smith told 11 me that if I want to continue on, you know, I have to 12 fill -- fill out this application. And -- 13 MS. JENNIFER MCALEER: If you wanted to 14 continue -- 15 DR. ERNEST CUTZ: -- I -- I -- 16 MS. JENNIFER MCALEER: -- what? 17 DR. ERNEST CUTZ: -- put it as for 18 information purposes only; it wasn't put as, you know, 19 I'm applying for. 20 MS. JENNIFER MCALEER: Right. Dr. Smith 21 told you if you wanted to continue you had to apply. To 22 continue doing what, any medicolegal -- 23 DR. ERNEST CUTZ: To -- to -- 24 MS. JENNIFER MCALEER: -- autopsies? 25 DR. ERNEST CUTZ: Any medicolegal

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1 autopsies, right. 2 MS. JENNIFER MCALEER: All right. 3 DR. ERNEST CUTZ: That's correct. 4 MS. JENNIFER MCALEER: And you indicated 5 "for information purposes only." And why did you do 6 that? 7 DR. ERNEST CUTZ: Well, because it asked 8 question -- how many cases the individual performs, so I 9 just fill it out to say, you know, this is -- this is my 10 experience in this field. 11 MS. JENNIFER MCALEER: And what was the 12 response that you received to your application? 13 DR. ERNEST CUTZ: I don't recall there 14 was a response. I don't think anything has changed. 15 MS. JENNIFER MCALEER: All right. Did -- 16 did Dr. Smith or did Dr. Chiasson tell you you had been 17 appointed a Regional -- 18 DR. ERNEST CUTZ: No, I -- 19 MS. JENNIFER MCALEER: -- Forensic 20 Pathologist? 21 DR. ERNEST CUTZ: I would -- if that was 22 the case, I would have, maybe, received a letter, but I 23 never received any letter. 24 MS. JENNIFER MCALEER: Okay. Well, let's 25 turn to Tab 61, which is a letter from you to Dr.

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1 Chiasson. 2 DR. ERNEST CUTZ: Yes. 3 MS. JENNIFER MCALEER: Now, it's a couple 4 of months later. It's January 21st, 1997. 5 You've had the opportunity to review this 6 letter? It's PFP056973. 7 DR. ERNEST CUTZ: Yes, I did. 8 MS. JENNIFER MCALEER: All right. And 9 what was the purpose in writing this letter, Dr. Cutz? 10 DR. ERNEST CUTZ: I wrote this letter in 11 response to information passed on to me by Dr. Becker, 12 telling me that the Coroner's Office was considering 13 removing me and Dr. Wilson from -- from the rotation; 14 doing medicolegals at the hospital. 15 MS. JENNIFER MCALEER: So all 16 medicolegals? 17 DR. ERNEST CUTZ: Yes. 18 MS. JENNIFER MCALEER: And what -- what 19 else did Dr. Becker tell you? 20 DR. ERNEST CUTZ: Well, you know, he said 21 that, you know, if -- if I want any -- any sort of 22 explanation as to the reasons and/or, you know, what -- 23 what -- how can one mediate the situation, I have to -- 24 to see Dr. Chiasson. 25 MS. JENNIFER MCALEER: And did you, in

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1 fact, meet with Dr. Chiasson -- 2 DR. ERNEST CUTZ: Yes, I did. 3 MS. JENNIFER MCALEER: -- to discuss this 4 issue? 5 DR. ERNEST CUTZ: Yeah. 6 MS. JENNIFER MCALEER: And what -- what 7 was your recollection of those discussions? 8 DR. ERNEST CUTZ: Well, I sort of outline 9 in my letter here that, you know, the -- my experience at 10 doing these cases at the Hospital for Sick Children and 11 outlining my, you know, experience in the different kinds 12 of conditions which include, you know, natural deaths as 13 well as -- as well as cases of child maltreatment or 14 suspected homicide. 15 And I bring to his attention one (1) 16 particular illustrated case to show that I have the same 17 level of concern and erudition in carrying out pathology 18 investigations, and I give -- give him example of it. 19 MS. JENNIFER MCALEER: Well, did Dr. 20 Chiasson explain to you why -- well, first of all, did he 21 verify what Dr. Becker had told you, that there was a 22 prospect that you and Dr. Wilson would be removed from 23 the roster doing medicolegal work? 24 Did he tell you that was something they 25 were considering?

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1 DR. ERNEST CUTZ: Well, when I asked for 2 the meeting I said, This is what I'd like to discuss with 3 him. So he didn't sort of say, you know, You're going to 4 be removed. But, you know, we were discussing the -- the 5 situation. 6 MS. JENNIFER MCALEER: And what was your 7 understanding as a result of your letter and your meeting 8 with Dr. Chiasson? Did you continue to perform 9 medicolegal autopsies? 10 DR. ERNEST CUTZ: Yes, I did. 11 MS. JENNIFER MCALEER: And was your 12 performance of those medicolegal autopsies restricted in 13 any way? 14 DR. ERNEST CUTZ: No, it wasn't 15 restricted. I continued, as before, doing the non- 16 homicide cases. 17 You know, when I asked as to what the 18 reasons were for removing me, it was sort of very vague. 19 Something saying I was soft on crime, and I didn't collab 20 -- or cooperate with the police which came to me as a 21 total surprise. 22 MS. JENNIFER MCALEER: Okay. So who said 23 you were soft on crime? 24 DR. ERNEST CUTZ: Dr. Chiasson. Or there 25 was a perception of.

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1 MS. JENNIFER MCALEER: And do you know 2 what the basis of that perception was? 3 DR. ERNEST CUTZ: He didn't explain, 4 didn't give examples. 5 MS. JENNIFER MCALEER: And -- and the 6 second reason was because you had difficulty 7 communicating with the police? 8 DR. ERNEST CUTZ: No, that I did not 9 cooperate with the police, which came as a total 10 surprise, as I don't recall any incident. I was most 11 cooperative at all instances with the police. I had no 12 reason to -- so it came as a total surprise to me. 13 MS. JENNIFER MCALEER: And did Dr. 14 Chiasson explain to you what the basis of that concern 15 was -- 16 DR. ERNEST CUTZ: He said he has -- he 17 has no specific examples. 18 MS. JENNIFER MCALEER: Okay. Did you 19 discuss this issue with Dr. Smith? 20 DR. ERNEST CUTZ: No. 21 MS. JENNIFER MCALEER: And after -- after 22 this point in time, Dr. Cutz, you did continue to do 23 medicolegal autopsies? 24 DR. ERNEST CUTZ: That's right. I 25 thought the meeting with Dr. Chiasson was useful because

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1 we cleared the air, you know, this -- this -- to see what 2 the problems were. And, you know, actually I -- I -- 3 part of the letter was -- you know, I gave him the 4 breakdown of all the cases I did in the past five (5) 5 years, which was two hundred, twenty-five (225) cases, 6 and -- and show him that, you know, it -- major portion 7 were pediatric disease, which is no way anybody would 8 have diagnosis outside of a pediatric centre. 9 Okay. So -- so we -- we rendered a very 10 valuable service to -- to making the right diagnosis for 11 the families. Okay. And then I show him the percentage 12 of cases which went to inquests, which went to -- okay, 13 which -- in every instance I was involved, a correct 14 diagnosis was made, the crime was pursued, the crime was 15 prosecuted and the person was jailed for -- for the 16 crime. 17 MS. JENNIFER MCALEER: All right. 18 DR. ERNEST CUTZ: So I -- I saw no -- no 19 problems in -- in that or... 20 MS. JENNIFER MCALEER: Okay. And, Dr. 21 Taylor, did you apply to be a regional forensic 22 pathologist? 23 DR. GLENN TAYLOR: I can't remember 24 actually applying. I don't have anything in my files 25 that said I applied, but I was appointed.

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1 MS. JENNIFER MCALEER: You were -- all 2 right. So you were appointed a regional forensic 3 pathologist? 4 DR. GLENN TAYLOR: Associate regional. I 5 think it was associate pathologist, is what my 6 designation was. 7 MS. JENNIFER MCALEER: Okay. All right. 8 Okay. If we could change topics again to discuss some 9 general hospital policies and procedures. 10 In the 1990s was -- from -- from the time 11 period that you were there, Dr. Taylor, but Dr. Cutz, for 12 all of you experience, did the hospital have a general 13 policy or practice with respect to the storage of tissue 14 blocks or slides? 15 Dr. Cutz...? 16 DR. ERNEST CUTZ: Yes, I mean, procedure 17 for the storage -- you know, those pediatric cases are 18 quite different from the adult, in terms of long-term 19 prognosis; is that, you know, in pediatric centres 20 storage goes for a much longer period. For example, we 21 still have slides from the 1920's in -- in -- from the 22 beginning of the hospital, practically. Whereas in the 23 adult hospital, the slides and things are discarded after 24 five (5) years, I believe. 25 So -- so that, you know, there's a policy

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1 to keep blocks, slides, and there's also -- keep some red 2 tissues for certain period time, in case one needs to go 3 back. And, you know, these are stored in -- in hospital 4 facilities. 5 MS. JENNIFER MCALEER: So the tissue 6 blocks are stored in hospital facilities? 7 DR. ERNEST CUTZ: Yes. 8 MS. JENNIFER MCALEER: And that was the 9 expectation in the 1990s? 10 DR. ERNEST CUTZ: Well, I think it's been 11 since I remember. There's always been -- as I say, going 12 back to the '20s. 13 MS. JENNIFER MCALEER: Okay. And the 14 slides as well are supposed to be stored somewhere in the 15 hospital? 16 DR. ERNEST CUTZ: That's right, yes. 17 MS. JENNIFER MCALEER: And does that mean 18 that pathologists would not generally have tissue blocks 19 or slides in their office or are there circumstances in 20 which one would expect to find tissue blocks and slides 21 in one's office? 22 DR. ERNEST CUTZ: Well, generally, we 23 don't like to keep it because otherwise you just get 24 overwhelmed. And, you know, occasionally, one may keep 25 slide if it's something very unusual or -- or for

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1 teaching purposes, but the general cases, which are, you 2 know, hospital patients, those are stored in -- in -- so 3 that other people may have access to it. 4 MS. JENNIFER MCALEER: And, Dr. Taylor, 5 would agree with Dr. Cutz? Was it your understanding 6 that in the 1990s there was an expectation that tissue 7 blocks and slides would generally be stored in facilities 8 at HSC? 9 DR. GLENN TAYLOR: Generally, yes. 10 There'd be certain circumstances, perhaps, where some 11 slides would be retained and even some blocks, but they 12 should be in the archive of the hospital. 13 MS. JENNIFER MCALEER: In -- in what 14 circumstances would one retain those in one's office? 15 DR. GLENN TAYLOR: If there was a request 16 for the slides to be reviewed by say an outside agency, 17 sometimes it might be easier to keep them in your office 18 when you just sign the slides out, rather than have them 19 filed and the be retrieved; that would be very uncommon. 20 Blocks -- 21 MS. JENNIFER MCALEER: Sorry, it would be 22 uncommon to -- 23 DR. GLENN TAYLOR: It would unco -- 24 MS. JENNIFER MCALEER: -- store them or 25 to not store them?

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1 DR. GLENN TAYLOR: To store -- to not 2 store them. So the circumstance where they would be 3 retained in the office waiting to be transported out 4 would be uncommon, but it'd sometimes make things a bit 5 easier for the secretaries and other staff who have to 6 transport things back and forth. Although it's usually 7 not that big of an issue, so it's very uncommon that they 8 would be kept. 9 If there's a study going on that may be 10 reviewing certain conditions represented by the slides, 11 then those slides may be in the office of the 12 pathologist. Our policy is that they should be so marked 13 in our computer system so that the tracking can be in 14 place and we know where they are. 15 MS. JENNIFER MCALEER: Would that have 16 been the practice in the 1990s? 17 DR. GLENN TAYLOR: Not likely. There was 18 a card system where a small card was put in where the 19 slides are normally stored saying the date the slides 20 were removed and who had the slides, and that may or may 21 not have been adhered to. 22 Paraffin blocks, a similar situation might 23 be apply -- applicable to the slides where the case is 24 being referred out and for some reason it would be easier 25 for the pathologist to keep them, but generally not; it's

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1 easier that they're tracked by the -- the lab staff. 2 There may be slides that -- or blocks that 3 come in from outside as specific consult materials for a 4 pathologist, and they may be stored in the office until 5 the case is completed and the materials returned, if 6 that's what's requested by the referring institution. 7 If the -- if the blocks are being used to 8 -- to recut slides or do additional studies on, then 9 they're -- then in that circumstance of a referral 10 they're usually in the lab someplace. I occasionally 11 keep tabs of them myself because I have the slides and I 12 just want everything to be together when I'm ready to 13 complete the case and send stuff back. But those are 14 uncommon situations. 15 MS. JENNIFER MCALEER: If we could turn 16 to Tab 52, please, of Volume I, PFP138745. This is a 17 pathology policy and procedure. Were -- were these 18 policies and procedures generally kept in a binder or 19 would they be loose, how -- are you familiar with -- 20 DR. GLENN TAYLOR: Yeah, this -- 21 MS. JENNIFER MCALEER: -- policies and 22 procedures, Dr. Cutz? 23 DR. ERNEST CUTZ: Yeah, this -- and this 24 one was issued in 1987. 25 MS. JENNIFER MCALEER: Right, September

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1 3rd. 2 DR. ERNEST CUTZ: And it was -- then it 3 was reviewed in '95. But yes, and then Dr. Baker was 4 very well organised and he kept all of these policy and 5 procedures in binders and -- and accessible to, you know, 6 whoever need it in the lab. 7 MS. JENNIFER MCALEER: All right. And 8 this particular policy or procedure is with respect to 9 referred in specimens known as "B" cases. 10 DR. ERNEST CUTZ: That's correct. 11 MS. JENNIFER MCALEER: What are "B" 12 cases, Dr. Cutz? 13 DR. ERNEST CUTZ: Yes, the "B" cases, it 14 makes -- of course we use designations for surgical 15 specimen. We us "S" as surgical and "A" as autopsy, 16 which is -- then there's a year and then there's a 17 number. 18 Now the "B" cases, in order to know right 19 away that this is not a in-hospital case, that this is a 20 consult, somebody refers slides or material from the 21 outside, so we give it a "B" number. And so this way one 22 -- you know, one doesn't include the -- because they -- 23 they may be a different type of situation and the urgency 24 is not as -- not as acute as it would be on the in- 25 hospital cases.

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1 MS. JENNIFER MCALEER: In particular, an 2 in house surgical pathology case. 3 DR. ERNEST CUTZ: That's right, yeah. 4 So, they were to separate these out so we know these are 5 referred cases and then you could also make statistics on 6 number of referred cases. You know, you get the 7 referrers from across Canada from, you know, North 8 America or from -- from around the world. 9 MS. JENNIFER MCALEER: All right. And it 10 refers to a referred in book in the main office -- 11 DR. ERNEST CUTZ: That's correct. 12 MS. JENNIFER MCALEER: -- and that these 13 cases are then given a "B" number. 14 DR. ERNEST CUTZ: That's correct. 15 MS. JENNIFER MCALEER: And you may or may 16 not have heard Ms. Johnson's evidence yesterday, but is 17 this generally what's referred to as accessioning within 18 the hospital? 19 DR. ERNEST CUTZ: That's correct, yes. 20 MS. JENNIFER MCALEER: And is it your 21 understanding, Dr. Cutz, that this policy was in fact 22 followed, or there was an expectation, I should say, that 23 the staff pathologists follow this policy? 24 DR. ERNEST CUTZ: Well, I personally 25 followed it, because, you know, I wanted to know -- in

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1 the event I want to go back to something there, I want to 2 be able to find it. So if it had a number and it had the 3 "B" number, I knew it was a consult and I could track it. 4 So I, you know, had no problem as I always followed this. 5 MS. JENNIFER MCALEER: All right. And, 6 Dr. Taylor, if I understand your evidence, you're saying 7 that despite the fact there is a policy that sometimes 8 from just a practical perspective, a pathologist may 9 retain some materials in his or her office? 10 In -- in particular I think, as you 11 indicated with respect to referred in work? 12 DR. GLENN TAYLOR: Yeah. 13 MS. JENNIFER MCALEER: Or did I 14 misunderstand you? 15 DR. GLENN TAYLOR: They can be obtained 16 in the office, but they should be accessioned -- 17 MS. JENNIFER MCALEER: I see. 18 DR. GLENN TAYLOR: -- so the department 19 should know that the materials have been received. And 20 certainly my practice at this time when I got a "B" case, 21 was to have it accessioned. Then it may stay in my 22 office for a while, but people would know where it was. 23 MS. JENNIFER MCALEER: All right. Thank 24 you. Mr. Commissioner, that might be a convenient time 25 to break for the lunch.

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1 COMMISSIONER STEPHEN GOUDGE: Okay. 2 We'll rise now then until two o'clock. 3 4 --- Upon recessing at 12:46 p.m. 5 --- Upon resuming at 2:01 p.m. 6 7 THE REGISTRAR: All Rise. Please be 8 seated. 9 COMMISSIONER STEPHEN GOUDGE: Ms. 10 McAleer...? 11 12 CONTINUED BY MS. JENNIFER MCALEER: 13 MS. JENNIFER MCALEER: Thank you, Mr. 14 Commissioner. Mr. Commissioner, before the lunch break, 15 we were reviewing some of the general policies and 16 procedures of the Hospital for Sick Children as they 17 applied in the 1990s. Dr. Cutz, was there any policy 18 regarding the storage of wet tissue? 19 Is there any reason why one would store 20 wet tissue in one's office? 21 DR. ERNEST CUTZ: Well, sorry -- with wet 22 tissues, it's -- it's meant to say, these are tissues 23 which are fixed in formalin. It's -- it's a fixative 24 which is used. Normally, there's one (1) of the part of 25 the tissue processing is fixation and then it's processed

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1 to say -- to paraffin and to cut the sections. 2 And we keep parts of specimen or 3 lesions or whatever is -- is necessary for any further 4 studies, as the need arises. So we keep the remainder of 5 -- of the fixed tissue in case we need to go back. 6 MS. JENNIFER MCALEER: And would you ever 7 store that in your office? 8 DR. ERNEST CUTZ: I -- I would -- well, 9 practically, I would never because of the fumes from 10 formalin, which, you know, which -- which is health 11 hazard, so I wouldn't want to keep it in my office. And 12 so that needs to be kept in vent -- well ventilated 13 areas. 14 And so there are -- there are designated 15 areas within the department which have these kind of 16 storage facilities and -- and those have special 17 ventilation. 18 MS. JENNIFER MCALEER: Dr. Taylor, is 19 there any reason why one would store wet tissue in one's 20 office? 21 DR. GLENN TAYLOR: The only time that 22 I've done that is when I've been specifically requested 23 to store it by either the risk management at the hospital 24 or police for short-term, so that can be picked up by 25 somebody for other purposes.

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1 MS. JENNIFER MCALEER: And what would 2 qualify as a short-term? 3 DR. GLENN TAYLOR: Oh, couple of days at 4 most. 5 MS. JENNIFER MCALEER: And have either 6 one of you ever had occasion to deal with material that's 7 been seized at an autopsy and designated as evidence or 8 potential evidence in a criminal proceeding? 9 Now, Dr. Taylor, have you had occasion to 10 do that? 11 DR. GLENN TAYLOR: I haven't for an 12 autopsy, but I have as a -- as a surgical specimen. 13 MS. JENNIFER MCALEER: You've had 14 surgical specimens that could potentially be used as 15 evidence? 16 DR. GLENN TAYLOR: Yes. 17 MS. JENNIFER MCALEER: And where do you 18 store that material in the hospital? 19 DR. GLENN TAYLOR: Up until recently, I 20 stored it in a locked cabinet in my locked office. 21 MS. JENNIFER MCALEER: And as far as 22 you're aware, did the hospital have any policies or 23 procedures in the 1990s with respect to where one would 24 store evidence or potential evidence? 25 DR. GLENN TAYLOR: I'm not aware of any.

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1 MS. JENNIFER MCALEER: Dr. Cutz, are you? 2 DR. ERNEST CUTZ: No, I am not aware of 3 special policy because, you know, you -- this situation 4 would arise very rarely, if ever. So, you know, to make 5 a policy would be questionable. 6 I personally never had this, sort of, 7 situation where, you know -- but generally, any tissues 8 or -- or slides, et cetera, belong -- belong into a case, 9 which has been under coroner's warrant. 10 It's all potentially discoverable 11 evidence and -- so that bet -- bet -- be better stored at 12 a safe -- safe and secure place. 13 MS. JENNIFER MCALEER: Dr. Taylor, have 14 you even been retained to do consultation work and have 15 been sent the evidence from another jurisdiction, or 16 another police force, or another hospital? 17 DR. GLENN TAYLOR: Evidence in the form 18 of slides or photographs, yes. 19 MS. JENNIFER MCALEER: You have. And 20 when you receive that material, where do you usually keep 21 it? 22 DR. GLENN TAYLOR: That's kept in my 23 office. 24 MS. JENNIFER MCALEER: And was that the 25 practice in the 1990s, as well? Did you have occasion to

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1 receive -- 2 DR. GLENN TAYLOR: Yes. 3 MS. JENNIFER MCALEER: -- material like 4 that after coming to Hospital for Sick Kids in 1995? 5 DR. GLENN TAYLOR: Yes. 6 MS. JENNIFER MCALEER: And it had been 7 your practice to keep it in your office? 8 DR. GLENN TAYLOR: Yes. 9 DR. GLENN TAYLOR: And again, woul -- you 10 mentioned a -- a locked closet in your office or whe -- 11 where do you keep it? 12 DR. GLENN TAYLOR: If I was using them I 13 would keep them on my desk. If they were just being 14 retained for a later time, they would be in a -- a locked 15 cabinet. 16 MS. JENNIFER MCALEER: And, Dr. Cutz, 17 have you also received material from outside the hospital 18 that is designated as evidence or that you know could, 19 potentially, be used as evidence in a court proceeding? 20 DR. ERNEST CUTZ: Yes, I did. I used 21 similar procedure to Dr. Taylor. 22 MS. JENNIFER MCALEER: You also have 23 somewhere in your office where you can lock material? 24 DR. ERNEST CUTZ: Or a cabinet which can 25 be locked with a key, yes.

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1 MS. JENNIFER MCALEER: And it was your 2 practice to keep it there? 3 DR. ERNEST CUTZ: Yes, correct. Yes. 4 MS. JENNIFER MCALEER: I want to talk to 5 you briefly about secretarial support. 6 Dr. Taylor, in your experience at the 7 Hospital for Sick Children, have you found that there is 8 sufficient secretarial support to assist you in your 9 work? 10 DR. GLENN TAYLOR: Yes, I have. 11 MS. JENNIFER MCALEER: And have you ever 12 had an experience where a lack of secretarial support had 13 an impact on your completion of medicolegal -- 14 medicolegal report or caused a delay with respect to 15 completion of a medicolegal report? 16 DR. GLENN TAYLOR: On occasion, if 17 there's a secretary or two (2) away, then there would be 18 a bit of a backlog. But in my experience, it wasn't more 19 than a week or at most, two (2) weeks, for those kind of 20 reports to be completed. 21 MS. JENNIFER MCALEER: And Dr. Cutz, same 22 question to you. Have you, in your experience, found 23 there to be sufficient secretarial support within the 24 Pathology Division at the hospital? 25 DR. ERNEST CUTZ: Well, there has been a

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1 reduction in the number of secretaries. But in terms of 2 priorities, I mean, it depends on the staff's priorities. 3 And I found, you know, if I needed something urgently for 4 whatever reason, it will get done. There may be delays 5 which are, you know, days to a week but, you know, 6 nothing beyond -- beyond that. 7 MS. JENNIFER MCALEER: And in your 8 experience have you ever not been able to complete a 9 post-mortem report because of a lack of support from the 10 administrative assistants? 11 DR. ERNEST CUTZ: No, I never had that 12 situation. 13 MS. JENNIFER MCALEER: Again I want to 14 change topics a bit and ask you about the SCAN Team at 15 the Hospital for Sick Children. 16 Dr. Taylor, can you briefly describe your 17 understanding as to the role of the SCAN Team? 18 DR. GLENN TAYLOR: In the hospital, in 19 general? 20 MS. JENNIFER MCALEER: Yes. 21 DR. GLENN TAYLOR: "SCAN" stands for 22 Suspected Child Abuse and Neglect. And my understanding 23 of the members of the team is that they evaluate children 24 that are suspected of having experienced child abuse or 25 neglect.

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1 It's an evaluation team and perhaps, -- 2 and I don't know the clinical side of it very well as to 3 the follow-throughs. I presume there will be 4 counselling, social -- social work involved and so on to 5 try to the rectify the situation if it's found to exist. 6 MS. JENNIFER MCALEER: And during your 7 time at the Hospital for Sick Kids between 1995 and 1999, 8 what, if any, interaction did you have with the SCAN 9 Team? 10 DR. GLENN TAYLOR: I think I had a couple 11 of instances where I was autopsying a child that was 12 suspected of having physical abuse, and I called the SCAN 13 Team person that was on call to have a look at the 14 injuries on the child with me. 15 MS. JENNIFER MCALEER: And what -- for 16 what purpose would you ask somebody from the SCAN Team to 17 look at the injuries on a child that you were autopsying? 18 DR. GLENN TAYLOR: Well, the pattern of 19 bruising in a child abuse case can be very informative, 20 and I had some -- some experience with evaluating such 21 bruises. 22 But my level of comfort with assessing 23 what might or might not be a significant bruise was not 24 high, and I wanted somebody who saw bruises which were, 25 presumed to be, as a result of inflicted injury on a more

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1 frequent occurrence than I -- than I did. 2 So I -- I called a person in to have a 3 look at the injuries on such a child. 4 MS. JENNIFER MCALEER: And how would that 5 work, Dr. Taylor? Would that individual actually come 6 into the autopsy room with you, and would you discuss 7 your individual observations over the body as you're 8 conducting the autopsy? 9 DR. GLENN TAYLOR: That's correct. 10 MS. JENNIFER MCALEER: And would you then 11 -- when the autopsy was finished, would there be a 12 continued consultation with the member of the SCAN team? 13 DR. GLENN TAYLOR: Usually not. It was 14 my -- I did this occasionally in British Columbia as well 15 -- and it was my practice then to ask for a written 16 report of that person's observations at autopsy. 17 Now I can't remember on the one (1) or two 18 (2) occasions in Toronto whether I did that or not. But 19 usually, things kind of ended at that point. 20 MS. JENNIFER MCALEER: And if you -- let 21 me put it this way. Would you then find yourself in a 22 position, at times, where you would be depending upon the 23 expertise or the opinions of the individual from the SCAN 24 Team that had assisted you or had consulted with you on 25 the autopsy?

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1 DR. GLENN TAYLOR: No, I kind of used it 2 more as -- as a consult, in the sense, of information 3 that I would evaluate in the context of the overall 4 autopsy findings. So for instance, if there were some 5 bruises that looked like they may be pinch marks, I would 6 include that observation. 7 But I would not -- I would not use the 8 information to directly guide my thinking on the case. I 9 would use it to sort of add to, like, any other ans -- 10 and the SCAN Team members might not like this -- but any 11 other ancillary tests like the radiology or the 12 biochemistry or toxicology in evaluating the overall 13 picture in the -- of the autopsy. 14 MS. JENNIFER MCALEER: And -- 15 COMMISSIONER STEPHEN GOUDGE: Why might 16 they not like it? 17 DR. GLENN TAYLOR: Oh, I'm just being a 18 little bit facetious, Commissioner. 19 COMMISSIONER STEPHEN GOUDGE: And I guess 20 one (1) of the questions that is the back drop for my 21 question of you, Dr. Taylor, is that one wonders about 22 what the interplay was during this period of time between 23 the SCAN Team and Dr. Smith's autopsies? 24 DR. GLENN TAYLOR: I didn't have a lot of 25 interaction with them, but I'm sure that if -- that my

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1 colleagues in diagnostic imaging or radiology probably 2 don't like being called an ancillary test as well, but. 3 COMMISSIONER STEPHEN GOUDGE: Okay. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: All right. So 7 it's -- it's some information that you would take into 8 account when making your own conclusions and findings? 9 DR. GLENN TAYLOR: Yes. 10 MS. JENNIFER MCALEER: And would you 11 source that information in your post-mortem examination 12 report? Would you indicate that you had consulted with 13 or perhaps, "consulted with" isn't the right word, but 14 that -- that you had had somebody in from the SCAN Team 15 to provide you with their observations? 16 DR. GLENN TAYLOR: Yes, I would. 17 MS. JENNIFER MCALEER: Dr. Cutz, same 18 line of questioning for you. In your experience at the 19 Hospital for Sick Kids, what has been your interaction 20 with the members of the SCAN Team? 21 DR. ERNEST CUTZ: Yes, over the years, I 22 have had several occasions to interact with them, and it 23 would be under different circumstances. Some would be -- 24 let's say a child was admitted to the hospital and was 25 examined by a SCAN Team and then subsequently died, and

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1 there was an autopsy. 2 Then I would, sort of, interact with them 3 to ask what their impressions were, and what -- what 4 their concerns were, so that when we do the autopsy, we 5 sort of focus on those areas. 6 And I may invite them to the autopsy room 7 just to observe, but they would not be there during the 8 whole process -- procedure. Other situation would be 9 where after checking the clinical chart, one sees that 10 the SCAN Team was involved or was consulted and then 11 either the consultation resulted in -- in saying, You 12 know, we found nothing suspicious or was the other way 13 saying, you know maybe these injuries are such and such. 14 So there are -- I will consult with them 15 as well. 16 MS. JENNIFER MCALEER: All right. So you 17 may review written material that's been prepared -- 18 DR. ERNEST CUTZ: That's right, yes. 19 MS. JENNIFER MCALEER: -- by the SCAN 20 Team or you may actually call them or -- or speak to them 21 in person -- 22 DR. ERNEST CUTZ: Well, if -- 23 MS. JENNIFER MCALEER: -- before actually 24 starting the autopsy? 25 DR. ERNEST CUTZ: Well, if there's a

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1 record that the -- that the patient was -- was seen by 2 the SCAN Team, then, you know, that would trigger 3 immediately to, sort of, consult with them. 4 MS. JENNIFER MCALEER: Okay. 5 DR. ERNEST CUTZ: If there isn't, then, 6 you know, as long as I have some concerns or there's some 7 indication the SCAN Team should be involved, then -- then 8 I will contact them. 9 MS. JENNIFER MCALEER: And, Dr. Taylor 10 indicated that, on occasion, SCAN Team members would 11 attend in the autopsy suite. Would they do so with you 12 as well on occasion? 13 DR. ERNEST CUTZ: Yes, on occasion and I 14 think Dr. Huyer who became member of SCAN Team later on, 15 I think he was also a coroner. And so he would stay for 16 the autopsy and he would -- he would, sort of, wait for 17 the results, kind of. 18 MS. JENNIFER MCALEER: And what -- what 19 purpose, if any, did the SCAN Team member serve to you in 20 the autopsy room? 21 DR. ERNEST CUTZ: It was more to get the 22 information as to what areas or what things we should be 23 focussing on in -- in -- based on their information. 24 MS. JENNIFER MCALEER: Would you ask them 25 to assist you with interpreting bruise patterns, or burn

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1 patterns or observations on the body? 2 DR. ERNEST CUTZ: Yes, with on the 3 outside, yes. 4 MS. JENNIFER MCALEER: And, again, would 5 you source that information in the completion of your 6 post-mortem examination report? 7 DR. ERNEST CUTZ: Yes, I would request 8 for them to give me a return -- returned report. 9 MS. JENNIFER MCALEER: Right, but when 10 you actually drafted your own post-mortem examination 11 report, would you make reference to the fact that you had 12 received some input from members of the SCAN Team if, in 13 fact, that had happened during the course of an autopsy? 14 DR. ERNEST CUTZ: Yes, what I would 15 suggest to them that they send copy to the Coroner's 16 Office, rather than making it part of my record, but 17 there's no place to -- to sort of indicate this, you 18 know, or this strictly filling out which is referred to 19 the autopsy. 20 MS. JENNIFER MCALEER: All right. So, 21 does that mean, Dr. Cutz, that perhaps if Dr. Huyer had 22 attended one (1) of your autopsies and I were to read 23 your post-mortem examination report, it may not be 24 apparent on the face of the document -- the document 25 being your post-mortem examination report -- the Dr.

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1 Huyer had, in fact, attended at the autopsy? 2 DR. ERNEST CUTZ: Well, his name would be 3 on who attended, yeah. 4 MS. JENNIFER MCALEER: I see. And would 5 the specific information that you obtained from Dr. 6 Huyer, if any, would that be identified on the post- 7 mortem examination report? 8 DR. ERNEST CUTZ: No. 9 MS. JENNIFER MCALEER: And just jumping 10 forward a little bit, what is the -- the present practice 11 with respect to members of the SCAN Team? Is it similar 12 to what we've just reviewed, Dr. Taylor, or has -- have 13 there been any changes in the last number of years? 14 DR. GLENN TAYLOR: I don't recall having 15 the SCAN -- any member of the SCAN Team in the autopsy 16 room since I returned in 2003. I don't know if some of 17 my other colleagues may have, but I certainly haven't 18 asked them in. 19 And I think, in part, that relates to the 20 type of cases that I have been dealing with over the past 21 few years. There have been very few cases of suspected 22 inflicted injury on children. 23 MS. JENNIFER MCALEER: You're not aware 24 of any change of policy then -- 25 DR. GLENN TAYLOR: No.

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1 MS. JENNIFER MCALEER: -- or practice. 2 DR. GLENN TAYLOR: I'm not aware of any 3 change in practice or policy. 4 MS. JENNIFER MCALEER: Dr. Cutz, have you 5 noticed any change in the frequency or infrequency of 6 contact with the SCAN Team? 7 DR. ERNEST CUTZ: Well, my experience is 8 similar to Dr. Taylor's, but I don't recall lately that, 9 you know, what -- how much interaction is this 10 guaranteeing. 11 MS. JENNIFER MCALEER: And again, you're 12 not aware of any change in policy or procedure at the 13 hospital with respect to the interaction between the SCAN 14 Team and the Pathology Department? 15 DR. ERNEST CUTZ: No. 16 MS. JENNIFER MCALEER: Okay. Change 17 topics to Dr. Smith's surgical pathology work. If we 18 could turn to Tab 44 of the Volume I, please, which is 19 PFP137837. 20 21 (BRIEF PAUSE) 22 23 MS. JENNIFER MCALEER: Now, this is a 24 letter from Dr. Becker to Dr. Smith dated July 20th, 25 1995. I understand that neither one (1) of you, prior to

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1 preparing for the proceedings today, had actually seen a 2 copy of this letter, is that correct? 3 DR. ERNEST CUTZ: No, I have not seen 4 this letter before. 5 MS. JENNIFER MCALEER: Dr. Taylor? 6 DR. GLENN TAYLOR: I don't think I have 7 either. 8 MS. JENNIFER MCALEER: Okay. I just want 9 to review some of the information that's contained in the 10 letter and ask you about your general experiences at the 11 hospital. The letter starts: 12 "This letter is to inform you that you 13 have failed to meet departmental 14 standards. As you know, these are 15 guidelines which were established and 16 agreed upon in 1994 by all staff 17 pathologists, including yourself." 18 Now let me just stop there for a moment. 19 Did the department -- as members of the department, was 20 there a general accepted standard with respect to the 21 turnaround time for surgical pathology reports and post- 22 mortem medicolegal reports? 23 DR. ERNEST CUTZ: Yes, there was. 24 MS. JENNIFER MCALEER: And -- and what 25 was that standard, Dr. Cutz?

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1 DR. ERNEST CUTZ: I think for the 2 surgicals, I believe the maximum time, it would be about 3 between three (3) -- three (3) days and a week. 4 MS. JENNIFER MCALEER: Three (3) days and 5 a week? 6 DR. ERNEST CUTZ: Between three (3) days 7 and a week is the maximum. If it's beyond a week, we 8 usually issue a supplemental report; for autopsies, I 9 think it's three (3) months. 10 MS. JENNIFER MCALEER: And does it matter 11 whether they're medicolegal autopsies or hospital 12 autopsies? 13 DR. ERNEST CUTZ: Regardless, yeah, it's 14 always three (3) weeks. 15 MS. JENNIFER MCALEER: Sorry, three (3) 16 months or three (3) weeks? 17 DR. ERNEST CUTZ: Oh, sorry, three (3) -- 18 three (3) months. 19 MS. JENNIFER MCALEER: Okay. Dr. Taylor, 20 does the -- do you agree with that? Is that your 21 understanding as to the practice in the 1990's? 22 DR. GLENN TAYLOR: I think it was more 23 like 90 percent of the cases should be completed within a 24 week and 10 percent may take longer, and there should be 25 reasons why they take longer; special tests or special

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1 procedures that are required. 2 MS. JENNIFER MCALEER: And when you say 3 "cases", you mean the surgical cases. 4 DR. GLENN TAYLOR: Surgical cases, sorry. 5 Yeah, surgical cases. For autopsies, three (3) months 6 was kind of the target, yes. 7 MS. JENNIFER MCALEER: And again, that 8 applies to both medicolegal and hospital autopsies? 9 DR. GLENN TAYLOR: Yes. 10 MS. JENNIFER MCALEER: Okay. Third 11 paragraph of that letter -- actually the second paragraph 12 makes reference to the fact that -- or as Dr. Becker says 13 to Dr. Smith: 14 "You were informed about three (3) 15 incomplete cases from early March 1995 16 on five (5) separate occasions 17 including my recent note to you at the 18 beginning of July." 19 Next paragraph: 20 "If the case is a diagnostically 21 difficult one for you, you have the 22 option of asking one of the other 23 surgical pathologists to sign out the 24 case." 25 Now, do either one of you recall Dr. Smith

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1 ever requesting your assistance because he found a case 2 to be diagnostically difficult? Dr. Cutz...? 3 DR. ERNEST CUTZ: I don't recall a 4 situation like that, no. 5 MS. JENNIFER MCALEER: Dr. Taylor, do you 6 recall? 7 DR. GLENN TAYLOR: Well, he's asked me to 8 have a look at slides, but I was never asked to sign out 9 a whole case for him. 10 MS. JENNIFER MCALEER: Okay. 11 COMMISSIONER STEPHEN GOUDGE: These are 12 all surgical cases -- 13 DR. GLENN TAYLOR: These are surgical 14 cases, Commissioner, yes. 15 COMMISSIONER STEPHEN GOUDGE: -- based on 16 the numbering? 17 DR. GLENN TAYLOR: Yes. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: The letter then 21 continues down in the second last paragraph. 22 "I'm advising you that you must 23 strictly adhere to the departmental 24 guidelines. Furthermore, I would like 25 -- I would also like to suggest that it

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1 would be to your benefit to 2 participate, some time in the next 3 year, in a CME course on surgical 4 pathology in order to enhance your 5 diagnostic skills, so that completing 6 cases in a timely fashion will be less 7 burdensome to you." 8 Now, do either of you know if -- whether 9 or not, Dr. Smith actually did take a CME course, in or 10 about the summer of 1995, further to Dr. Becker's 11 recommendation? 12 DR. ERNEST CUTZ: I can't recall. 13 MS. JENNIFER MCALEER: You don't know. 14 DR. ERNEST CUTZ: I don't know if he did 15 or not. 16 MS. JENNIFER MCALEER: Dr. Taylor...? 17 DR. GLENN TAYLOR: I wasn't there till 18 the fall. 19 MS. JENNIFER MCALEER: That's correct. 20 But once you did arrive in the fall, were you aware or 21 did you hear that Dr. Smith had been -- it had been 22 recommended -- 23 DR. GLENN TAYLOR: I was not aware of 24 that. 25 MS. JENNIFER MCALEER: -- that he take

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1 the CME course? 2 DR. GLENN TAYLOR: I was not aware of 3 that. 4 MS. JENNIFER MCALEER: All right. In 5 your experience, Dr. Taylor, is this a significant letter 6 for a pathologist to receive or -- or not? 7 DR. GLENN TAYLOR: I think it's a 8 significant letter, yes. 9 MS. JENNIFER MCALEER: And why is that? 10 DR. GLENN TAYLOR: I'm assuming the cases 11 of concern, the three (3) incomplete cases, which look to 12 be several months old relate directly to patient care and 13 are not referral cases that are being sent for a -- a 14 third or a fourth cons -- consultation. 15 If they are directly related to patient 16 care, then they should be dealt with in an expeditious 17 manner. And three (3) to four (4) months is not 18 expeditious. There may be some reasons as to why the 19 case can't be totally completed, but there should be no 20 reasons why a case can't be completed to the point where 21 the information required by the clinician can be 22 substantially provided. 23 MS. JENNIFER MCALEER: And in your 24 experience, Dr. Cutz, is it unusual to receive a letter 25 that's -- begins with, "You failed to meet departmental

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1 standards"? 2 DR. ERNEST CUTZ: Well, I think it's 3 significant. I personally wouldn't like to get a letter 4 like this. 5 MS. JENNIFER MCALEER: I'm sorry? 6 DR. ERNEST CUTZ: I wouldn't like to get 7 a letter like this. 8 COMMISSIONER STEPHEN GOUDGE: You would 9 not like to get a letter? 10 DR. ERNEST CUTZ: No. 11 COMMISSIONER STEPHEN GOUDGE: You ever 12 written a letter like this, Dr. Taylor? 13 DR. GLENN TAYLOR: Once. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: All right. If we 17 could move on then to Tab 69, please. This is PFP137856. 18 COMMISSIONER STEPHEN GOUDGE: Sorry, what 19 tab, Ms. McAleer? 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: It is Tab 69, 23 Volume I. And again, gentlemen, I understand that prior 24 to preparing for these proceedings, neither one of you 25 had actually ever seen this memo from Dr. Thorner to Dr.

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1 Becker, correct? 2 DR. ERNEST CUTZ: Yes, correct. 3 DR. GLENN TAYLOR: Correct. 4 MS. JENNIFER MCALEER: Although, the 5 cases that are referred to in this memo specifically make 6 reference to both of you, agreed? 7 DR. GLENN TAYLOR: Correct. 8 DR. ERNEST CUTZ: Correct. 9 MS. JENNIFER MCALEER: All right. With 10 respect -- the -- the memo starts -- this is from Dr. 11 Thorner. It says: 12 "My return from the pathology 13 conference in Orlando, I've come across 14 four (4) recent cases of Dr. Smith's in 15 which there are diagnostic 16 discrepancies. I'm outlining the 17 events below, as I understand them." 18 Now, the first case, Dr. Cutz, is with 19 respect to a patient, that I understand, that you had had 20 some involvement with. Are you able to outline to the 21 Commissioner your involvement in this case? And just a - 22 - a brief synopsis to what the issue was with respect to 23 this particular patient. 24 DR. ERNEST CUTZ: Yes. I wasn't 25 involved. I got involved because the clinician involved

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1 with this patient, Dr. Marcon, who is a 2 gastroenterologist, approached me to -- to -- and since 3 I'm sort of the main gastrointestinal pathologist -- 4 asked me about the sort of curious report she received 5 from Dr. Smith where they sent the biopsy which was from 6 large -- a large intestine, from the colon, and they -- 7 they received a report which said that they were small 8 intestinal mucosae. 9 In other words, there was a small 10 intestinal metaplasia -- change in one (1) type of mucosa 11 to another -- which would be highly unusual under the 12 circumstances. And so she asked me if I can look at it. 13 MS. JENNIFER MCALEER: And did you, in 14 fact, take a look at the case? 15 DR. ERNEST CUTZ: Well, I -- I can't 16 remember the details now, but I would have looked at the 17 slides, yes. 18 MS. JENNIFER MCALEER: All right. Maybe 19 I could draw your attention -- we have another document 20 that also speaks to that case. It's in Volume II, Tab 21 80, and it's PFP137858. 22 DR. ERNEST CUTZ: Yes. 23 MS. JENNIFER MCALEER: Yes. And you've 24 had the opportunity to review that memo, Dr. Cutz? 25 DR. ERNEST CUTZ: Well, I -- I wrote it

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1 and so I just had an opportunity to look at it; so it's 2 quite a while ago. 3 MS. JENNIFER MCALEER: All right. And do 4 you recall -- what was the concern with respect to Dr. 5 Smith's involvement? 6 DR. ERNEST CUTZ: Well, I think what it - 7 - what it refers to is the diagnosis Dr. Marcon 8 questioned of small intestine metaplasia in the biopsies 9 which were from a large intestine. And then it says: 10 "These cases or case was signed out 11 while I was away," 12 So it's probably the same meeting as Dr. 13 Thorner was away. 14 And then: 15 "During my absence, Dr. Smith was 16 signing out these biopsies." 17 And I think that may be a reason that my 18 name appeared on the report, but it was actually Dr. 19 Smith who -- who saw the slides and signed it out. And I 20 just, you know, said what my opinion was that, you know, 21 I didn't think there was this lesion described. And, you 22 know, I just did it -- it was referred back to Dr. Smith 23 to correct the report. 24 MS. JENNIFER MCALEER: And was there any 25 impact on patient care in this case, as far as you

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1 recall? 2 DR. ERNEST CUTZ: It wouldn't have a 3 direct impact. It's -- it's more for accuracy and also 4 consistency with clinical. In other words, the 5 clinicians have to have confidence in their pathologists; 6 what diagnoses pathologists provide to them. 7 MS. JENNIFER MCALEER: And do you know 8 why there was a difference in interpretation? 9 Is it correct to say there was a 10 difference in interpretation, Dr. Cutz? Or how would you 11 phrase the difference? 12 DR. ERNEST CUTZ: I cannot recall now the 13 detail, why it was -- why it was misinterpreted. But, 14 you know, it was a clear-cut, you know, difference in 15 what it should have been. 16 MS. JENNIFER MCALEER: And that's a 17 microscopic -- 18 DR. ERNEST CUTZ: That's right. 19 MS. JENNIFER MCALEER: -- assessment? 20 DR. ERNEST CUTZ: Yes. 21 MS. JENNIFER MCALEER: Okay. With 22 respect to the second case, Dr. Taylor. Do you recall 23 your involvement in that case? 24 DR. GLENN TAYLOR: I vague -- vaguely 25 recall my involvement at the time. I was asked by Paul

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1 to have a look at both this case and the third case to 2 get my opinion because there was an issue with the 3 diagnosis that had been made. 4 MS. JENNIFER MCALEER: And when you say 5 "Paul", that's Dr. Thorner? 6 DR. GLENN TAYLOR: Yes. Sorry. Dr. 7 Thorner. 8 MS. JENNIFER MCALEER: So Dr. Thorner -- 9 can you -- can you tell us the circumstances under which 10 Dr. Thorner approached you and asked you to look at these 11 cases? 12 DR. GLENN TAYLOR: Dr. Thorner said that 13 diagnoses had been made on these two (2) cases that he 14 didn't agree with, and he wanted my opinion as kind of a 15 -- an impartial third party to have a look at the cases 16 and see what I thought about diagnoses. 17 MS. JENNIFER MCALEER: And these are 18 cases in which Dr. Smith had been the pathologist, who 19 did the first diagnosis? 20 DR. GLENN TAYLOR: That's correct, yes. 21 MS. JENNIFER MCALEER: And what was your 22 finding? 23 DR. GLENN TAYLOR: I agreed with Dr. 24 Thorner's diagnoses and disagreed with Dr. Smith's 25 diagnoses.

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1 MS. JENNIFER MCALEER: And were you able 2 to -- or are you able to provide us with any kind of 3 explanation as to why it is you and Dr. Smith had a 4 different view? 5 DR. GLENN TAYLOR: The case number 2 -- 6 sorry, the diagnosis that was made by Dr. Smith, 7 histologically by microscope, that condition can look 8 something like the diagnosis that Dr. Thorner and I made. 9 It's -- there are differences, but they can look somewhat 10 similar and that's a matter of experience, I think, to 11 pick -- pick out the differences. 12 The third -- case number 3: This is a 13 very unusual lesion, which requires more than just the 14 histology or the microscopic appearance, I think, to sort 15 out. The diagnosis that was made by Dr. Smith was even 16 more unusual for the site which is what caused the -- 17 sort of review. 18 And putting together the site, the nature 19 of the lesion and the clinical circumstances, I came up 20 with the same diagnosis that Dr. Thorner came up with. 21 Subsequently, this particular case was 22 sent out at the request of a oral pathology resident, I 23 think, or an oral -- oral surgery resident to be reviewed 24 by an oral pathologist, who's a pathologist that 25 specializes in diseases of the mouth region, and he

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1 agreed with Dr. Thorner and myself as far as our 2 diagnosis. 3 MS. JENNIFER MCALEER: And did you have 4 occasion to speak to Dr. Smith about either of these 5 cases? 6 DR. GLENN TAYLOR: I can't recall, no. 7 COMMISSIONER STEPHEN GOUDGE: Just 8 dealing with the first couple of lines of what it said 9 about that third case, Dr. Taylor. 10 Do I read it right that Dr. Smith's 11 diagnosis was syringoma of the palate? Am I reading that 12 right? 13 DR. GLENN TAYLOR: Correct. 14 COMMISSIONER STEPHEN GOUDGE: And the 15 memo goes on to say: 16 "...which would be an extremely usual 17 site for this lesion." 18 DR. GLENN TAYLOR: Yeah, that should be 19 "unusual." 20 COMMISSIONER STEPHEN GOUDGE: I would 21 have thought so. 22 DR. GLENN TAYLOR: Yes. 23 COMMISSIONER STEPHEN GOUDGE: Okay. 24 Thank you. 25

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1 CONTINUED BY MS. JENNIFER MCALEER: 2 MS. JENNIFER MCALEER: And did you form 3 an opinion, Dr. Taylor, as to why it was that Dr. Smith's 4 diagnosis was different than yours? 5 I think you said it was perhaps a matter 6 of experience. Was -- was that it? 7 DR. GLENN TAYLOR: That's part of it, 8 yes. 9 MS. JENNIFER MCALEER: Were there any 10 other components? 11 DR. GLENN TAYLOR: To get the diagnosis 12 of the third case, I think would have required a bit of 13 reading. And you have to have the right books; know 14 where to look, I think, to kind of pick that up. 15 So, in a sense, it is an experience issue, 16 but it's also a matter of spending the time and effort to 17 try to get the correct answer. 18 MS. JENNIFER MCALEER: Now looking at the 19 fourth case. Although you are not specifically 20 referenced in that synopsis, Dr. Taylor, I understand 21 that you actually have looked at that case? 22 DR. GLENN TAYLOR: Recently, yes. 23 MS. JENNIFER MCALEER: And can you 24 explain to Mr. Commissioner, the issue with respect to 25 this case?

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1 DR. GLENN TAYLOR: The issue was that at 2 the time of surgery of this child that had a mass in her 3 face, a small biopsy was taken in the operating room for 4 assessment by a pathologist. 5 And the purpose of that procedure is to 6 not necessarily make a diagnosis but to identify whether 7 the tissue represents lesional tissue -- meaning it's not 8 normal tissue but it is some kind of abnormality. And 9 as, kind of, a next level to determine if the tissue is, 10 at least, malignant or benign, because that can influence 11 the therapy that the child is going to get immediately at 12 the operating room table. 13 This was interpreted by Dr. Smith as being 14 reactive which means benign. And as a consequence, the 15 child was not -- did not receive an intravascular 16 catheter or port for subsequent delivery of chemotherapy. 17 COMMISSIONER STEPHEN GOUDGE: Which would 18 have happened at -- 19 DR. GLENN TAYLOR: Which would have 20 happened -- 21 COMMISSIONER STEPHEN GOUDGE: -- the time 22 of the operation? 23 DR. GLENN TAYLOR: -- at that operation 24 while she was under that general anaesthetic, yes. 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. GLENN TAYLOR: The diagnosis 2 eventually was made of a malignancy, and the child had to 3 go back to the operating room for insertion of that 4 catheter. So the error caused the child to receive a 5 second general anaesthetic that she didn't require -- she 6 shouldn't have required. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 9 CONTINUED BY MS. JENNIFER MCALEER: 10 MS. JENNIFER MCALEER: And I understand, 11 Dr. Taylor, you have recently reviewed these slides again 12 and have confirmed that, in fact, the original slides 13 were not reactive? 14 DR. GLENN TAYLOR: The original slides 15 did show malignancy, yes. 16 MS. JENNIFER MCALEER: And do you have 17 any explanation, or have you had occasion to speak to Dr. 18 Smith about this case? 19 DR. GLENN TAYLOR: No. 20 MS. JENNIFER MCALEER: And do you have 21 any understanding as to what may have caused the 22 misdiagnosis? 23 DR. GLENN TAYLOR: I don't know why the 24 diagnosis of malignant tissue was not made in that case. 25 MS. JENNIFER MCALEER: And, Dr. --

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1 COMMISSIONER STEPHEN GOUDGE: How common 2 are mistakes like that? 3 DR. GLENN TAYLOR: They're reasonably 4 common. We, sort of, aim for a 95 percent correct respo 5 -- correct diagnosis, but there are ways of dealing with 6 uncertainty. And in this particular instance, depending 7 upon how confident the pathologist was, first off, the 8 baseline is, it should have been recognized as not 9 reactive tissue, it should have been recognized as -- 10 COMMISSIONER STEPHEN GOUDGE: As 11 malignant. 12 DR. GLENN TAYLOR: Well, not necessarily 13 as malignant, but as lesional tissue, anyways, something 14 that's not normal or reactive. 15 So the -- depending upon how confident the 16 pathologist is and how much experience a pathologist has, 17 they -- they can tell the surgeon that there is 18 malignancy, and if they are very confident about the 19 diagnosis and give a diagnosis; sometimes they prove 20 wrong on that, but at least saying "malignant". 21 The next step is to say "suspicious for 22 malignancy" and then -- then the bottom step, where the 23 level of competence is kind of a -- the lowest, would be 24 to say something like, "lesional tissue present, defer to 25 permanent sections", which means they have to wait a day.

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1 So the child would have had another 2 anaesthetic eventually in this circumstance, but, at 3 least, it was flagged at, I'm worried about this tissue; 4 I can't make a diagnosis. 5 Now, the other -- the other aspect of all 6 of this evaluation, at least at our place, is that if the 7 pathologist evaluating the frozen section is uncertain, 8 it's a very common practice to walk it -- walk the slide 9 down the -- down the hallway and go into somebody else's 10 office and say, Can you have a quick look at this? I'm 11 doing a frozen section and I'm concerned about this. 12 What do you think? 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: Dr. Cutz, do you 16 agree with everything that Dr. Taylor has just explained 17 to Mr. Commissioner? 18 DR. ERNEST CUTZ: Yes, yes. 19 MS. JENNIFER MCALEER: Okay. 20 COMMISSIONER STEPHEN GOUDGE: One (1) way 21 to read this memo is, This is a relatively worrying 22 number of mistakes; that is why I'm writing the memo. Is 23 that a fair reading of this memo from somebody in your 24 position as the Chair of the Department, Dr. Taylor? 25 DR. GLENN TAYLOR: Well, there's four (4)

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1 mistakes here listed with eight hundred (800) numbers, so 2 that's, you know, at least a 4 percent if you go by the 3 eight hundred (800) numbers. 4 COMMISSIONER STEPHEN GOUDGE: Four (4) 5 out of the eight hundreds (800s); four (4) out of the one 6 hundred (100). 7 DR. GLENN TAYLOR: For -- but they're all 8 -- they're all in that sequence, so it would be a little 9 bit concerning to me to -- you know, I'd want to know 10 what's going on. 11 COMMISSIONER STEPHEN GOUDGE: Okay. 12 13 CONTINUED BY MS. JENNIFER MCALEER: 14 MS. JENNIFER MCALEER: And I take it 15 neither one of you is aware of any followup as a result 16 of Dr. Thorner's memo to Dr. Becker, are you? 17 DR. GLENN TAYLOR: No. 18 DR. ERNEST CUTZ: No, I don't know what 19 happened in that -- 20 MS. JENNIFER MCALEER: Tab -- Tab 71, 21 please, which is PFP137850. And again, prior to 22 preparing for these proceedings, I take it neither one of 23 you had ever seen this letter. 24 DR. GLENN TAYLOR: Correct. 25 DR. ERNEST CUTZ: No, I have not seen

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1 this. 2 MS. JENNIFER MCALEER: And I understand, 3 Dr. Taylor, that it's the hospital's position that you 4 cannot determine whether or not this letter was actually 5 ever sent, is that correct? 6 DR. GLENN TAYLOR: That's my 7 understanding, yes. 8 MS. JENNIFER MCALEER: Okay. And looking 9 at the letter, it starts: 10 "Dear Charles, 11 As you are aware, the surgical reports 12 for which you have been responsible 13 have not been completed according to 14 the established and agreed upon in 15 1994." 16 So it's a similar way to the other letter 17 started: 18 "You have received regular reminders 19 over the past two (2) years about the 20 delays and completion of the reports. 21 In addition..." 22 Moving down a little bit: 23 "In addition, during the limited number 24 of weeks per year that you have 25 responsible for completion of the

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1 surgical reports, there have been a 2 disproportion in the number of 3 complaints about diagnostic 4 inconsistencies from the pediatricians 5 and surgeons." 6 Now let me just stop there. Apart from 7 the cases that we just reviewed that both of you were 8 involved in, to some degree, are you aware of any other 9 complaints with respect to Dr. Smith's surgical work? 10 Dr. Taylor? 11 DR. GLENN TAYLOR: Sorry, only through 12 preparations for this appearance. I don't think I recall 13 any specific ones, other than the few that Paul brought - 14 - I'm sorry, Dr. Thorner brought to me during that time. 15 MS. JENNIFER MCALEER: All right. And 16 there's two (2) more that we haven't discussed yet that 17 we'll -- we'll speak to, but with respect -- with the 18 exception of those and the ones we reviewed, you weren't 19 aware of any other complaints. 20 DR. GLENN TAYLOR: That's correct, yes. 21 MS. JENNIFER MCALEER: Okay. Dr. Cutz, 22 were you aware of any complaints or concerns from some of 23 the pediatricians or surgeons at the Hospital for Sick 24 Kids regarding Dr. Smith's surgical work, apart from the 25 ones that we've reviewed in preparation for today's

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1 evidence? 2 DR. ERNEST CUTZ: Not during -- not 3 during this period. I -- I think what this seems to say 4 is that the proportion of cases Dr. Smith handled in this 5 period, which, you know, because he was on a reduced 6 schedule, the proportion of problems with these cases was 7 -- was too high. 8 MS. JENNIFER MCALEER: Right. I und -- 9 DR. ERNEST CUTZ: So -- so this -- 10 MS. JENNIFER MCALEER: -- I understand 11 that interpretation. 12 DR. ERNEST CUTZ: Yeah. 13 MS. JENNIFER MCALEER: But you're not 14 aware of any other case? 15 DR. ERNEST CUTZ: Not in -- not in this 16 time period, no. 17 MS. JENNIFER MCALEER: Okay. Are you 18 aware of any after this time period? 19 DR. ERNEST CUTZ: No, I'm -- I'm aware of 20 some prior to this. 21 MS. JENNIFER MCALEER: All right. What - 22 - what are those? 23 DR. ERNEST CUTZ: I -- I had a 24 conversation with one (1) of the surgeons or the sur -- 25 surgeons was complaining to me or telling me that he had

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1 a case where a mistake has been made in -- in reading the 2 biopsy for ganglion cells, which is again intra-operative 3 biopsy in -- in, you know, newborn infants, practically, 4 to determine whether -- whether the intestine has a -- 5 has a functionality or not. 6 MS. JENNIFER MCALEER: Do you remember 7 the name of that surgeon? 8 DR. ERNEST CUTZ: Yes, it was Dr. Barry 9 Shandling. 10 MS. JENNIFER MCALEER: And what was the 11 nature of the concern that was raised with you? 12 DR. ERNEST CUTZ: Well, what -- what Dr. 13 Shandling told me is that the frozen section Dr. Smith 14 was looking at, he -- he reported as -- as ganglion cells 15 were absent; there was no ganglion cells. In other 16 words, this was a -- a lesion or tissue and subsequently, 17 he -- he performed a colostomy. He -- he performed -- 18 formed the operation. 19 And then after the -- you know, as a 20 followup, the biopsy, which was reported as negative, 21 then suddenly it had got ganglion cells. In other -- 22 MS. JENNIFER MCALEER: As I understand 23 it -- 24 DR. ERNEST CUTZ: -- in other words, if 25 that was the information then he wouldn't have made -- he

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1 wouldn't perform the operation. 2 MS. JENNIFER MCALEER: All right. So as 3 I understand it, Dr. Cutz, it is normal to have the 4 ganglion cells? 5 DR. ERNEST CUTZ: That's right. 6 MS. JENNIFER MCALEER: And a 7 determination was made that they were not present? 8 DR. ERNEST CUTZ: Right. 9 MS. JENNIFER MCALEER: And as a result, 10 there was an operation. 11 DR. ERNEST CUTZ: Right. 12 MS. JENNIFER MCALEER: And then testing, 13 after the fact, determined that they, in fact, had been 14 present all along. 15 DR. ERNEST CUTZ: Right. 16 MS. JENNIFER MCALEER: Is that correct? 17 DR. ERNEST CUTZ: That's correct, yes. 18 MS. JENNIFER MCALEER: So we're looking 19 at -- it was a case of unnecessary surgery? 20 DR. ERNEST CUTZ: Right. 21 MS. JENNIFER MCALEER: And that's the way 22 it was reported to you? 23 DR. ERNEST CUTZ: Yes. I think Dr. -- 24 Dr. Shandling was very concerned because he has to 25 explain this to the parents.

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1 2 MS. JENNIFER MCALEER: And did you ever 3 have any personal discussions with Dr. Smith about that 4 case? 5 DR. ERNEST CUTZ: No, this, I was in the 6 -- this is -- I heard from Dr. Shandling. 7 MS. JENNIFER MCALEER: Okay. All right. 8 So continuing with the letter then that we were looking 9 at at Tab 71, next paragraph: 10 "Neither Paul nor I could see any 11 improvement in the reporting time or 12 the accuracy of the reports over the 13 past three (3) years. Therefore, I 14 regret to inform you that I must 15 curtail you responsibilities in 16 surgical pathology until you prove to 17 me evidence of successful completion of 18 continuing education courses that will 19 improve your skills in surgical 20 pathology." 21 So now this is 1997. The other letter 22 that we had looked at earlier is from 1995. Do you know, 23 either of you, whether or not as a result of this letter 24 -- which we don't know if it was sent or not -- whether 25 Dr. Smith, in fact, took further CME training as

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1 suggested by Dr. Becker in this letter? Dr. Taylor, do 2 you know? 3 DR. GLENN TAYLOR: I don't -- I don't 4 know, no. 5 DR. ERNEST CUTZ: I don't know, eith -- 6 MS. JENNIFER MCALEER: Dr. Cutz, do you 7 know? 8 DR. ERNEST CUTZ: I don't know, either, 9 no. 10 MS. JENNIFER MCALEER: Okay. And what is 11 the significance of that to suggest that one's work in a 12 particular field be curtailed? Would -- would -- how 13 would you view that, Dr. Cutz, if you were to receive 14 this letter? 15 DR. ERNEST CUTZ: Well, that's removing 16 privileges. Like, you know, they are -- as a 17 professional you -- you have authorization to do certain 18 procedures or -- I think, then if -- if you are deemed 19 not to be qualified or not to be performing, then your 20 privileges are removed. 21 MS. JENNIFER MCALEER: But are we talking 22 about a -- a removal of privileges as such as opposed to 23 a redirection of one's work in another area? I just want 24 to make sure that we don't confuse two (2) different 25 concepts.

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1 DR. ERNEST CUTZ: Well, I -- yes. What - 2 - what I -- as I read it this -- that would mean that Dr. 3 Smith would not be allowed to do surgical pathology any 4 longer, but at the same time, he may continue in autopsy 5 pathology. 6 MS. JENNIFER MCALEER: Okay. And, Dr. 7 Taylor, does that -- in your understanding, does that 8 affect one's privileges per se at a hospital? 9 DR. GLENN TAYLOR: No, I don't think so. 10 I think the distribution of responsibilities within a 11 division of pathology is -- is, in part, a result of a 12 discussion between the division head and the individual 13 pathologist. 14 And I think there -- there should be an 15 acknowledgement of the -- of the strengths and the 16 weaknesses of -- of the person and try to direct the 17 person to -- towards their strengths. 18 So I'm not sure I would ever, kind of, 19 write a letter like this myself. What I might do is 20 discuss the situation with the pathologist and get an 21 idea of what that pathologist was interested in. 22 And given -- given the abilities of the 23 department to try to accommodate that, direct -- make 24 sure that I could direct the person towards those 25 strengths that they have, and downplay the weaknesses.

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1 COMMISSIONER STEPHEN GOUDGE: There's 2 only one (1) other thing though, and that's forensic 3 pathology? 4 DR. GLENN TAYLOR: Well, there's surgical 5 pathology, Commissioner, and there's surgical pathology. 6 There's very many sub-specialties within that particular 7 discipline. 8 COMMISSIONER STEPHEN GOUDGE: I see. 9 DR. GLENN TAYLOR: So, for instance, Dr. 10 Smith was actually involved with kidney biopsies, which 11 is a very busy service, and he was, except for some 12 issues with turn around times, was functioning reasonably 13 well in -- in that particular sub-speciality role. 14 And there are other sub-specialties which 15 could be picked up. The issues that have come up; 16 neoplastic pediatric surgical pathology and 17 Hirschsprung's disease are -- they're kind of disciplines 18 -- sub-disciplines in of themselves. 19 And with respect to Hirschsprung's 20 disease, it's probably -- mis-diagnosis in Hirschsprung's 21 disease either for or against, is probably the most 22 common reason for civil litigation related to pediatric 23 surgical pathologists. 24 It's a very difficult problem, and it 25 causes all kinds of trouble to all kinds of pathologists.

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1 COMMISSIONER STEPHEN GOUDGE: What's the 2 name of the disease? 3 DR. GLENN TAYLOR: It's Hirschsprung's 4 disease is -- is the acronym given to the disease process 5 where we're testing -- looking for ganglion cells in the 6 bowl. 7 COMMISSIONER STEPHEN GOUDGE: I see. 8 9 CONTINUED BY MS. JENNIFER MCALEER: 10 MS. JENNIFER MCALEER: The situation that 11 Dr. Cutz just described? 12 DR. GLENN TAYLOR: Correct. 13 MS. JENNIFER MCALEER: Okay. 14 COMMISSIONER STEPHEN GOUDGE: Can I 15 just -- 16 MS. JENNIFER MCALEER: Sorry, go ahead, 17 Dr. -- Mr. Commissioner. 18 COMMISSIONER STEPHEN GOUDGE: Ms. 19 McAleer. The drafting or the letter as drafted, Dr. 20 Taylor, uses a blunter instrument then you would then? 21 DR. GLENN TAYLOR: It does, yes. 22 COMMISSIONER STEPHEN GOUDGE: What 23 proportion of Dr. Smith's time would each of you estimate 24 he was spending then, in surgical pathology as opposed to 25 pediatric forensic pathology? Was it a third, or was it

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1 half? 2 DR. GLENN TAYLOR: Yeah, as a rough 3 guess, I would say probably one-third (1/3) surgical 4 pathology, two-thirds (2/3s) autopsy pathology. But I'd 5 have to check the -- the rotations to see. 6 MS. JENNIFER MCALEER: Mr. Commissioner, 7 if you look in front of you, you should have a binder 8 called Senior Pathology Rotation Schedule? 9 COMMISSIONER STEPHEN GOUDGE: Yes, I do. 10 11 CONTINUED BY MS. JENNIFER MCALEER: 12 MS. JENNIFER MCALEER: And in that 13 binder, if you look at Tab 11, for example, which is 14 PFP117047. Dr. Taylor, this is a rot -- a rotation 15 schedule for the division? 16 DR. GLENN TAYLOR: Yes. 17 MS. JENNIFER MCALEER: And if we look at 18 the top, across from date, we have surgical autopsy, 19 medicolegal and then, weekend. And if we go down the 20 columns week by week, we can see which particular 21 pathologist has been assigned to a particular category of 22 work? 23 DR. GLENN TAYLOR: Yes. 24 COMMISSIONER STEPHEN GOUDGE: Is autopsy 25 the hospital autopsy practice?

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1 DR. GLENN TAYLOR: Those are hosp -- yes, 2 hospital parental -- 3 COMMISSIONER STEPHEN GOUDGE: Non-warrant 4 autopsies? 5 DR. GLENN TAYLOR: -- parental consent to 6 the autopsies, yes. 7 COMMISSIONER STEPHEN GOUDGE: And is the 8 implication of this schedule in 1997, Dr. Taylor, that 9 each of these blocks of work occupied about a third of 10 the efforts of the department? 11 DR. GLENN TAYLOR: Hmm... 12 COMMISSIONER STEPHEN GOUDGE: Or is 13 that -- 14 DR. GLENN TAYLOR: In general -- 15 COMMISSIONER STEPHEN GOUDGE: I mean, it 16 looks neatly divided into thirds; I'm sure it's not. 17 DR. GLENN TAYLOR: In general terms, but 18 there are out -- there are additional things going on in 19 the background; additional responsibilities that aren't 20 included here, but basically about a third, yes. Each 21 one (1) of those is about a third. 22 COMMISSIONER STEPHEN GOUDGE: Okay. So, 23 can I translate this to Dr. -- 24 MS. JENNIFER MCALEER: That -- 25 COMMISSIONER STEPHEN GOUDGE: -- to Dr.

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1 Smith in 1997? I take it your rough estimate might be he 2 was spending a third of his time in the surgical rotation 3 or the surgical pathology work? 4 DR. GLENN TAYLOR: Yes. 5 COMMISSIONER STEPHEN GOUDGE: And two- 6 thirds (2/3s) doing either hospital autopsies or 7 medicolegal autopsies? 8 DR. GLENN TAYLOR: Yes, Commissioner. 9 COMMISSIONER STEPHEN GOUDGE: Okay. The 10 amount of the grant that the Coroner's Office provided to 11 the hospital, the two hundred thousand dollars 12 ($200,000), a portion of it was designated as part of the 13 Director's salary? 14 DR. GLENN TAYLOR: Yes. 15 COMMISSIONER STEPHEN GOUDGE: And I 16 recall a number from the one (1) sheet, we saw a hundred 17 and twenty-five thousand dollars ($125,000). 18 DR. GLENN TAYLOR: A hundred and twenty- 19 five thousand (125,000) is what I remember as well, yes. 20 COMMISSIONER STEPHEN GOUDGE: What was 21 that to approximate in terms of his time? 22 I mean, there must have been a notional 23 approximation in somebody's head about how much time the 24 Director was to spend doing medicolegal. 25 DR. GLENN TAYLOR: Hmm.

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1 COMMISSIONER STEPHEN GOUDGE: And 2 administration. 3 DR. GLENN TAYLOR: So I guess -- I'm 4 just trying to factor in that other people were doing 5 medicolegal cases as -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. GLENN TAYLOR: -- well. 8 COMMISSIONER STEPHEN GOUDGE: I mean, one 9 (1) way of -- 10 DR. GLENN TAYLOR: So -- 11 COMMISSIONER STEPHEN GOUDGE: -- doing it 12 would be to estimate what his total income was for the 13 year -- 14 DR. GLENN TAYLOR: Yes. 15 COMMISSIONER STEPHEN GOUDGE: -- and put 16 that as a denominator over the numerator of a hundred and 17 twenty-five thousand (125,000). 18 DR. GLENN TAYLOR: Correct. So I'm not - 19 - I'm not sure exactly how that particular number was 20 arrived -- or derived. 21 If it was to pay for the Director, which 22 this -- I think the initial grant preceded a director 23 being appointed, so therefore, I think it might reflect 24 one (1) FTE, one (1) full-time equivalent person, doing - 25 - doing forensic cases. But there were three (3) or four

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1 (4) people doing the medicolegal cases so -- 2 COMMISSIONER STEPHEN GOUDGE: I see. 3 DR. GLENN TAYLOR: -- how that 4 translate -- 5 COMMISSIONER STEPHEN GOUDGE: I see. 6 DR. GLENN TAYLOR: -- how that 7 translates -- 8 COMMISSIONER STEPHEN GOUDGE: So -- 9 DR. GLENN TAYLOR: -- to an individual-- 10 COMMISSIONER STEPHEN GOUDGE: I see. 11 DR. GLENN TAYLOR: -- I'm not exactly 12 sure. 13 COMMISSIONER STEPHEN GOUDGE: So that the 14 sheet we saw, the 1991-1992 reconciliation, might have 15 been a surrogate for, Here's what we are going to pay the 16 unit to do medicolegal autopsies -- 17 DR. GLENN TAYLOR: Correct. 18 COMMISSIONER STEPHEN GOUDGE: -- as 19 opposed to, Here is how much we are going to pay the 20 Director? 21 DR. GLENN TAYLOR: Correct. 22 COMMISSIONER STEPHEN GOUDGE: Okay. 23 24 CONTINUED BY MS. JENNIFER MCALEER: 25 MS. JENNIFER MCALEER: Do you --

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1 COMMISSIONER STEPHEN GOUDGE: So that -- 2 I mean, could you give me -- I suppose you don't then 3 know, you cannot tell from the budget figure what 4 anybody's estimation was of the amount of time the 5 Director would spend on medicolegal? 6 DR. GLENN TAYLOR: No, I'd have to think 7 about that one, sir. 8 COMMISSIONER STEPHEN GOUDGE: Yeah, okay. 9 Thanks, Ms. McAleer. 10 11 CONTINUED BY MS. JENNIFER MCALEER: 12 MS. JENNIFER MCALEER: Just two (2) 13 points of clarification, Mr. Commissioner. 14 If we look at the -- the schedule, for 15 example, that's at Tab 11. I know Dr. Taylor has 16 indicated that it's approximately a third of the time 17 that Dr. Smith would have been engaged in surgical 18 pathology work. 19 But if you actually go through week by 20 week and add it up, you'll see that Dr. Smith in 1997, 21 for example, was -- spent nine (9) weeks on surgical. So 22 nine (9) of fifty-two (52) wouldn't be a third of his 23 time on surgical work. 24 DR. GLENN TAYLOR: Right. 25 MS. JENNIFER MCALEER: It's also my

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1 understanding, Dr. Taylor, that even if one is on, let's 2 say surgical for that week, that doesn't necessarily mean 3 that Dr. Smith wouldn't be doing some medicolegal work as 4 well that week, perhaps, or on follow-up on past cases, 5 writing reports. 6 DR. GLENN TAYLOR: That's possible, yes. 7 Usually on surgicals at Sick Kids, we're pretty busy and 8 our practice is kind of confined to that particular area 9 during that week. 10 There may be opportunities to complete 11 reports. There certainly would be good opportunity to do 12 an autopsy, for instance, during that week, but there may 13 be times when reports could be worked on but it's pretty 14 busy. 15 MS. JENNIFER MCALEER: All right. 16 COMMISSIONER STEPHEN GOUDGE: Is that 17 schedule a way of getting a rough cut at how much time a 18 pathologist was spending in each of the three (3) work 19 areas? 20 DR. GLENN TAYLOR: Yes, I think so. The 21 autopsy service -- 22 COMMISSIONER STEPHEN GOUDGE: It won't be 23 accurate because in -- 24 DR. GLENN TAYLOR: No. 25 COMMISSIONER STEPHEN GOUDGE: -- each

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1 particular week, as you just said, you might do something 2 in one (1) of the other two (2) areas. 3 DR. GLENN TAYLOR: That's correct. With 4 the autopsy rotation, there may be weeks in which there 5 are a few cases, and there may be weeks in which there 6 are very many cases so opportunities -- 7 COMMISSIONER STEPHEN GOUDGE: You might 8 end up doing some surgical work during your autopsy 9 weeks? 10 DR. GLENN TAYLOR: Completing cases and 11 so on, yes. 12 COMMISSIONER STEPHEN GOUDGE: Okay, 13 thanks. 14 MS. JENNIFER MCALEER: The other source 15 of information, Mr. Commissioner, is that at the back of 16 the HSC Institutional Report, Appendix B to the 17 Institutional Report, HSC has actually provided us with a 18 year-by-year pathologist -- by pathologist breakdown. 19 COMMISSIONER STEPHEN GOUDGE: Of...? 20 MS. JENNIFER MCALEER: Of the work that 21 each pathologist has done in the areas of hospital 22 autopsy, medicolegal autopsy, -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 MS. JENNIFER MCALEER: -- surgical 25 autopsy. So you can actually see the number of cases --

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 MS. JENNIFER MCALEER: -- that each 3 pathologist completed in a given year. 4 COMMISSIONER STEPHEN GOUDGE: Okay. 5 Thanks. That's helpful. 6 7 CONTINUED BY MS. JENNIFER MCALEER: 8 MS. JENNIFER MCALEER: So turning back to 9 Tab 71, then, the April 18th, 1997 letter. And it 10 continues: 11 "In addition to the restriction on 12 surgical pathology, you will not be 13 doing surgical pathology on a regular 14 rotation, and accordingly, the salary 15 from the division of pathology will be 16 reduced by twenty thousand (20,000) in 17 1997." 18 Now, Dr. Taylor, from your background 19 review, do you -- do you know if that actually happened? 20 Do you know if Dr. Smith's salary was, in fact, reduced 21 by twenty thousand (20,000)? 22 DR. GLENN TAYLOR: I don't think it 23 happened. 24 MS. JENNIFER MCALEER: And you're 25 basing --

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1 COMMISSIONER STEPHEN GOUDGE: Why would 2 that be? I mean, I assumed that if he was not doing 3 surgical, even using the blunt instrument that you say is 4 a little too blunt, he would be spending his time doing 5 other stuff? Either the hospital autopsies or the 6 forensic autopsies. 7 DR. GLENN TAYLOR: I -- 8 COMMISSIONER STEPHEN GOUDGE: Why do they 9 dock his pay? 10 DR. GLENN TAYLOR: I can't speak for Dr. 11 Becker in this regard, sorry. 12 COMMISSIONER STEPHEN GOUDGE: Okay. 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: And, Dr. Cutz, I 16 take it, you don't have any knowledge as to whether or 17 not -- or I shouldn't say any knowledge -- contrary to 18 what Dr. Taylor's inquiries have been that -- that the 19 salary was, in fact, not reduced? 20 DR. ERNEST CUTZ: I don't -- I don't 21 know. I don't know whether the salary was reduced or 22 not? 23 MS. JENNIFER MCALEER: Okay. 24 COMMISSIONER STEPHEN GOUDGE: You get one 25 (1) salary? You don't get a salary with different

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1 components depending on whether you are doing medicolegal 2 and -- 3 DR. GLENN TAYLOR: You -- you get one (1) 4 salary, yes. 5 6 CONTINUED BY MS. JENNIFER MCALEER: 7 MS. JENNIFER MCALEER: And then if we 8 turn back again to the rotation schedule that we were 9 looking at in that separate binder at Tab 11, PFP117047. 10 This letter or draft letter is dated April 18th, 1997. 11 COMMISSIONER STEPHEN GOUDGE: Sorry, what 12 tab is this? 13 MS. JENNIFER MCALEER: I'm sorry, it's 14 Tab 11 of the binder of surgical pathology schedules -- 15 sorry of senior pathology rotation schedules. 16 COMMISSIONER STEPHEN GOUDGE: Yes. 17 18 CONTINUED BY MS. JENNIFER MCALEER: 19 MS. JENNIFER MCALEER: Tab 11. So if we 20 look in the column called surgical, and we skim down, we 21 see Dr. Smith, for example, on rotation April 21st to 22 27th. 23 Do you see that, Dr. Taylor? It's -- 24 DR. GLENN TAYLOR: Yes. 25 MS. JENNIFER MCALEER: -- week nineteen

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1 (19), we see Dr. Smith. 2 DR. GLENN TAYLOR: Yes. 3 MS. JENNIFER MCALEER: And then we don't 4 see him again until September 29th. Whereas previously 5 he seemed to have been on the rotation a little bit more 6 frequently than that. 7 Would you agree with me? 8 DR. GLENN TAYLOR: Sorry, what was the 9 date? 10 MS. JENNIFER MCALEER: Sorry, so from row 11 19 -- 12 DR. GLENN TAYLOR: September -- 13 COMMISSIONER STEPHEN GOUDGE: Line 44 on 14 the second page. 15 MS. JENNIFER MCALEER: -- down to 44 - 16 - sorry 42. 17 DR. GLENN TAYLOR: 42, yes. 18 MS. JENNIFER MCALEER: 42. 19 COMMISSIONER STEPHEN GOUDGE: 42. And he 20 is on again at 44. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: Right. So would 24 you agree that's a little less -- there's a bit of a gap 25 there. He's -- he's not doing surgical work for a period

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1 of time that's longer than had been the practice? 2 DR. GLENN TAYLOR: Yes, I notice a gap. 3 MS. JENNIFER MCALEER: And do you know 4 whether or not he was, in fact, taken off surgicals? 5 DR. GLENN TAYLOR: I don't know the 6 reason for the gap. 7 MS. JENNIFER MCALEER: Okay. Dr. Cutz, 8 do you know? 9 DR. ERNEST CUTZ: No, I -- you know, I 10 guess, if you're not on it that means, you know, you've 11 been taken off. But, you know, whether -- because there 12 was arrangement or whether they discussed it, I don't -- 13 don't -- I have no knowledge. 14 MS. JENNIFER MCALEER: All right. So if 15 we could turn to Tab 73 in Volume I. 16 Dr. Taylor, have you 17 had the opportunity to review this document? 18 DR. GLENN TAYLOR: I'm not sure I've seen 19 this particular document. 20 MS. JENNIFER MCALEER: And do you know 21 what the issue is that's being identified in this 22 document? 23 DR. GLENN TAYLOR: Sorry, we're at -- I 24 want to check to make sure -- 25 MS. JENNIFER MCALEER: We're at Tab --

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1 yeah. 2 DR. GLENN TAYLOR: -- I'm at the right 3 document. The 73, it's a letter from -- 4 MS. JENNIFER MCALEER: It is -- 5 DR. GLENN TAYLOR: -- Dr. Becker to Dr. 6 Smith? 7 MS. JENNIFER MCALEER: It is, but, Dr. 8 Taylor, I think we can actually skip this document. 9 We'll -- we'll move on. 10 Tab 74, please. It's PFP137811. 11 And this document you've reviewed before? 12 DR. GLENN TAYLOR: Yes, I have. 13 MS. JENNIFER MCALEER: Okay. And this is 14 with respect to -- it says, "Re. Quality Assurance Issue" 15 and it's a patient that suffers from Wilms' Tumour? 16 DR. GLENN TAYLOR: Yes. 17 MS. JENNIFER MCALEER: What is -- what is 18 Wilms' Tumour. 19 DR. GLENN TAYLOR: Wilms' Tumour is a 20 malignant tumour of the kidney that affects children. 21 MS. JENNIFER MCALEER: Okay. And did -- 22 were you involved in this case, at the time, Dr. Taylor? 23 DR. GLENN TAYLOR: Yes, I was. 24 MS. JENNIFER MCALEER: All right. And 25 what was your involvement?

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1 DR. GLENN TAYLOR: I can't remember the 2 exact sequence of events, but I was asked to review the 3 case because there was an issue of interpretation of the 4 slides that came up, I think about a year later when the 5 child represented with a recurrence of the tumour. 6 So I was asked to -- the original slides 7 were reviewed at that time by Dr. Thorner and he asked me 8 to have a look at those slides, as well. 9 MS. JENNIFER MCALEER: All right. So 10 when the patient was first examined or when the 11 pathologist was first involved, was the pathologist Dr. 12 Smith, or was it Dr. Thorner, or somebody else? 13 DR. GLENN TAYLOR: It was Dr. Smith. 14 MS. JENNIFER MCALEER: Okay. And what 15 diagnosis had Dr. Smith reached, with respect to this 16 patient? 17 DR. GLENN TAYLOR: Dr. Smith diagnosed 18 Wilms' Tumour. 19 MS. JENNIFER MCALEER: And when you were 20 asked to get involved, what was your diagnosis? 21 DR. GLENN TAYLOR: The diagnosis was 22 still Wilms' Tumour. The issue was interpretation of a 23 couple of areas that might or might not represent an 24 invasion of the tumour beyond the kidney, and this makes 25 it -- this -- if there was an invasion of the tumour

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1 beyond the kidney, then that would have a caused a 2 different treatment protocol for the child. 3 MS. JENNIFER MCALEER: So when Dr. Smith 4 did his diagnosis, did he find that there was beyond the 5 kidney, it had spread beyond the kidney? 6 DR. GLENN TAYLOR: He did not make that 7 diagnosis. 8 MS. JENNIFER MCALEER: And when you 9 reviewed the slides did you make that diagnosis? 10 DR. GLENN TAYLOR: Yes, I did. 11 MS. JENNIFER MCALEER: And what would 12 have been the difference in treatment? 13 DR. GLENN TAYLOR: I -- I can't remember 14 the protocols for that period, but it would have at least 15 included a different or additional chemotherapy and 16 possibly radiation therapy. 17 MS. JENNIFER MCALEER: And -- 18 COMMISSIONER STEPHEN GOUDGE: It would 19 have been a much more aggressive treatment. 20 DR. GLENN TAYLOR: It would have more 21 aggressive treatment, yes. 22 23 CONTINUED BY MS. JENNIFER MCALEER: 24 MS. JENNIFER MCALEER: And did I 25 understand to indicate that the error actually didn't

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1 surface until a year later? 2 DR. GLENN TAYLOR: Correct. 3 MS. JENNIFER MCALEER: So, did this error 4 have an impact on patient care, would that be fair to 5 say, Dr. Taylor? 6 DR. GLENN TAYLOR: Yes, it did. 7 COMMISSIONER STEPHEN GOUDGE: What was 8 the outcome? 9 DR. GLENN TAYLOR: I don't know what the 10 outcome is, sir. 11 12 CONTINUED BY MS. JENNIFER MCALEER: 13 MS. JENNIFER MCALEER: Now, overall, Dr. 14 Taylor, having reviewed the diagnostic discrepancies as 15 they've -- as they've been termed, the cases that you 16 were involved in and -- and the cases that Dr. Cutz was 17 involved in, based on your review of these documents, if 18 you had been head of the department in 1997 would you 19 have had it -- any concerns regarding Dr. Smith's 20 competency in the area of surgical pathology? 21 DR. GLENN TAYLOR: I would have been 22 concerned about some of the cases, for sure; that missing 23 the invasion related to the Wilms' tumour is a serious 24 omission. And I would have been concerned about the 25 frozen section issue because there's ways of handling

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1 frozen sections that aren't -- that the pathologist is 2 not totally confident about that appear not to have been 3 done in -- in that particular case. 4 MS. JENNIFER MCALEER: And you're 5 referring to number 4 on Dr. Thorner's memo. 6 DR. GLENN TAYLOR: Correct. 7 MS. JENNIFER MCALEER: Okay. And would - 8 - if you'd -- you'd -- if you agree that you had concerns 9 about surgical pathology, would that have caused you any 10 concern with respect to Dr. Smith's competency with 11 respect to doing hospital autopsies or medicolegal 12 autopsies? 13 DR. GLENN TAYLOR: Probably not. Again, 14 they're -- they're different disciplines, in a sense, and 15 the type of mistakes that are brought out by these 16 documents are mistakes that could be made fairly easily 17 by somebody who's doing pediatric surgical pathology, but 18 not doing surgical pediatric oncological or cancer 19 pathology. 20 So, for instance, if somebody has an area 21 of interest in gastrointestinal pathology or liver 22 pathology, they may not be up to date on all of the 23 pathology rules and finer points that relate to the 24 cancer type of pathology in -- in children. 25 There may be no relation of the person's

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1 ability in one (1) sub-specialty area to another sub- 2 specialty area. And as far as surgical pathology goes 3 and an autopsy pathology goes, they're all -- they're 4 also -- there's a bit of a divide there. 5 I mean, there are basics in microscopic 6 interpretation of tissues and so on, but the finer 7 points, which are actually what matter most often in 8 surgical pathology, may not be in the -- in say a person 9 who does autopsies on a regular basis, in that person's 10 knowledge base or experience, and vice-versa. 11 COMMISSIONER STEPHEN GOUDGE: I assume, 12 Dr. Taylor, perhaps wrongly, in fact I take it wrongly, 13 from what you've just said, that within the realm of 14 surgical pathology, all the pathologists assigned would 15 do the full range of surgical pathology. 16 DR. GLENN TAYLOR: That's not the case, 17 sir. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 DR. GLENN TAYLOR: Even -- 20 COMMISSIONER STEPHEN GOUDGE: What 21 happens if you're on the roster for a week and, you know, 22 it's an oncology case and your interest is, like Dr. 23 Cutz, gastroenterology? 24 DR. GLENN TAYLOR: So Dr. Cutz is on the 25 roster for a weekend and his interest is in

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1 gastrointestinal pathology -- 2 COMMISSIONER STEPHEN GOUDGE: All right. 3 DR. GLENN TAYLOR: -- and he handles 4 those cases because he has a basic knowledge of pediatric 5 surgical pathology and he is aware of kind of how we sort 6 of rate our confidence in the cases. 7 So, for instance -- and I'm sorry, I'm 8 speaking for Dr. Cutz but I -- 9 COMMISSIONER STEPHEN GOUDGE: Yeah, and I 10 did not mean -- I did not mean to use you Dr. Cutz 11 individually. 12 DR. GLENN TAYLOR: I respect -- 13 DR. ERNEST CUTZ: The last weekend or -- 14 DR. GLENN TAYLOR: The last weekend, yes. 15 So I do not want to take him off weekends okay, because 16 that means I have to cover more weekends -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 Right. 19 DR. GLENN TAYLOR: -- and I don't want to 20 do that. But the usual approach is lesional tissue 21 present, defer till Monday or whenever the permanent 22 sections come out. And that is a legitimate way to 23 handle -- 24 COMMISSIONER STEPHEN GOUDGE: So you 25 defer; the --

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1 DR. GLENN TAYLOR: -- many of these 2 cases. 3 COMMISSIONER STEPHEN GOUDGE: -- 4 permanent sections come out and then -- 5 DR. GLENN TAYLOR: Yeah. 6 COMMISSIONER STEPHEN GOUDGE: -- one of 7 your colleagues who is perhaps the most specialized in 8 pediatric oncology would read that slide? 9 DR. GLENN TAYLOR: That's correct. And 10 usually the clinical circumstances for -- in those 11 situations are the clinicians have a pretty good idea 12 that it's going to be a malignancy. And if you can -- if 13 the pathologist can say that it is lesional tissue -- 14 COMMISSIONER STEPHEN GOUDGE: They will 15 probably go ahead on the basis -- 16 DR. GLENN TAYLOR: -- they'll probably 17 go ahead -- 18 COMMISSIONER STEPHEN GOUDGE: -- that it 19 will be confirmed as malignant. 20 DR. GLENN TAYLOR: -- and then we'll work 21 it out -- we'll work it out later. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. GLENN TAYLOR: Okay. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 That is helpful. Okay.

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1 2 CONTINUED BY MS. JENNIFER MCALEER: 3 MS. JENNIFER MCALEER: So is it fair to 4 say, though, Dr. Taylor, that at least with respect to 5 one (1) of the issues that are identified -- I think 6 you've indicated that it could have been a matter of more 7 diligence with respect to literature review? 8 DR. GLENN TAYLOR: Correct. 9 MS. JENNIFER MCALEER: Now would that not 10 equally apply to one's work in the field of medicolegal-- 11 DR. GLENN TAYLOR: No, not necessarily. 12 MS. JENNIFER MCALEER: -- autopsies? 13 DR. GLENN TAYLOR: Again, it's a matter 14 of interest and what stimulates the person. So I don't 15 necessarily do a in-depth reading on say kidney biopsies, 16 but I'll do some in-depth reading on certain 17 cardiovascular problems that children get. 18 Similarly, if somebody has an interest in 19 forensic pathology they may do a lot of reading in that 20 area and find perhaps that the surgical pathology is kind 21 of a burden that they have to bear and they just want to 22 deal with it as best as they can but not spend a lot of 23 time reading about it. 24 MS. JENNIFER MCALEER: And I thought you 25 had also indicated that with respect to case number 4 in

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1 Dr. Thorner's memo, that potentially one of the issues 2 there was how one expresses a degree of certainty, with 3 respect to one's diagnosis. 4 DR. GLENN TAYLOR: That is one (1) of the 5 issues, yes. 6 MS. JENNIFER MCALEER: And would that not 7 equally apply to one's work in the field of medicolegal 8 autopsy? 9 DR. GLENN TAYLOR: Yeah, there's a bit -- 10 bit of a tighter bond there, I think. Yes. 11 COMMISSIONER STEPHEN GOUDGE: What do you 12 mean by that? 13 DR. GLENN TAYLOR: Well, I guess it's a 14 measure perhaps of caution. For instance, if somebody -- 15 and I -- again, I'm kind of, in a sense, speculating, but 16 if somebody is cautious dealing with surgical material 17 that they may or may not have a good feeling or 18 understanding for, then they're likely to be cautious in 19 other circumstances that they don't have a good feeling 20 for or understanding for. 21 And vice versa. If they're not cautious 22 then perhaps they may, in that other situation, be less 23 cautious than somebody else. 24 COMMISSIONER STEPHEN GOUDGE: Thank you. 25

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1 CONTINUED BY MS. JENNIFER MCALEER: 2 MS. JENNIFER MCALEER: Generally 3 speaking, what was Dr. Smith's workload like compared to 4 the other members of the Pathology Division? 5 Dr. Cutz, what was your impression? 6 DR. ERNEST CUTZ: I think we tried to 7 sort of balance, as far as time commitment, of the 8 various staff and their commitment and interest so that 9 it's equally distributed between the staff. But usually 10 we have these three (3) big responsibilities which also 11 relates to the University; it's service, research and 12 teaching. And various members would have different 13 involvement in these activities yet these are our -- our 14 -- you know, these are our obligations. 15 And so to make time available for these 16 activities, one has to balance the service with these 17 other activities. And so people who are more service- 18 oriented, they would tend to do more service and people 19 who are more say, academic and research, they would do 20 less. 21 And so the schedule was, you know, made up 22 to accommodate all these different interests and so there 23 were certain pathologists doing more autopsies or more 24 surgicals than others. 25 MS. JENNIFER MCALEER: Did you have a

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1 perception though, Dr. Cutz, that Dr. Smith was 2 overworked, underworked? How did he compare to you and 3 your colleagues? 4 DR. ERNEST CUTZ: From the schedule, it 5 didn't look it was any different from -- from anybody 6 else because it was sort of evenly distributed. But what 7 one doesn't know, as Dr. Taylor mentioned, is as far as 8 number of cases, it's out of our control, so you may have 9 a busy week or you may have a light week. And so that 10 the cases he handled, I would have no idea how many cases 11 he -- he would have had at one (1) particular period of 12 time. 13 MS. JENNIFER MCALEER: All right. Dr. 14 Taylor, apart from what we can tell from the schedule, 15 what was your perception as to how busy Dr. Smith was? 16 DR. GLENN TAYLOR: I think he was fairly 17 busy. He had a lot of autopsy cases. He was handling 18 many of the -- up to half of the forensic coroner's cases 19 and they are very time consuming. He was still 20 maintaining a surgical res -- set of surgical 21 responsibilities for -- for the -- for the years that I 22 was there, except for the -- for that one (1) kind of 23 dropout that you mentioned, so I think he was working 24 pretty hard. 25 MS. JENNIFER MCALEER: Okay. Did he

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1 appear to have any problems with respect to organisation? 2 DR. GLENN TAYLOR: Organisation of what? 3 MS. JENNIFER MCALEER: Well, let's not -- 4 not his time, but organisation with respect to his 5 office, for example? 6 DR. GLENN TAYLOR: Oh, his office was a 7 disaster, yes. 8 MS. JENNIFER MCALEER: Okay. Dr. Cutz, 9 would you agree with that? 10 DR. ERNEST CUTZ: Yes. 11 MS. JENNIFER MCALEER: And we have some 12 photos. If you look at Tab 71 of binder 1 -- actually, 13 it's binder 2, sorry, Tab 71. 14 15 (BRIEF PAUSE) 16 17 MS. JENNIFER MCALEER: PFP137518. Tab 71 18 of Volume II, Dr. Cutz. 19 DR. ERNEST CUTZ: Yes. 20 MS. JENNIFER MCALEER: All right. Dr. 21 Taylor, is that an accurate reflection of Dr. Smith's 22 office as it was generally? 23 DR. GLENN TAYLOR: As it was most of the 24 time? 25 MS. JENNIFER MCALEER: As it -- yeah, as

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1 it was most of the time. 2 DR. GLENN TAYLOR: Yes, it is. 3 MS. JENNIFER MCALEER: Okay. And Dr. 4 Cutz, would you agree with that? 5 DR. ERNEST CUTZ: Yes. 6 MS. JENNIFER MCALEER: And Dr. Taylor, as 7 head of the division right now, would you have any 8 concerns if one of your pathologists had an office that 9 looked like this? 10 DR. GLENN TAYLOR: Well, I'd hope he kept 11 -- kept the door closed, at least. 12 MS. JENNIFER MCALEER: Any concerns 13 beyond appearance? 14 DR. GLENN TAYLOR: Well, if the person 15 can find stuff, knows where it is, then I'm not going to 16 make too much of an issue of the appearance. But my 17 concern would be losing materials or not knowing where 18 reports are or slides in the office, which is a serious 19 concern. 20 And if -- if that was the case, then I 21 would definitely ask the person to organise the office 22 and -- and get those things in a -- in some kind of shape 23 that -- that they can be accessed. 24 MS. JENNIFER MCALEER: Is this unusual? 25 Do most pathologist's office look like this within the

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1 department? 2 DR. GLENN TAYLOR: It's a sliding scale, 3 but this is at one far end of the scale. 4 MS. JENNIFER MCALEER: Which end? 5 DR. GLENN TAYLOR: The -- the messy end. 6 MS. JENNIFER MCALEER: Now, Dr. Taylor, 7 do you recall there being a concern with respect to -- we 8 -- we've seen some concerns articulated about late 9 surgical reports, do you recall there being a concern 10 with respect to late autopsy reports? 11 DR. GLENN TAYLOR: Yes. 12 MS. JENNIFER MCALEER: And did you have - 13 - when you came back to the depart -- actually, before 14 you left the department, 1995 to 1999, what was your 15 understanding as to the concern regarding late autopsy 16 reports? 17 DR. GLENN TAYLOR: Well, there was an 18 extended turnaround time for -- for many of the reports. 19 Dr. Smith wasn't the only one that had issues with 20 turnaround times, but I think he had the most on the 21 list, which is what we call "the delinquent list". 22 MS. JENNIFER MCALEER: And did you ever 23 speak to Dr. Smith about his delinquent medicolegal 24 autopsy reports? 25 DR. GLENN TAYLOR: As a staff pathologist

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1 and as one of his staff forensic pathologist, no, I did 2 not. 3 MS. JENNIFER MCALEER: Okay. Do you know 4 if Dr. Becker did or Dr. Phillips did? 5 DR. GLENN TAYLOR: My understanding is 6 that Dr. Becker had brought up that topic many times with 7 him in various -- various ways. 8 MS. JENNIFER MCALEER: Okay. And -- and 9 what was the result, as far as you knew? 10 DR. GLENN TAYLOR: Now, I can't think of 11 what happened towards the -- toward 1999. I don't know 12 what happened after 1999, but I don't think that there 13 was a lot of change during the years '95 to say mid-'99 14 when I was there. 15 MS. JENNIFER MCALEER: Does that accord 16 with your recollection, Dr. Cutz? 17 DR. ERNEST CUTZ: No, actually the late 18 report was a regular feature in our staff meetings, 19 where, you know, people were reminded to -- to, you know, 20 complete their reports. 21 At one (1) point there was a list 22 distributed which listed, you know, which reports and 23 which staff had delinquent reports, in terms of, you 24 know, to do some kind of a follow up. 25 But as far as I could see there was no

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1 change on Dr. Smith's part, like it was a recurring and 2 as -- I -- I could see Dr. Becker was really frustrated 3 and didn't really know what -- what he should do, because 4 there -- there was no improvement. 5 MS. JENNIFER MCALEER: Thank you. That 6 might be a convenient time to break. 7 COMMISSIONER STEPHEN GOUDGE: Yes, just 8 before we break, I want to go back and ask you a 9 question, Dr. Cutz, about something you said when you 10 talked about the three (3) major responsibilities of both 11 the hospital and the department: Service, research and 12 teaching. 13 And just focus on pediatric forensic 14 pathology as a context in which to have a discussion with 15 you. 16 Obviously, service is a major obligation 17 of the hospital with that component of the department's 18 work. And I took from your CV that you found major 19 research interests within that as it relates to SIDS. 20 Is that fair? 21 DR. ERNEST CUTZ: That's correct, yes. 22 COMMISSIONER STEPHEN GOUDGE: Are there 23 other areas of pediatric forensic pathology like SIDS 24 that are particularly right for research work? 25 DR. ERNEST CUTZ: Yes, there is actually

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1 a large number of rare pediatric conditions which become 2 apparent when -- when, you know, a child dies suddenly 3 like this, which are due to different mechanisms. 4 Like, for example, there are rare 5 metabolic diseases which can present like this. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. ERNEST CUTZ: And -- and, you know, 8 as -- as the knowledge advances a lot of this can be 9 screened on a -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. ERNEST CUTZ: -- sort of genetic 12 screening basis. Then there are rare congenital defects 13 of various types: a hole in the heart -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. ERNEST CUTZ: -- or in the lungs, 16 different organs. And so -- so there's literature 17 accumulating with, you know, as -- as these disorders are 18 being diagnosed. But you know, by in large this would be 19 very rare conditions. 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. ERNEST CUTZ: And one (1) way the 22 pediatric community is dealing with the rare aspect is -- 23 is to set up consortium where material is material is 24 pulled from different centres -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. ERNEST CUTZ: -- throughout North 2 America. So rare pediatric diseases are being focussed, 3 you know, assembling the cases. You know, they may have 4 a few cases here and there to sort of study it as a group 5 and then -- and then look at variabilities and look at 6 defects, et cetera. 7 COMMISSIONER STEPHEN GOUDGE: And they 8 would all become parts of the database through sudden 9 death and autopsy? 10 DR. ERNEST CUTZ: That's correct, yes. 11 COMMISSIONER STEPHEN GOUDGE: Okay. That 12 set of research areas are all within what you have 13 described as the 90 percent of the medicolegal work that 14 is natural as opposed to criminal, if I can use that? 15 DR. ERNEST CUTZ: That's -- that's at 16 least what we have -- we see here at Sick Kids, and we've 17 seen for -- since I've been there. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 What about teaching as something that can 20 be done in the context of pediatric forensic pathology? 21 Is that something that the unit has 22 potential to do, Dr. Taylor or Dr. Cutz? 23 DR. GLENN TAYLOR: I think it has great 24 potential to do that. 25 COMMISSIONER STEPHEN GOUDGE: Has it done

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1 much in the past? 2 DR. GLENN TAYLOR: I'm not sure about the 3 distant past, but we certainly had residents and fellows 4 in our autopsy suite during the performance of 5 medicolegal autopsies. 6 COMMISSIONER STEPHEN GOUDGE: They would 7 be specializing in anatomical pathology and would be 8 doing forensics as a rotation or something? 9 DR. GLENN TAYLOR: That's correct. And 10 there is provision in the current agreement with the 11 Office of the Chief Coroner that those kind of 12 educational activities are -- are promoted, yes. 13 Mr. Commissioner -- 14 COMMISSIONER STEPHEN GOUDGE: And is it 15 your -- can they be enhanced? 16 DR. GLENN TAYLOR: They could be 17 enhanced, I think. And that's a bit of an administrative 18 issue, which may be down the road. 19 COMMISSIONER STEPHEN GOUDGE: Explain 20 that? 21 DR. GLENN TAYLOR: One (1) of the 22 concerns that has been made is with regards to 23 administrative support. Now the administrative support 24 as far as typing up the -- up the reports, and dealing 25 with the -- sort of the basic secretarial issues I think

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1 is okay, but what we -- what the unit doesn't have is it 2 doesn't have somebody who can coordinate various studies, 3 perhaps, that might be take -- that might be performed on 4 the autopsies done in the -- in the unit. 5 We don't have somebody to coordinate the 6 educational activities, coordinate putting together 7 rounds and so on for other services that the Forensic 8 Pathology Unit pathologists may be contributing to. This 9 is kind of outside of the regular secretarial area and -- 10 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 11 DR. GLENN TAYLOR: -- and it's something 12 that would, in part, enhance the academic mandate of the 13 hospital in a sense. Although, we're trying to keep 14 everything, you know, sort of separate, but it would 15 still with -- through the auspices of the Pediatric 16 Forensic Unit and the Office of the Chief Coroner's 17 blessing would certainly promote those kind of academic 18 activities: teaching and research. 19 COMMISSIONER STEPHEN GOUDGE: Does the 20 research arising out of pediatric forensic pathology, Dr. 21 Cutz, require coronial consent? 22 DR. ERNEST CUTZ: Well, coronial consent 23 is -- is actually warrant for the post-mortem 24 examination, which doesn't depend on parental consent. 25 So with -- without it --

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1 COMMISSIONER STEPHEN GOUDGE: Right. But 2 you saw of any information arising out of particular 3 autopsies done under warrant would not require the 4 coroner's consent if use were to be made in research? 5 DR. ERNEST CUTZ: I think under current 6 legislation there's no permission to do research under 7 coroner's warrant. You -- you are actually not -- not -- 8 COMMISSIONER STEPHEN GOUDGE: You are not 9 permitted at all. 10 DR. ERNEST CUTZ: permitted. You are not 11 permitted at all. 12 COMMISSIONER STEPHEN GOUDGE: I see. Dr. 13 Taylor...? 14 DR. GLENN TAYLOR: Well, we have been 15 doing some research -- and I hope we don't get into 16 trouble for this -- and it has been with the approval of 17 the Office of the Chief Coroner and it has been with the 18 con -- concomitant approval of the Institutional Research 19 Ethics Board. 20 COMMISSIONER STEPHEN GOUDGE: At the 21 university? 22 DR. GLENN TAYLOR: At -- at the hospital. 23 COMMISSIONER STEPHEN GOUDGE: At the 24 hospital. 25 DR. GLENN TAYLOR: So we have published

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1 various studies over the past three (3) or four (4) 2 years. And there are additional studies that we are 3 undertaking in the unit. 4 And many of these actually relate to more 5 basic issues, such as healing of bone fractures in 6 children and healing of wounds in children because the 7 wound healing and the bone fracture healing in different 8 in children than it is in adults and it's that -- it's 9 different at different ages even. And there isn't a good 10 handle on how quickly things heal in children. 11 And the opp -- we have the opportunity 12 through the Pediatric Forensic Pathology Unit where there 13 is a sort of condensation or grouping of -- of cases to 14 look at these base -- very basic issues that are 15 important to understanding injury in children and healing 16 in children. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 Thanks, that is helpful. Thanks, Ms. McAleer. 19 Okay. Well, let us break now and come 20 back at twenty (20) to 4:00. 21 22 --- Upon recessing at 3:24 p.m. 23 --- Upon resuming at 3:40 p.m. 24 25 THE REGISTRAR: Okay. All rise. Please

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1 be seated. 2 COMMISSIONER STEPHEN GOUDGE: Ms. 3 McAleer...? 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: Thank you, Mr. 7 Commissioner. 8 We're going to change topics again. There 9 have been some discussion and some documentation produced 10 with respect to a re-visioning of the OPFPU that was 11 contemplated both by the Office of the Chief Coroner and, 12 as I understand it, by the Hospital for Sick Children 13 beginning in or around 1997 and straight through to 1999. 14 Without going through all of the documents 15 because we don't have time today, Dr. Cutz, could you 16 please turn your attention to Tab 3. 17 DR. ERNEST CUTZ: Which volume? 18 MS. JENNIFER MCALEER: And Tab 3 of 19 Volume II. I'm sorry, Tab 3 of Volume II. It's 20 PF117786. 21 DR. ERNEST CUTZ: Yes. 22 MS. JENNIFER MCALEER: All right. Now, 23 Dr. Cutz, are you familiar with this document? Have you 24 seen it before? 25 DR. ERNEST CUTZ: I have -- I have not

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1 seen the typed document, but reading through it I can 2 recognize some of the elements of a letter I drafted and 3 discussed with Dr. Becker. 4 MS. JENNIFER MCALEER: All right. And 5 what was the nature of the letter you drafted and 6 discussed with Dr. Becker? 7 DR. ERNEST CUTZ: It was to see how to 8 deal with all the issues which came up and how to move 9 forward. You know, to reconcile this problem between, 10 you know, doing cases of natural disease versus forensic 11 cases. 12 And I think the feeling Dr. Becker and I 13 had that the academic component is being neglected and so 14 that, you know, our interest in doing it was to -- to 15 advance the academic agenda. And so we, you know, it 16 basically proposed that we would still continue doing the 17 cases of natural deaths and we will discontinue doing the 18 criminally suspicious deaths. 19 MS. JENNIFER MCALEER: So that was the 20 view that you and Dr. Becker held. Did you discuss it 21 with your colleagues within the Division? 22 DR. ERNEST CUTZ: I think it -- it was 23 discussed at -- at our staff meeting. 24 MS. JENNIFER MCALEER: Okay. And if we 25 look at page 1 of this document.

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1 First of all, Dr. Cutz and Dr. Taylor, do 2 we know if this document was ever delivered to the Office 3 of the Chief Coroner? 4 DR. ERNEST CUTZ: I -- I have no 5 knowledge whether it was -- it was delivered, no. 6 MS. JENNIFER MCALEER: Dr. Taylor, do you 7 know? 8 DR. GLENN TAYLOR: I don't know either. 9 MS. JENNIFER MCALEER: Okay. And Dr. 10 Cutz, the memo starts with: 11 "The Hospital for Sick Children must 12 make a decision about a number of 13 issues recently raised by the Coroner's 14 Office. This is an excellent 15 opportunity for re-visioning the role 16 of pathology at the Hospital for Sick 17 Children and its relationship to the 18 Coroner's Office. This summary 19 outlines the background costs and 20 proposal for handling medicolegal 21 autopsies." 22 DR. ERNEST CUTZ: Yes. 23 MS. JENNIFER MCALEER: And if we turn the 24 page, halfway down through that first paragraph where it 25 starts "Historically". Do you see that, Dr. Cutz?

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1 DR. ERNEST CUTZ: Yes. 2 MS. JENNIFER MCALEER: So second page, 3 halfway down. 4 DR. ERNEST CUTZ: Yeah. 5 MS. JENNIFER MCALEER: "Historically, 6 parents of children who die of Sudden 7 Infant Death Syndrome have been 8 vigorously questioned by insensitive 9 law enforcement agencies resulting in 10 inappropriate accusations. Often the 11 reason for this aggressivity is related 12 to the misinterpretation of autopsy 13 findings by pathologists not trained in 14 recognizing natural pediatric disease." 15 Now, do you recall discussing that issue 16 with Dr. Becker? 17 DR. ERNEST CUTZ: I think this is 18 something Dr. Becker put himself. I don't recall -- 19 MS. JENNIFER MCALEER: That was -- 20 DR. ERNEST CUTZ: -- covering this. 21 Yeah. No. 22 MS. JENNIFER MCALEER: All right. So 23 continuing. 24 "In children who have died suddenly and 25 unexpectedly and have been investigated

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1 by the Coroner's Office, we have found 2 at the Hospital for Sick Children that 3 60 percent of cases have a medical 4 cause of death; 20 percent are due to 5 Sudden Infant Death Syndrome; 13 are 6 accidental deaths; and 7 percent are 7 identified as homicidal and other 8 causes of death." 9 Again, does that accord with your -- 10 DR. ERNEST CUTZ: Yes. 11 MS. JENNIFER MCALEER: -- recollection? 12 DR. ERNEST CUTZ: Yes. 13 MS. JENNIFER MCALEER: And Dr. Taylor, 14 would you agree with those numbers? 15 DR. GLENN TAYLOR: Yes, approximately. 16 Yes. 17 COMMISSIONER STEPHEN GOUDGE: The 18 universe there are the cases done under warrant? 19 DR. GLENN TAYLOR: Yes. 20 DR. ERNEST CUTZ: Yeah. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: And then it says: 24 "Homicide child abuse of children under 25 one (1) year of age account for less

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1 than 1.5 percent of deaths. Without 2 special pediatric pathology expertise, 3 this percentage could be falsely 4 elevated due to medical diseases 5 mimicking aspects of child abuse." 6 Let me stop there. 7 Dr. Cutz, what does that mean, "medical 8 diseases mimicking as aspects of child abuse"? 9 DR. ERNEST CUTZ: There are certain 10 medical conditions, I can think of one (1), where a 11 medical disease on the outside and in -- in a setting may 12 seem that -- that there is a foul play involved. 13 MS. JENNIFER MCALEER: And the paragraph 14 continues: 15 "We have had several instances of high 16 suspicion by the Coroner's Office in 17 cases that have later turned out to be 18 clearly of metabolic origin. One (1) 19 example is a child who died of..." 20 Is that Menkes disease? 21 DR. ERNEST CUTZ: Menkes disease, yes. 22 MS. JENNIFER MCALEER: And is that the 23 example you were thinking of? 24 DR. ERNEST CUTZ: Well, that's one (1) of 25 the examples.

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1 Now I wasn't involved in this particular 2 case. That could have been a neuropathology case Dr. 3 Becker studied. 4 MS. JENNIFER MCALEER: All right. And 5 then if we turn to the next page, page 3, and three- 6 quarters (3/4s) of the way down, before the list of 7 bullets. You see where it says: 8 "For the past three (3) years --" 9 DR. ERNEST CUTZ: Yes. 10 MS. JENNIFER MCALEER: "-- we have at the 11 Hospital for Sick Children classified 12 all autopsies, medicolegal and non- 13 medicolegal to one (1) of five (5) 14 categories attempting to corelate the 15 premodo -- pre-mortem clinical 16 diagnosis with the post-mortem 17 pathological observations. Over these 18 years the percentage in each class have 19 remained remarkably constant. The 20 following assignations are provided 21 after open discussion with clinical 22 colleagues." 23 Now having reviewed that document, Dr. 24 Cutz, were -- were you part of this, did you -- were you 25 part of this classification process?

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1 DR. ERNEST CUTZ: Well, this -- this is a 2 classification which was introduced at our pathol -- 3 weekly clinical pathologic conference rounds and it was - 4 - it was to track and -- and classify every case into 5 these five (5) classes, and this is -- this is a 6 classification developed by an American pathologist, I 7 forget his name. 8 DR. GLENN TAYLOR: Goldman. 9 DR. ERNEST CUTZ: Goldman, yeah. 10 MS. JENNIFER MCALEER: All right. And -- 11 and what is the import of that with respect to 12 medicolegal work or is there any? 13 DR. ERNEST CUTZ: Well, sample -- you 14 know, if -- if the case is done under the coroner's 15 warrant and, for example, it's a type of case that the 16 child dies in the hospital and there may be a question of 17 malpractice or there may be a question of mis-diagnosis 18 or something like that, so then this may be relevant, but 19 it -- it would not be relevant to the homicide type of 20 case. 21 MS. JENNIFER MCALEER: All right, so if - 22 - if you continue to do medicolegal autopsies at the 23 Hospital for Sick Children, you would have access to 24 information that would assist with these statistics. 25 Is that correct --

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1 DR. ERNEST CUTZ: Yes. 2 MS. JENNIFER MCALEER: -- Dr. Taylor? 3 DR. GLENN TAYLOR: That's correct, yes. 4 MS. JENNIFER MCALEER: Okay. And then if 5 we skip forward to page 5 to the proposal section of this 6 memo. 7 DR. ERNEST CUTZ: Mm-hm. 8 MS. JENNIFER MCALEER: Let's go down to 9 the bottom where it says, "I suggest the following plan 10 [colon]": 11 "The Hospital for Sick Children 12 discontinue its institutional link, 13 Pediatric Forensic Unit, with the 14 Coroner's Office." 15 Now do you recall, Dr. Becker -- sorry, 16 Dr. Cutz, speaking to Dr. Becker about this proposition 17 that the institutional link be severed with the Office of 18 the Chief Coroner? 19 DR. ERNEST CUTZ: Yes. 20 MS. JENNIFER MCALEER: And what was your 21 understanding as to why Dr. Becker was making this 22 proposal? 23 DR. ERNEST CUTZ: I think -- I mean this 24 proposal was to -- I mean was a reassessment as to what 25 happened to that point and how we should move forward.

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1 And with all the problems which have -- 2 which have arisen at the time and in order to keep with 3 the, you know, principal hospital mission, which is to -- 4 to focus on treatment and diagnosis of children's 5 diseases, this seemed like, you know, a reasonable thing 6 to do. 7 MS. JENNIFER MCALEER: And when you talk 8 about all the problems that have arou -- arised at the 9 time -- or had arisen at the time, are we talking about 10 delays with respect to post-mortem examination reports, 11 is that one (1) of the problems? 12 DR. ERNEST CUTZ: Well, that -- that was 13 one (1) of them. 14 MS. JENNIFER MCALEER: And was there also 15 a concern with respect to how cases were being triaged 16 and who actually was performing medicolegal autopsies at 17 the Hospital for Sick Children? 18 DR. ERNEST CUTZ: Well, the triage was 19 done at the Coroner's Office end, but there were problems 20 with communication in terms of, you know, what the cases 21 were about and then what should one do or shouldn't do, 22 that's -- that kind of a -- 23 MS. JENNIFER MCALEER: And Dr. Taylor, I 24 under -- 25 DR. ERNEST CUTZ: -- issue.

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1 MS. JENNIFER MCALEER: Sorry, Dr. Cutz. 2 DR. ERNEST CUTZ: Yeah, that's -- 3 MS. JENNIFER MCALEER: Dr. Taylor, I 4 understand that there was decision made at one (1) point 5 at the Office of the Chief Coroner to triage the cases so 6 that all of the criminally suspicious cases during this 7 time period would be done by either Dr. Smith or 8 yourself. 9 Do you recall being apprised of that? 10 DR. ERNEST CUTZ: I'm sure I must, but I 11 can't recall specifically being advised of that. I 12 certainly don't have any -- I can't remember anything in 13 writing with regards to that. 14 MS. JENNIFER MCALEER: Did you note that 15 you were doing more criminally suspicious cases in the 16 late 1990s than when you had first joined the hospital? 17 DR. GLENN TAYLOR: I think my role was 18 really a backup for Dr. Smith and I think actually the -- 19 in that period of time the -- I actually did more earlier 20 than later in that four (4) year period. 21 And I didn't do a lot, mind you, but I 22 think the first couple of years I actually did a few more 23 than in the subsequent second years that I was -- 24 COMMISSIONER STEPHEN GOUDGE: This is '95 25 to '99?

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1 DR. GLENN TAYLOR: '95 to '99, yes. 2 COMMISSIONER STEPHEN GOUDGE: How many 3 would you have done that you considered criminally 4 suspicious in that period of time? 5 DR. GLENN TAYLOR: Yeah, I think -- and I 6 -- I just added up everything the other day, but it 7 included my BC stuff, so my BC Children's and Sick Kids 8 then and now, there's only about twenty (20) cases that 9 are of interest to either the criminal justice system or 10 went to inquest or resulted in some kind of custody 11 judgment. 12 COMMISSIONER STEPHEN GOUDGE: And that 13 includes the period of time as head of the department -- 14 DR. GLENN TAYLOR: That includes my -- 15 COMMISSIONER STEPHEN GOUDGE: -- since 16 you came back. 17 DR. GLENN TAYLOR: -- that -- that 18 includes my twenty-six (26) year career so far, yes. 19 COMMISSIONER STEPHEN GOUDGE: Okay. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: And at the bottom 23 of page 5, the last sentence starts with: 24 "In our examination, the Hospital for 25 Sick Children has determined that there

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1 is a significant risk to the reputation 2 of the hospital and to that of its 3 pathology staff." 4 Do -- do either of you know what the 5 identified risk was? 6 DR. ERNEST CUTZ: I'm not sure whether 7 the dates correspond, but maybe at that point Dr. Becker 8 might have heard some problems regarding Dr. Smith's 9 work. 10 MS. JENNIFER MCALEER: You're -- you're 11 only speculating, though, aren't you, Dr. Cutz? 12 DR. ERNEST CUTZ: Well, I -- I'm not sure 13 of that dates, you know, whether -- whether there was 14 some information available at that time. 15 COMMISSIONER STEPHEN GOUDGE: As far as 16 our records are concerned, the data on the document, 17 95/05/07... 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: I'm not certain, 21 Commissioner, if that's May 7th, 1999 or if that's July 22 5th, 1999. We don't -- we don't know that, do we, Drs. 23 Becker -- or sorry, Dr. Cutz -- 24 DR. ERNEST CUTZ: Yeah, I -- I don't 25 know. If there's no date on it, I wouldn't know the

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1 date. 2 MS. JENNIFER MCALEER: Right. 3 DR. ERNEST CUTZ: But I presume that, you 4 know, since Dr. Becker expresses serious concerns that, 5 you know, he must have some reason for it. 6 MS. JENNIFER MCALEER: Dr. Taylor, do you 7 know what the reference to the reputation of the hospital 8 refers to? 9 DR. GLENN TAYLOR: I'm sorry, I got lost 10 here. Where -- where are we. 11 MS. JENNIFER MCALEER: The -- the last 12 sentence of page 5 and the top sentence of page 6. Well, 13 it's the same sentence, but it begins at the bottom of 14 page 5 and over to the top of page 6. 15 DR. GLENN TAYLOR: I -- I'm sorry, I 16 don't know what that means. 17 MS. JENNIFER MCALEER: So then the last 18 sentence of that paragraph: 19 "The Hospital for Sick Children will 20 perform medical natural death cases 21 only, and, therefore, there will no 22 longer be a need for a pediatric 23 forensic unit at the Hospital for Sick 24 Children." 25 Now, Dr. Taylor, did you have discussions

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1 with Dr. Becker about this proposal? 2 DR. GLENN TAYLOR: I can't recall. 3 COMMISSIONER STEPHEN GOUDGE: It would 4 continue to do a series of cases done under coroner's 5 warrant? 6 DR. ERNEST CUTZ: Yes. 7 8 CONTINUED BY MS. JENNIFER MCALEER: 9 MS. JENNIFER MCALEER: And then -- 10 COMMISSIONER STEPHEN GOUDGE: Does that 11 mean that the author of the memo -- sorry, Ms. McAleer. 12 MS. JENNIFER MCALEER: No, that's fine. 13 COMMISSIONER STEPHEN GOUDGE: It kind 14 infers that the whole purpose of the unit is to do the 15 criminally suspicious cases? 16 DR. ERNEST CUTZ: That's right, yeah. 17 And also the term "forensic" would be associated with the 18 unit rather than with the hospital. 19 COMMISSIONER STEPHEN GOUDGE: We have 20 seen a variety of uses in the last five (5) weeks of that 21 term. Everything from something done under coroner's 22 warrant to something that is headed for the court. 23 24 CONTINUED BY MS. JENNIFER MCALEER: 25 MS. JENNIFER MCALEER: Then continuing

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1 down the list. If we go to the next page, page 7, number 2 5 of the proposal. 3 "The separate fees that are provided by 4 the Coroner's Office to the pathologist 5 for medicolegal cases would be placed 6 in the pediatric pathology consultation 7 account to maintain independence from 8 the hospital in any real or perceived 9 conflict of interest. These funds 10 would be available for academic 11 endeavours." 12 Now, am I correct in my understanding that 13 the practice had been that pathologists would get paid 14 separately for the coroner's work they did. Is that 15 correct? On a -- 16 DR. ERNEST CUTZ: That's correct, yes. 17 MS. JENNIFER MCALEER: -- fee-for-service 18 basis? 19 DR. ERNEST CUTZ: Yes. 20 MS. JENNIFER MCALEER: And is what being 21 -- is what it is being proposed here that instead of that 22 the money would go into some centre -- central account to 23 be used in the hospital? 24 DR. ERNEST CUTZ: A departmental account, 25 yes.

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1 MS. JENNIFER MCALEER: All right. And, 2 Dr. Taylor, do you recall having any discussions with Dr. 3 Becker about this proposition? 4 DR. GLENN TAYLOR: No, I don't. 5 MS. JENNIFER MCALEER: Dr. Cutz, do you? 6 Was this part of your memo? 7 DR. ERNEST CUTZ: Well, I didn't -- 8 didn't write this particular, but we discussed it. 9 MS. JENNIFER MCALEER: All right. And 10 why would that be preferable? 11 DR. ERNEST CUTZ: I think, you know, this 12 -- this way it isolate the hospital. In other words, 13 it's not the individual pathologists, but it's -- it's 14 you know, an account which -- which is -- represents the 15 consultations provided by the department. 16 MS. JENNIFER MCALEER: Okay. And then 17 the last point, point 6. 18 "The pathologists employed by the 19 Hospital for Sick Children would not be 20 performing autopsies at the Coroner's 21 Office and would report according to 22 hospital bylaws to the divisional head 23 and departmental chief." 24 So under this proposal, Dr. Becker (sic), 25 was it your understanding that nobody from the Hospital

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1 for Sick Kids would go over to the OCCO to perform the 2 criminally suspicious cases? 3 DR. ERNEST CUTZ: Not on official, yes. 4 Not -- not on officially. If they had a private 5 arrangement I think they could, but not -- not in an 6 official role. 7 MS. JENNIFER MCALEER: So your 8 understanding is this wouldn't prohibit one (1) of the 9 staff pathologists from going over to the OCCO and 10 continuing to do criminally suspicious work? 11 DR. ERNEST CUTZ: Well, as -- as I read 12 it, that the responsibility or oversight would be through 13 the division or department head of the -- of Department 14 of Pathology at Sick Kids. 15 And so that he wouldn't take any 16 responsibility for any work done at the Coroner's Office. 17 MS. JENNIFER MCALEER: Okay. And did you 18 discuss this issue or this point with Dr. Becker? 19 DR. ERNEST CUTZ: No, I think this is Dr. 20 Becker's... 21 MS. JENNIFER MCALEER: Okay. Dr. Taylor, 22 I take it you didn't either? 23 DR. GLENN TAYLOR: No. 24 MS. JENNIFER MCALEER: Okay. And did -- 25 did you, Dr. Cutz, have any discussions with Dr. Smith

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1 about this proposal? 2 DR. ERNEST CUTZ: No, we did not. 3 MS. JENNIFER MCALEER: You don't know 4 what his views were with respect to this proposal? 5 DR. ERNEST CUTZ: I -- I -- I don't know. 6 MS. JENNIFER MCALEER: All right, we can 7 put that aside. And as -- as far as you both know, this 8 was never adopted? 9 DR. ERNEST CUTZ: Yeah, I -- I don't know 10 if it was sent or -- or whether it was sent, but it 11 wasn't adopted, no. 12 MS. JENNIFER MCALEER: All right. 13 COMMISSIONER STEPHEN GOUDGE: I take it - 14 - can I just ask -- 15 MS. JENNIFER MCALEER: Go ahead. 16 COMMISSIONER STEPHEN GOUDGE: -- a couple 17 of questions, Ms. McAleer? I take it, Dr. Cutz, that 18 using the language of this memo, it's your view that it 19 is possible to distinguish what are referred to here as 20 medical natural death cases from what you call forensic 21 cases? 22 DR. ERNEST CUTZ: Yes. 23 COMMISSIONER STEPHEN GOUDGE: Is that 24 easy to do at the front end of an autopsy in every case? 25 DR. ERNEST CUTZ: It may not be, you

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1 know, 100 percent, but there are different jurisdictions 2 dealing with this elsewhere. In other words, you know, 3 nothing is 100 percent. You cannot guarantee that, you 4 know, once you do the autopsy, you'll find something 5 unexpected. 6 And -- and the other way also that, you 7 know, something is very suspicious, and then you find 8 that it wasn't. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 It's easy to do this classification if one looks in the 11 rearview mirror? 12 DR. ERNEST CUTZ: That's right. 13 COMMISSIONER STEPHEN GOUDGE: Is it as 14 easy looking through the windshield, going forward, 15 before you've done the autopsy? 16 DR. ERNEST CUTZ: Well, I think based on 17 statistics and -- and based on giving a benefit of a 18 doubt in saying, you know, pre -- presume innocence, 19 rather than we presume guilt, you know, one could -- one 20 could do it. 21 COMMISSIONER STEPHEN GOUDGE: Okay. So 22 that one would take only the cases that one was very 23 sure, in your terms were forensic cases, and stream them 24 as this memo implies; that's one (1) way to do it? 25 DR. ERNEST CUTZ: Right, yes. Yeah.

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1 COMMISSIONER STEPHEN GOUDGE: What do you 2 think, Dr. Taylor? How easy is this triaging to do at 3 the front end of the death investigation? 4 DR. GLENN TAYLOR: I think -- I think 5 you'll be right 95 of the time, but there's a 5 percent 6 chance that something is going to show up that was 7 unexpected by the circumstances and by the external 8 examination of the body. 9 And then I think as Dr. Cutz mentioned, 10 you have to have fallback positions in place to deal with 11 those cases that slip through the initial triage. And -- 12 COMMISSIONER STEPHEN GOUDGE: Or that 13 turn out a little differently -- 14 DR. GLENN TAYLOR: Correct. 15 COMMISSIONER STEPHEN GOUDGE: -- then the 16 triaging anticipates? 17 DR. GLENN TAYLOR: Correct. 18 COMMISSIONER STEPHEN GOUDGE: What kind 19 of mechanism? 20 DR. GLENN TAYLOR: Well, for instance, if 21 a case is, sort of, presented as sudden unexpected 22 natural death by whatever means, and through the initial 23 autopsy examination, a subdural hematoma is found, or 24 some other evidence that has an association with an 25 inflicted injury, there should be a means by which that

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1 can be properly turned over to the appropriate forensic 2 pathologist. 3 And I think in the past that was done if - 4 - if a SIDS type case was being autopsied and then -- 5 COMMISSIONER STEPHEN GOUDGE: Suddenly a 6 subdural hematoma was discovered? 7 DR. GLENN TAYLOR: -- shows up, stop, 8 inform the coroner, and the coroner would be requested to 9 get a hold of a forensic pathologist to either oversee 10 the case or take over the case completely. 11 COMMISSIONER STEPHEN GOUDGE: Okay. And 12 vice versa, I take it? 13 DR. GLENN TAYLOR: And vice versa. And 14 now the issue is -- I -- I guess, if you're handing over 15 a case, what was done up to that point -- 16 COMMISSIONER STEPHEN GOUDGE: Exactly. 17 DR. GLENN TAYLOR: -- would the forensic 18 pathologist, sort of, like what was done up to that 19 point. And I think -- 20 COMMISSIONER STEPHEN GOUDGE: Or have 21 done things differently? 22 DR. GLENN TAYLOR: -- or had done things 23 -- this -- differently. And this is where I think having 24 a, sort of, a standard protocol becomes very important. 25 COMMISSIONER STEPHEN GOUDGE: Okay.

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1 Which way would you tilt by presumption? That is, would 2 you use Dr. Cutz's presumption of innocence and say 3 unless really demonstrably from the get-go, criminally 4 suspicious be treated as, Let me use the division in this 5 memo, a Sick Kids case rather than a -- 6 DR. GLENN TAYLOR: I would screen those 7 that are obviously or highly suspicious for an interest 8 to the Criminal Justice System over to the forensic 9 pathologist. 10 I would approach the rest, the 95 percent 11 or so, with an attitude of doing the best and most 12 thorough autopsy that I can, taking into account that 13 it's most likely going to be a natural death but there 14 may be an unexpected -- even in -- even in that selected 15 group, an unexpected surprise. 16 And there needs to be in place then, 17 appropriate protocols to deal with that particular 18 situation. 19 COMMISSIONER STEPHEN GOUDGE: I take it 20 that's essentially what you were telling me -- 21 DR. ERNEST CUTZ: Yes. 22 COMMISSIONER STEPHEN GOUDGE: -- Dr. 23 Cutz? Okay. Thanks, Ms. McAleer. 24 25 CONTINUED BY MS. JENNIFER MCALEER:

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1 MS. JENNIFER MCALEER: Thank you, Mr. 2 Commissioner. 3 If we could turn to Tab 72 of Volume II, 4 it's PFP124246. Tab 72. 124246. 5 And Dr. Cutz and Dr. Taylor, I understand 6 that neither one of you was aware of the fact that Dr. 7 Smith had participated in a trial that took place in 8 Timmins in the late 1990s and that resulted in the 9 decision which is at Tab 72. 10 Is that correct? 11 DR. ERNEST CUTZ: No, I didn't know 12 anything about this case. 13 MS. JENNIFER MCALEER: Right. And that 14 prior to any media reports, you had actually not heard 15 anything about this case. 16 Is that correct? 17 DR. ERNEST CUTZ: No, I have not. 18 MS. JENNIFER MCALEER: Is that correct 19 for you as well, Dr. Taylor? 20 DR. GLENN TAYLOR: That's what I recall, 21 yes. 22 MS. JENNIFER MCALEER: Okay. And you've 23 both now had the opportunity to review the decision that 24 is at Tab 72, Justice Dunn's decision. 25 Dr. Taylor, as Head of the Department, is

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1 this a decision that -- if a case like this took place 2 now while you're Head of the Department, would you have 3 wanted to know about this decision? 4 DR. GLENN TAYLOR: Yes. 5 MS. JENNIFER MCALEER: And do you have 6 any suggestions as to how decisions might be circulated 7 or make their way to somebody who is in your position? 8 DR. GLENN TAYLOR: Well, the direct 9 contact, I think, would have to be through the Office of 10 the Chief Coroner. The way the unit is structured now, 11 there is a -- sort of an executive or overseeing 12 committee that includes a representative of the Office of 13 the Chief Coroner and the Chief Forensic Pathologist. 14 And I would think that a decision like 15 this should probably come through that venue to myself as 16 the Division Head, the Director of the Unit and probably 17 the other member of that committee which is the Vice- 18 President that has responsibility for laboratories. 19 MS. JENNIFER MCALEER: So you would 20 suggest that the onus be on the Coroner's Office to bring 21 the decision to your attention? 22 DR. GLENN TAYLOR: I'm not sure how we 23 would - you know, I'm just thinking of myself how I would 24 otherwise be notified of this decision. I mean, somebody 25 would have to bring it to my attention, I think.

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1 MS. JENNIFER MCALEER: What about asking 2 your pathologists to let you know if they're -- if 3 they're testifying or if they're involved in a case or if 4 they're aware that a decision has been released -- 5 DR. GLENN TAYLOR: Okay. 6 MS. JENNIFER MCALEER: -- with respect to 7 a case they've been involved in? 8 DR. GLENN TAYLOR: If they're aware of a 9 decision and it has -- has some significance, then I 10 think that that might -- that it might be good to come 11 from that person. 12 My experience, not great as it is, is that 13 I often don't know what happened at the end of the trial. 14 I haven't been informed personally of very many outcomes 15 of trials. 16 MS. JENNIFER MCALEER: So I take it 17 there's no policy in place right now then at the hospital 18 with respect to making sure that in future cases that 19 comment upon the hospital or professionals associated 20 with the hospital comes to your attention? 21 DR. GLENN TAYLOR: I'm not aware of a 22 policy, no. 23 MS. JENNIFER MCALEER: Now you indicated 24 that if you had been the head of the department, you 25 would have wanted to know about this decision.

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1 DR. GLENN TAYLOR: No, I'm -- I am the 2 Head -- 3 MS. JENNIFER MCALEER: Sorry. As the 4 Head now. 5 DR. GLENN TAYLOR: -- of the Department. 6 If it happened now -- 7 MS. JENNIFER MCALEER: If it happened 8 now -- 9 DR. GLENN TAYLOR: Yes. 10 MS. JENNIFER MCALEER: -- you'd want to 11 know. 12 Well, let me put it backwards. If you had 13 been the head of the department when this decision was 14 released, would you have wanted to know? 15 DR. GLENN TAYLOR: Well, the structure of 16 the unit was different then, and there wasn't a formal 17 arrangement or a formal executive committee. And there 18 was the issue of maintaining independence of the hospital 19 and the coroner's service, so I -- it would be -- 20 personally, I would probably want to know about it. 21 But then there are issues with regards to 22 the independence of the coroner's -- of the PFPU and the 23 coroner service from the hospital and sort of 24 complicating things. So now, there's -- I think there's 25 a clear -- a clear route to go because of the Executive

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1 Committee of PFPU, which includes hospital 2 representatives, formally. 3 MS. JENNIFER MCALEER: So why would you 4 want to know about this decision? 5 DR. GLENN TAYLOR: At the least, I think 6 there's some very -- very important educational aspects 7 to it. The -- the whole discussion about Shaken Baby 8 Syndrome and -- and whether it exists or whether you need 9 head impact injuries to go along with it and so on is -- 10 is -- been going -- that debate has been going on since 11 this judgment, and it's continued to go on now. 12 And I think it would be, from an 13 educational point, at least, for the benefit of the 14 members of the unit to either analyse this case or 15 analyse the issues that the case presents. 16 MS. JENNIFER MCALEER: Turning then -- 17 moving forward a little bit to -- 18 COMMISSIONER STEPHEN GOUDGE: Sorry, I am 19 going to butt in again. 20 MS. JENNIFER MCALEER: Go ahead. 21 COMMISSIONER STEPHEN GOUDGE: Using 22 shaken baby as an example, and going back to the 23 streaming implicit in the revisioning memo you two (2) 24 and I were talking about; where would shaken baby cases 25 fit into your streaming?

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1 DR. GLENN TAYLOR: If there was strong 2 suspicion that -- from the circumstantial evidence and 3 the historical information, my preference would be to 4 have it done by the forensic pathologist. The trouble is 5 that often -- that history or the circumstances aren't 6 clear and the findings occur at autopsy that raise -- 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. GLENN TAYLOR: -- the -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. GLENN TAYLOR: -- possibility of that 11 diagnosis. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. GLENN TAYLOR: And then by that time, 14 the autopsy is mostly finished. 15 COMMISSIONER STEPHEN GOUDGE: It is done. 16 DR. GLENN TAYLOR: Fortunately, at Sick 17 Kids, we have two (2) neuropathologists that are just 18 down the hall that we can call in to help us with that 19 situation. But it is basically done at that time, so it 20 is -- becomes a difficult situation. 21 COMMISSIONER STEPHEN GOUDGE: I mean, my 22 intuitive sense, Dr. Taylor, is that on the streaming 23 that the three (3) of us were talking about, you would 24 both say, They'll go to Sick Kids rather than go to the 25 Coroner's Office?

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1 DR. GLENN TAYLOR: Unless there was very 2 strong circumstantial evidence or historical information 3 to -- 4 COMMISSIONER STEPHEN GOUDGE: Am I 5 reading you right, Dr. Cutz? You have not -- 6 DR. ERNEST CUTZ: I think if -- if there 7 is an impact injury, doc -- documented impact injury -- 8 COMMISSIONER STEPHEN GOUDGE: Suppose no 9 impact injuries; pure shaken baby where all you have got 10 is a history, which may be questionable. And if there is 11 to be a shaken baby diagnosis, it is after autopsy? 12 DR. ERNEST CUTZ: Well, as Dr. Taylor 13 mentioned, it's -- it's continuous debate and then 14 there's some new research to suggest -- I had experience 15 with a case which was labelled as a Shake -- Shaken Baby 16 Syndrome and after doing the autopsy, it turned out that 17 the child has a coagulation problem and a vitamin K 18 deficiency. 19 And had a liver pathology, which explained 20 it. So it's exculpated the -- the -- 21 COMMISSIONER STEPHEN GOUDGE: I am just 22 trying to get where a case like the one I -- 23 DR. ERNEST CUTZ: So -- so that -- that 24 one -- you know, that may not have been recognized as -- 25 as a pediatric --

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1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 DR. ERNEST CUTZ: -- disease, had it been 3 done somewhere else. As a case is -- you know, they are 4 difficult. Like, it's not -- you know, it's -- those are 5 difficult cases. And one has to, you know, do the full - 6 - full extent of -- of examination we need to do. 7 COMMISSIONER STEPHEN GOUDGE: Yes, but on 8 your presumption, the way you were giving me the 9 presumption, -- 10 DR. ERNEST CUTZ: Yeah. 11 COMMISSIONER STEPHEN GOUDGE: -- you 12 would say that autopsy gets conducted at Sick Kids? 13 Because you don't know going in -- 14 DR. ERNEST CUTZ: Well, the -- 15 COMMISSIONER STEPHEN GOUDGE: -- you 16 don't -- 17 R. ERNEST CUTZ: -- to me if there is 18 injury, then it goes to the Coroner's Office. 19 COMMISSIONER STEPHEN GOUDGE: But you do 20 not know about the triad -- 21 DR. ERNEST CUTZ: Yeah. 22 COMMISSIONER STEPHEN GOUDGE: -- 23 potential clues to shaken baby until after the autopsy is 24 done? So going in, does it not get done at Sick Kids? 25 DR. ERNEST CUTZ: Well, in -- I think in

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1 that situation may be more prudent to send it to the 2 Coroner's Office. And then if -- if they can consult 3 with pediatric pathologists. 4 COMMISSIONER STEPHEN GOUDGE: Okay. What 5 about -- obviously SIDS cases -- 6 DR. ERNEST CUTZ: Yeah. 7 COMMISSIONER STEPHEN GOUDGE: -- and sick 8 kids. 9 DR. ERNEST CUTZ: Right. 10 COMMISSIONER STEPHEN GOUDGE: What about 11 Sudden Unexpected Deaths Under 2, Dr. Taylor? Do they 12 all go one (1) way or the other, or do you use the same 13 streaming? 14 DR. GLENN TAYLOR: I'd use the same 15 streaming. If there's clear -- and this is, sort of, 16 hypothetical because we now have a full boarded forensic 17 pathologist on staff at Sick Kids who -- 18 COMMISSIONER STEPHEN GOUDGE: I 19 understand that. 20 DR. GLENN TAYLOR: Okay. 21 COMMISSIONER STEPHEN GOUDGE: And that -- 22 DR. GLENN TAYLOR: But going back to the 23 re-visioning -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. GLENN TAYLOR: -- proposal and

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1 following through with that, I would use the same 2 streaming principle for there. If the -- if the case -- 3 if the -- it looks like that there are injuries to the 4 child that are of a suspicious nature, or there's clear 5 indication that the child was -- was hurt, or there's 6 circumstantial, you know, or historical information that 7 suggests that inflicted injuries is a high probability, 8 those would go, the rest would stay. 9 COMMISSIONER STEPHEN GOUDGE: Okay, 10 thanks. And that's consistent with the schematic that 11 you and I discussed arising out of that memo. 12 DR. GLENN TAYLOR: Yes. 13 COMMISSIONER STEPHEN GOUDGE: Okay, 14 thanks. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: Dr. Cutz, when was 18 the first time that you became aware that there were any 19 concerns with respect to Dr. Smith's work in the field of 20 medicolegal autopsies? 21 DR. ERNEST CUTZ: I think the first time 22 I heard about it which was reported in the press, and 23 then there was W5 program or some TV program, I -- I saw 24 it. 25 MS. JENNIFER MCALEER: Are you referring

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1 to the Fifth Estate Program -- 2 DR. ERNEST CUTZ: Fifth Estate, sorry, 3 yeah. 4 MS. JENNIFER MCALEER: -- from November 5 of 1999? 6 DR. ERNEST CUTZ: Yes. 7 MS. JENNIFER MCALEER: And did you 8 actually watch that program? 9 DR. ERNEST CUTZ: Yes, I did. 10 MS. JENNIFER MCALEER: Did you know about 11 it before it aired? 12 DR. ERNEST CUTZ: No, I did not. 13 MS. JENNIFER MCALEER: And what -- what 14 was your impression after having reviewed the -- the 15 program? 16 DR. ERNEST CUTZ: Well, it was -- you 17 know, it came as -- as a big surprise, to some extent 18 and, you know, this problem has arose and, you know, we 19 were concerned that one (1) of our pathologists is -- is 20 involved in it. 21 MS. JENNIFER MCALEER: You said -- you 22 said "we were concerned", did you actually have any 23 discussions with anybody at the Hospital for Sick 24 Children after viewing this program? 25 DR. ERNEST CUTZ: Yes, we did.

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1 MS. JENNIFER MCALEER: And with whom did 2 you speak? 3 DR. ERNEST CUTZ: I think it was 4 mentioned at our staff meeting. It was Dr. Becker and, 5 you know, other staff. It -- it was mentioned at a staff 6 meeting. 7 MS. JENNIFER MCALEER: And, Dr. Taylor, 8 you had left the hospital at that point in time; you left 9 in October of 1999? 10 DR. GLENN TAYLOR: Correct. 11 MS. JENNIFER MCALEER: All right. And 12 what do you recall, Dr. Cutz, as to what was discussed at 13 the staff meeting? 14 DR. ERNEST CUTZ: I think, at that point, 15 it was qua -- kind of unclear as to what Dr. Smith's 16 involvement was and what -- whether there may be some 17 misinformation because the Coroner's Office officials 18 were sort of backing Dr. Smith. 19 So it gave -- gave an impression that, you 20 know, this was something which -- which is still not 21 resolved or it's, you know, not clear what -- what the 22 problems are, and so we were kind of waiting to see what 23 -- how it will evolve. 24 MS. JENNIFER MCALEER: And was Dr. Smith 25 present at that meeting when it was discussed?

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1 DR. ERNEST CUTZ: No, he wasn't. 2 MS. JENNIFER MCALEER: Okay. And do you 3 recall whether Dr. Becker indicated that he was going to 4 speak to Dr. Smith about this issue? 5 DR. ERNEST CUTZ: I think, initially, Dr. 6 Becker, because as -- as I mentioned, we were not really 7 sure what -- what they -- what the story was about, and I 8 think he wanted to find out more about it, maybe talking 9 to Dr. Smith, but whether he did; I don't know. 10 MS. JENNIFER MCALEER: Okay. Do you know 11 if Dr. Becker made any inquiries of the OCCO about the 12 program? 13 DR. ERNEST CUTZ: I don't believe so. I 14 -- I don't think -- but I don't know; I don't know. 15 MS. JENNIFER MCALEER: Are you aware of 16 any other discussions, internally, at HSC about the Fifth 17 Estate video, or any changes that may have been made, or 18 decisions that may have been taken as a result of the 19 airing of that program? 20 DR. ERNEST CUTZ: Well, some of the 21 staff, you know, asked us what we knew about it, and, you 22 know, I just didn't really know more than what the 23 program showed. 24 MS. JENNIFER MCALEER: You say "some of 25 the staff", do you mean the pathology assistants?

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1 DR. ERNEST CUTZ: No, the staff in the 2 hospital. 3 MS. JENNIFER MCALEER: Oh, the other 4 staff is the -- 5 DR. ERNEST CUTZ: Other staff, yes, 6 clinicians. 7 MS. JENNIFER MCALEER: I see. And did 8 you hear anything more about the Fifth Estate video or -- 9 or any actions taken as a result? 10 DR. ERNEST CUTZ: Well, not -- well, 11 there were some further coverage over -- over the 12 subsequent years, but not -- not especially -- 13 MS. JENNIFER MCALEER: Not in and around 14 this time. 15 DR. ERNEST CUTZ: That's right, yeah. 16 MS. JENNIFER MCALEER: Okay. And you 17 referred to subsequent media coverage. If we go to Tab 18 11 of Volume II. We know that in January of 2001, Dr. 19 Smith wrote to Dr. Young and indicated that he would no 20 longer perform medicolegal autopsies. 21 Now were you aware of this, Dr. Cutz, at 22 the time, that Dr. Smith was no longer going to be 23 performing medicolegal autopsies for the Office of the 24 Chief Coroner? 25 DR. ERNEST CUTZ: No, I became aware of

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1 it by reading an article in the newspaper. 2 MS. JENNIFER MCALEER: You became aware 3 of the fact that he would no longer be doing this work? 4 DR. ERNEST CUTZ: That's right. 5 MS. JENNIFER MCALEER: And if we turn to 6 Tab 86 of the same binder, and it's my understanding this 7 document doesn't actually have a PFP number yet but you 8 should have a PDF of it, Mr. Registrar. It's the Senior 9 Staff Advisory Committee Minutes. Thank you. 10 And that's from the -- first of all, what 11 was the Senior Staff Advisory Committee, Dr. Cutz? 12 DR. ERNEST CUTZ: Well, that's just the 13 name for a staff meeting, to be... 14 MS. JENNIFER MCALEER: All right. 15 And these are the minutes from February 16 16th, 2001. And if we look at the second page, top of 17 the second page, under the heading "Autopsies"? 18 DR. ERNEST CUTZ: Yes. 19 MS. JENNIFER MCALEER: And I think you 20 are listed as being in attendance at that meeting. 21 DR. ERNEST CUTZ: Yes. 22 MS. JENNIFER MCALEER: Yes, you are. 23 "Autopsies: 24 In view of recent events, Dr. Smith 25 will limit his participation in

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1 forensic autopsies. Doctors Wilson and 2 Cutz will do the majority of forensic 3 cases. Dr. Smith will do the HSC 4 cases. Doctors Chiasson and Rose, at 5 the Coroner's Office, will do the 6 pediatric cases that are handled by 7 Doctors Cutz and Wilson -- [sorry] that 8 are not handled by Doctors Cutz and 9 Wilson. Dr. Chiasson holds a cross- 10 appointment to HSC, and Dr. Ross will 11 be cross-appointed." 12 Now do you recall any other discussion at 13 this meeting about the fact that Dr. Smith's 14 participation in forensic autopsies was going to be 15 limited? 16 DR. ERNEST CUTZ: Well, my understanding 17 at that point was that there's going to be review of Dr. 18 Smith's work and that he may be cleared and he may resume 19 his function. There was -- that this is a temporary -- 20 temporary stoppage, kind of. 21 MS. JENNIFER MCALEER: Is that how it was 22 communicated to you at the meeting? 23 DR. ERNEST CUTZ: That -- that was my 24 understanding; that this -- this is not going -- this is 25 a -- this is a temporary arrangement --

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1 MS. JENNIFER MCALEER: And did you have 2 any -- 3 DR. ERNEST CUTZ: -- and it may change in 4 the future. But, you know, depending on the review. 5 MS. JENNIFER MCALEER: And did you have 6 any discussions with Dr. Smith? Did he provide you with 7 any background information or any explanation with 8 respect to the fact that he would no longer be doing the 9 forensic autopsies? 10 DR. ERNEST CUTZ: Not directly, no. 11 MS. JENNIFER MCALEER: And you mentioned 12 the review. As far as you were aware, Dr. Cutz, did the 13 hospital participate in that review in any manner, or did 14 they correspond or discuss the review with the Office of 15 the Chief Coroner. 16 DR. ERNEST CUTZ: No, the review I know, 17 in the newspaper article, it said that Dr. Smith has -- 18 has voluntarily resigned and that he welcomes a review of 19 his -- of his work. That's -- that what it stated. 20 MS. JENNIFER MCALEER: Right. And when 21 you say "resigned" you mean from the medicolegal work? 22 DR. ERNEST CUTZ: Well, stop doing the 23 work for the Coroner's Office. 24 MS. JENNIFER MCALEER: And do you know, 25 Dr. Cutz, whether or not the Hospital for Sick Kids

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  1  participated in that review in any way?
  2                 DR. ERNEST CUTZ:   No, I have no knowledge
  3  of that.
  4                 MS. JENNIFER MCALEER:   Now, as I
  5  understand it, despite the fact that Dr. Smith was no
  6  longer going to be participating in medicolegal
  7  autopsies, did -- he -- he maintained his position as
  8  Director of the Unit?
  9                 Is that correct?
 10                 DR. ERNEST CUTZ:   Yes.
 11                 MS. JENNIFER MCALEER:   And what were your
 12  views, Dr. Cutz, with respect to the fact that Dr. Smith
 13  retained his directorship of the unit?
 14                 DR. ERNEST CUTZ:   Well, my impression was
 15  that, you know, that this is a -- this is a temporary
 16  situation while he's being reviewed and so that, you
 17  know, his function -- his administrative function would
 18  continue.  And since it didn't involve any actual work
 19  with medicolegal cases, you know, he continued to stamp -
 20  - stamp the invoices.
 21                 MS. JENNIFER MCALEER:   And were there --
 22                 COMMISSIONER STEPHEN GOUDGE:   And to
 23  review the reports?
 24                 DR. ERNEST CUTZ:   And at present, review
 25  the reports, yes.

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1 COMMISSIONER STEPHEN GOUDGE: I'm sorry? 2 DR. ERNEST CUTZ: Yes. 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: Did you recall, 6 Dr. Cutz, if he actually reviewed any of your reports, 7 because it looks like you and Dr. Wilson are going to 8 pick up the slack so to speak? 9 DR. ERNEST CUTZ: Yep. 10 MS. JENNIFER MCALEER: Would you submit 11 the reports to him? 12 DR. ERNEST CUTZ: Yes. I mean, the 13 procedure didn't change. In other words, you know, it 14 had to be submitted and stamped and sent out. 15 MS. JENNIFER MCALEER: And were the 16 results of any review ever communicated to you or to your 17 colleagues at the Hospital for Sick Kids? 18 DR. ERNEST CUTZ: Yes, since that 19 article, I didn't hear anything about the review. 20 MS. JENNIFER MCALEER: Dr. Taylor, you 21 returned in 2003. At that point in time, Dr. Smith is 22 still the Director of the Unit, correct? 23 DR. GLENN TAYLOR: Yes. 24 MS. JENNIFER MCALEER: And what was your 25 understanding as to his role at that time?

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1 DR. GLENN TAYLOR: It was predominant -- 2 or primarily administrative. He would be, again, 3 checking the reports and making sure the paperwork going 4 to the Coroner's Office was in -- was in place. 5 MS. JENNIFER MCALEER: And was he 6 actually performing any medicolegal autopsies at that 7 point in time? 8 DR. GLENN TAYLOR: I'd have to check the 9 schedule. I know he did some in 2003, but I can't 10 remember what the -- what the months were that he was 11 doing those in. That stopped shortly after I arrived 12 there though. 13 MS. JENNIFER MCALEER: And why did it 14 stop? 15 DR. GLENN TAYLOR: I think he was -- I 16 can't remember exactly if he was taken off all autopsies 17 or all medicolegal autopsies at that point. This was 18 through direction -- under direction of the -- I think it 19 was the Administration of the hospital for the regular 20 autopsies. That happened later on in the year. 21 And then the Coroner's Office, I think, 22 for the rest of the -- for the coroner's cases. I can't 23 remember exactly the sequence of events. 24 MS. JENNIFER MCALEER: All right. Well, 25 if we look at Tab 25 of Volume II.

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1 (BRIEF PAUSE) 2 3 MS. JENNIFER MCALEER: This is a letter 4 from Dr. McLellan to Dr. Smith copied to you, Dr. Taylor, 5 and it's from July 12th, 2004, accepting Dr. Smith's 6 decision to step aside from the position of Director of 7 the OPFPU. 8 Now to go back to what you said a moment 9 ago, is it your understanding that the hospital may have 10 actually asked him to stop doing hospital autopsies prior 11 to this point? 12 DR. GLENN TAYLOR: I think at one (1) 13 point it was decided just to take him off the autopsy 14 service altogether, and have him focus on doing surgical 15 pathology. And I can't remember the exact timing of all 16 of that. 17 MS. JENNIFER MCALEER: Okay. And -- 18 COMMISSIONER STEPHEN GOUDGE: It was 19 after you came back? 20 DR. GLENN TAYLOR: It was after I came 21 back, yes. 22 MS. JENNIFER MCALEER: And -- 23 COMMISSIONER STEPHEN GOUDGE: So were you 24 involved in that? 25 DR. GLENN TAYLOR: I was involved in

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1 implementing the decision, yes. 2 3 CONTINUED BY MS. JENNIFER MCALEER: 4 MS. JENNIFER MCALEER: Was it your 5 decision? 6 DR. GLENN TAYLOR: No. 7 MS. JENNIFER MCALEER: Whose -- 8 COMMISSIONER STEPHEN GOUDGE: Made above 9 you? 10 DR. GLENN TAYLOR: Yes. 11 COMMISSIONER STEPHEN GOUDGE: By whom, do 12 you know? 13 DR. GLENN TAYLOR: It came to me through 14 the -- I'm can't remember if it was -- sorry, again, I 15 can't remember the exact details. I think it came 16 through the Vice President, but it may have come through 17 Dr. Phillips, who was the acting DPLM Chief, who I 18 reported to. 19 20 CONTINUED BY MS. JENNIFER MCALEER: 21 MS. JENNIFER MCALEER: And do you know 22 why he was taken off hospital autopsies? 23 DR. GLENN TAYLOR: I think it was because 24 of the publicity that was being generated, and they just 25 wanted -- it was a decision to try to cool things down a

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1 little bit. 2 MS. JENNIFER MCALEER: So if he was no 3 longer the Director of the Unit, and possibly no longer 4 doing hospital autopsies, what would he be doing? 5 DR. GLENN TAYLOR: Surgical pathology. 6 MS. JENNIFER MCALEER: And when you came 7 back in 2003, before Dr. -- before Dr. Smith actually 8 gave up the position of Directorship in 2004, did you 9 have any concerns about the fact that he was the Director 10 of the OPFPU? 11 DR. GLENN TAYLOR: I had no concerns with 12 regards to his administrative function. It was -- it 13 seemed to me a little bit strange that if he was not 14 engaged in coroner's cases, that he would still be in 15 that position. 16 But that was not my call at that time. 17 That was up to the Office of the Chief Coroner. 18 MS. JENNIFER MCALEER: And did you ever 19 speak to the Office of the Chief Coroner about the 20 concerns you had? 21 DR. GLENN TAYLOR: Yes. 22 MS. JENNIFER MCALEER: You did? 23 DR. GLENN TAYLOR: Yes. 24 MS. JENNIFER MCALEER: And what was the 25 response?

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1 DR. GLENN TAYLOR: One (1) of the 2 responses, eventually, was that I took over, on interim 3 basis, being the Director of the Unit. That was in -- 4 that was in 2004. 5 MS. JENNIFER MCALEER: When -- when Dr. 6 Smith resigned the position? 7 DR. GLENN TAYLOR: Yes. 8 MS. JENNIFER MCALEER: Okay. And was 9 that shortly after you had voiced your concern to the 10 Office of the Chief Coroner or was there a -- an 11 intervening time period? 12 DR. GLENN TAYLOR: No, no, I think -- I 13 think things -- I think there were decisions in progress, 14 when the conversations that I had with the Office of the 15 Chief Coroner took place, already. 16 MS. JENNIFER MCALEER: I'm sorry, could 17 you elaborate? 18 DR. GLENN TAYLOR: It's -- 19 MS. JENNIFER MCALEER: What -- what was 20 the nature of your discussions with the Office of the 21 Chief Coroner? 22 DR. GLENN TAYLOR: It was basically 23 something to the effect that Dr. Smith was no longer 24 going to be the Director, and would I be interested in 25 taking it over.

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1 COMMISSIONER STEPHEN GOUDGE: Who did you 2 talk to there, do you remember? 3 DR. GLENN TAYLOR: It was Dr. McLellan. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: And again, though, 7 was that shortly before July of 2004 or was that closer 8 to when you came back in 2003? 9 DR. GLENN TAYLOR: It was probably 10 somewhere in the middle, but I can't remember exactly. 11 MS. JENNIFER MCALEER: Okay. And then 12 you took over as Director of the Unit, July 2004? 13 DR. GLENN TAYLOR: Yes. 14 MS. JENNIFER MCALEER: And you maintained 15 the position of Director until October of 2005 when Dr. 16 Chiasson was appointed? 17 DR. GLENN TAYLOR: Yes. 18 MS. JENNIFER MCALEER: Okay. And what, 19 if any, changes did you make to the Unit when you took 20 over? 21 DR. GLENN TAYLOR: The procedure for 22 review of -- of reports was still in place, so I did 23 that. Dr. Chiasson reviewed by reports. I implemented-- 24 COMMISSIONER STEPHEN GOUDGE: Did you 25 consider that an aspect of quality assurance or was that

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1 just pure administration? 2 DR. GLENN TAYLOR: No, I considered it 3 quality assurance as well. It -- from an administrative 4 point of view, there wasn't a lot to do. The secretaries 5 could put all of the paperwork together, so it was more 6 of a quality assurance function. 7 COMMISSIONER STEPHEN GOUDGE: Did it 8 strike you as odd that Dr. Smith had kept that while not 9 doing medicolegal autopsies? 10 DR. GLENN TAYLOR: Well, I think that's 11 what I was trying to explain, yes. 12 COMMISSIONER STEPHEN GOUDGE: Yes. 13 DR. GLENN TAYLOR: I did institute some 14 meeting of the staff that are involved with the Unit, so 15 we had business meetings of the Pediatric Forensic 16 Pathology Unit. I can't remember how many we had. With 17 Dr. Chiasson's help, we started to have more regular 18 rounds with regards to the forensic cases. 19 I'm not sure if there were any other major 20 changes to the Unit at that time. A lot of 21 administrative things were done through the Office of the 22 Chief Coroner with -- with Dr. McLellan to try to tidy up 23 some of the issues that were outstanding. 24 For instance, the contract or agreement 25 hadn't really been addressed since 1991, so that was

299

1 done. And some various -- various other administrative 2 things were done. I did -- 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: So -- 6 DR. GLENN TAYLOR: Sorry. 7 MS. JENNIFER MCALEER: Sorry. I was 8 going to say your -- your current agreement is at Tab 57 9 of the binder. It is -- line 2, it's 033773. 10 DR. GLENN TAYLOR: Yes. 11 MS. JENNIFER MCALEER: And this is the 12 2007 version, but, as I understand it, the significant 13 changes were actually made in 2004? 14 DR. GLENN TAYLOR: That's correct, yes. 15 MS. JENNIFER MCALEER: Okay. And this is 16 the current agreement by which the OPFPU is governed? 17 DR. GLENN TAYLOR: Yes, it is. 18 MS. JENNIFER MCALEER: And it provides 19 for an Executive Committee, that you've referred to 20 before? 21 DR. GLENN TAYLOR: Yes. 22 MS. JENNIFER MCALEER: And what is the 23 role with the Executive Committee? 24 DR. GLENN TAYLOR: It's to meet on an 25 annual basis or more frequently, if necessary, to discuss

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1 issues related to the interactions of the hospital and 2 the Office of the Chief Coroner and the Division of 3 Pathology to air any -- any issue -- any problems that 4 may have been identified. 5 It has some impact on the negotiations for 6 the size of the grant. And this is being looked at, sort 7 of, currently. But primarily, it's -- it's a means of 8 getting the major, sort of, players together to -- in a - 9 - in a form that they can communicate with regards to the 10 provision of pediatric forensic pathology at the Hospital 11 for Sick Children. 12 MS. JENNIFER MCALEER: And do I 13 understand it correctly, Dr. Taylor, that the hospital 14 now has input into who assumes the role of Director of 15 the Unit? 16 DR. GLENN TAYLOR: Yes. 17 MS. JENNIFER MCALEER: And is that 18 different than your understanding as what had been in 19 place in the past? 20 DR. GLENN TAYLOR: I have to go back to 21 the '91 agreement to see how the Director -- maybe it 22 wasn't even in the '91 agreement. 23 MS. JENNIFER MCALEER: I don't -- I don't 24 believe it was. 25 DR. GLENN TAYLOR: Right. So it was

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1 different, yes. 2 MS. JENNIFER MCALEER: Well, different in 3 -- in the fact that it is articulated in a document, -- 4 DR. GLENN TAYLOR: Yes. 5 MS. JENNIFER MCALEER: -- but was it your 6 understanding that prior to 2004 that the hospital had 7 any input into who was the director of the unit? 8 DR. GLENN TAYLOR: I don't think they 9 did. I may be wrong on that, but I don't think that 10 there was an approval required from Administration for an 11 appointment to -- as Director. 12 MS. JENNIFER MCALEER: Does that accord 13 with your recollection, Dr. Cutz? 14 DR. ERNEST CUTZ: I think it's Dr. 15 Phillips who proposed Dr. Smith to take this position, 16 and I think it -- it was -- it was approved by the VP, 17 the Vice-President. 18 MS. JENNIFER MCALEER: That was your 19 understanding at the time? 20 DR. ERNEST CUTZ: Yes, mm-hm. 21 MS. JENNIFER MCALEER: And, Mr. 22 Commissioner, I note that it's after 4:30. If I might -- 23 COMMISSIONER STEPHEN GOUDGE: How are you 24 doing? 25 MS. JENNIFER MCALEER: I'm -- I'm doing

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1 fine. I have probably about ten (10) more minutes if 2 that's fine with you. 3 COMMISSIONER STEPHEN GOUDGE: Sure. 4 MS. JENNIFER MCALEER: Okay. 5 COMMISSIONER STEPHEN GOUDGE: Is -- can 6 we tax your patience for another ten (10) minutes? 7 DR. GLENN TAYLOR: Yes, Commissioner. 8 COMMISSIONER STEPHEN GOUDGE: Thank you. 9 10 CONTINUED BY MS. JENNIFER MCALEER: 11 MS. JENNIFER MCALEER: Thank you. Dr. 12 Taylor, who is currently performing medicolegal autopsies 13 at the Hospital for Sick Children? 14 DR. GLENN TAYLOR: Dr. David Chiasson, 15 myself, Dr. Greg Wilson, and Dr. Gino Summers for some -- 16 for selective cases, and Dr. Pollanen, when he's 17 available. 18 MS. JENNIFER MCALEER: And is there any 19 system of triaging that's in place? Who decides who does 20 which autopsies? 21 DR. GLENN TAYLOR: Dr. Chiasson, as the 22 Unit Director really is an -- is responsible for the 23 triage, and if he's not available, and then -- it's the 24 pathologist that is on duty that is responsible for the 25 triage.

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1 How the triage system works is that first 2 -- first response is by Dr. Chiasson or Dr. Pollanen -- 3 MS. JENNIFER MCALEER: For all cases, Dr. 4 Taylor? 5 DR. GLENN TAYLOR: No, no, these are for 6 the -- sorry, for the criminally suspicious cases. For 7 all cases not criminally suspicious, the pathologist 8 that's on duty is -- sort of, does the case, and if there 9 are any concerns raised by that pathologist, then they're 10 discussed with Dr. Chiasson, if he's available, or 11 myself, or Dr. Pollanen. 12 MS. JENNIFER MCALEER: Okay. And if we 13 can quickly go to Tab 67 of Volume II, PFP137592. You're 14 familiar with this document, Dr. Taylor? 15 DR. GLENN TAYLOR: Yes. 16 MS. JENNIFER MCALEER: And with respect 17 to the second page, 2.2, there is a list of criteria. 18 Does this assist one in the triaging process? 19 DR. GLENN TAYLOR: I think so, yes. 20 MS. JENNIFER MCALEER: And can you 21 explain to us what -- what is the significance of these 22 criteria? 23 DR. GLENN TAYLOR: These are just 24 potential flags that there may be a non-natural cause of 25 death in the child, so there are a number of

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1 circumstantial and historical pointers. 2 In addition, there is some physical 3 findings that may raise suspicion, so the idea is to try 4 to stream the cases so that those who have expertise or 5 are willing, I guess, in a sense, to do the criminally 6 suspicious cases can have those cases directed to them, 7 if necessary, rather than leaving them to the pathologist 8 that is on duty for the foren -- for the medicolegal 9 cases who may not have either the expertise or the 10 interest to do those cases. 11 So it's a -- it's a means of identifying 12 cases to be streamed away from the 95 percent that -- 13 that we usually do. 14 MS. JENNIFER MCALEER: And, Dr. Cutz, you 15 had a discussion with the Commissioner earlier today 16 about pointers. Are these the pointers that you had in 17 mind? 18 DR. ERNEST CUTZ: It -- yes, it's some of 19 them, and -- and in fact, there is a letter at your reach 20 which uses these kind of criteria to -- to do a risk 21 assessment; tell you that -- if you have two (2) or three 22 (3) of these diseases, you know, 80 percent chance, as 23 opposed to different combination of these. 24 COMMISSIONER STEPHEN GOUDGE: How does 25 this list look to you as a viable list, given the

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1 literature you know? 2 DR. ERNEST CUTZ: Well, these are all 3 recognized signs of -- of child abuse. 4 COMMISSIONER STEPHEN GOUDGE: Are there 5 any others that you would add? 6 DR. ERNEST CUTZ: Well, the -- these are 7 pretty obvious ones -- I mean, and anybody doing some 8 work, you know -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. ERNEST CUTZ: -- would need -- need a 11 list like this to -- to remind them that -- 12 COMMISSIONER STEPHEN GOUDGE: So this is 13 a pretty workable list? 14 DR. ERNEST CUTZ: Yes. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: And what internal 18 oversight is there within the department now with respect 19 to the performance of medicolegal work? 20 DR. GLENN TAYLOR: Medicolegal work? 21 MS. JENNIFER MCALEER: Correct. 22 DR. GLENN TAYLOR: There's the review by 23 the director of the autopsy report, which has become a 24 bit more inclusive than it used to be. And in that Dr. 25 Chiasson will not just review the report, but on occasion

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1 he will review the images that are available and perhaps 2 even the slides, before completing his review. 3 The cases are presented at our rounds, so 4 there's an internal QA. And we're now presenting all 5 cases at either the departmental Friday morning rounds or 6 at the add-on forensic rounds, which occur about once 7 every month or every other month. 8 MS. JENNIFER MCALEER: And when you say 9 "all cases" are you including the criminally suspicious 10 cases? 11 DR. GLENN TAYLOR: They are included now, 12 yes. 13 MS. JENNIFER MCALEER: Okay. 14 DR. GLENN TAYLOR: And -- 15 MS. JENNIFER MCALEER: Is there more 16 consultation within the department on medicolegal cases 17 or has that -- 18 DR. GLENN TAYLOR: I think so. I think 19 that there's pretty good communication between -- between 20 the people that are doing the cases now. And certainly 21 if there's any area of expertise, sort of a -- 22 subspeciality area, that somebody has and a question 23 comes up by another person regarding that area then 24 there's pretty -- pretty free interchange of ideas and 25 opinions.

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1 And I think that the unit is -- is quite 2 collegial and I think it's functioning reasonably well 3 right now. 4 MS. JENNIFER MCALEER: And, Dr. Taylor, 5 what is your view as to whether or not the criminally 6 suspicious cases should continue to be done at the 7 Hospital for Sick Children? 8 DR. GLENN TAYLOR: Well, it's a difficult 9 question for me because I don't like doing them myself; I 10 find them very difficult, very tricky, there's too many - 11 - too many variables. And I'm not trained formally in 12 interpretation of many of the injuries that are -- that 13 can be encountered in the 5 percent of case. 14 Fortunately, we have now a full-time staff 15 member who is a Board certified and appropriately trained 16 forensic pathologist to help with those. 17 So the fact that I don't like doing them 18 and somebody else is there kind of removes one (1) major 19 objection to doing them at Sick Kids. 20 On the other hand, they do, I think, 21 distress the staff to a degree. The dissection 22 procedures and some of the other procedures that are -- 23 that may not -- may be necessary to properly examine such 24 a case are beyond what we normally do as far as our usual 25 thorough work-up of autopsy cases. I think --

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1 COMMISSIONER STEPHEN GOUDGE: Would be 2 even more thorough? 3 DR. GLENN TAYLOR: Well, there are 4 specialized dissection techniques that we just don't do 5 on a regular basis. And I think it's been mentioned 6 about the face dissection and various other things -- 7 COMMISSIONER STEPHEN GOUDGE: Right, 8 right. 9 DR. GLENN TAYLOR: -- which are -- can be 10 distressing. 11 The issue of having attendance by police 12 doesn't particularly bother me that much. It -- but it 13 is a hospital and having police with guns walking through 14 the halls is a bit upsetting to some of the staff. 15 So those are the -- the reasons for maybe 16 moving it away; having access to the secure environment 17 at the Office of the Chief Coroner, for instance, if 18 that's where they went; having the forensic pathologist 19 there for their input. 20 On the other hand, the reasons for keeping 21 those cases are the same the reasons for keeping the 95 22 percent that are essentially pediatric disease-related 23 deaths, and that is the -- the facilities that we have; 24 the expertise in pediatric pathology that we have; the 25 accessibility of pediatric radiologists -- not just the

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1 radiologist, but the pediatric -- sorry, the radiology 2 technologists who deal with children and can take x-rays 3 of children appropriately; having the neuropathologist in 4 the -- in the division just down the hall to -- to help 5 with the cases; having the various laboratories that we 6 deal with; the cases with the investigation all handy are 7 all reasons to keep them. 8 So I'm kind of torn a little bit. I think 9 we can do them. My personal feeling is that I don't want 10 to do them but if David wants to do them then I think we 11 can tolerate that. But there are -- there are good 12 reasons for -- for perhaps moving them out of the 13 hospital. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: And, Dr. Cutz, I 17 understand you are no longer doing medicolegal autopsies, 18 is that correct? 19 DR. ERNEST CUTZ: Yes. 20 MS. JENNIFER MCALEER: And I understand 21 one (1) of the reasons is because of a -- a difference -- 22 or your -- your views with respect to the area of SIDS 23 research. 24 Is that correct? 25 DR. ERNEST CUTZ: Yes.

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1 MS. JENNIFER MCALEER: And can you please 2 explain to the Commissioner your concerns in that area? 3 DR. ERNEST CUTZ: Well, there was a 4 number of reasons. This is -- in 2006 I decided that 5 under those circumstances I, you know, better not 6 continue in this work because it made it difficult for 7 me. 8 But anyway, there was sort of three (3) 9 concerns. One (1) -- one (1) is that, you know, the 10 academic component has been markedly diminished to -- to 11 practically non-existent; it's heavy emphasis on the 12 forensic. 13 So the investigation part, for example, 14 look at genetic defects, molecular defects, you know, 15 it's practically non-existent. And things that we should 16 be doing at the leading hospital are not being done. 17 I think the -- you know, there's been a 18 change in attitude. In the '90s as far -- you know, from 19 the '90s, as far as what direction the SIDS research is 20 taking. One (1) good example is -- is the State of 21 California, which has -- has a special legislation which 22 mandates and supports research into Sudden Infant Deaths 23 and Sudden Infant Death Syndrome. And out of that work 24 has come some very interesting new findings in relation 25 to the SIDS, made possible because of -- because of that.

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1 And I feel that Ontario is kind of lacking behind on 2 this. 3 And at one (1) point we were the 4 powerhouse of SIDS research, you know, that has -- that 5 has kind of stopped. And the -- the coroner arrangement, 6 even the new -- new agreement doesn't include research or 7 academic component; it's heavily, heavily forensic. 8 The other thing, I disagree in terms of 9 how should these cases be classified, and as I explained, 10 I participated in these two (2) panels. One (1) -- the 11 latest one (1) in 2004, which was an international panel, 12 included five (5) forensic pathologists, three (3) 13 pediatric pathologists -- pediatricians, to decide -- 14 review the situation when we use SIDS, when we SUDS, when 15 we use -- and there is very clear criteria on -- on how 16 this would be used. 17 And I find that in Ontario this is not 18 being followed. A lot of the cases are classified as "is 19 undetermined" or "overlaying," or -- which I think it 20 skews the statistics. 21 MS. JENNIFER MCALEER: "Overlaying," you 22 mean sleeping condition? 23 DR. ERNEST CUTZ: That's right, yeah. So 24 those are outdated concepts. 25 And the third was I had some issues with -

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1 - with Dr. Chiasson's management style. 2 MS. JENNIFER MCALEER: Just a difference 3 of personalities? 4 DR. ERNEST CUTZ: Yeah. 5 MS. JENNIFER MCALEER: Thank you, Mr. 6 Commissioner. Those are all of my questions unless you 7 have any additional questions? 8 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 9 McAleer. 10 Thank you, gentlemen. And we've prevailed 11 on you fifteen (15) minutes longer then we promised. I 12 hope you'll still come back tomorrow. 13 We will adjourn then until 9:30 tomorrow 14 morning. 15 16 (WITNESSES RETIRE) 17 18 --- Upon adjourning at 4:45 p.m. 19 20 Certified correct, 21 22 _______________ 23 Rolanda Lokey, Ms. 24 25