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 19th, 2007 25


1 Appearances 2 Linda Rothstein (np) ) Commission Counsel 3 Mark Sandler (np) ) 4 Robert Centa (np) ) 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 (np) ) Hospital for Sick Children 22 Barbara Walker-Renshaw ) 23 Kate Crawford (np) ) 24 Paul Cavalluzzo (np) ) Ontario Crown Attorneys' 25 Association


1 APPEARANCES (CONT'D) 2 Mara Greene ) Criminal Lawyers' 3 Breese Davies (np) ) Association 4 Joseph Di Luca (np) ) 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 (np) ) 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 (np) ) of Toronto and Nishnawbe 21 Sheila Cuthbertson (np) ) Aski-Nation 22 Julian Falconer (np) ) 23 24 25


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


1 TABLE OF CONTENTS Page No. 2 3 ERNEST CUTZ, Resumed 4 GLENN PAUL TAYLOR, Resumed 5 6 Cross-Examination by Ms. Erica Baron 6 7 Cross-Examination by Mr. Phillip Campbell 22 8 Cross-Examination by Mr. Peter Wardle 60 9 Cross-Examination by Ms. Vanora Simpson 96 10 Cross-Examination by Ms. Suzan Fraser 109 11 Cross-Examination by Ms. Luisa Ritacca 119 12 Cross-Examination by Ms. Carolyn Silver 160 13 Cross-Examination by Mr. William Carter 176 14 Re-Direct Examination by Ms. Jennifer McAleer 269 15 16 17 Certificate of transcript 271 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. Okay, you all have the list. I had to pare a 7 few people back a little bit just so we could finish at 8 the end of today as we're required to, to get on with the 9 witnesses we have tomorrow, and release Doctors Cutz and 10 Taylor. 11 So we begin with you, Ms. Baron. 12 13 ERNEST CUTZ, Resumed 14 GLENN PAUL TAYLOR, Resumed 15 16 CROSS-EXAMINATION BY MS. ERICA BARON: 17 MS. ERICA BARON: Good morning. My name 18 is Erica Baron, I'm one (1) of the lawyers for Dr. Smith. 19 And Dr. Cutz, I hope you won't be offended, but I'm not 20 going to have any questions for you today. But Dr. 21 Taylor, I do have a few questions for you. 22 DR. GLENN TAYLOR: Okay. 23 MS. ERICA BARON: I'm wondering if you 24 can -- if we can just start briefly with something that 25 was raised with Ms. McAleer -- that you raised with Ms.


1 McAleer yesterday about whether Dr. Smith ever stopped 2 performing hospital autopsies? 3 DR. GLENN TAYLOR: Yes. 4 MS. ERICA BARON: And -- and you had some 5 question in your mind as to whether that had ever 6 happened or not, and I'm hoping that I can help you sort 7 of resolve that question. 8 DR. GLENN TAYLOR: Okay. 9 MS. ERICA BARON: If you could turn up 10 the Senior Pathologist Rotation Schedule binder, Tab 78. 11 It's, Registrar, PFP116976. And it appears to me -- this 12 is the -- the schedule from April of 2005. And if you 13 look in the -- the week of April 4th, 2005. 14 I take it surgicals is surgical pathology, 15 autopsy is hospital autopsies, coroner is medicolegal 16 autopsies. 17 Am I understanding the schedule correct? 18 DR. GLENN TAYLOR: Yes. 19 MS. ERICA BARON: And this appears to 20 show that Dr. Smith was on schedule for doing autopsies 21 in April of 2005? 22 DR. GLENN TAYLOR: Yes, it does. And I'm 23 a bit embarrassed, because I made up this schedule. 24 MS. ERICA BARON: No, that's fine, I just 25 -- so -- so does this help clarify for you that Dr. Smith


1 never did stop doing autopsies, hospital alone autopsies 2 at the hospital? 3 DR. GLENN TAYLOR: Yes, it does. 4 MS. ERICA BARON: Now, Dr. Taylor, you 5 were asked some questions by Ms. McAleer yesterday about 6 Dr. Smith's skills as a surgical pathologist and I want 7 just turn to talk about that briefly. 8 Would you agree with me that the standards 9 expected of pediatric pathologists at Sick Kids are very 10 high? 11 DR. GLENN TAYLOR: Yes. 12 MS. ERICA BARON: And that many of cases 13 being handled by Sick Kids are amongst the more 14 challenging from a diagnostic perspective? 15 DR. GLENN TAYLOR: Yes, I agree. 16 MS. ERICA BARON: And you told us with 17 respect to some of the concerns that Ms. McAleer took you 18 to with Dr. Smith's surgical pathology diagnoses in the 19 1997 period and -- and an earlier one referred to by Dr. 20 Cutz that these were challenging diagnoses? 21 DR. GLENN TAYLOR: Yes, I agree with 22 that. 23 MS. ERICA BARON: Now, I want to move 24 forward to something that Ms. McAleer didn't take you to 25 yesterday, in 2005, when I understand that you took steps


1 to obtain an external review of Dr. Smith's surgical 2 pathology work? 3 DR. GLENN TAYLOR: Yes, I did. 4 MS. ERICA BARON: Now, before I go to 5 that external review, I'm wondering if you can turn to 6 the reviews that you conducted, the annual reviews that 7 you conducted, of Dr. Smith in 2003/2004, 2004/2005 8 period. And those are found in Volume III at Tabs 43 and 9 44. 10 DR. GLENN TAYLOR: Yes, I have those. 11 MS. ERICA BARON: So let's start with -- 12 let's start with the 2003/2004 one, which is found at Tab 13 44. I'm wondering if you can help me by just confirming 14 that the column "A" is above average, the column "B" is 15 excellent and the column "C" is very good. 16 That's what those letters stand for in 17 this evaluation? We don't have the attachment. 18 DR. GLENN TAYLOR: Yes, that's correct. 19 MS. ERICA BARON: Okay. And so would it 20 be fair to say that your assessment of Dr. Smith in the 21 2000 -- his work in 2003/2004 period was that in all 22 categories he was very good or excellent? 23 DR. GLENN TAYLOR: That's correct, yes. 24 MS. ERICA BARON: And then if you could 25 turn to the -- the previous tab, which is the 2004/2005


1 evaluation you did of Dr. Smith. 2 DR. GLENN TAYLOR: Yes, I have that. 3 MS. ERICA BARON: He's actually gotten 4 better. He's excellent in all categories, by your 5 assessment. 6 DR. GLENN TAYLOR: Correct. 7 MS. ERICA BARON: So I take it that your 8 decision to seek an external review of Dr. Smith's 9 surgical pathology work was not driven by any concerns 10 that you had about his skills as a surgical pathologist? 11 DR. GLENN TAYLOR: That's correct. 12 MS. ERICA BARON: Right. But 13 nonetheless, you thought it was a prudent step to confirm 14 your view of Dr. Smith's -- Smith's surgical pathology 15 work? 16 DR. GLENN TAYLOR: I thought it prudent 17 to test my opinion of Dr. Smith's abilities, yes. 18 MS. ERICA BARON: All right. And I take 19 it that you decided to retain Dr. Dimmick, who's a 20 pediatric pathologist at the University of British 21 Columbia? 22 DR. GLENN TAYLOR: That's correct. 23 MS. ERICA BARON: I assume he's at a 24 hospital, but he's a professor at the University of 25 British Columbia, as well?


1 DR. GLENN TAYLOR: Yes, he worked at BC 2 Children's Hospital. He was a colleague of mine and one 3 of my mentors. 4 MS. ERICA BARON: All right. And I'm 5 wondering now if you could turn up Volume III, Tab 45. 6 This is PFP137907. 7 DR. GLENN TAYLOR: Yes. 8 MS. ERICA BARON: And this is a letter 9 dated April 28th, 2005 from you to Dr. Smith. And I take 10 it prior to proceeding with the external review you 11 advised Dr. Smith that you were doing so? 12 DR. GLENN TAYLOR: Yes. 13 MS. ERICA BARON: And you sought his 14 agreement to A) the nature of the review and B) the 15 reviewer that you'd selected? 16 DR. GLENN TAYLOR: That's correct. 17 MS. ERICA BARON: And he agreed to -- to 18 both of those things? 19 DR. GLENN TAYLOR: He agreed. He did not 20 sign the letter. 21 MS. ERICA BARON: Right. I -- I do see 22 that we -- didn't sign the letter, but he did -- he did 23 express his agreement to you in person? 24 DR. GLENN TAYLOR: Yes, he did. 25 MS. ERICA BARON: Okay. So if you could


1 turn then -- you'll have to pick up a new volume, I'm 2 afraid. This is Volume II. It's Tab 40 in Volume II. 3 It's PFP137904. 4 DR. GLENN TAYLOR: I'm sorry, which tab 5 number is that? 6 MS. ERICA BARON: 40. 7 DR. GLENN TAYLOR: 40. 8 MS. ERICA BARON: First, I want to 9 understand that you didn't select a random sampling of 10 cases for Dr. Dimmick to review. You actually set about 11 selecting cases that were of significance to patient 12 care? 13 DR. GLENN TAYLOR: That's correct. 14 MS. ERICA BARON: And in particular, you 15 selected diagnosis of cancer or other cases that were 16 apparently important to the care that a patient would 17 receive? 18 DR. GLENN TAYLOR: That's correct. 19 MS. ERICA BARON: So this wasn't a random 20 sampling per se, but it was more focussed on the impacts 21 Dr. Smith's surgical pathology work was having patient 22 care. 23 DR. GLENN TAYLOR: That's correct. 24 MS. ERICA BARON: And am I right that you 25 didn't tell, at least from -- on the face of this letter,


1 that you didn't tell Dr. Dimmick what methodology he 2 should use to conduct the review, you simply asked him to 3 advise whether he was in agreement with Dr. Smith's 4 diagnosis? 5 DR. GLENN TAYLOR: I created a form that 6 had various categories on the form that were supposed to 7 be indicted by Dr. Dimmick and the procedure was that he 8 would review the slides, then review the report that Dr. 9 Smith had written and then check off the appropriate box 10 on the form, whether there was a complete agreement, 11 there was disagreement with no consequences to patient 12 care, a disagreement with minor consequences, a 13 disagreement with major consequences. 14 MS. ERICA BARON: All right. So I take 15 it because that's not set out in the letter, that he was 16 to review the slides first and then review Dr. Smith's 17 report. 18 Was that something that came up in a 19 conversation with Dr. Dimmick? 20 DR. GLENN TAYLOR: I can't remember if I 21 specifically said that or if actually Dr. Dimmick just 22 approached it that way. 23 MS. ERICA BARON: Right. But 24 nonetheless, that is how Dr. Dimmick approached his 25 review.


1 DR. GLENN TAYLOR: That's correct. 2 MS. ERICA BARON: So he -- 3 COMMISSIONER STEPHEN GOUDGE: How many 4 slides are there in the typical surgical case? 5 DR. GLENN TAYLOR: Well, it dep -- 6 depends very much on the nature of the case, Mr. 7 Commissioner, so... 8 COMMISSIONER STEPHEN GOUDGE: Say an 9 oncology case? You get a biopsy and then there are 10 slides taken from that then. 11 DR. GLENN TAYLOR: If it's a biopsy, it 12 may be as few as a half dozen slides. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. GLENN TAYLOR: If it's a resection 15 specimen, for instance, of a kidney tumour, it could be 16 thirty (30) or forty (40) slides. 17 COMMISSIONER STEPHEN GOUDGE: I see. 18 Okay, thanks. Sorry, Ms. Baron. 19 20 CONTINUED BY MS. ERICA BARON: 21 MS. ERICA BARON: That's fine. Maybe you 22 could turn then up Tab 42 in that volume, which is 23 PFP137906. 24 DR. GLENN TAYLOR: Yes. 25 COMMISSIONER STEPHEN GOUDGE: Sorry, tab?


1 MS. ERICA BARON: Tab 42. 2 COMMISSIONER STEPHEN GOUDGE: Thank you. 3 4 CONTINUED BY MS. ERICA BARON: 5 MS. ERICA BARON: So -- so you told us 6 that Dr. Dimmick approached it as looking at the slides, 7 and I understand then he reached his own diagnosis about 8 the case and then he looked at Dr. Smith's report. 9 DR. GLENN TAYLOR: That's my 10 understanding, yes. 11 MS. ERICA BARON: Okay. And would he 12 have had some information about the nature of the case? 13 I take it when -- normally pathologists get some sort of 14 information about what kind of case it is. 15 DR. GLENN TAYLOR: He had the -- the only 16 information he had was what was on the report itself, so 17 there's usually a short clinical history or indication of 18 what the clinical problem is. Usually; not always, but 19 usually. 20 MS. ERICA BARON: Right. Okay. And he - 21 - so after he made his own diagnosis he then compared it 22 to Dr. Smith's and filled out these various forms that -- 23 that you don't have in your binders, but -- but we -- we 24 have a sense of what he concluded. 25 I take it the method that Dr. Dimmick


1 used, though, in reaching his own conclusion first and 2 then comparing it to Dr. Smith's conclusion gives you 3 greater confidence in the -- in the validity and 4 reliability of -- of the review that Dr. Dimmick did. 5 DR. GLENN TAYLOR: I -- I think so. It's 6 -- it's sort of a blind test, in a sense; not a true 7 blind test, but it is a -- it is a type of blind test. 8 MS. ERICA BARON: It's not truly blind 9 because he knew he was reviewing Dr. Smith's work. 10 DR. GLENN TAYLOR: Correct. 11 MS. ERICA BARON: But it was blind in the 12 sense that he would not have been influenced in reaching 13 his diagnosis by the diagnosis that Dr. Smith had 14 reached. 15 DR. GLENN TAYLOR: That's correct. 16 MS. ERICA BARON: And so then looking at 17 this letter from Dr. Dimmick and I -- I acknowledge that 18 it -- it didn't go back to you, were you no longer the -- 19 the head of the department at that time? 20 DR. GLENN TAYLOR: This letter -- Dr. 21 Dimmick was actually retained by the hospital through the 22 Vice-president, Dr. Laxer, so his correspondence with 23 regards to this matter officially went through Dr. Laxer. 24 MS. ERICA BARON: But you received a copy 25 in due course?


1 DR. GLENN TAYLOR: I did. 2 MS. ERICA BARON: Including all of the 3 review forms that were attached? 4 DR. GLENN TAYLOR: I have those, yes. 5 MS. ERICA BARON: Okay. And so Dr. 6 Dimmick says the following: 7 "Of the sixty (60) surgical pathology 8 cases, I concur with Dr. Smith's 9 diagnosis in fifty-seven (57)." 10 And that's a 95 percent agreement, right? 11 Correct? 12 DR. GLENN TAYLOR: Yes. 13 MS. ERICA BARON: And in the remaining 14 three (3) we disagree in a minor way that has no negative 15 implications for patient care? 16 DR. GLENN TAYLOR: Correct. 17 MS. ERICA BARON: So this did, indeed, 18 confirm your view at the -- at the relevant time about 19 Dr. Smith's skills as -- as a surgical pathologist? 20 DR. GLENN TAYLOR: That's correct. 21 MS. ERICA BARON: And indeed, it's a 95 22 percent correct rate, which I think is what you told us 23 yesterday you strive for at the Hospital for Sick 24 Children. 25 DR. GLENN TAYLOR: We strive for 100


1 percent, but 95 percent is kind of the accepted limits 2 for any laboratory test. But we certainly strive for 100 3 percent. 4 MS. ERICA BARON: And I take it indeed, 5 because these were some of the more challenging cases 6 that Dr. Dimmick reviewed, there's a good chance that -- 7 that Dr. Smith's error rate is -- is less than 5 percent 8 for -- for that time period? 9 DR. GLENN TAYLOR: I'm not sure I can 10 totally agree with that, but these were challenging cases 11 and there are -- in many of them there were opportunities 12 to make errors that a non-pediatric surgical pathologist 13 may easily make. 14 COMMISSIONER STEPHEN GOUDGE: Where does 15 the 95 percent come from, Dr. Taylor? 16 DR. GLENN TAYLOR: It's -- 17 COMMISSIONER STEPHEN GOUDGE: Is that 18 share amongst world class hospitals or is it something 19 unique to Sick Kids or to the Department? 20 DR. GLENN TAYLOR: Well, it's kind of a 21 generic number, in the sense that any laboratory test -- 22 a normal for any laboratory test is within the 95 percent 23 range, so there's outliers above ninety-seven point five 24 (97.5) and below two point five (2.5). So the normal 25 range for a test is considered to be 95 percent accurate.


1 COMMISSIONER STEPHEN GOUDGE: Okay. When 2 you enunciated it before, I had in my head of perhaps an 3 overly simplistic image that what you were expecting was 4 accuracy in every case, that was your target, what you 5 would tolerate was accuracy in ninety-five (95) our of 6 one hundred (100). 7 I take it that's not quite what the 95 8 percent represents? 9 DR. GLENN TAYLOR: No, it's not quite 10 what it means, Commissioner. We try to get 100 percent 11 accuracy. It's recognized that we can't be accurate all 12 the time. And as I mentioned yesterday -- yesterday, 13 there are kind of fallback positions regarding how 14 confident the pathologist is in -- 15 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 16 DR. GLENN TAYLOR: -- making the 17 diagnosis. 18 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 19 DR. GLENN TAYLOR: So we may not make a 20 definitive diagnosis, but we should be able to at least 21 provide information to the surgeon or to the oncologist 22 that helps him with the immediate management of -- of the 23 patient. 24 COMMISSIONER STEPHEN GOUDGE: Okay. But 25 for quality assurance purposes, how do you know when your


1 diagnostic rate, however it's measured, falls below what 2 you want? 3 DR. GLENN TAYLOR: We have a policy -- or 4 procedure for comparing frozen section diagnoses with the 5 final result. So that's one (1) way that we check -- 6 check that. And -- 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. GLENN TAYLOR: -- if there are major 9 discrepancies, then a reason is looked for. So that 10 information comes to me. 11 COMMISSIONER STEPHEN GOUDGE: Okay. 12 Thanks. Thanks, Ms. Baron. 13 14 CONTINUED BY MS. ERICA BARON: 15 MS. ERICA BARON: So -- so thinking about 16 it in the context that you've just put about if -- if 17 there's not certainty about the diagnosis, then at least 18 you'd be able to give some information to the clinician 19 that will assist them in -- in patient care. 20 Taking it from that perspective, given 21 that the three (3) cases that Dr. Dimmick had concerns 22 with, that he didn't agree entirely with Dr. Smith, they 23 had no impact for patient care, so in that sense, it was 24 100 percent pass rate for Dr. Smith? 25 DR. GLENN TAYLOR: Well you can look at


1 it that way, yes. But I deliberately structured the 2 report forms -- because the exercise in my mind was to 3 find -- to determine whether or not Dr. Smith was making 4 errors -- if he was making errors that had an impact on 5 patient care. That's the bottom line. 6 So this is how I structured the form. And 7 having three (3) out of sixty (60) that are minor 8 differences perhaps in interpretation or a diagnosis that 9 sort of is similar to but not the same as -- as one (1) 10 thing, but if -- if those differences had an impact on 11 patient care, I'd want to know about that. In this case 12 they didn't, and therefore as far as I'm concerned, 13 they're kind of in a sense noise. 14 COMMISSIONER STEPHEN GOUDGE: Kind of off 15 the table? 16 DR. GLENN TAYLOR: They're in a -- kind 17 of background noise in this situation. 18 COMMISSIONER STEPHEN GOUDGE: And I 19 suppose you might well be able to say to yourself, As 20 with the three (3) I'm not sure who's, quote, "right", 21 Dr. Dimmick or Dr. Smith? 22 DR. GLENN TAYLOR: I -- I actually can't 23 remember looking specifically at the three (3) cases, so 24 I don't know for sure if I can say who's -- 25 COMMISSIONER STEPHEN GOUDGE: If you


1 served as a tie breaker or not? 2 DR. GLENN TAYLOR: Correct. 3 4 CONTINUED BY MS. ERICA BARON: 5 MS. ERICA BARON: So -- so to make it 6 clear, Dr. Smith's surgical pathology work was not having 7 a negative impact on patient care for the -- for this 8 period of time? 9 DR. GLENN TAYLOR: In my opinion, and 10 that's why he retain -- he remained on the surgical 11 pathology service performing those duties. 12 MS. ERICA BARON: And to the contrary, 13 his surgical pathology work was providing important 14 information for -- for patient care at the Hospital for 15 Sick Children? 16 DR. GLENN TAYLOR: As we expect, yes. 17 MS. ERICA BARON: Yes. Thank you, those 18 are my questions. 19 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 20 Baron. 21 Mr. Campbell...? 22 23 CROSS-EXAMINATION BY MR. PHILLIP CAMPBELL: 24 MR. PHILLIP CAMPBELL: Good morning 25 Doctors. My name is Phil Campbell, I work -- I act for a


1 number of people who were brought before the courts in 2 cases where Dr. Smith was involved. 3 I'm not sure anybody else is going to 4 pursue Ms. Baron's line of questioning with you, so I 5 just want to ask you, Dr. Taylor, having surveyed 6 yesterday the views of -- of Dr. Becker and the 7 background concerns, I think primarily of the Chief 8 Oncologist in the '90s, about Dr. Smith's surgical 9 pathology, and then having seen your own assessments of 10 him today, fortified by Dr. Gimmick, I'm wondering how we 11 should, at the end of that survey, square the concerns in 12 the '90s, which were documented, with your own views in 13 the period in 2005. 14 DR. GLENN TAYLOR: Well, the errors that 15 were identified in yesterday's testimony are real errors. 16 The issue is what happ -- what was happening at the time 17 and what kind of focus and concentration perhaps Dr. 18 Smith was having on those surgical cases and what -- what 19 his focus was on other matters; like his medicolegal or 20 autopsy cases. 21 I think over the subsequent ten (10) 22 years, Dr. Smith did obtain his American Board of 23 Pathology's specialty qualifications in pediatric 24 pathology so there had to be some studying and renewing 25 of information for that process, so I suspect that he was


1 doing some reading and re-learning in preparation for 2 that event. 3 And then in 2000 and on, his medicolegal 4 work was being de-emphasized from a point of view of the 5 amount of time that he was spending on it, and his 6 surgical pathology work was -- was being retained and 7 maybe, I haven't looked at the numbers, perhaps even 8 increasing, compared to his '90s. So he's getting more 9 experience and he was seeing more stuff and he was having 10 to deal with more problems and therefore being forced to 11 focus, I think, a little bit more on -- on the surgical 12 pathology. 13 And certainly when I came back to Toronto 14 in 2003, I knew Charles as an intelligent person and 15 certainly somebody who had the ability to do surgical -- 16 pediatric surgical pathology in an appropriate manner. 17 And I did not have major concerns when I first arrived 18 there with regards to his surgical pathology abilities. 19 My major concern that I had with him was the turnaround 20 time for his surgicals and he still had some autopsies 21 that I had some concerns about. 22 The issue of his abilities as a surgical 23 pathologist, I think was primarily driven by the adverse 24 publicity that he had with regards to his dealings with 25 the -- with medicolegal autopsies. And there was some


1 impetus to really test his surgical pathology abilities, 2 which I did not think were significantly lacking. 3 But that's how the test arose and I think 4 it was a reasonably appropriate test, in that the cases 5 that were selected were those that could have significant 6 impact on patient care. 7 MR. PHILLIP CAMPBELL: When you did your 8 own assessments in the early 2000s and initiated Dr. 9 Dimmick's review, you were unaware of the criticisms in 10 the late '90s. 11 Is that right? 12 DR. GLENN TAYLOR: That's correct, yes. 13 MR. PHILLIP CAMPBELL: You've said those 14 were real errors and significant matters that are 15 documented in the late '90s, and you offered the theory 16 yesterday or the sort of rationale for this, that a 17 doctor may be strong in one (1) area but weak in another, 18 and that substandard surgical pathology skills don't 19 necessarily reflect on his capacity to do sophisticated 20 criminal -- criminally suspicious cases, for example. 21 DR. GLENN TAYLOR: Yes, I said that. 22 Yes. 23 MR. PHILLIP CAMPBELL: Wouldn't you agree 24 with me that that rationale, while a possibility is only 25 a possibility, and that substandard surgical pathology


1 skills may also reflect a broader lack of overall medical 2 ability? 3 DR. GLENN TAYLOR: I have to agree with 4 that statement. In my -- my experience, however, I have 5 colleagues who are very good in one (1) area and not so 6 good in the other area, and it main -- mainly comes down 7 to interest, and focus, and the time spent doing things. 8 As -- and -- I think I mentioned that I 9 have some colleagues that are doing autopsies and 10 medicolegal autopsies included that I would not put on 11 surgical pathology because -- simply because of their 12 sort of lack of training to the current standards that 13 are expected for surgical pathologists and the 14 expectations that the clinical services have in the 15 Hospital for Sick Children for in-depth knowledge with -- 16 with regards to their particular disciplines. 17 MR. PHILLIP CAMPBELL: Okay. What we 18 know now is that the surgical pathology shortcomings were 19 recognized and documented in the '90s, and that there was 20 no review at that time of whether his other work 21 reflected a similar level of shortcomings. No review at 22 that time, but there has, of course, been a review very 23 recently. 24 Am I right in saying that if you were, for 25 instance, in a management capacity and you sought a


1 reference from a previous employer and the things that we 2 see documented in the late '90s about Dr. Smith were 3 drawn to your attention, as you sought a -- a reference 4 for a perspective employee, those findings would be of 5 concern to you in a hiring decision? 6 DR. GLENN TAYLOR: They would be, 7 depending upon the job description of the person. If I 8 was looking for a surgical pathologist, I have to agree 9 that I'd be concerned, yes. 10 MR. PHILLIP CAMPBELL: And if you were 11 looking for a forensic pathologist are you saying that 12 you would be unconcerned, or are you saying that you 13 would have an open mind and want to find out whether his 14 -- his other skills were similarly lacking? 15 DR. GLENN TAYLOR: Well, I -- yeah. No, 16 I would -- if -- if I was looking for a forensic 17 pathologist, I would certainly want to get some more 18 information about the -- the abilities of the person 19 with regards to forensic pathology. If I was looking for 20 a kidney pathologist, I would certainly want to know the 21 background and the training and sort of the track record 22 of -- of such a person with regards to kidney pathology. 23 So -- and they're different disciplines, 24 so depending upon what I would be looking for I would 25 want to make sure that the fit is appropriate for the


1 discipline that I'm hiring for. 2 MR. PHILLIP CAMPBELL: The surgical 3 pathology findings that are documented by Dr. Becker 4 would surely, I suggest, cause you to want more 5 information about this perspective hire -- hire 6 candidate? 7 DR. GLENN TAYLOR: Again, if I was 8 looking for somebody to do cardiovascular pathology, it 9 may not be totally relevant. I'd really want to know 10 about the cardiovascular pathology abilities of that 11 person. 12 If I was hiring into -- if I looking for 13 primarily a surgical pathologist, yes, I would definitely 14 be concerned and want more information. 15 MR. PHILLIP CAMPBELL: Okay. The -- I 16 want to go back to "think dirty", and then mostly still 17 questioning you on this, Dr. Taylor. You and Dr. Cutz 18 expressed somewhat different understanding yesterday of 19 what that term can mean and how it can be applied by 20 pathologists who are -- who are encouraged to think that 21 way. 22 And -- and you, Dr. Taylor, view it as a - 23 - as a kind of caution, as a warning to be alert to the 24 possibility that something dirty has happened? 25 DR. GLENN TAYLOR: Yes.


1 MR. PHILLIP CAMPBELL: Do you see how 2 another -- another pathologist or another reader of that 3 memo could view "think dirty" as a kind of -- as a kind 4 of analytical starting point, so that if there's an 5 unexplained or mysterious death they are to regard it as 6 dirty until they can find enough evidence to satisfy 7 themselves that it's not dirty? 8 DR. GLENN TAYLOR: I think that's a 9 possibility with that wording, yes. And I probably would 10 have worded things a little bit differently and I think I 11 mentioned that yesterday. 12 MR. PHILLIP CAMPBELL: Yes, I understand. 13 But that's a distinction that you understand, between it 14 just being a caution and being treated as something more 15 than just a caution, but as a kind of tool of analysis? 16 DR. GLENN TAYLOR: That's correct, yes. 17 MR. PHILLIP CAMPBELL: Okay. And it 18 would be inappropriate if it's used in the latter way? 19 DR. GLENN TAYLOR: Yes, I agree. 20 MR. PHILLIP CAMPBELL: You heard Dr. 21 Cutz's description of four (4) coroner's cases he'd done 22 where he and Dr. Smith disagreed, and Dr. Smith was 23 drawing significantly more sinister inferences from a 24 body of data than Dr. Cutz was. 25 DR. GLENN TAYLOR: Yes.


1 MR. PHILLIP CAMPBELL: And let's for a 2 moment assume that Dr. Cutz accurately described the 3 important evidence and -- and the nature of the 4 disagreement. I'd like to ask you if -- if you think 5 about those cases, if you can maybe perceive in them and 6 in the disagreement the possible role of thinking dirty 7 in Dr. Smith's own approach. 8 DR. GLENN TAYLOR: Mm-hm. 9 MR. PHILLIP CAMPBELL: The venetian blind 10 case, he had con -- both doctors had conclusive evidence 11 that the child died by hanging in the venetian blind 12 chord. There was no affirmative evidence, as I 13 understand the description, that the child had been 14 placed there deliberately by another person, as opposed 15 to accidentally. 16 On the other hand, as the evidence is 17 presented to us, there's no way to know with any 18 certainty that that didn't happen. If you're thinking 19 dirty, it -- it can fundamentally affect what you're 20 prepared to draw out of that simple and limited fact 21 scenario. 22 Is that fair to say? 23 DR. GLENN TAYLOR: So as stated, I'd have 24 to agree with you, but I wasn't -- or I don't remember 25 being at the presentations that Dr. Cutz made with


1 regards to those cases and what the context of the -- of 2 Dr. Smith's comments were. It may very well have been 3 something like just bouncing things off and -- and maybe 4 Dr. Cutz can better answer what the context was. 5 So as the case is presented, it may have 6 been that somebody, Charles or somebody else, said, well, 7 what about the possibility that it wasn't an accident, 8 did you think -- you know, did you think of that? And -- 9 and I think that's a fair comment to -- to make in the 10 sense of putting out all the possibilities for the -- 11 this situation or the scenario that's presented. 12 Whether that's driving -- whether the 13 "think dirty" sort of idea is driving things -- driving 14 the person making the comment to push the other person, 15 the person whose case that he actually has responsibility 16 for, Dr. Cutz in this case, to change his diagnosis, I 17 don't know, I wasn't -- I can't recall that -- that 18 exchange. 19 Certainly I would not be too annoyed if 20 somebody -- if I was in Dr. Cutz's position and somebody 21 just sort of, well -- well, what about did you think 22 could it be some -- somebody -- deliberately doing to 23 this child? And, you know, I would just probably say, 24 Well, yeah, that's -- this -- that's a possibility, but 25 the -- the weight of the evidence and everything else is


1 by far pointing to it being an accident. 2 MR. PHILLIP CAMPBELL: And if Dr. Smith 3 used -- if Dr. Smith simply put the inquiry as you've 4 described it: have you eliminated homicide here or is 5 there any evidence of homicide here? that would certainly 6 not be -- that would be like the first use of "think 7 dirty"; let's make sure we've covered all the 8 possibilities. 9 DR. GLENN TAYLOR: Yes. 10 MR. PHILLIP CAMPBELL: But if there is a 11 resistance to a finding of accident because of a -- of a 12 starting point, an analytical starting point, to which 13 you are wedded, that is it's dirty until it's shown to be 14 clean, then you have a potentially undesirable use of 15 "think dirty". 16 Is that fair to say? 17 DR. GLENN TAYLOR: I agree with that 18 statement, yes. 19 MR. PHILLIP CAMPBELL: So we -- we might 20 want to know a little bit more about the extent and -- 21 and nature of the disagreement, but I think we appreciate 22 it as an example. 23 And the same thing in the Dextromethorphan 24 example, right? 25 DR. GLENN TAYLOR: Yes.


1 MR. PHILLIP CAMPBELL: And -- and the 2 example about Dr. Smith viewing the -- the death from the 3 fungal ball in the -- in the -- I guess in the throat or 4 the esophagus as -- as indicative of Munchausen By Proxy, 5 that is a relatively rare phenomenon, fair to say? 6 DR. GLENN TAYLOR: Yes. 7 MR. PHILLIP CAMPBELL: And if you've got 8 on the one hand a viable theory that accounts for a 9 child's death and no positive evidence of Munchausen By 10 Proxy, you have to -- you have to cling to a theory of -- 11 of dirty in order to interpret those facts, insofar as we 12 know them, as indicative of -- of homicide, correct? 13 DR. GLENN TAYLOR: I'm -- I'm sorry, I 14 think I kind of lost you there. 15 MR. PHILLIP CAMPBELL: I'm just -- I 16 guess what I'm saying is that on the facts of that case 17 as described to us, it is a stretch to go from 18 eliminating Dr. Cutz's diagnosis, of which there was at 19 least the evidence of the existence of the fungal ball, 20 to Munchausen By Proxy, for which, as far as we know, 21 there was no positive evidence. 22 DR. GLENN TAYLOR: I agree it's a bit of 23 a stretch, yes. 24 MR. PHILLIP CAMPBELL: And working from a 25 presumption or an analytical starting point of homicide,


1 could get you there but it would be an undesirable way of 2 thinking. 3 DR. GLENN TAYLOR: I agree with that 4 statement as well, yes. 5 MR. PHILLIP CAMPBELL: All right. Both 6 of you have been alive to and very candid about the 7 advantages of training in forensic pathology for doctors 8 doing criminally suspicious cases. Or put differently, 9 you've both been very aware of the disadvantages of not 10 having that training. 11 DR. GLENN TAYLOR: Yes. 12 MR. PHILLIP CAMPBELL: That's correct 13 for -- 14 DR. GLENN TAYLOR: That's correct. 15 MR. PHILLIP CAMPBELL: -- both of you? 16 DR. GLENN TAYLOR: Yes. 17 MR. PHILLIP CAMPBELL: Dr. Cutz, as well? 18 DR. ERNEST CUTZ: Mm-hm. 19 MR. PHILLIP CAMPBELL: The Commissioner 20 may see fit to make recommendations about the 21 qualifications that are either required or desirable to 22 do forensic work and especially in the pediatric sphere. 23 And I'd like you both, if you would, to be 24 a bit more specific about where you, as obviously highly 25 qualified pediatric pathologists, feel the want of -- of


1 focussed forensic training in terms of the boundaries you 2 set about the work you want to do and the comfort you 3 feel with it. 4 Maybe Dr. Cutz, you'd care to go first in 5 that. 6 DR. ERNEST CUTZ: Yes. I think, you 7 know, forensic medicine is a -- is quite a complex 8 discipline with different sets of principles and 9 knowledge from a regular medical practice and, therefore, 10 I think it requires study and experience to -- to do it 11 in the proper way. 12 And I -- I think, you know, it's -- in any 13 other branch of medicine, you know, the specialist -- 14 this is why you have specialists because they are well- 15 versed in -- in -- in the sort of background knowledge 16 and -- and the information they require for their work. 17 MR. PHILLIP CAMPBELL: That's being 18 fairly general. 19 DR. ERNEST CUTZ: Yeah -- 20 MR. PHILLIP CAMPBELL: My questions is to 21 -- is to ask you to be a bit more specific -- 22 DR. ERNEST CUTZ: Yeah. 23 MR. PHILLIP CAMPBELL: -- in terms of the 24 kinds of things you look at the autopsy table and -- 25 DR. ERNEST CUTZ: Right.


1 MR. PHILLIP CAMPBELL: -- say, Boy, I 2 wish I knew a bit more about this area. 3 DR. ERNEST CUTZ: It has more to do with, 4 you know, the way the information is handled and the way 5 the information is presented in courts of law, which, you 6 know, one needs to be trained in that. It's not as much 7 to do with actual pathology knowledge. 8 But what I -- I would suggest that, you 9 know, any forensic work or any case which has a forensic 10 aspect is better done by somebody who -- who is fully 11 trained in forensic pathology. 12 MR. PHILLIP CAMPBELL: And you feel 13 strongly about this? 14 DR. ERNEST CUTZ: Yes. 15 COMMISSIONER STEPHEN GOUDGE: Can I just 16 ask, Mr. Campbell: Dr. Cutz, you have been clear that 17 the component of forensic pathology that focusses on what 18 you call the presentation of the information, from the 19 point of the autopsy through to the court proceeding, is 20 a very important part of the specialty. 21 But just dealing with the pathology piece 22 of forensic pathology, is it possible to differentiate 23 forensic pathology from pediatric pathology this way; 24 that pediatric pathology focuses on -- has as its primary 25 experience-base, disease as opposed to injury?


1 DR. ERNEST CUTZ: That's correct. 2 COMMISSIONER STEPHEN GOUDGE: And would 3 it be the reverse for forensic pathology? 4 DR. ERNEST CUTZ: Yes. 5 COMMISSIONER STEPHEN GOUDGE: I mean, 6 what do you think of that? 7 It is obviously a matter of emphasis, but 8 is there any sort of element of truth to the 9 differentiation I just invited Dr. Cutz to comment on? 10 DR. GLENN TAYLOR: I think there's a grey 11 zone. Forensic pathologists certainly are trained to 12 determine the cause of death and the cause of death is 13 often, even in adults, disease not trauma or homicide. 14 So they're trained to do that and they're trained to do - 15 - to do it on children as well. 16 The extent of the training with regards to 17 death determination in children when it comes to 18 pediatric diseases or the complications of treatment of 19 pediatric diseases like the various types of surgeries or 20 chemotherapy and so on, isn't as deep as it is for a 21 pediatric pathologist that's working in a tertiary care 22 pediatric hospital. 23 So the forensic pathologist can determine 24 death in a child -- in children. The -- the issue is 25 missing some things perhaps and under-recognizing


1 pediatric disease or treatments for pediatric disease in 2 the -- in the determination. 3 Pediatric pathologists that deal with -- 4 that do autopsies do have experience in certain kinds of 5 traumatic deaths in children, inflicted injury deaths, 6 and they include things like the Shaken Baby Syndromes. 7 And most pediatric pathologists that are involved in that 8 -- and there's not so many in North America; in Canada, 9 yes, not in United Stated, but certainly in the UK -- are 10 cognizant of the controversies and the sort of pitfalls 11 in dealing with those kind of cases, and often want a 12 forensic pathologist to be either involved or actually 13 doing those kind of cases. 14 But they're certainly trained in dealing 15 with some kinds of traumatic injuries. And it's -- 16 COMMISSIONER STEPHEN GOUDGE: What I 17 would call injury -- 18 DR. GLENN TAYLOR: And it's part of the - 19 - it's part of the examinable content for the American 20 Board of Pathology examination in pediatric pathology, 21 forensic pathology, is included in that, and traumatic 22 injuries to children are included in that. So there is - 23 - there is a grey zone and an overlap. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. GLENN TAYLOR: So it becomes -- down


1 to, in part, what the -- what the training is of the 2 person and what their experience is and what 3 consultations they have immediately available when things 4 start to look a little more difficult for them. 5 COMMISSIONER STEPHEN GOUDGE: Right. A 6 little big more grey? 7 DR. GLENN TAYLOR: Correct. 8 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 9 Campbell. 10 11 CONTINUED BY MR. PHILLIP CAMPBELL: 12 MR. PHILLIP CAMPBELL: And the same 13 question that I put to Dr. Cutz: Where have -- where, if 14 at all, have you felt the want of focussed forensic 15 pathology training in your own work on -- on coroners' 16 cases? 17 DR. GLENN TAYLOR: I guess my major 18 discomfort over the years has been with injury 19 interpretation and the relevance of the injuries that are 20 present to the cause of death of the child. 21 And I -- as an example, I can give you a - 22 - a case that I had in which the child did have external 23 evidence of injury, but the autopsy found another 24 potential natural cause of death. And the question then 25 is: What did the child die from and what did the child


1 die with? So how do you separate out potentially 2 conflicting causes of death injury versus a natural 3 disease process that can cause death, but doesn't 4 necessarily have to cause death? 5 So this is where I personally run into 6 trouble. I don't think it's that difficult if -- if 7 there's obvious evidence of inf -- inflicted injury 8 without any other kind of background issues. But 9 unfortunately with children there often are many 10 background issues, so for me as a pediatric pathologist, 11 and I admit basically a disease focus more than forensic 12 pathology, I -- I have trouble sorting those things out 13 and this is where I usually require help. 14 MR. PHILLIP CAMPBELL: Cause of death is 15 obviously a -- a major focus of any autopsy pathologist 16 including in the forensic area, but it -- speaking as a 17 criminal lawyer, I -- I can tell you something that I 18 expect you're already familiar with, which is that the 19 justice system often wants to know from the pathologist 20 an awful lot more than just the clinical cause of death. 21 They want, insofar as they can, to 22 recreate from findings on the body, events that preceded 23 the death of -- of the child or -- or the adult in a -- 24 in a typical case. So they want to know how long was 25 their life after the blow was struck or after the


1 accident. How far away did -- how far did somebody fall 2 or were they thrown. What position was somebody in when 3 they were stabbed and what position was the stabber in. 4 I could go on, and -- 5 DR. GLENN TAYLOR: Yes. 6 MR. PHILLIP CAMPBELL: -- in front of 7 many juries have gone on. What -- 8 DR. GLENN TAYLOR: Mm-hm. 9 COMMISSIONER STEPHEN GOUDGE: You only 10 have forty-five (45) minutes, Mr. Campbell. 11 12 CONTINUED BY MR. PHILIP CAMPBELL: 13 MR. PHILLIP CAMPBELL: I've always been 14 free of -- of that concern. Do you find -- it may be 15 that a lot of those questions in a pediatric case are 16 less prominent, but they must -- they or similar 17 questions must sometimes arise, and I want to ask you 18 whether you're comfortable with that kind of -- 19 DR. GLENN TAYLOR: They do arise, and I 20 am not comfortable with that. In part it's due to 21 perhaps deficiencies in my training in forensic 22 pathology, but also, in children the timing issue is -- I 23 think is extremely complicated. 24 And I think I mentioned something about 25 that yesterday, with -- with regards to wound healing,


1 fracture healing. I think it's a very difficult topic to 2 discuss at an academic venue, and much more difficult to 3 discuss in a -- in the courtroom. 4 MR. PHILLIP CAMPBELL: All right. 5 COMMISSIONER STEPHEN GOUDGE: Can I just 6 follow this up, Mr. Campbell. 7 I would take it -- let me ask it as a 8 question: Am I right, Dr. Taylor, that whether one is 9 speaking of the context Mr. Campbell put to you, that is 10 the pathologist giving evidence or even in a surgical 11 practice, there must be a consciousness on the part of 12 the pathologist about the outer limits of his or her own 13 expertise and not going beyond it? 14 DR. GLENN TAYLOR: That's, in my opinion, 15 a very important attribute to have, yes. 16 COMMISSIONER STEPHEN GOUDGE: How's that 17 inculcated in the speciality? 18 DR. GLENN TAYLOR: It -- you know, it's 19 basically left to the individual pathologist to realize 20 when they're at the end of their ability to confidently 21 offer diagnosis, and they need help. 22 We try to deal with it in an 23 administrative systematic way by having quality assurance 24 policies in place to catch things if they may have gone-- 25 COMMISSIONER STEPHEN GOUDGE: Right.


1 DR. GLENN TAYLOR: -- over that edge. 2 COMMISSIONER STEPHEN GOUDGE: It's at 3 that point, among others, that quality assurance becomes 4 absolutely critical? 5 DR. GLENN TAYLOR: Correct. 6 COMMISSIONER STEPHEN GOUDGE: And that's 7 true of surgical pathology, it's true of forensic 8 pathology. 9 DR. GLENN TAYLOR: It's true of all of 10 pathology, I think. And it -- it does come down to the 11 individual pathologist to recognize and appreciate when 12 they're getting into trouble, or when they just don't 13 know and they need help. 14 COMMISSIONER STEPHEN GOUDGE: Is it an 15 explicit aspect of pathology training? 16 DR. GLENN TAYLOR: It's not explicit, but 17 it certainly is something that people who do pathology 18 should learn fairly quickly. And we have in our training 19 program, like in any other residency program, sort of 20 layers of responsibility that are taken on as the person 21 progresses through their training, and part of that, 22 because it's layered, they know, you know, when they need 23 more information. Information is provided by a 24 subsequent trainee, but then there's another level and so 25 on.


1 So they -- so it should be something that 2 is learned during the training process; how far you can 3 take things, what -- what your knowledge base is in an 4 area and when you need to look at the books to try to 5 sort things out, or when you need to show another person 6 the case to get help on it. 7 COMMISSIONER STEPHEN GOUDGE: Yes. Do 8 you have any comment on this subject, Dr. Cutz? 9 DR. ERNEST CUTZ: Yes. No, I think 10 that's very important thing and I think, like in medical 11 profession generally, this is something which one learns 12 very early on, that, you know, one has to recognize his 13 limits and -- and be ready to seek opinion of others. 14 And also to take a kind of a approach that 15 when you don't know you can look things up, you can 16 explore it to -- to find out and if you reach limits 17 there, then you can ask an opinion of somebody else. 18 And it is a -- it is a behaviour or sort 19 of an approach, which is being assessed actually for the 20 residents. You know, one (1) of the questions that the 21 assessment says: Does -- does this person recognize 22 limits of his knowledge, or does he seek -- or I think, 23 you know, we are -- we are aware of -- of the situation 24 that, you know, this -- are in practice and, you know, I 25 think most of us abide by it.


1 And, you know, do you have a nice 2 collegial environments -- it's no problem to -- to share 3 the information or ask opinions and that's what -- that's 4 what we are in fact doing. 5 COMMISSIONER STEPHEN GOUDGE: Thanks. 6 Sorry, Mr. Campbell. 7 8 CONTINUED BY MR. PHILLIP CAMPBELL: 9 MR. PHILLIP CAMPBELL: Let me just add 10 one (1) piece to this, in terms of identifying and then 11 sticking to the limits of where the science takes you. 12 When you get thrust into the criminal 13 justice system on a coroner's case and there's a murder 14 trial and a dead baby, I'm going to suggest you both 15 probably sensed the enormous desire of the participants 16 in the justice system to get definitive scientific 17 answers from you. 18 And -- and I'd like to speak to whether 19 you've experienced the desire of the police to give you 20 something on timing or something on cause that you're 21 uncomfortable with, or of lawyers, or perhaps even of a 22 judge. 23 DR. GLENN TAYLOR: Well, certainly there 24 is -- there is pressure in that venue, the Court, to be 25 black or white and in pediatric pathology there is black


1 and white, but there's a lot of gray, as well. 2 And I've been personally in a position 3 where I've been pressured to go one way or another and in 4 this one (1) particular instance I still stuck to my guns 5 and said "undetermined", despite information or points of 6 view provided by one side or the other in that -- in that 7 setting. So there -- there is definitely pressure to come 8 up with an answer. 9 And I think in part, training as a 10 pediatric pathologist rec -- where it's recognised that 11 there is a lot of grey in disease and in diagnosis, sort 12 of perhaps makes it, not easier, but in my mind, 13 sometimes more appropriate to stick to undetermined if I 14 really don't know what's going on. But certainly I have 15 been pressured in either way to say one (1) thing or 16 another. 17 MR. PHILLIP CAMPBELL: And it's not all 18 together easy to resist the pressure. 19 DR. GLENN TAYLOR: It's not easy, I 20 agree. 21 MR. PHILLIP CAMPBELL: Do you agree with 22 that, Dr. Cutz? 23 DR. ERNEST CUTZ: Yes. No, as I 24 mentioned yesterday, you see I -- in my practice I try to 25 use a more balanced approach, to look at all the various


1 options and then based on evidence, raise these -- raise 2 these options. 3 And in -- in some cases, or, you know, I 4 would take an approach from a standpoint of a defence 5 pathologist. In other words, if I was a defence 6 pathologist criticising myself, what -- what holes I 7 could find in your evidence, and -- and, you know, so -- 8 so that, you know, to really ensure that the evidence I'm 9 presenting, I can defend it from, you know, both -- both 10 sides. 11 And as far -- you know, it served me quite 12 well in -- in the past. And, you know, I think there are 13 a lot of uncertainties and, you know, one gets, as -- as 14 was mentioned, pushed one way or another, but I think we 15 just should resist that. And I -- I always maintain that 16 we provide an independent opinion, that's -- that's what 17 the physicians do, provide an independent opinion. 18 MR. PHILLIP CAMPBELL: We've talked about 19 problems with lack of focussed forensic training and 20 problems with just communicating an opinion and -- and 21 identifying its limits. 22 I don't know if you both have enough of a 23 bird's eye view of the coronial and pathology system in 24 the Province to know this, but there's evidence here that 25 a great many autopsies have been conducted in serious


1 criminal cases across the Province by pathologists 2 without focussed forensic training, and probably with a 3 good deal less pediatric training than -- than you both 4 have. 5 And we've had a ver -- an Inquiry here 6 very much focussed on Dr. Smith, but I wonder what you'd 7 say about the proposition that knowing what you know 8 about the limits of a pediatric pathologist doing 9 forensic pathology, the dangers, potential dangers, of 10 that and the -- and also, I suppose, the progress of 11 science over fifteen (15) years or twenty (20) years, if 12 there might not be significant value in looking at the 13 work of doctors other than Dr. Smith himself in light of 14 those concerns. 15 DR. GLENN TAYLOR: Well, I think 16 reviewing work is -- is an important thing to do. And 17 I've certainly had my cases reviewed, both by experts and 18 through the Justice System -- those cases that I've been 19 involved with. 20 As far as -- 21 MR. PHILLIP CAMPBELL: You mean at the 22 time they arose. You're not talking about reviewed 23 retrospectively? 24 DR. GLENN TAYLOR: Correct. 25 MR. PHILLIP CAMPBELL: Oh, okay.


1 DR. GLENN TAYLOR: Now, a retrospective 2 review, the logistics would be not my issue, I guess 3 but... 4 MR. PHILLIP CAMPBELL: They'd be 5 significant, for sure? 6 DR. GLENN TAYLOR: Yeah. And I guess the 7 -- the goals of such a review would have to be clearly 8 identified. 9 If there are concerns about -- about 10 miscarriages of justice or of the quality of pathology's 11 provision for the Justice System, then some review might 12 be justified. But, you know, knowing a little bit about 13 the extent of the review that was done on Dr. Smith's 14 cases, applying that to a couple of score of other 15 pathologists would be a difficult proposition, I think. 16 MR. PHILLIP CAMPBELL: Yeah, I don't 17 think we're talking about a factor of forty (40) here, 18 though. 19 DR. GLENN TAYLOR: Hmm. 20 MR. PHILLIP CAMPBELL: You know, it was 21 probably twice as many cases over twice as many years. I 22 think of it as a factor of four (4) not forty (40). But 23 I appreciate that it is a -- it's a significant 24 logistical challenge. 25 But I'm not hearing you question the


1 premise of the challenge, that -- that non-forensically 2 trained pathologists may be more prone to error, that 3 science changes and that it is difficult to give and 4 stick by evidence-based opinions in the Criminal Justice 5 System. 6 DR. GLENN TAYLOR: I guess I'd have a 7 little bit of issue with the first statement in that many 8 of the people doing forensic pathology, in my experience, 9 that haven't had American Board Certification are 10 excellent forensic pathologists and have had their work 11 evaluated in the Court System on many occasions and have 12 not run into, as far as I know, trouble. 13 It has to be recognized that a lot of 14 forensic training, like any training, even pediatric 15 pathology, comes with experience. And the environment 16 that you're in and the type of experience that that 17 offers can be extremely important in -- in the concept of 18 training somebody. 19 And I certainly wouldn't want to suggest 20 that all of the pathologists doing forensic pathology 21 that don't have American Board Certification are not 22 competent in any way. I think there are some -- that 23 there are many, many who are very competent and have had 24 their competence tested in the -- in the Judicial System. 25 MR. PHILLIP CAMPBELL: Yeah, I don't


1 think that would have to be a premise of a wider-ranging 2 review. I suppose, simply the possibility, that there 3 are some who have done substandard work in serious cases 4 might -- might be enough to at least consider whether 5 there should be a review. That -- 6 DR. GLENN TAYLOR: Yeah. I'm not opposed 7 to reviews. 8 MR. PHILLIP CAMPBELL: Okay. What about 9 you, Dr. Cutz? 10 DR. ERNEST CUTZ: I basically agree with 11 what Dr. Taylor said. I think, you know, there are a lot 12 of pathologists doing excellent work and, you know, 13 unless -- unless found to otherwise. 14 I mean, if there are problems identified, 15 then I could see, you know, need for review. But I think 16 this seems to be an isolated incident rather than a -- 17 you know, a problem which affects, you know, the 18 pathology community everywhere. 19 MR. PHILLIP CAMPBELL: Well, let me just 20 challenge that for a second. 21 Obviously, if we identify problems, that 22 could be a trigger for a review, intensive or -- 23 DR. ERNEST CUTZ: Yeah. 24 MR. PHILLIP CAMPBELL: -- or otherwise. 25 But Dr. Smith, who the Commissioner may


1 well find made fundamental errors in forensic pathology 2 and made some of them repeatedly, under the scrutiny of 3 the Criminal Justice System; Dr. Smith worked in a world- 4 class institution, beside other people doing similar 5 work, for many years and was answerable to the Coroner -- 6 Chief Coroner, whose job is to supervise death 7 investigation in the Province, without those fundamental 8 failings being identified for ten (10) or twenty (20) 9 years, from 1981 through 2001. 10 Wouldn't you accept that it is difficult 11 without detailed analysis of cases to identify when 12 somebody is doing substandard pathology work? It strikes 13 me as, more than anything in the world of law or 14 medicine, as detail work. 15 DR. ERNEST CUTZ: Well, I -- I presume 16 that in -- in the current atmosphere, it may be 17 worthwhile to do a random check, perhaps. You know, I 18 don't know if you would need to review every single case 19 or you could, you know, select the cases perhaps, which 20 you may want to -- want to review. One would need to 21 look at the -- you know, whether it's even feasible and 22 who -- who would do this kind of review. You know, who 23 would have the time and expense? 24 MR. PHILLIP CAMPBELL: Dr. Cutz, you 25 described the four (4) cases where you and Dr. Smith


1 found yourself in significant disagreement yesterday. 2 Was it -- as one (1) way of -- of identifying the nature 3 of the disagreement, was it your understanding that Dr. 4 Smith, if conducting the autopsies, would have signed out 5 those four (4) cases as cases of foul play? I understand 6 that he didn't override your judgment, but was it your 7 understanding that that's what he'd have done if it was 8 hid judgment? 9 DR. ERNEST CUTZ: I -- I cannot tell what 10 he would have done. I think, you know, it was raised and 11 -- like I arrived at my conclusion after I considered all 12 the possibilities, so I wasn't taking it lightly and as 13 it was, I didn't consider foul play as a possibility. So 14 I thought it was, you know, not necessary to raise it. 15 MR. PHILLIP CAMPBELL: All right. Was 16 Dr. Smith simply raising it, or was he expressing an 17 opinion about it? 18 DR. ERNEST CUTZ: Well, he was expressing 19 opinion, which I had hard to -- accept without actually 20 knowing what the basis of -- of that was. If just by, I 21 presume, evidence of criminal activity going on, which, 22 you know, we may not be aware. 23 MR. PHILLIP CAMPBELL: We heard a couple 24 of days ago that Dr. Smith expressed the view that you 25 were overly reluctant to infer criminality from a body of


1 autopsy data. And I -- I would take it that you formed 2 the view, from these cases and your work along side Dr. 3 Smith, that he was overly quick to draw an inference of 4 homicide or criminality from autopsy data. 5 Is that fair to say? 6 DR. ERNEST CUTZ: Yes. 7 MR. PHILLIP CAMPBELL: Did -- looking 8 back, I suppose is the fairest way to put this -- looking 9 back now to the conclusions you drew then, do you wish 10 that you had been more forceful or proactive in drawing 11 these shortcomings to the attention of either the 12 hospital or the Chief Coroner? 13 DR. ERNEST CUTZ: I think, at the time 14 these -- these occurred, it -- it -- I interpret it as, 15 you know, making comments regarding other possibilities. 16 And I'm not sure whether Dr. Smith realized that, you 17 know, that my -- my work -- work approach, in other 18 words, when I said something, it was something which I 19 have carefully considered. 20 So I'm not sure whether that -- he took 21 that into consideration. And I think some of these, in 22 fact, hap -- happened in front of the officials. I think 23 that I recall at least one (1) of these cases which were 24 presented in one (1) of these forensic rounds, and they 25 were represented from the Coroner's Office.


1 MR. PHILLIP CAMPBELL: And in a position 2 to witness the exchanges between you and Dr. Smith? 3 DR. ERNEST CUTZ: That's right, yeah. 4 MR. PHILLIP CAMPBELL: Okay. Dr. Taylor, 5 a -- a similar question of you with -- with a slightly 6 different background. I understand -- and I don't know 7 that you were expressly questioned about this yesterday - 8 - that you came to the view that Dr. Smith was sometimes 9 giving causes of death that you regarded as -- I think 10 your word was "unjustified"? 11 And primarily, I took that to mean that he 12 was inferring criminality on a body of evidence that you 13 felt left cause of death undetermined, is that right? 14 DR. GLENN TAYLOR: I'm sorry, I -- I 15 can't remember saying the word, "unjustified." 16 MR. PHILLIP CAMPBELL: Well, it -- it may 17 be -- I -- I have only a paraphrase of what you've said 18 and that may be a paraphrase. 19 DR. GLENN TAYLOR: And -- and I can't 20 remember the context in which I said that. 21 MR. PHILLIP CAMPBELL: Well, I was going 22 to ask you about the context because I don't know it 23 either. But I only know a body -- 24 DR. GLENN TAYLOR: No, I'm just -- 25 MR. PHILLIP CAMPBELL: -- of material


1 that's kind -- 2 DR. GLENN TAYLOR: I'm just trying to -- 3 MR. PHILLIP CAMPBELL: -- of changed 4 here. 5 DR. GLENN TAYLOR: -- remember the 6 conversation that all of this came out of, which I'm 7 having trouble, so maybe you can help me. What was I 8 saying? 9 MR. PHILLIP CAMPBELL: You were saying 10 that -- well, I can only give you the paraphrase that 11 I've got and I'll do that. 12 Between 1995 and 1999, you worked 13 alongside of Dr. Smith and had no ques -- concerns 14 regarding his competence. In criminally suspicious and 15 homicide cases, he was more confident in his conclusions 16 than you were. For example, in some cases in which you 17 may have concluded the cause of death was undetermined, 18 Dr. Smith might have given a definitive cause of death. 19 On occasion, you thought Dr. Smith's 20 confidence in the cause of death was not justified. You 21 never spoke to Dr. Smith or any of his colleagues about 22 this. 23 DR. GLENN TAYLOR: Yeah, I remember now, 24 thanks. 25 MR. PHILLIP CAMPBELL: Okay. I'm not


1 interested in probing you on subtle differences between-- 2 DR. GLENN TAYLOR: No, no. 3 MR. PHILLIP CAMPBELL: -- what you say 4 now and then, I just want to try and get behind this a 5 bit. 6 DR. GLENN TAYLOR: And so the original 7 question was? 8 MR. PHILLIP CAMPBELL: Well, the original 9 question was: Did you feel that way about Dr. Smith's 10 views regarding -- inferring criminality from autopsy 11 data? 12 DR. GLENN TAYLOR: I think there were -- 13 on occasion, there were -- I did have that view, yes. 14 MR. PHILLIP CAMPBELL: And was that view 15 about cases where he was the primary reporting 16 pathologist or you were? 17 DR. GLENN TAYLOR: He was. 18 MR. PHILLIP CAMPBELL: And did you 19 question or challenge Dr. Smith about this? 20 DR. GLENN TAYLOR: Those -- if -- if I 21 can give you the context, I believe those were in the 22 setting of one (1) of our rounds, whether they were with 23 forensic pathologists or -- or a weekly autopsy rounds, 24 so there would have been other people there. So this 25 would have been brought up as part of the discussion with


1 regards to the case. 2 Did I report those concerns specifically 3 to somebody? No, I didn't. 4 MR. PHILLIP CAMPBELL: Looking back now, 5 from a -- from what one (1) witness called the 6 retroscope, would you wish that you had been more 7 proactive in identifying these shortcomings to others? 8 DR. GLENN TAYLOR: Well, if it could 9 have, sort of, taken out some of the apparent 10 miscarriages of justice and all of the harm that has 11 fallen from those, yes. 12 But in the context of discussing these 13 rounds and a couple of cases come up and thinking to 14 myself perhaps, Well, I don't think I would have gone 15 that far. Charles was, sort of, the forensic pathology 16 specialist for our group -- I don't know how far I would 17 have actually taken it. 18 MR. PHILLIP CAMPBELL: Just so I can -- 19 and I guess this is going to be it for me -- so I can get 20 some perspective on this. You've described a sort of low 21 level but still identifiable concern about Dr. Smith and 22 his -- and the inferences he was prepared to draw. 23 DR. GLENN TAYLOR: Mm-hm. 24 MR. PHILLIP CAMPBELL: Would you, in your 25 own experience of forensic pathology, which is not a


1 dominant part of your career but a considerable part of 2 it, would you have felt the same way about any other 3 colleagues? 4 DR. GLENN TAYLOR: Oh -- 5 MR. PHILLIP CAMPBELL: Either they were a 6 little more -- they were noticeably more conservative 7 than I am or noticeably more venturesome in 8 DR. GLENN TAYLOR: Yes -- 9 MR. PHILLIP CAMPBELL: -- opinions? 10 DR. GLENN TAYLOR: -- I have. And even 11 recently, one (1) of my colleagues went further than I 12 would have went. But I respect that person's opinion, 13 and that person has more particular experience in the 14 area than I do. So if I was -- if I had the case, I 15 wouldn't have gone as far as that person did, but that 16 person has a lot of background and experience and 17 training in that particular area so I defer to that. 18 But, you know, it's what I'm comfortable 19 with dealing with and what other people are comfortable 20 with dealing with. 21 MR. PHILLIP CAMPBELL: Okay, thank you. 22 That's my time. 23 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 24 Campbell. 25 Mr. Wardle...?


1 MR. PETER WARDLE: Good morning. 2 DR. GLENN TAYLOR: Good morning. 3 MR. PETER WARDLE: Good morning, Mr. 4 Commissioner. 5 COMMISSIONER STEPHEN GOUDGE: Good 6 morning. 7 8 CROSS-EXAMINATION BY MR. PETER WARDLE: 9 MR. PETER WARDLE: Dr. Taylor, Dr. Cutz, 10 my name is Peter Wardle and I act for a number of 11 families who have been affected by some of Dr. Smith's 12 findings. 13 I want to start with you, Dr. Cutz, 14 because you're the first witness we've heard from who 15 actually was there when Dr. Smith arrived at Sick Kids, 16 so I want to go back to some of the answers you gave 17 yesterday about the sort of 1981 period. And really my 18 focus is on how Dr. Smith came to focus or specialise in 19 this area. 20 So as I understand it, he was hired on a 21 full- time basis at the hospital in 1981? 22 DR. ERNEST CUTZ: Yes. 23 MR. PETER WARDLE: And you were already 24 there and had been for some time? 25 DR. ERNEST CUTZ: Yes.


1 MR. PETER WARDLE: And am I right that 2 Dr. Smith at that time didn't have a strong research 3 background? 4 DR. ERNEST CUTZ: No, he did not. 5 MR. PETER WARDLE: And you told us 6 yesterday that he gradually began doing medicolegal work 7 over a period of time. 8 DR. ERNEST CUTZ: No, I think every staff 9 -- coming on staff, as myself, you know, ten (10) years 10 earlier when I came on staff, you know, you were included 11 in the rotation of -- of autopsies, which included the 12 medicolegals. 13 MR. PETER WARDLE: No, I -- what I was 14 really thinking of is you -- 15 DR. ERNEST CUTZ: So the -- 16 MR. PETER WARDLE: -- developed an 17 interest in that area over time. 18 DR. ERNEST CUTZ: Well, I -- I'm not sure 19 as to when he started to have interest in it, but, you 20 know, we all were doing the rotation. 21 MR. PETER WARDLE: And am I right that 22 over time, as we go from 1981 and we go towards 1991 when 23 the unit was created, he developed more of a relationship 24 with the Coroner's Office than other people in your unit? 25 DR. ERNEST CUTZ: Yes, that I understand.


1 Yeah. 2 MR. PETER WARDLE: Okay. And am I right, 3 as well, that Dr. Phillips took an interest in Dr. 4 Smith's career? 5 DR. ERNEST CUTZ: Yes. 6 MR. PETER WARDLE: And fostered his 7 interest in medicolegal cases of coroners' work? 8 DR. ERNEST CUTZ: Yes. 9 MR. PETER WARDLE: And you told us 10 yesterday that Dr. Smith was also friends with Dr. Young. 11 Do you recall saying that? 12 DR. ERNEST CUTZ: Yes, that's my 13 understanding. 14 MR. PETER WARDLE: Okay. And -- and what 15 do you know about that and how did you find that out? 16 DR. ERNEST CUTZ: Well, I -- I think it - 17 - it might have been Dr. Phillips mentioning it at our -- 18 our staff meetings, and this was during the period of the 19 Dubin Inquiry, when there was a lot of, sort of, 20 investigation going on in the hospital and it was 21 mentioned that Dr. Smith, because he knows or he's a 22 friend of Dr. Young, he would be an excellent liaison 23 with -- with the Coroner's Office to kind of help to -- 24 to smooth the -- sort of the investigation part -- 25 MR. PETER WARDLE: Mm-hm.


1 DR. ERNEST CUTZ: -- so that, you know, 2 the hospital is not subject to all these investigations. 3 MR. PETER WARDLE: Okay. And is it fair 4 to say from your observation that Dr. Young also 5 sponsored and encouraged Dr. Smith's career in terms of 6 his interest in forensic pediatric pathology? 7 DR. ERNEST CUTZ: Yes. That's my 8 understanding, yes. 9 MR. PETER WARDLE: And you told us 10 yesterday, and we've come back to this a little bit this 11 morning, that your view that -- was that forensic 12 pathology was a complex discipline that was very 13 different from pediatric pathology. 14 Do you recall saying that? 15 DR. ERNEST CUTZ: Yes, yes. 16 MR. PETER WARDLE: One (1) of the things 17 I didn't hear you say yesterday -- you told us that Dr. 18 Mancer was at the hospital for a period of time. 19 DR. ERNEST CUTZ: Yes. 20 MR. PETER WARDLE: And he had a formal 21 training in forensic pathology. 22 DR. ERNEST CUTZ: Well, I -- I know that 23 he took courses at the Armed Forced Institute. I'm not 24 sure, you know, how long or how detailed those courses 25 were, but he did coroner's work at the Office of the


1 Chief Coroner on -- on a sort of part-time basis. 2 MR. PETER WARDLE: Do you know if there 3 was anyone who actually mentored Dr. Smith in this area 4 during this time period, 1981 to 1991? 5 DR. ERNEST CUTZ: Well, I guess all the 6 more senior staff, that includes Mancer, and myself, and 7 -- and Dr. Becker. 8 MR. PETER WARDLE: But in terms of 9 developing his forensic skills as a -- as a forensic 10 pathologist, whatever he learned, do you know if there 11 was anyone who was actually assisting him or was he just 12 learning from doing the cases? 13 DR. ERNEST CUTZ: It -- there wasn't any 14 formal sort of teaching, I think. You know, we were all 15 available to provide assistance as needed, but basically 16 he was left to -- to develop his skills and -- and 17 knowledge on his own. 18 MR. PETER WARDLE: And you didn't 19 observe, for example -- you didn't have a relationship 20 with Dr. Hillsdon Smith at the Office of the Chief 21 Coroner? Dr. Hillsdon Smith wasn't mentoring him any 22 fashion? 23 DR. ERNEST CUTZ: Not that I know of, no. 24 MR. PETER WARDLE: Okay. So the -- what 25 I'm driving at is, you know, would it be fair to say that


1 Dr. Smith's, you know, training as a forensic pathologist 2 during this period, as you saw it, was really derived 3 totally from on-the-job experience? 4 DR. ERNEST CUTZ: That's correct. 5 MR. PETER WARDLE: So in a way would it 6 be unfair to say that he was self taught? 7 DR. ERNEST CUTZ: To a large extent, I 8 think, you know, he might have studied it in more detail 9 which I have no knowledge of, but in terms of the 10 practical aspects he -- he worked at the hospital. 11 MR. PETER WARDLE: And then I want to 12 just move forward a little bit to when the Unit started. 13 And I think what you told us yesterday was 14 that during the '80's and to some extent in the early 15 '90's, you and your colleagues, there was an informal 16 triage that certain obvious homicide cases wouldn't come 17 to Sick Kids? 18 DR. ERNEST CUTZ: Yes. 19 MR. PETER WARDLE: And that was because 20 you and your colleagues didn't feel comfortable doing 21 those cases? 22 DR. ERNEST CUTZ: No, I mean, the 23 understanding, to start out, was that Hospital for Sick 24 Children will do natural -- pediatric natural deaths. 25 This is what our expertise is, and this is what the


1 Coroner Office ask us to do. They didn't ask us to do 2 homicide cases. 3 And -- and the understanding was if 4 there's a homicide in the age group of children it will 5 not be done at Sick Children's, it's going to be done at 6 the Coroner's Office. 7 MR. PETER WARDLE: And I think you also 8 told us that even after the -- the, you know, creation of 9 the unit in 1991, you interpreted the agreement that had 10 been reached as giving you the discretion to refuse to do 11 a case if you thought that it wasn't within your area of 12 expertise? 13 DR. ERNEST CUTZ: That's my 14 understanding, yes. 15 MR. PETER WARDLE: Okay. But am I right, 16 that as we get into the '90's and the unit's been 17 created, and then a couple of years later Dr. Smith is 18 picked to head it, now criminally suspicious cases are 19 now coming to the hospital that didn't come before? 20 DR. ERNEST CUTZ: Yes. 21 MR. PETER WARDLE: And that's really a 22 function, isn't it, almost completely of Dr. Smith's 23 interest in that area? 24 DR. ERNEST CUTZ: Yes, I believe so. 25 MR. PETER WARDLE: So, you know, this is


1 something I'm interested in, because it seems to me when 2 we go back and we look at the past, we have this 3 individual who, to a large extent, is self taught; he's 4 appointed to this position. 5 And we have a fairly significant change in 6 the type of work that's now coming to your hospital, 7 correct? 8 DR. ERNEST CUTZ: That's correct, yes. 9 MR. PETER WARDLE: And he's then the 10 person who's going to get a large amount of those cases? 11 DR. ERNEST CUTZ: Yes. 12 MR. PETER WARDLE: Okay. And the 13 oversight, as we've talked about, I think, yesterday. 14 The oversight for those cases, the medicolegal cases is 15 coming from elsewhere? 16 It's not coming from within the hospital, 17 correct? 18 DR. ERNEST CUTZ: Well, there was no 19 formal oversight. As -- as we explained yesterday, it 20 was really a contract, if you like, between the 21 pathologists and -- and the investigating coroner. 22 MR. PETER WARDLE: Correct. But in terms 23 of anyone -- any kind of quality assurance over 24 medicolegal cases, you know, for example, review of -- of 25 post-mortem examination reports, that was being done


1 either by Dr. Smith or the people who worked in the unit 2 or -- 3 DR. ERNEST CUTZ: Yes. 4 MR. PETER WARDLE: -- for Dr. Smith, you 5 just simply know -- you simply don't know who was doing 6 it? 7 DR. ERNEST CUTZ: That's right. 8 MR. PETER WARDLE: So any oversight of 9 that kind was really provided, if it was provided at all, 10 by the Coroner's Office? 11 DR. ERNEST CUTZ: That's correct. 12 MR. PETER WARDLE: And I took it as well 13 from what you said yesterday, that you and Dr. Becker 14 weren't completely happy with this change. That is the 15 fact that the hospital was now doing more criminally 16 suspicious cases; that that was something that you and 17 Dr. Becker weren't completely happy with? 18 DR. ERNEST CUTZ: Yes. We thought it -- 19 hospital shouldn't get involved in this. 20 MR. PETER WARDLE: Now this is -- the 21 next set of questions is really for both of you, 22 understanding, Dr. Taylor, that you weren't there for 23 part of this period. But as I understand it, in a broad 24 sense Dr. Smith's work could be divided into three (3) 25 components: surgical work, hospital autopsies and


1 medicolegal autopsies. 2 Is that fair? 3 DR. GLENN TAYLOR: Yes. 4 MR. PETER WARDLE: And we've heard a lot 5 of evidence including, I think yesterday, that through 6 much of the '90's he was doing approximately 50 percent 7 of the criminally suspicious medicolegal cases, would 8 that accord with your recollection? 9 DR. ERNEST CUTZ: No, I think he did 50 10 percent of all the case -- all of the cases. Now what 11 percentage were -- I couldn't know what the percentage of 12 criminally susp -- because he would do all of them, 13 whatever came. 14 MR. PETER WARDLE: All right. So let -- 15 let me back up. He was doing 50 percent of the 16 medicolegal case? 17 DR. ERNEST CUTZ: Of all -- of all 18 medicolegal autopsies, yes. 19 MR. PETER WARDLE: And would it be fair, 20 from what we've covered already, that because of his 21 interest in criminally suspicious cases, he was probably 22 doing more of those cases than any of the other 23 pathologists in the unit? 24 DR. ERNEST CUTZ: He would do -- he would 25 do all of the cases in -- in that category, which may


1 account to 10 -- 10 percent. Out of his 50 percent, 10 2 percent would be criminally suspicious. 3 MR. PETER WARDLE: All right. And -- and 4 that was because a) he had an interest in that work, and 5 b) the other pathologists in the group really didn't want 6 to do that kind of work? 7 DR. ERNEST CUTZ: That's correct, yes. 8 MR. PETER WARDLE: Okay. And in terms of 9 the medicolegal cases -- and let's just stick with that, 10 you know, roughly 50 percent -- the hospital -- how did 11 the hospital evaluate Dr. Smith's work on medicolegal 12 cases; that is, cases done under coroner's warrant? 13 DR. ERNEST CUTZ: I think they -- those 14 were evaluated similarly to other -- I mean, we showed 15 all these cases at our weekly rounds. 16 MR. PETER WARDLE: Mm-hm. 17 DR. ERNEST CUTZ: And so the -- these 18 were also shown. But most of the cases shown at those 19 rounds, as I explained yesterday, we needed permission 20 from the coroner to show it. 21 MR. PETER WARDLE: Right. 22 DR. ERNEST CUTZ: And so if it was 23 criminally suspicious or under investigation, it wouldn't 24 be shown. So those would be mostly the natural death 25 cases, and those always reviewed in our rounds.


1 MR. PETER WARDLE: I was really asking a 2 somewhat different question. I understand at the 3 hospital every year there's a performance evaluation and 4 Ms. Baron already took, I think, Dr. Taylor to a couple 5 of those evaluations in the 2004/2005 period. 6 DR. GLENN TAYLOR: Yes. 7 MR. PETER WARDLE: And I take it that 8 during the '90s, there was also an annual performance 9 evaluation, correct? 10 DR. ERNEST CUTZ: I'm not really sure 11 what -- what it -- it was less formal. I -- you know, I 12 don't know if there were any specific forms. Like, there 13 may have been some forms. 14 MR. PETER WARDLE: All right. Well, 15 we've seen some forms, -- 16 DR. ERNEST CUTZ: Yeah. 17 MR. PETER WARDLE: -- and I'm going to 18 come to one (1) in a minute, but my question was really 19 this: How did the hospital, in terms of evaluating Dr. 20 Smith's performance, evaluate his work in medicolegal 21 autopsies being done for the Coroner's Office? 22 DR. ERNEST CUTZ: I think that was the 23 role for the Chief to do. I mean, we didn't really -- 24 you know, personally, I had no knowledge as to how it was 25 done.


1 MR. PETER WARDLE: Okay. Because the -- 2 we have this situation -- let me just suggest this to 3 you. We have a hospital employee who's doing a 4 significant amount of his work for a completely separate 5 entity, correct? 6 DR. ERNEST CUTZ: Yes. 7 MR. PETER WARDLE: And there's a -- to 8 some extent, there's a bit of a dividing wall -- and 9 we've heard this from the witnesses who came from the 10 Chief Coroner's Office, they weren't always apprised at 11 whatever concerns were being expressed at Sick Kids, and 12 it appears from what we've heard from the two (2) of you 13 that you weren't always aware of what was being expressed 14 at the Coroner's Office, correct? 15 DR. ERNEST CUTZ: Yes. 16 MR. PETER WARDLE: Okay. And let me just 17 give you an example of that, if I may. I'm going to ask 18 you to turn up in Volume III, Tab 41, and this is 19 PFP137686. And actually maybe what I'll do -- I'm just 20 going to go backwards one (1) -- a little bit before we 21 get to that. 22 If we could go first to Volume III, Tab 23 31, and this is PFP137687. So you'll see, Dr. Taylor and 24 Dr. Cutz, that this is for -- this is a -- an annual 25 professional review and the year is 1996/1997. It


1 appears to have Dr. Becker's signature, although it's 2 quite illegible at the bottom. Do you see that? 3 DR. ERNEST CUTZ: Yes. 4 MR. PETER WARDLE: And this is obviously 5 -- just from looking at it quickly -- a somewhat 6 unfavourable review, and it relates to the issues that 7 both of you talked about yesterday, correct? 8 DR. ERNEST CUTZ: Yes. 9 MR. PETER WARDLE: But then if we go 10 forward a little bit. And I want to take you to Volume 11 III, Tab 41, PFP137686. 12 13 (BRIEF PAUSE) 14 15 MR. PETER WARDLE: So this is -- this is 16 past the difficulties that both of you spoke about 17 yesterday. 18 DR. ERNEST CUTZ: Yes. 19 MR. PETER WARDLE: It's a -- this is two 20 (2) or three (3) years later now, and you'll see the date 21 of this review is June of 2000, and the evaluation has 22 total performance, "very good", and the reviewer is LEB - 23 - that would be Dr. Becker -- and then you'll see it 24 says, "provides leadership in forensic pathology." 25 DR. ERNEST CUTZ: Yes.


1 MR. PETER WARDLE: And just stopping 2 there, we've heard from a number of other witnesses from 3 the Office of the Chief Coroner that, by the time of this 4 review, there were serious concerns developing, at that 5 office, about Dr. Smith's capabilities with respect to 6 certain cases. 7 And this suggests to me that, first of 8 all, that information wasn't being shared with anyone at 9 Sick Kids, correct? 10 DR. ERNEST CUTZ: I -- I don't know what 11 basis Dr. Becker made these conclusions. I think, at 12 that time, it wasn't really clear that what is said about 13 Dr. Smith to be actually true or it was, you know, a ver 14 -- very far thing, and -- and actually, officials from 15 the Coroner's Office were saying they -- they -- you 16 know, they fully support and stand behind what Dr. Smith 17 was doing, so it was -- 18 MR. PETER WARDLE: Right. 19 DR. ERNEST CUTZ: -- kind of unclear and 20 that it was something in evolution. 21 MR. PETER WARDLE: And -- and I 22 appreciate that -- 23 DR. ERNEST CUTZ: Yes, yeah. 24 MR. PETER WARDLE: -- that to some extent 25 Dr. Becker is not here --


1 DR. ERNEST CUTZ: Yes. 2 MR. PETER WARDLE: -- so -- 3 DR. ERNEST CUTZ: Correct. 4 MR. PETER WARDLE: -- I'm asking 5 questions of the two (2) of you. 6 DR. ERNEST CUTZ: That's the way I could 7 explain it, that he -- he kind of ended -- you know, that 8 Dr. Smith was in this very difficult situation being -- 9 MR. PETER WARDLE: Right. 10 DR. ERNEST CUTZ: -- sort of 11 investigated, but, you know, everything seems to be fine. 12 MR. PETER WARDLE: But I guess what I'm 13 getting at is there -- there's a -- there's this divide 14 through this period. You know your group has the 15 concerns in 1997; we've heard that those concerns don't 16 get expressed to the Coroner's Office. 17 Now we're in June of 2000; there are 18 clearly concerns at the Coroner's Office at this point 19 related to several cases, and it would appear from this 20 document that Dr. Becker may not have been aware of those 21 concerns. 22 DR. ERNEST CUTZ: It's -- well, it well 23 may be, yes. 24 MR. PETER WARDLE: Okay. And just 25 dealing with -- I know you've said yesterday, Dr. Taylor,


1 that -- that one can distinguish between, for example, 2 surgical pathology expertise and forensic pathology 3 expertise; that one may be competent in one (1) area and 4 not in the other, correct? 5 DR. GLENN TAYLOR: Yes. 6 MR. PETER WARDLE: But you do agree that 7 issues about delays, turnaround time, organization are 8 sort of common themes that would apply to any work a 9 pathologist is doing, correct? 10 DR. GLENN TAYLOR: Yes. 11 MR. PETER WARDLE: And just -- I'm not 12 going to go through this in detail, but the problems that 13 Dr. Smith had, with respect to turnaround time, were a -- 14 were a fairly consistent refrain right through until 15 almost the end of his tenure at Sick Kids, isn't that 16 right? 17 DR. GLENN TAYLOR: That's correct. 18 MR. PETER WARDLE: Okay. And I'll just 19 ask you to turn up a couple of documents quickly. I'm 20 not going to belabour this, but in Volume II at Tab 75, 21 and this is PFP138144 -- 22 23 (BRIEF PAUSE) 24 25 MR. PETER WARDLE: So, Dr. Becker, (sic)


1 just looking at the first page of this, it appears to be 2 dated November 30, 1999. 3 DR. GLENN TAYLOR: Are you referring to 4 Taylor or Cutz? 5 MR. PETER WARDLE: I'm sorry, Dr. Taylor. 6 Okay, if we look at the first page, top right hand 7 corner, this is November 30, 1999. 8 DR. GLENN TAYLOR: Yes. 9 MR. PETER WARDLE: And as I understand 10 it, and I'm -- I've never worked at your hospital, so I'm 11 interpellating, but this appears to be a list of Dr. 12 Smith's unsigned-out cases, which means cases he hasn't 13 finished working on yet, correct? 14 DR. GLENN TAYLOR: Correct. 15 MR. PETER WARDLE: And it's -- it's done 16 in date order, so the number of days since the case was 17 opened appears in the column "days since accession", is 18 that correct? 19 DR. GLENN TAYLOR: Yes. 20 MR. PETER WARDLE: And it's -- it goes 21 from the, sort of longest delay to the shortest, so the 22 longest is right at the top of the page. 23 DR. GLENN TAYLOR: Yes. 24 MR. PETER WARDLE: And these have a 25 number, so these would be autopsy cases?


1 DR. GLENN TAYLOR: Yes. 2 MR. PETER WARDLE: Hospital autopsy 3 cases? 4 DR. GLENN TAYLOR: I'm not sure in '99. 5 Maybe Ernest can help. 6 Whether you're doing the AML and the "A's" 7 together? 8 DR. ERNEST CUTZ: No, I -- I -- you know, 9 I think that's right. When we switched to the computer 10 our system all the autopsies were designated at "A", so 11 you couldn't tell whether it was medicolegal or not. You 12 had to do another function to find out. 13 So this is probably a mixture of cases. 14 These are both hospital -- 15 MR. PETER WARDLE: Thank you. 16 DR. ERNEST CUTZ: -- and medicolegal. 17 MR. PETER WARDLE: So this would -- this 18 would tell us that there -- there are a number of 19 significant delays in his cases as of that point in time, 20 correct? 21 DR. GLENN TAYLOR: Yes. 22 MR. PETER WARDLE: And then just looking 23 at the last page, this page is PFP138148 and in my 24 document it's all together. It's the -- 25 DR. GLENN TAYLOR: Sorry, which tab is


1 that? 2 MR. PETER WARDLE: It's the same tab, the 3 very last page, Dr. Taylor. If you don't have it you 4 might just want to look at your screen. 5 DR. GLENN TAYLOR: I don't -- sorry, I 6 don't have this one, but -- 7 8 (BRIEF PAUSE) 9 10 MR. PETER WARDLE: So this would appear 11 to be a list of -- a different list of medicolegal cases? 12 DR. ERNEST CUTZ: Yeah. So maybe the "A" 13 list was hospital cases and then these -- these are 14 medicolegal. 15 MR. PETER WARDLE: And you can see from 16 looking at this that these cases are -- some of them go 17 back to 1995. One (1) group of cases, in particular. 18 DR. ERNEST CUTZ: Yes, mm-hm. 19 MR. PETER WARDLE: Am I reading that 20 correctly, Dr. Taylor? 21 DR. GLENN TAYLOR: I think so, yes. 22 DR. ERNEST CUTZ: Yeah. 23 MR. PETER WARDLE: Okay. And then -- and 24 then going ahead a little bit in time into 2002, if we go 25 to Volume II, Tab 73, and this is PFP137793.


1 This would indicate that in May of 2000, 2 Maxine Raymond is reporting to Dr. Becker that the 1995 3 autopsies are now complete for Dr. Smith. 4 Do you see that? 5 DR. ERNEST CUTZ: Yes. 6 MR. PETER WARDLE: And then going -- 7 going to Volume II, Tab 76, this is PFP138105. This is a 8 document printed off November 30 of 2000. 9 And you'll see again as the -- as the 10 document we looked at a year earlier a number of cases 11 with significant delays between accessioning and signing 12 them out, correct? 13 DR. ERNEST CUTZ: Yes. 14 MR. PETER WARDLE: And then Volume II, 15 Tab 74, PFP137776. 16 Now, this, as I understand it, deals with 17 surgical cases, is that right, Dr. Taylor? 18 DR. GLENN TAYLOR: Yes, that's correct. 19 MR. PETER WARDLE: So this is an 20 indication that there are unsigned out surgical cases and 21 that a secretary has been asked to locate the slides and 22 put them in a -- folders on Dr. Smith's desk next to his 23 microscope. 24 Do you see that? 25 DR. GLENN TAYLOR: Yes.


1 MR. PETER WARDLE: So that would indicate 2 that there's still a concern in the middle or late of -- 3 this is October of 2001 -- about these specific kinds of 4 delays, correct? 5 DR. GLENN TAYLOR: Yes. 6 MR. PETER WARDLE: And then I don't know 7 if we looked at this document yesterday, but Volume II, 8 Tab 13, this is PFP137707. This is a memo which -- or an 9 email dated March 12, 2002. It appears to be from Dr. 10 Becker to Dr. Smith, copied to Dr. Thorner, subject: 11 Delinquent Reports: 12 "Charles, I have been reviewing the 13 late surgical and autopsy reports for 14 the past year and note that you have a 15 long list of outstanding cases." 16 And it goes on to say this: 17 "Represents a fall below the standard 18 of care that is expected at Hospital 19 for Sick Children." 20 And then a little further on in the email: 21 "The situation has become so serious 22 that I may have to delay signing the 23 annual HSC reappointment form for you 24 if you cannot complete the oldest 75 25 percent of your cases by the end of


1 June. I am prepared to provide you 2 with any assistance that you require, 3 but you may be -- you must be very 4 specific about what it is that you may 5 need." 6 So just stopping there for a second, that 7 would indicate that the -- the serious concerns that I 8 think we talked about yesterday, with respect to turn 9 around time in 1997, was still a very major problem as 10 late as 2002, correct? 11 DR. GLENN TAYLOR: Correct. 12 MR. PETER WARDLE: And this would be a 13 significant wake-up call to a staff physician at the 14 Hospital for Sick Children, wouldn't it; receiving an 15 email like this? 16 DR. GLENN TAYLOR: It would to me, yes. 17 MR. PETER WARDLE: Okay. And then 18 finally, going forward to Volume II, Tab 78. 19 20 (BRIEF PAUSE) 21 22 MR. PETER WARDLE: PFP137589. This now 23 involves you directly, Dr. Taylor. It appears that 24 you've had some success with Dr. Smith as is reflected in 25 the first paragraph of this memo, correct?


1 DR. GLENN TAYLOR: Yes. 2 MR. PETER WARDLE: And the backlog is 3 gone, and -- although you're still working with him, as I 4 understand it from reading this, to have him clean up 5 surgical cases? 6 DR. GLENN TAYLOR: Yes. 7 MR. PETER WARDLE: Okay. And do you know 8 whether any of these delays that we've just gone through 9 in -- in the time period from 1997 to 2003, do you know 10 whether the Coroner's Office was aware that you were -- 11 your department was struggling with Dr. Smith in these 12 areas? 13 DR. GLENN TAYLOR: I can't speak for the 14 years up to 2003. In 2003 when I arrived, there was -- 15 made an effort to get Char -- Dr. Smith to complete his 16 autopsy cases. I don't know if the coroner's -- I can't 17 remember the coroner's service being directly involved in 18 that effort; that was sort of my job as the division head 19 to deal with. 20 MR. PETER WARDLE: Right. And... 21 22 (BRIEF PAUSE) 23 24 MR. PETER WARDLE: Both of you talked a 25 little bit yesterday about what took place in 2001 and


1 the events that lead Dr. Smith to be restricted from 2 doing autopsies in criminally suspicious cases. I took 3 from what you said though, and it -- it was really you, 4 Dr. Cutz, that you weren't told a great deal about what 5 was going on at the Coroner's Office. 6 Is that fair? 7 DR. ERNEST CUTZ: Yes. 8 MR. PETER WARDLE: And did you have a 9 clear understanding as to what Dr. Smith was being 10 allowed to do and what he wasn't allowed to do? 11 DR. ERNEST CUTZ: We didn't -- we maybe 12 heard from Dr. Smith what -- what he told us, that, you 13 know, he -- he can do non -- non-suspicious cases and can 14 do the hospital cases, but we haven't real -- I don't 15 recall receiving any kind of official notice. 16 MR. PETER WARDLE: And, Dr. Taylor, when 17 you came back from British Columbia, which -- remind me 18 again, was when exactly? The last -- 19 DR. GLENN TAYLOR: This last time? July 20 2003. 21 MR. PETER WARDLE: -- time. Okay. When 22 you came back in July 2003, what did you understand was 23 the status quo with respect to Dr. Smith and the 24 Coroner's Office, in terms of what he was doing and what 25 he wasn't doing?


1 DR. GLENN TAYLOR: He was still the 2 Director of the Pediatric Forensic Pathology Unit, and he 3 was still doing some coroner's cases. I don't think I 4 had any written notice directed tow -- to me that he was 5 not doing a certain sub-set of those cases. But I had 6 learned from my colleagues that he was not doing the 7 criminally suspicious cases. 8 MR. PETER WARDLE: And aside from what 9 you may have hear -- read in media reports, because we 10 know by 2003 there was a lot in the media about Dr. 11 Smith, but did you have -- were you ever given any 12 specifics about what the concerns were at the Coroner's 13 Office about work that had been done in the past? 14 DR. GLENN TAYLOR: I don't think I was 15 given any -- any specifics, and my knowledge was 16 basically from the media reports. 17 MR. PETER WARDLE: Okay. And were you 18 ever told, for example, that by 2003, people within the 19 Coroner's Office had concerns about Dr. Smith's 20 credibility? 21 DR. GLENN TAYLOR: I did have some 22 information given to me in 2003 that there were issues 23 developing in -- with the coroner service and -- and Dr. 24 Smith, yes. 25 MR. PETER WARDLE: Okay. Issues around


1 his credibility? 2 DR. GLENN TAYLOR: Some of his work. I 3 don't -- I don't think credibility was a word I remember 4 but certainly about some of his work. 5 MR. PETER WARDLE: Okay. And I just want 6 to turn up one (1) last document. Dr. Smith eventually 7 left the hospital in 2005. Is that correct? 8 DR. GLENN TAYLOR: Yes. 9 MR. PETER WARDLE: And I'm going to ask 10 you to look in Volume II at Tab 45. 11 12 (BRIEF PAUSE) 13 14 MR. PETER WARDLE: This is an application 15 -- this relates to an application, as I understand it, 16 filed by Dr. Smith for licensing with the College of 17 Physicians and Surgeons in Saskatchewan. 18 Do you see that, Dr. Taylor? 19 DR. GLENN TAYLOR: Yes. 20 MR. PETER WARDLE: And it appears to be a 21 form -- I would call it like a reference -- and you'll 22 see it's signed at the bottom right by -- it appears to 23 be Dr. Phillips. 24 Is that correct? 25 DR. GLENN TAYLOR: Yes.


1 MR. PETER WARDLE: Was Dr. Phillips still 2 at Sick Kids in the fall of 2005? 3 DR. GLENN TAYLOR: He was an emeritus 4 pathologist. 5 MR. PETER WARDLE: Okay. And you'll see 6 Dr. Phillips has ticked off a number of the boxes and 7 under box 3: Do you consider the applicant to be 8 reliable, ethical with good character? And he's added -- 9 he's put "yes" to all three (3) questions. 10 And I guess my -- my question is, first of 11 all: Were you asked to provide any kind of reference for 12 Dr. Smith when he moved to Saskatchewan, Dr. Taylor? 13 DR. GLENN TAYLOR: Yes, I was. 14 MR. PETER WARDLE: And did you complete 15 something similar to this? 16 DR. GLENN TAYLOR: Yes, I did. 17 MR. PETER WARDLE: Okay. And did you 18 have any information at the time, from the Coroner's 19 Office, that would deal directly with Dr. Smith's 20 credibility? 21 DR. GLENN TAYLOR: Yes, I did. 22 MR. PETER WARDLE: Okay. And did you 23 make mention of that on the form? 24 DR. GLENN TAYLOR: I believe I did, yes. 25 MR. PETER WARDLE: Okay.


1 Just looking back in retrospect and 2 thinking about this -- the institutional setup here, with 3 this individual working for the hospital but doing a 4 significant amount of work for the Coroner's Office which 5 is a completely separate entity. 6 In retrospect, does it not appear that 7 that organizational setup was fraught with difficulty 8 right from the outset? 9 DR. GLENN TAYLOR: Hm. There are 10 difficulties but there are advantages to having it -- to 11 having those two (2) institutions distinct. 12 I think what the situation needs is some 13 kind of bridge, and I think that's being addressed now 14 with this executive team that I mentioned yesterday. 15 It would, I think, have been very useful 16 to have some kind of similar arrangement between the two 17 (2) institutions; maintaining their independence because 18 of conflict of interest issues and various other aspects 19 of being a hospital versus the coroner service, but 20 having some kind of bridge between them that issues could 21 be freely discussed and perhaps, acted upon. 22 MR. PETER WARDLE: Just from what we've 23 gone through, sharing of information was clearly a 24 problem, if we go back over this relationship. 25 Isn't that fair?


1 DR. GLENN TAYLOR: That's fair, yes. 2 MR. PETER WARDLE: And it goes in both 3 directions. The Coroner's Office at times wasn't sharing 4 information that Sick Kids needed to have from what we've 5 heard, correct? 6 DR. GLENN TAYLOR: Correct. 7 MR. PETER WARDLE: And it also appears 8 that Sick Kids -- and I'm not being critical of you, Dr. 9 Taylor, but it also appears that Sick Kids wasn't always 10 sharing information that it had with the Coroner's 11 Office. 12 DR. GLENN TAYLOR: It wasn't sharing that 13 information. Whether there was the potential -- a real 14 barrier of trying to maintain arm's length relationship 15 between the -- the two (2) institutions as a factor, 16 which I -- probably was a significant factor, but I agree 17 that there should have been some kind of route for 18 transmission of important information between the two (2) 19 institutions. 20 MR. PETER WARDLE: Thank you very much. 21 Those are all my questions. 22 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 23 Wardle. 24 Let me just ask you a couple of questions 25 before we break, Dr. Taylor. You spoke of the need for a


1 bridge between the hospital and the Coroner's Office. 2 Tell me a little more about what this executive team is 3 examining. 4 Who is on it -- 5 DR. GLENN TAYLOR: Well, the team was 6 structured in August -- it was restructured in August of 7 this year, and on it is the vice-president responsible 8 for laboratories at the Hospital for Sick Children. 9 COMMISSIONER STEPHEN GOUDGE: His name or 10 her name? 11 DR. GLENN TAYLOR: Her name now is Shauna 12 McCraig (phonetic) -- forgive me if I've mis -- 13 mispronounced the name or misrepresented the name -- just 14 started. At the time that the committee was created, it 15 was Dr. Ronald Axer (phonetic). 16 COMMISSIONER STEPHEN GOUDGE: And when 17 was it created? 18 DR. GLENN TAYLOR: It was started in the 19 late spring and the current structure of it was finalized 20 in August of 2007. 21 COMMISSIONER STEPHEN GOUDGE: Okay. Can 22 you complete the structure. Who else is on it? 23 DR. GLENN TAYLOR: The head of the 24 division of pathology, myself, the -- a representative of 25 the Office of the Chief Coroner. And the meetings have


1 been with the Chief Coroner -- and the -- 2 COMMISSIONER STEPHEN GOUDGE: That was 3 Dr. McLellan -- 4 DR. GLENN TAYLOR: McLellan -- 5 COMMISSIONER STEPHEN GOUDGE: -- up until 6 he left and now Dr. Porter? 7 DR. GLENN TAYLOR: -- and -- and recently 8 Dr. Porter, yes. 9 COMMISSIONER STEPHEN GOUDGE: Yes. 10 DR. GLENN TAYLOR: And the Chief Forensic 11 Pathologist for the Province, Michael Pollanen. 12 COMMISSIONER STEPHEN GOUDGE: Okay. And 13 is there written mandate for the executive team? 14 DR. GLENN TAYLOR: There is a terms of 15 reference, yes. 16 COMMISSIONER STEPHEN GOUDGE: Okay. 17 Explain your, a little bit, your concern about the 18 independence required between the two (2) institutions. 19 DR. GLENN TAYLOR: Well, the main issue, 20 which probably has been raised, is that 25 to 30 percent 21 of the coroner's cases that are performed at the Hospital 22 for Sick Children are on patients of the Hospital for 23 Sick Children. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. GLENN TAYLOR: And the issue of those


1 coroner's cases being performed by employees of the 2 hospital does raise a potential conflict of interest. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. GLENN TAYLOR: So -- 5 COMMISSIONER STEPHEN GOUDGE: So is that 6 where it bites most directly? 7 DR. GLENN TAYLOR: That's where it bites 8 most directly. So -- 9 COMMISSIONER STEPHEN GOUDGE: Are there 10 concerns with any other parts of the work done at the 11 hospital for the Coroner's Office, independence concerns; 12 that is, is there -- 13 DR. GLENN TAYLOR: There -- 14 COMMISSIONER STEPHEN GOUDGE: -- is there 15 another dimension to the -- 16 DR. GLENN TAYLOR: Yeah, I can't think of 17 one (1) off the top of my head. 18 COMMISSIONER STEPHEN GOUDGE: That is 19 the -- 20 DR. GLENN TAYLOR: That's -- that's the 21 main one by far, yes. The -- the responsibility or 22 desire to make sure that there is no potential conflict 23 of interest, if there is a -- an intra-hospital death 24 during a surgical procedure, for instance, where there 25 may be issues of malpractice coming out, having those


1 cases done by pathologists at Sick Kids may raise obvious 2 concerns for a conflict of interest. 3 If the cases are done as an agent of the 4 coroner service through the warranting system then the 5 coroner -- then the pathologist's involvement with the 6 case is then under coroner's warrants and the reporting 7 is to the coroner not to the hospital. 8 COMMISSIONER STEPHEN GOUDGE: Right, 9 right. Is the executive addressing at all the 10 relationship between the OPFPU and the hospital and the 11 Coroner's Office? 12 DR. GLENN TAYLOR: Yes. 13 COMMISSIONER STEPHEN GOUDGE: So that has 14 arisen, and in the context of this independence issue? 15 DR. GLENN TAYLOR: In the context of the 16 independence issue, recognizing that, yes, we have to 17 have a -- have a -- an understood or a demonstrated 18 separation of the two (2), but the fact is that the unit 19 is in the Hospital for Sick Children and it's using 20 employees and resources of the Hospital for Sick 21 Children. 22 COMMISSIONER STEPHEN GOUDGE: To do these 23 very -- 24 DR. GLENN TAYLOR: To do these cases, 25 yes.


1 COMMISSIONER STEPHEN GOUDGE: Yes. Okay. 2 Let me just move to another more microcosmic issue -- 3 well, not microcosmic -- but Mr. Wardle took you to a 4 series of memos expressing concern with Dr. Smith's 5 timeliness and then to your memo that indicated he had 6 got on top of his backlog. 7 And as I read that sequence, the gap 8 between Dr. Becker's last memo expressing significant 9 concern and your memo documenting his having got on top 10 of the backlogs about eighteen (18) months? 11 DR. GLENN TAYLOR: Yes. 12 COMMISSIONER STEPHEN GOUDGE: When does 13 Dr. Becker go off sick or -- 14 DR. GLENN TAYLOR: It was in late Spring 15 of 2002. 16 COMMISSIONER STEPHEN GOUDGE: Okay, and 17 he's then replaced on an acting basis by Dr. Phillips 18 until you come onboard -- 19 DR. GLENN TAYLOR: Yes. 20 COMMISSIONER STEPHEN GOUDGE: -- a year 21 after that? 22 DR. GLENN TAYLOR: Yes. 23 COMMISSIONER STEPHEN GOUDGE: Okay. What 24 was the state of play in Dr. Smith's timeliness when you 25 arrived?


1 DR. GLENN TAYLOR: He had delays in his 2 autopsy reports still. 3 COMMISSIONER STEPHEN GOUDGE: What order 4 of magnitude, that is, if you compare them to the 5 material that Dr. Becker was looking at, with Dr. -- 6 DR. GLENN TAYLOR: Yeah, I can't recall 7 for certain, Commissioner, but I think it was about the 8 same. 9 COMMISSIONER STEPHEN GOUDGE: Okay. How 10 did you work your magic? 11 DR. GLENN TAYLOR: I had a -- 12 COMMISSIONER STEPHEN GOUDGE: I guess 13 what I'm getting at, and I don't mean to be facetious, 14 Dr. Taylor, but clearly one (1) of the issues is what 15 tools are available for somebody in the position you now 16 hold where there is this sort of delinquency in a senior 17 staff pathologist? 18 DR. GLENN TAYLOR: I had assistance from 19 the hospital legal counsel. 20 COMMISSIONER STEPHEN GOUDGE: Okay. 21 Without breaching solicitor client confidence, were there 22 letters written to Dr. Smith or anything like that? 23 DR. GLENN TAYLOR: There was a meeting 24 held. 25 COMMISSIONER STEPHEN GOUDGE: Between


1 you, hospital counsel and Dr. Smith? 2 DR. GLENN TAYLOR: Correct. 3 COMMISSIONER STEPHEN GOUDGE: And did 4 that work? 5 DR. GLENN TAYLOR: Yes, it did. 6 COMMISSIONER STEPHEN GOUDGE: Thanks. 7 Okay, we'll break now for fifteen (15) minutes and come 8 back at twenty-five (25) to 12:00 with, I guess, you, Ms. 9 Simpson. 10 11 --- Upon recessing at 11:19 a.m. 12 --- Upon resuming at 11:35 a.m. 13 14 THE REGISTRAR: All rise. Please be 15 seated. 16 COMMISSIONER STEPHEN GOUDGE: Ms. 17 Simpson...? 18 19 CROSS-EXAMINATION BY MS. VANORA SIMPSON: 20 MS. VANORA SIMPSON: Thank you. Drs, my 21 name is Vanora Simpson. I'm one (1) of the lawyers that 22 acts for the Association in Defence of the Wrongly 23 Convicted. 24 Now, I'm going to focus my questions this 25 morning for you on the peer review mechanisms and quality


1 control measures. I'd like to ask some more questions 2 about how it actually works. If I understand correctly, 3 the goal is to catch and ideally correct any errors 4 before the case is out the door. 5 Is that correct -- 6 DR. GLENN TAYLOR: Yes. 7 MS. VANORA SIMPSON: -- from both of your 8 perspectives? 9 DR. ERNEST CUTZ: Yes. 10 MS. VANORA SIMPSON: And I think we 11 discussed yesterday two (2) key processes that might 12 assist in that effort: one (1) was the checking of 13 reports and the second was the discussion of cases in 14 rounds. 15 I'm going to start by orienting my 16 questions to Dr. Cutz with respect to the checking of 17 reports. 18 You described four (4) cases where you had 19 a disagreement with Dr. Smith. And I understand at least 20 two (2) of them that disagreement emerged when he was 21 looking at your report before it went out the door. And 22 that was the SIDS case involving the -- the infant who 23 passed away at one (1) year plus two (2) weeks. And the 24 second one (1) was this croup case. 25 Is that correct that both of those, the


1 disagreement was identified, not in rounds, but at the 2 report stage? 3 DR. ERNEST CUTZ: Well, it's only the 4 first one which was after report; the -- the second then 5 was his round -- all -- all the other ones in the rounds. 6 MS. VANORA SIMPSON: All the others were 7 in the rounds? 8 DR. ERNEST CUTZ: Yes. 9 MS. VANORA SIMPSON: In your cases where 10 you had that disagreement, I understood you -- you stuck 11 to your guns, you were -- did not change your opinion, 12 and in the SIDS case the report went out as sudden infant 13 death, not undetermined. 14 Is that right? 15 DR. ERNEST CUTZ: That's correct. 16 MS. VANORA SIMPSON: Now, in these cases 17 you had settled on a natural cause of death, and I 18 understand Dr. Smith was leaning in the direction of a 19 traumatic or homicidal cause of death. 20 Is that right? 21 DR. ERNEST CUTZ: Yes. 22 MS. VANORA SIMPSON: Logically it could 23 have been the reverse. There's no reason why a 24 pathologist couldn't have been leaning in the direction 25 of a traumatic or homicidal cause of death while the


1 reviewer thought it was natural. 2 DR. ERNEST CUTZ: Yes, that's possible. 3 MS. VANORA SIMPSON: And so if they stuck 4 to their guns, we would have had a report go out which 5 could have had very serious implications for a police 6 investigation or for an individual suspect. 7 DR. ERNEST CUTZ: Well, it's hard to tell 8 because that was just one (1) stage. Now, you know, if 9 they were substantiation -- that's the question. If -- 10 if it was substantiated or could be substantiated, then 11 it's a different matter. 12 MS. VANORA SIMPSON: That was going to be 13 my next question. 14 What happens when the reviewer disagrees? 15 DR. ERNEST CUTZ: Well, I think then -- 16 then it has to be reconciled to see, you know, what the 17 evidence is and go from there, you know, to look at -- 18 look at all the option. If there's some new information 19 which wasn't available at the time, one has to consider 20 it. 21 MS. VANORA SIMPSON: And what if it can't 22 be reconciled, as in your SIDS case? Presumably, Dr. 23 Smith also -- 24 DR. ERNEST CUTZ: Yeah. 25 MS. VANORA SIMPSON: -- stuck to his


1 guns, and it went out despite his disagreement. 2 DR. ERNEST CUTZ: Well, I presume then, 3 that would be something which the coroner would have to 4 deal with because he's the one who determines the actual 5 manner of death. And so -- so then the decision would 6 have to be made at that stage. You know, which -- or 7 they could ask some other pathologist to review it. I'm 8 not sure how. It hasn't -- it hasn't happened to me so I 9 don't really know how would you handle it. 10 MS. VANORA SIMPSON: Are you aware of any 11 mechanism by which the coroner would know that there were 12 those differences of opinion? 13 Your SIDS case just went out as a SIDS 14 case; he wouldn't have known -- or she wouldn't have 15 known that the reviewer had thought differently. 16 DR. ERNEST CUTZ: Well, that was internal 17 matter. Like it was just within -- within the department 18 and was between colleagues so... 19 And, you know, I -- to my -- it worked out 20 to my satisfy -- I was satisfied so I, you know, didn't 21 feel that it was necessary to go any further than that. 22 MS. VANORA SIMPSON: But you see where 23 the concern might come from if the results or the pattern 24 of difference was opposite. 25 And I guess my question is: Would it be a


1 good idea or do you agree with there being some record 2 kept of that difference of opinion or some mechanism 3 developed for reconciling differences of opinion? 4 DR. ERNEST CUTZ: I think it depends at - 5 - at what level it is. I think they -- now, all these 6 cases are being reviewed. So any homicides or suspicious 7 cases are reviewed by an independent -- I guess it's the 8 Chief Pathologist or the head of the unit who reviews 9 these and so then you have, you know, an additional check 10 and balances in the system. 11 MS. VANORA SIMPSON: Dr. Taylor, do you 12 have any comments on this area of questions? 13 DR. GLENN TAYLOR: I can't speak for the 14 past. I can let you know what we're trying to do now and 15 that is all the cases are reviewed by the Director of the 16 Pediatric Forensic Pathology Unit. I review his cases. 17 For criminally suspicious cases, Dr. 18 Pollanen, as the Chief Forensic Pathologist, also reviews 19 the cases. 20 We do have a form in which written 21 comments are made, and those forms are kept as part of 22 the pathologist's permanent file on the matter. They're 23 not submitted with the report to the Coroner's Office, 24 but they are retained. 25 In my experience, when there has been a


1 serious disagreement with my report, for instance, the 2 Crown or the defence or the police or whoever, has -- has 3 my blessing to ask for a review. Nobody likes having 4 their work reviewed but in such cases, where there's 5 police and potential court involvement being present, I 6 basically suggest a review. 7 This can cause problems because if a -- if 8 a contrary opinion arises then what do you do? And in 9 one (1) circumstance where there were quite different 10 opinions between my -- my analysis and the reviewer's 11 analysis, it was sent to a third party for review. 12 And those are all weighed in assessing. I 13 mean, those become part of the permanent record for the 14 case, and they are admitted in court. And those 15 different points of view are considered in such a 16 circumstance. 17 MS. VANORA SIMPSON: Mr. Registrar, I 18 know I told you I would only be going to one (1) document 19 but it looks like two (2). I wonder if you could pull up 20 PFP137614, and gentlemen, that's at Volume II, Tab 61. I 21 think that may be the form you were just referring to. 22 DR. GLENN TAYLOR: Yes, either this form 23 or -- this was April 2007. I'm not sure if we -- if Dr. 24 Chiasson revised it slightly more. But basically, it's 25 the -- this is the form.


1 MS. VANORA SIMPSON: So if any of those 2 boxes for "no" are ticked off, it goes into the file, but 3 does anybody else hear about it? 4 DR. GLENN TAYLOR: The pathologist that 5 did the report hears about it and should make corrections 6 if -- if there are appropriate corrections to be made. 7 MS. VANORA SIMPSON: And again, what 8 happens if it's a case where people are sticking to their 9 guns, and doesn't -- they don't think there's a 10 correction to make? 11 DR. GLENN TAYLOR: So those issues -- the 12 -- the boxes here are primarily format and content, not 13 opinion. The opinion is usually made in the comments 14 section. If there's a significant difference of opinion 15 as to the cause of death or the interpretation of the 16 pathology then that will -- or there are additional 17 things to think about, that'll be put into the comment. 18 They are there -- this does not -- and I 19 may be wrong, because I -- I can't remember for sure what 20 Dr. Chiasson has decided to do. This -- as far as I 21 know, this does not go to the coroner. This stays with 22 us. If there are significant issues, I would expect that 23 Dr. Chiasson would discuss it with the pathologist and an 24 alternate means of resolving those differences would be 25 decided upon.


1 And that could include having, say Dr. 2 Pollanen, review the case if he wasn't already going to 3 review the case. 4 MS. VANORA SIMPSON: In the interest of 5 preventing wrongful convictions and miscarriages of 6 justice, would either of you have a difficulty with all 7 of those disagreements being provided to defence counsel 8 for an individual accused if the -- a person is charged? 9 DR. GLENN TAYLOR: As I mentioned to you, 10 I've had my -- my reports reviewed with dis -- with 11 contrary opinions, and I have no problem with those being 12 included in -- as -- as far as I'm concerned they're 13 fully disclosable. 14 MS. VANORA SIMPSON: Dr. Cutz? 15 DR. ERNEST CUTZ: Yes, same opinion. 16 MS. VANORA SIMPSON: So the secondary I'd 17 like to turn to then is the rounds. And, Dr. Taylor, I'm 18 going to focus the questions for you. I think I'm going 19 to pick up where Mr. Campbell left off. 20 It seems to me that you identified, at a 21 relatively early point, a problem that may have later 22 caused some fairly grave consequences in individual 23 cases, and that was Dr. Smith's over-confidence in 24 determining causes of death. 25 And you suggested that -- you deferred to


1 his expertise. It was discussed in the group in the 2 round, but you did nothing further with it, is that 3 correct? 4 DR. GLENN TAYLOR: That's correct. 5 MS. VANORA SIMPSON: It seems to me 6 that's a missed opportunity? 7 DR. GLENN TAYLOR: Well, the context is 8 discussing the cases, presenting much of the information 9 but not necessarily all of the information related to the 10 case, and then presenting the conclusions for the case. 11 And in the one (1) that I'm thinking of, I 12 wouldn't have gone as far with the conclusions as Dr. 13 Smith. I have to say that there have been many other 14 presentations at rounds, not necessarily even medicolegal 15 cases or coroner's cases, but other circum -- I say 16 hospital cases, where a conclusion was maybe a little bit 17 further than I would go. 18 I have to recognize that this is part 19 personality. I'm a little bit paranoid about some 20 things, and maybe -- maybe over-cautious about some 21 things. But I -- but there are people that know more -- 22 more about certain areas than I do, and I recognize that. 23 And if their argument is -- is reasonable, 24 then I will defer to their opinion. 25 MS. VANORA SIMPSON: So it seems to me


1 the rounds then, and the presentation of the cases, the 2 batting around of ideas and suggestions that happens at 3 that time is not the time nor the place to catch errors? 4 DR. GLENN TAYLOR: Oh, it certainly can 5 get people back on track if they seem to be way off 6 track. And if there's a general clamouring that somebody 7 has missed something that is very significant, then that 8 can be incorporated into the presenters's final report. 9 And that has happened on occasion. 10 MS. VANORA SIMPSON: Okay. Finally, I'd 11 like you to turn up the next tab, Volume II, Tab 62, Mr. 12 Registrar. This is the document we discussed at the 13 break, PFP137733. This is also an April 2007 document 14 that outlines quality assurance mechanisms at the 15 Division of Pathology. 16 And I'd like you to turn to page 4. We've 17 highlighted a portion. It may be easier on your screen. 18 It talks about random audits, and that random audits are 19 something that are recommended or suggested in the 20 literature as a valuable quality assurance mechanism. 21 And then under that, at Update 2007, this 22 is the paragraph immediately above the Number 11. It 23 says that: 24 "The work of an individual pathologist 25 was reviewed; sixty (60) cases, fifty-


1 seven (57) are congruent with the 2 original result." 3 I'm thinking those numbers are not just a 4 coincidence. And, Dr. Taylor, what it's referring to is 5 Dr. Dimmick's 2000 review -- 2005 review of Dr. Smith's 6 cases? 7 DR. GLENN TAYLOR: Yes. 8 MS. VANORA SIMPSON: It seems to me there 9 -- there's no suggestion that a further random blind 10 audit program is contemplated, and there's nothing 11 between 2005-2007? 12 DR. GLENN TAYLOR: No, we don't have a 13 blind auditing program which is a component of many 14 pathology practices. It's something that has been 15 discussed between myself and Dr. Chiasson with regards to 16 the autopsies. Time, logistics and staffing are all 17 issues. But I fully agree that that is a good mechanism 18 for QA which we haven't yet applied. 19 MS. VANORA SIMPSON: Thank you, sir. 20 COMMISSIONER STEPHEN GOUDGE: Sorry. 21 Elaborate the staffing challenge that goes with that. 22 DR. GLENN TAYLOR: Well, it takes time. 23 To do a proper audit would be reviewing the slides, the 24 inf -- all of the information that's available -- 25 COMMISSIONER STEPHEN GOUDGE: The


1 original data? 2 DR. GLENN TAYLOR: The original data, 3 yes, to do it properly. And that would probably be a 4 three (3) -- two (2) or three (3) hour task, even doing 5 it quickly with a straightforward case. 6 If it was a more involved case, which many 7 of ours are, it could be, at least, a half a day. And to 8 fit in say, five (5) cases every month or something like 9 that -- people talk about a 10 percent blind audit rate - 10 - we would be probably at about -- so we'd be looking at 11 three (3) cases; it would be a full day's work. 12 So it's not something that I've worked 13 into the scheduling yet, and I'd have to juggle some 14 other things around. 15 COMMISSIONER STEPHEN GOUDGE: When you 16 say people talk about a 10 percent blind audit rate, is 17 that, sort of, generic quality assurance discussion 18 amongst world-class hospitals? 19 DR. GLENN TAYLOR: Yes. 20 COMMISSIONER STEPHEN GOUDGE: And is it 21 practised elsewhere in other pathology departments? 22 DR. GLENN TAYLOR: It's practised in some 23 of the pediatric pathology departments that I know of in 24 the United States, yes. 25 COMMISSIONER STEPHEN GOUDGE: Any in


1 Canada? 2 DR. GLENN TAYLOR: It wasn't practice -- 3 COMMISSIONER STEPHEN GOUDGE: In BC, 4 where -- 5 DR. GLENN TAYLOR: -- in BC where I was 6 before. I'm not sure about other places. 7 COMMISSIONER STEPHEN GOUDGE: Okay, 8 thanks. 9 Ms. Simpson...? 10 MS. VANORA SIMPSON: That's all. Thank 11 you, Commissioner. Thank you, Doctors. 12 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 13 Simpson. 14 Ms. Greene...? 15 MS. MARA GREENE: Yes. I have no 16 questions, thank you. 17 COMMISSIONER STEPHEN GOUDGE: Ms. 18 Fraser...? 19 20 CROSS-EXAMINATION BY MS. SUZAN FRASER: 21 MS. SUZAN FRASER: Dr. Cutz, Dr. Taylor, 22 my name is Sue Fraser and I'm here on behalf of an 23 organization called Defence for Children International, 24 which is an international grassroots charitable 25 organization which aim is to promote and protect the


1 rights of the child as spelled out in the UN Convention. 2 And, Dr. Cutz, I just wanted to pick up on 3 a point that you raised yesterday. And you made 4 reference to the fact that in 2004, you had sat on an 5 international panel with five (5) forensic pathologists, 6 three (3) pediatricians and discussed the type of 7 criteria -- this is what I understood, for determining 8 Sudden Infant Death Syndrome and Sudden Unexpected Death. 9 Did I understand that properly? 10 DR. ERNEST CUTZ: Yes. 11 MS. SUZAN FRASER: All right. And am I 12 right in understanding that that -- because you had also 13 at another time discussed the National Institute of 14 Health -- that that was a panel related to the National 15 Institute of Health? 16 DR. ERNEST CUTZ: It was convened by the 17 National Institute of Health. 18 MS. SUZAN FRASER: All right. And do I 19 understand properly that the purpose of that panel was to 20 reach a, sort of, consensus or international standard on 21 the -- on those types of definitions? 22 DR. ERNEST CUTZ: It was that plus it was 23 to update because in the intervening fifteen (15) or so 24 years, there's been development, new research and new 25 information available. So that was to update it to the


1 current level of the knowledge. 2 MS. SUZAN FRASER: All right. So the 3 National Institute of Health, is that an American 4 organization? 5 DR. ERNEST CUTZ: Yes. 6 MS. SUZAN FRASER: All right. But it's 7 internationally recognized, as I understand it? 8 DR. ERNEST CUTZ: It's -- it's the major 9 funding agency for health research in the world. 10 MS. SUZAN FRASER: All right. And from 11 what I think you're telling me, is that fifteen (15) 12 years before 2004 -- so that's 1989 -- if I'm doing my 13 math properly, that there had -- they had convened a 14 similar panel and come up with a criteria for diagnosing 15 SIDS? 16 DR. ERNEST CUTZ: Yes. As I explained -- 17 and my understanding for the panel, was to -- to set some 18 guidelines. And this was in advance of National 19 Institute of Health targeted funding for SIDS research. 20 There was to be about $50 million invested into SIDS 21 research. 22 And to make sure that the research is done 23 in well-characterized groups of patients -- so they call 24 in the panel to define the criteria. And then this was, 25 you know -- any centres who were competing for this


1 funding had to, sort of, adhere or use these -- these 2 criteria that was to -- to ensure that the cases, which 3 are being analysed, you know, you -- you can produce 4 reproducible data. 5 MS. SUZAN FRASER: All right. So in -- 6 it's -- it's purpose was for research. Is it also 7 something that pathologists are supposed to use when 8 making outside of the research context, say, in a 9 medicolegal context, are to also apply that criteria? 10 DR. ERNEST CUTZ: Yes. No, I think the - 11 - the panel has considered this. And, you know, one (1) 12 of the members of the panel was -- was a forensic 13 pathologist, and even at that time, the concern was that 14 some of the cases could not -- may not be genuine SIDS. 15 There was also concern about the sleeping 16 environment. So that there were sort of, if you like, 17 two (2) definitions. One (1) was for administrative 18 purpose, and one (1) was for research purposes. 19 And the administrative was, you know, to 20 dealing with legal issues and also dealing with providing 21 appropriate health statistics, so that the cases are 22 properly classified and then you can follow trends and -- 23 and devise any sort of a procedure based on these trends. 24 MS. SUZAN FRASER: All right. And so I'm 25 just having trouble understanding how that would be


1 useful because I think, later in your evidence, you said 2 that Ontario's falling behind. And so I'm interested, 3 both from a research perspective and also from a, sort 4 of, diagnostic or analysis, when a child dies to 5 determine whether it's actually a SIDS death, what you 6 would propose in terms of the applicability of the 7 National Institute of Health guidelines to the Ontario 8 situation? 9 DR. ERNEST CUTZ: Well, as -- as I 10 mentioned, the '91 guidelines, that was a basis which was 11 used since then and it was a little bit more refined in 12 the 2004 panel deliberation where it was recognized that 13 not all the SIDS -- SIDS are the same. 14 And there are some, you know, subgroups 15 which need to be pointed out or -- or separated out. And 16 it also dealt with some of the issues in terms of 17 overlaying, co-sleeping -- as some of these other issues 18 which came up in the -- during the '90s. 19 MS. SUZAN FRASER: All right. 20 DR. ERNEST CUTZ: So I -- I think, you 21 know, that -- that was recommended by the panel. It was 22 published in the Journal of Pediatrics, and I understand 23 it -- American Association of Pediatrics has also 24 endorsed this recommendation. 25 MS. SUZAN FRASER: All right. If you


1 could turn then to the autopsy guidelines that you should 2 find in Volume II at Tab 67, which is PFP137592. 3 DR. ERNEST CUTZ: Yes. 4 MS. SUZAN FRASER: And turn to the first 5 -- the second page which is the actual first page of the 6 criteria. Have you reviewed these guidelines? Have you 7 had an opportunity to consider these guidelines? I know 8 you're not doing medicolegal autopsy -- 9 DR. ERNEST CUTZ: Yes. No, I -- I was 10 not involved in designing these guidelines. 11 MS. SUZAN FRASER: All right. And would 12 it be useful for a pathologist approaching a suspected 13 SIDS case to have and to use the National Institute's of 14 Health guide -- National Health Institute's guidelines? 15 DR. ERNEST CUTZ: Well, it would be 16 helpful if they do, but I think this covers all kinds of 17 cases. It doesn't just cover SIDS, so this -- this 18 refers to the -- the total population of -- of pediatric 19 cases coming through the Coroner's Office. 20 MS. SUZAN FRASER: Right. And as a 21 pathologist with experience in dealing with SIDS and 22 identifying SIDS cases, -- 23 DR. ERNEST CUTZ: Yeah. 24 MS. SUZAN FRASER: -- is the use of a 25 recognized protocol something that you believe is


1 important? 2 DR. ERNEST CUTZ: Yes. There -- in fact, 3 there is a protocol for investigation of SIDS cases, 4 which is also part of the -- part of the document, but 5 you see I wish to point out that these guidelines, it 6 says, "for criminally suspicious deaths and homicides in 7 infant and children," so this doesn't really refer to the 8 investigation of SIDS cases. 9 MS. SUZAN FRASER: All right. And when 10 you're talking about the other guidelines for sudden 11 infant death, are you talking about the coroner's 12 investigation statement that comes to you when you -- as 13 a pathologist? 14 DR. ERNEST CUTZ: Well, the coroner's 15 statement just, you know, you mean like the coroner's 16 warrant or -- 17 MS. SUZAN FRASER: Well, we -- I'm not 18 going to take your attention to it now, but we've -- 19 we've heard evidence about the coroner having a form 20 that's used first -- was first used for deaths under two 21 (2) -- 22 DR. ERNEST CUTZ: Yes. 23 MS. SUZAN FRASER: -- and now is used for 24 deaths under five (5). 25 Does that assist you?


1 DR. ERNEST CUTZ: Yes, I think that more 2 refers to the scene investigation and information 3 regarding clinical history and some other details 4 relevant to the -- to the investigation. 5 Yeah, I think that's -- that would be part 6 of the SIDS protocol. 7 MS. SUZAN FRASER: All right. 8 9 (BRIEF PAUSE) 10 11 MS. SUZAN FRASER: I understood your 12 evidence yesterday that Ontario is lagging behind, and I 13 took that to be because of the coroner -- the arrangement 14 with the Coroner's Office, and for that reason, Ontario 15 is lacking -- or lagging behind in SIDS research, and 16 that is the -- the problem that was identified in terms 17 of research that came -- the prohibition against doing 18 research for medicolegal cases? 19 DR. ERNEST CUTZ: Yeah, it -- it is a -- 20 it is part of -- part of the problem and I think there 21 are different approach in different jurisdiction. 22 MS. SUZAN FRASER: Yes. 23 DR. ERNEST CUTZ: And as I mentioned, in 24 the state of California -- and this was a specific 25 legislation enacted, which was actually supported by


1 parents of -- of children who died of SIDS, they made it 2 happen, which then allows to develop, you know, a tissue 3 bank and investigate SIDS at a more sophisticated level, 4 using the modern methods of molecular pathology. 5 MS. SUZAN FRASER: All right. And is it 6 fair to say that the current state of affairs has got in 7 the way of good research on SIDS? 8 DR. ERNEST CUTZ: Well, I think there's 9 no research. 10 MS. SUZAN FRASER: All right. And if 11 there's no research, is it fair to say that it's hard to 12 develop Ontario standards if you don't have Ontario 13 research? 14 DR. ERNEST CUTZ: Well, it would -- 15 desirable, I think, to -- to have it and I think, you 16 know, we have the resources at the Hospital for Sick 17 Children to do it. 18 MS. SUZAN FRASER: All right. Dr. Cutz, 19 are you familiar with the Paediatric Death Review 20 Committee from the Office of the Chief Coroner or 21 established by the Office of the Chief Coroner? 22 DR. ERNEST CUTZ: I heard about it, but 23 I'm not familiar with the details. 24 MS. SUZAN FRASER: All right. And I'm 25 just thinking of your Dextromethorphan case.


1 DR. ERNEST CUTZ: Yes. 2 MS. SUZAN FRASER: And if, the Registrar, 3 if you could turn to Tab 79 of Volume II, and you should 4 have Volume II in front of you, I think. It's PFP056409. 5 You'll see in the fourth paragraph at the 6 bottom -- and this is the coroner's investigation 7 statement. It says: 8 "In addition, in the new year the 9 Paediatric Death Review Committee 10 intends to also bring this issue to the 11 attention of the medical profession at 12 large." 13 DR. ERNEST CUTZ: Yes. 14 MS. SUZAN FRASER: Do you see that, Dr. 15 Cutz? 16 DR. ERNEST CUTZ: Yes, mm-hm. 17 MS. SUZAN FRASER: And were you ever 18 invited to the Paediatric Death Review Committee to speak 19 about this case? 20 DR. ERNEST CUTZ: No, I was not. 21 MS. SUZAN FRASER: All right. And to the 22 best of your knowledge, were the lessons that you learned 23 in that case made available to the medical profession at 24 large? 25 DR. ERNEST CUTZ: I'm not sure if this


1 particular case was -- was highlighted or -- or 2 advertised, but I think it -- it some -- you know, some 3 of these disorders are well-known in the pediatric 4 community. 5 MS. SUZAN FRASER: All right. And do you 6 agree with me that it's important, when lessons are 7 learned like this, that re -- that they be made 8 publically -- recommendations be made publically 9 available? 10 DR. ERNEST CUTZ: Yes, I think that would 11 be a logical conclusion. Now whether it was done in this 12 case or not, I'm not sure. 13 MS. SUZAN FRASER: All right. I thank 14 you, Mr. Commissioner, those are my questions. 15 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 16 Fraser. 17 Ms. Ritacca...? 18 19 CROSS-EXAMINATION BY MS. LUISA RITACCA: 20 MS. LUISA RITACCA: Thank you, 21 Commissioner. Good afternoon, Doctors. My name is Luisa 22 Ritacca and I'm one (1) of the lawyers for the Office of 23 the Chief Coroner. 24 25 (BRIEF PAUSE)


1 MS. LUISA RITACCA: Dr. Cutz, yesterday 2 and in evidence today, you indicated that Dr. Mancer was 3 one (1) of the pathologists at the Hospital for Sick 4 Children in the 1980s who performed medicolegal 5 autopsies, and was someone with some adult forensic 6 pathology experience. 7 Do you recall that? 8 DR. ERNEST CUTZ: Yes. 9 MS. LUISA RITACCA: And further, you 10 testified that you though that Dr. Smith did not have the 11 requisite forensic experience to be the Director of the 12 Unit. 13 Do you recall that? 14 DR. ERNEST CUTZ: Yes. 15 MS. LUISA RITACCA: Okay. And we know 16 that Dr. Chiasson, the current Director of the Unit, is a 17 Board certified forensic pathologist? 18 DR. ERNEST CUTZ: Yes. 19 MS. LUISA RITACCA: And so my first 20 question, I'll direct it first to you, Dr. Cutz. 21 Do you think that the Director of the unit 22 should be a Board certified forensic pathologist? 23 DR. ERNEST CUTZ: Yes. 24 MS. LUISA RITACCA: Dr. Taylor...? 25 DR. GLENN TAYLOR: Since I recruited and


1 hired Dr. Chiasson, yes. 2 MS. LUISA RITACCA: That was an easy 3 question then. 4 Doctors, you both spoke with the 5 Commissioner at some length with regard to triaging or 6 streaming cases -- I think I heard you both use both of 7 those words -- to either a pediatric pathologist or 8 forensic pathologist. 9 And as I understood your evidence, you 10 both indicated that probably about 5 percent of the 11 medicolegal pediatric cases should be more appropriately 12 handled by a forensic pathologist. 13 Have I got your evidence right? 14 DR. GLENN TAYLOR: I think there's -- 15 there's a point of debate. My personal feeling is that I 16 would rather a forensic pathologist did them than myself. 17 The issue where they're best done -- I think I discussed 18 this yesterday with Mr. Commissioner -- again can be 19 debated. 20 We have the facilities to do a good job on 21 the other 95 percent, and many of those facilities can be 22 applied to doing a very good job on that 5 percent. But 23 there are other, kind of, issues or considerations to be 24 made with regards to that 5 percent. 25 MS. LUISA RITACCA: And is it fair to say


1 that at present even the 5 percent of cases are being 2 done -- are in fact being done by a forensic pathologist, 3 either Dr. Chiasson or Dr. Pollanen? 4 DR. GLENN TAYLOR: The large majority 5 are, yes. 6 MS. LUISA RITACCA: Okay. And I also 7 understood you to say, Dr. Taylor, that it's a very rare 8 case that a particular case would be triaged incorrectly? 9 DR. GLENN TAYLOR: It's uncommon, yes. 10 MS. LUISA RITACCA: If I could ask you to 11 turn up Tab 67 of Volume II. I think in fact it was the 12 last document Ms. Fraser brought you to and that's at 13 PFP137592, Mr. Commissioner -- Mr. Registrar, rather. If 14 you go to page 2 of the document. 15 Well first, I understand that these 16 guidelines relate to all sudden unexpected deaths of 17 infants and children under five (5) years, is that 18 correct? 19 DR. GLENN TAYLOR: I think Section 2.1 20 excludes those that are identified as being criminally 21 suspicious. 22 MS. LUISA RITACCA: That's right. So 23 these guidelines apply to all cases that are not 24 criminally suspicious? 25 DR. GLENN TAYLOR: Correct.


1 MS. LUISA RITACCA: All right. So if we 2 look at Section 2.2, the first paragraph, it reads: 3 "In deaths of a criminally suspicious 4 potentially homicidal nature, the 5 reader is directed to the document 6 guidelines for the autopsy in 7 criminally suspicious deaths and 8 homicides in infants and children." 9 And it's a guideline that we've seen here 10 before. And it says: 11 "In general the pathologist needs to 12 keep an open mind to the possibilities 13 of occult violent death, child abuse, 14 sexual assault, maltreatment and 15 neglect, and therefore have a low 16 threshold for the utilization of the 17 guidelines for the autopsy in 18 criminally suspicious deaths and hom -- 19 homicides." 20 So am I to understand that if this low 21 threshold is met, it would be your opinion, Dr. Taylor, 22 that the case should be done by a forensic pathologist? 23 DR. GLENN TAYLOR: Again, it depends on 24 the circumstances. If -- if the threshold, which seems 25 to me to be up to the individual pathologist, --


1 MS. LUISA RITACCA: That's how I read it, 2 yes. 3 DR. GLENN TAYLOR: -- is met then it's -- 4 it's -- varies between the pathologists. Some of us have 5 lower thresholds than others. 6 MS. LUISA RITACCA: Right. 7 DR. GLENN TAYLOR: But I think the key is 8 that the pathologist doing the case should feel 9 comfortable in doing the case, and if that pathologist 10 does not feel comfortable then it should be referred to 11 one (1) of the forensic pathologists. 12 MS. LUISA RITACCA: And taking you, Dr. 13 Taylor, in your experience, given that the guideline 14 seems to be encouraging a low threshold -- and if I hear 15 your evidence correctly, you perhaps have a lower 16 threshold than some of your other colleagues. 17 Is that fair? 18 DR. GLENN TAYLOR: I don't have the 19 lowest threshold, that's for sure. 20 MS. LUISA RITACCA: Okay. 21 DR. GLENN TAYLOR: I have had experience 22 in doing such cases. I would prefer not to do them and 23 my usual approach would be to ask David if he could do 24 them. If not David then Michael, and then if Michael or 25 David are not available and I feel that I could handle


1 the case, even though I'm not happy about doing it, then 2 I would do it. 3 MS. LUISA RITACCA: All right. And if we 4 take that threshold together with what we see here in the 5 guidelines, can we assume that there are more than the 5 6 percent of cases that start off as criminally suspicious 7 or suspicious that would meet this threshold? 8 DR. GLENN TAYLOR: You know, if there are 9 it's going to be just a few percent more, because these 10 are all pretty -- pretty evident signs on the -- on the 11 body or the circumstances that would automatically raise 12 red flags, I think. And so those cases probably would 13 have been streamed even before this list was -- was 14 constructed here. 15 So it -- I don't think it would probably 16 change the numbers much, certainly not -- not above 10 17 percent, but it might -- there might be some grey cas -- 18 grey zone cases that would fall into this. 19 MS. LUISA RITACCA: And we've heard a 20 figure that is -- is actually included in the Coroner's 21 Office Institutional Report -- suggests that, you know, 22 once the investigation is done there's somewhere between 23 five (5) to fifteen (15) homicides in a ped -- in 24 pediatric cases that are -- go through the coroner's 25 system and that there's a great many more that fall in


1 the category of natural and undetermined. 2 And -- or -- would you be familiar with 3 those numbers at all or -- you wouldn't dis -- disagree 4 with me? 5 DR. GLENN TAYLOR: No, I wouldn't 6 disagree. Those are the num -- those are about the 7 percentages that 5 to 15 percent -- five (5) to fifteen 8 (15) cases per year in Ontario is -- is the same -- it 9 sounds like a reasonable number to me. 10 MS. LUISA RITACCA: And what I'm trying 11 to understand is, of the cases that end up as 12 unascertained or even natural, how many of those would 13 start of as suspicious because they meet the low 14 threshold in this guideline? 15 DR. GLENN TAYLOR: Some for sure. I 16 don't know the number, but some for sure. 17 MS. LUISA RITACCA: Some tens more or 18 dozens more, do you have any sense? 19 DR. GLENN TAYLOR: The issue would be is 20 there enough physical findings or autopsy findings to 21 properly classify the case. So -- and that comes down to 22 the -- the pathologist, in a sense, and where the 23 pathologist -- how confident the pathologist is. 24 So an undetermined diag -- final bottom 25 line in a circumstance where there are child injuries


1 that seem to be of an inflicted nature is not necessarily 2 an uncommon end result because a cause of death cannot 3 definitely defined. 4 So if you look at that group, which are 5 being treated as suspicious deaths from the beginning, in 6 a sense, it's probably another 5 percent or so. 7 MS. LUISA RITACCA: Okay. And when you 8 said in your evidence that -- you know, leaving aside 9 that Dr. Chiasson is currently the Director of the unit, 10 but that you personally wouldn't mind if that 5 percent 11 of cases were done outside of the hospital in another 12 unit. 13 Is that number actually more than 5 14 percent if we were to include the cases that end up as 15 natural or undetermined? 16 DR. GLENN TAYLOR: Well, that would be 17 open to discussion. If such an event occur -- such a 18 possibility was raised, it would be open to discussion. 19 And the discussion would be around what would be the best 20 initial investigation to be applied to those cases. 21 Would they be treated -- in that grey 22 zone, would they be treated as potential pediatric 23 disease cases or as potential pediatric criminally 24 suspicious forensic cases. 25 MS. LUISA RITACCA: Could -- could you


1 use the -- the threshold set out in 2.2 as the 2 demarcation? 3 DR. GLENN TAYLOR: I would not -- I would 4 not be opposed to using that as a cut. 5 MS. LUISA RITACCA: Would that mean there 6 would be a lot more cases being done outside of the 7 hospital? 8 DR. GLENN TAYLOR: I think -- as I 9 mentioned, I think it would maybe go from 5 to 10 10 percent. I suspect not more than -- than that, but I'd 11 have to have a look at -- a careful analysis of our cases 12 over the past few years to kind of get a food feeling for 13 that. 14 MS. LUISA RITACCA: Right. 15 COMMISSIONER STEPHEN GOUDGE: And it 16 would be the 5 percent that end up as the homicides, 17 together with another 5 percent. 18 DR. GLENN TAYLOR: Yeah, five (5) -- 19 COMMISSIONER STEPHEN GOUDGE: You could 20 start out -- 21 DR. GLENN TAYLOR: Yeah -- 22 COMMISSIONER STEPHEN GOUDGE: -- meeting 23 the guidelines. 24 DR. GLENN TAYLOR: I'm just -- Mr. 25 Commissioner, I'm just trying to think of our recent


1 experience and -- 2 COMMISSIONER STEPHEN GOUDGE: Yes, I 3 recognize it is an estimate 4 DR. GLENN TAYLOR: Yeah. So maybe 5 to 5 10 percent more. So somewhere upper limit of maybe 15 6 percent. But I -- we would really need to have a hard 7 look at the -- sort of the case definitions that we've 8 had over the past few years. 9 COMMISSIONER STEPHEN GOUDGE: And these 10 guidelines really became operative only this year. 11 DR. GLENN TAYLOR: They -- they were 12 codified this year. I'm sure that many of my colleagues 13 have these kind of things in mind when they;'re initially 14 assessing a case. 15 COMMISSIONER STEPHEN GOUDGE: Right. But 16 prior to this year there wasn't any formal guideline 17 document that listed these -- 18 DR. GLENN TAYLOR: No -- 19 COMMISSIONER STEPHEN GOUDGE: -- 20 guidelines as -- 21 DR. GLENN TAYLOR: -- that's -- that's 22 correct. 23 COMMISSIONER STEPHEN GOUDGE: -- a way of 24 triaging the cases going into an autopsy? 25 DR. GLENN TAYLOR: That's correct.


1 COMMISSIONER STEPHEN GOUDGE: So you 2 would have to go back and look at the case-by-case data 3 to see if, with hindsight, these cases would meet the 4 guidelines or not? 5 DR. GLENN TAYLOR: That's what I was 6 referring to, Commissioner. 7 COMMISSIONER STEPHEN GOUDGE: Yes. 8 9 CONTINUED BY MS. LUISA RITACCA: 10 MS. LUISA RITACCA: And, Dr. Taylor, when 11 we're discussing triaging cases, are you more concerned 12 with triaging a case to the appropriate person or to the 13 appropriate facility? 14 DR. GLENN TAYLOR: Well, the person is 15 probably the most important thing. The facilities are 16 very important and what support the facilities can offer, 17 but I think it still comes down to the person. 18 COMMISSIONER STEPHEN GOUDGE: Can I just 19 ask one (1) -- 20 MS. LUISA RITACCA: Sure. 21 COMMISSIONER STEPHEN GOUDGE: -- other 22 question, Ms. Ritacca? 23 It would be -- how confident are you in 24 this 5 percent additional estimate? I mean, it is going 25 to be within the ballpark isn't it, Dr. Taylor?


1 You wouldn't find if you went back and 2 actually rolled up your sleeves and took the time to do 3 this task -- 4 DR. GLENN TAYLOR: Well. 5 COMMISSIONER STEPHEN GOUDGE: -- that 6 you'd end up with 15 percent, as opposed to 5 percent? 7 DR. GLENN TAYLOR: I'm not 100 percent 8 confident, Commissioner. I have looked at the data of 9 our cases from the past four (4) years and they break 10 down -- and I haven't put in a grey zone -- I didn't 11 analyse them like that, but -- 12 COMMISSIONER STEPHEN GOUDGE: Yes, right. 13 I'm sure -- 14 DR. GLENN TAYLOR: -- but overall, it's 15 been about 3.3 percent of the cases in the past four (4) 16 years were of interest to the criminal justice system. 17 COMMISSIONER STEPHEN GOUDGE: From the 18 beginning? 19 DR. GLENN TAYLOR: At the end -- end -- 20 COMMISSIONER STEPHEN GOUDGE: Yes. 21 DR. GLENN TAYLOR: -- end of things. 22 The beginning part, I haven't looked at. This triaging 23 business, I haven't considered. But I'm looking at the 24 end result, so 3.3 percent were of interest to the 25 criminal justice system. There are about 9 percent


1 accidents; about 20 percent were SIDS, SIDS-like deaths, 2 or undetermined in the context of a SIDS-like death. 3 That would be the grey zone as far as I am concerned. 4 The other 70 percent are -- 5 COMMISSIONER STEPHEN GOUDGE: Which? The 6 SIDS-like deaths would provide the grey zone? 7 DR. GLENN TAYLOR: I think so. The other 8 70 percent are those that there's recognizable pediatric 9 diseases. 10 COMMISSIONER STEPHEN GOUDGE: Okay. So 11 it would be some component of that 20 percent that might 12 fit within the -- 13 DR. GLENN TAYLOR: Correct. 14 COMMISSIONER STEPHEN GOUDGE: -- 15 guidelines if the guidelines were applied with hindsight? 16 DR. GLENN TAYLOR: Correct. 17 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 18 Ritacca. 19 20 CONTINUED BY MS. LUISA RITACCA: 21 MS. LUISA RITACCA: And, Dr. Taylor, 22 yesterday you answered several questions, and in fact 23 this morning, about the role of review and peer review 24 within the Division of Pathology. 25 Is it fair to say that the idea of formal,


1 departmental quality assurance and review is relatively a 2 new concept in medicine? And when I say "new" I mean in 3 the last ten (10) to twenty (20) years. 4 DR. GLENN TAYLOR: Oh, it's a least 5 twenty (20) years because I have manuals from workshops 6 that I've taken on quality assurance in anatomical 7 pathology that are from the late '80s. 8 MS. LUISA RITACCA: And is it fair to say 9 you're doing more formalized quality assurance now than - 10 - than you were before? 11 DR. GLENN TAYLOR: Before ten (10) years 12 ago, yes. 13 MS. LUISA RITACCA: Yes. 14 15 (BRIEF PAUSE) 16 17 MS. LUISA RITACCA: And when Ms. Simpson 18 spoke to you about the peer review in -- at the hospital 19 currently for the medicolegal cases and she took you to 20 the report audit form, I just wanted to confirm that in 21 addition to those procedures and the procedures you 22 talked about with regard to the criminally suspicious 23 cases that go to the Chief Forensic Pathologist, my 24 understanding is that every sudden and unexpected death 25 of a child under five (5) presently is reviewed by the


1 Death Under Five Committee at the Office of the Chief 2 Coroner. 3 DR. GLENN TAYLOR: I'm not sure if every 4 one (1), but certainly a large number are, yes. 5 MS. LUISA RITACCA: And, Dr. Cutz, 6 yesterday you explained that, with respect to your 7 surgical pathology, part of the review process included 8 comment or followup by the clinicians who were requesting 9 the pathology, is that -- 10 DR. ERNEST CUTZ: Yes. 11 MS. LUISA RITACCA: -- fair? 12 DR. ERNEST CUTZ: It is. 13 MS. LUISA RITACCA: Okay. And I took 14 from your evidence that this review or consultation with 15 the clinicians is a beneficial process. 16 DR. ERNEST CUTZ: Yes. 17 MS. LUISA RITACCA: And -- and in part, 18 can we assume that it's beneficial -- that the benefit 19 derives because of the clinician's knowledge of the 20 patient and the patient history? 21 DR. ERNEST CUTZ: That's correct, yes. 22 MS. LUISA RITACCA: Okay. And as well, 23 can we conclude that the benefit derives because of the 24 clinician's general cli -- clinical background and 25 knowledge of oncology, or cardiology, or whatever the


1 case may be? 2 DR. ERNEST CUTZ: Well, it's -- it's the 3 kind of information the pathologist needs to make the, 4 you know, proper diagnosis. 5 MS. LUISA RITACCA: All right. And, Dr. 6 Cutz, I understood your evidence yesterday that part of 7 your frustration with the medicolegal cases in the Office 8 of the Chief Coroner is this growing trend to insist on 9 classifying cases as unascertained or no anatomical cause 10 of death instead of SIDS. 11 Is that fair? 12 DR. ERNEST CUTZ: What I meant to say is, 13 you know, based on this 2004 classification system, which 14 I feel is a -- is a more up-to-date way to -- to -- you 15 know, first of all, you have to recognize there is such a 16 thing as SIDS. 17 I mean, the SIDS is a medical condition 18 recognized by the World Health Organization. It's 19 recognized as a pediatric disease, and so -- and so there 20 are a conditions which may mimic SIDS; I mean, that's 21 what -- that's what we are talking about. 22 So we're excluding conditions which mimic 23 SIDS -- concealed trauma or anything of those nature -- 24 but those are, you know, minimal; 0.1 percent of cases. 25 I mean, it's -- it's not to say medicine biology is not


1 100 percent ever. 2 MS. LUISA RITACCA: And -- 3 DR. ERNEST CUTZ: So -- so that, you know 4 -- so the -- one has to recognize that there is a 5 clinical condition which, you know, people recognize as 6 SIDS and treat it as such. 7 MS. LUISA RITACCA: Okay. And we've been 8 told, and -- 9 DR. ERNEST CUTZ: Yeah. 10 MS. LUISA RITACCA: -- my understanding 11 was that -- and I -- I hear you when you say that SIDS is 12 a recognized medical disease -- 13 DR. ERNEST CUTZ: Right. 14 MS. LUISA RITACCA: -- but I -- I also 15 understood that it is -- can only be diagnosed by 16 excluding other possibilities; it's a diagnosis of 17 exclusion, is that correct? 18 DR. ERNEST CUTZ: Yes, that's correct. 19 Yes. 20 MS. LUISA RITACCA: Okay. So that means 21 that in order for a case to be SIDS, there would have to 22 be no positive findings at autopsy; is that a fair way of 23 saying it? 24 DR. ERNEST CUTZ: Yes. Well, that's for 25 the physical finding, but as far as, you know,


1 classifying, one has -- one must not confuse what's 2 called "risk factor in causation", and I think that's 3 what the problem -- problem is here. 4 MS. LUISA RITACCA: Okay, ex -- explain 5 that to me. 6 DR. ERNEST CUTZ: There are certain risk 7 factors where, you know -- babies, for example -- look at 8 various parameters of -- of the clinical history or the - 9 - for example, it's found that smoking mothers would have 10 higher incidents of -- of SIDS deaths infants, but we 11 cannot say it's the smoking who -- who killed the child. 12 MS. LUISA RITACCA: Right. 13 DR. ERNEST CUTZ: And same with the 14 sleeping position. The sleeping -- unsafe sleeping 15 position is a risk factor for SIDS, but it's not the 16 cause of death. So instead of, you know, calling it 17 "suffocation by sleeping position", which would imply 18 it's a perfectly normal child with no predisposition or 19 biology called underlying defect for SIDS. 20 I think -- you know, then -- then you mis- 21 skew (phonetic) the tot -- total, and -- and you stop 22 research into it, because then these are just accidents 23 of, you know, which were not preventable -- whatever. 24 So -- so that -- that was one (1) of the 25 reasons for us to do this protocol, to revise the


1 protocol. To -- to kind of reemphasize that SIDS hasn't 2 gone away, and it still needs to be investigated. The 3 biological basis is still -- needs to be -- needs to be 4 explained. 5 MS. LUISA RITACCA: And for the purposes 6 of the Coroner's Mandate which is to -- 7 DR. ERNEST CUTZ: Yes. 8 MS. LUISA RITACCA: -- thoroughly 9 investigate sudden and unexpected deaths, is it not more 10 accurate to say in a cas -- in the case that you took for 11 example, like a sleep position case; that -- that that, 12 in fact, is the cause of death; that it's undetermined 13 with overlaying or undetermined with sleep position 14 rather than say SIDS, where -- where the cause of death 15 determination of SIDS would be suggestive of something 16 natural and not telling the entire story? 17 DR. ERNEST CUTZ: Well, the problem with 18 that is if it's not really -- if it's a documented 19 obstruction of, you know, something, then, you know, 20 that's what it is; then it cannot be SIDS. 21 But in most of these cases, there's no 22 actual reliable evidence as to what happened or how it 23 happened. And -- and so it's just because the child was 24 in the bed with the uncle, it doesn't mean it was 25 suffocated by -- by the child (sic).


1 And if everything else is like you find in 2 a SIDS case who was in a crib out -- outside of any kind 3 of influence -- and that -- all these findings are the 4 same. I -- I think the, you know, dilemma is that we 5 don't really have a -- have a marker in which we can, you 6 know, -- or a diagnostic test, if you like. 7 MS. LUISA RITACCA: Right. 8 DR. ERNEST CUTZ: But I think this -- now 9 there is a possibility to develop such diagnostic tests, 10 and in contentious cases, these would be like the DNA 11 test in Judicial System. You could now say, Child has 12 this defect and therefore, it died of SIDS rather than 13 suffocation/sitter. 14 Now if you say all these cases die of 15 suffocation, you stop the research. It's not going to be 16 done any research on this. 17 MS. LUISA RITACCA: But in -- in 18 fairness, Dr. Cutz, when you say there's -- there's 19 usually no reliable evidence of the circumstances -- 20 DR. ERNEST CUTZ: Right. Yes. 21 MS. LUISA RITACCA: -- of the overlay -- 22 DR. ERNEST CUTZ: Yes. 23 MS. LUISA RITACCA: -- or of the co- 24 sleeping, there's also no reliable pathological evidence 25 of SIDS, because you agreed with me earlier that it's


1 actually a diagnosis of exclusion. 2 So you -- there's nothing in the pathology 3 that you find to say -- 4 DR. ERNEST CUTZ: No. 5 MS. LUISA RITACCA: -- reliably that it's 6 SIDS, is that fair? 7 DR. ERNEST CUTZ: Well, there are certain 8 pathological findings which we, you know, regularly find. 9 They would be not 100 percent specific, but you know, 10 there -- there may be findings which are, more commonly, 11 seen in SIDS than -- than in other conditions. 12 MS. LUISA RITACCA: But they're non- 13 specific findings? 14 DR. ERNEST CUTZ: Well, it depends again, 15 you see, what level of examination one is looking at. If 16 one just uses naked eye and then the regular histology, 17 there's noth -- nothing to see. 18 But if you use some more sophisticated 19 methods, you look at -- and there are examples, for 20 example, in -- in examinations of the brain. You know, 21 there are things which are not obvious, and when you do 22 these studies you -- you discover them. 23 And for example, this is one (1) of the 24 areas Dr. Becker was studying, you know, brain changes in 25 SIDS, and he found numbers of abnormalities which only


1 can be found using these more modern techniques. 2 MS. LUISA RITACCA: And those techniques 3 are not in use at the Hospital for Sick Children? 4 DR. ERNEST CUTZ: Well, not at the 5 present time. 6 MS. LUISA RITACCA: If I could ask you 7 turn up -- 8 COMMISSIONER STEPHEN GOUDGE: Are you 9 going to move away from SIDS? 10 MS. LUISA RITACCA: I was, yes. 11 COMMISSIONER STEPHEN GOUDGE: Can I 12 just -- 13 MS. LUISA RITACCA: No, go ahead, 14 Commissioner. 15 COMMISSIONER STEPHEN GOUDGE: -- ask a 16 couple of questions? Dr. Cutz, the sciences is 17 interesting. I hear you saying that, as a scientist who 18 spent a lifetime researching SIDS, I think we will find a 19 quote "cause" for SIDS with the right research? 20 DR. ERNEST CUTZ: That's -- that's my 21 belief, yes. 22 COMMISSIONER STEPHEN GOUDGE: Yes. We 23 don't have it now? 24 DR. ERNEST CUTZ: We don't have it as 25 yet, but we may be heading that way.


1 COMMISSIONER STEPHEN GOUDGE: What's the 2 most promising postulate hypothesis? 3 DR. ERNEST CUTZ: Well the postulate is - 4 - is that, you know, SIDS is not a uniform disease. 5 There are probably different disorders, and I can maybe 6 mention two (2) -- two (2) groups which eventually may 7 turn out to -- to be the right kind of answer. 8 And -- and Dr. Taylor is familiar with all 9 these new findings in -- in cardiac ion channels, which 10 are submicroscopic structures which regulate cell 11 function. And this is not something you can see either 12 with naked eye or looking in the microscope. 13 And there's -- there's a dozen of new 14 disorders recognized, which are mutations in genes, which 15 -- which affect the function of these channels. And so 16 that if you have a defect in the channel, your heart 17 stops, for example, and you do an autopsy, you see 18 absolutely nothing. 19 Now, if you would do molecular analysis of 20 either the heart muscle or depends where the gene is 21 expressed, you'd be able to determine that this child had 22 a mutation in the gene which caused the defect, for 23 example, okay. 24 And -- and there are published cases of -- 25 you know, cases which present, as I say it, and they have


1 a documented cardiac ion channel defect. And the next 2 big group is in the area of control of breathing, and so 3 this is something I and Dr. Becker were -- were 4 interested in. These are brain and peripheral nervous 5 system structures which affect the breathing. 6 'Cause in a voluntary breathing is -- is - 7 - you can influence it, but when you go to sleep, for 8 example, it goes on the automatic -- it is automatic 9 control of breathing, which is directed, you know, how 10 much oxygen is in the blood, et cetera. 11 And so this -- this is a very labile 12 system in the neo -- neonatal period. It's influenced by 13 development changes. It's influenced by molecular 14 changes. And so there's already a number of data showing 15 that there are groups of SIDS infants which have 16 mutations in genes, for example, involved, what's called 17 a acetylcholine transporter, which is one (1) of the 18 neurotransmitters in the brain. 19 And those babies would have -- you know, 20 they would have higher incidences of stoppage of 21 breathing while they are sleeping. And they may be at 22 risk to die of SIDS if they are in an unsafe -- sleep -- 23 sleep position. In other words, if there is -- 24 COMMISSIONER STEPHEN GOUDGE: So you 25 would have to combine that predisposition --


1 DR. ERNEST CUTZ: This -- this -- 2 COMMISSIONER STEPHEN GOUDGE: -- with the 3 sleeping position? 4 DR. ERNEST CUTZ: With the sleeping 5 position. And the same goes, let's say, effects of 6 smoking. What the smoking does, it changes the -- the 7 contour of breathing mechanism, -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. ERNEST CUTZ: -- so you become more 10 susceptible -- 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. ERNEST CUTZ: -- to -- to this. So, 13 so -- there's a number of factors which contribute to it. 14 And -- and -- so these are just two (2) examples. And as 15 the science is advancing, we find more and more. 16 COMMISSIONER STEPHEN GOUDGE: All right. 17 So rather than say the sleeping position alone is -- 18 DR. ERNEST CUTZ: That's right. 19 COMMISSIONER STEPHEN GOUDGE: -- the 20 cause of death, -- 21 DR. ERNEST CUTZ: Yeah. 22 COMMISSIONER STEPHEN GOUDGE: -- it would 23 be -- 24 DR. ERNEST CUTZ: There's a number of 25 factors.


1 COMMISSIONER STEPHEN GOUDGE: That is 2 interesting. So for you, the appropriate cause of death 3 in a true SIDS case is -- 4 DR. ERNEST CUTZ: Would be biologic -- 5 COMMISSIONER STEPHEN GOUDGE: -- yet to 6 be discovered? 7 DR. ERNEST CUTZ: Yet to be discovered. 8 COMMISSIONER STEPHEN GOUDGE: Yes. 9 Thanks. 10 11 CONTINUED BY MS. LUISA RITACCA: 12 MS. LUISA RITACCA: Dr. Cutz, if I could 13 ask you to turn up Volume I, Tab 42 first, and Mr. 14 Registrar, that's PFP032278. 15 DR. ERNEST CUTZ: Sorry, I don't -- 16 MS. LUISA RITACCA: It should be the memo 17 631. 18 DR. ERNEST CUTZ: Yes, mm-hm. 19 MS. LUISA RITACCA: Well, I'm only going 20 to spend -- 21 DR. ERNEST CUTZ: Yeah. 22 MS. LUISA RITACCA: -- a moment on -- on 23 the actual memo. Dr. Cutz, in your evidence yesterday, 24 it was very clear to me that you had significant concern 25 and opposition with respect to this memo --


1 DR. ERNEST CUTZ: Yeah. 2 MS. LUISA RITACCA: -- and that attached 3 protocol, -- 4 DR. ERNEST CUTZ: Yes. 5 MS. LUISA RITACCA: -- is that correct? 6 DR. ERNEST CUTZ: Yes. 7 MS. LUISA RITACCA: And you see here that 8 the memo was written and sent to all coroners, 9 pathologists, and chiefs of police in Ontario, you see 10 that? 11 DR. ERNEST CUTZ: Yes. 12 MS. LUISA RITACCA: And the memo and 13 attached protocol was to be used in the investigation of 14 the sudden and unexpected death of any child under two 15 (2) years of age? 16 DR. ERNEST CUTZ: Yes. 17 MS. LUISA RITACCA: And so it isn't 18 simply a protocol about SIDS related deaths? 19 DR. ERNEST CUTZ: That's correct. 20 MS. LUISA RITACCA: Okay. And the 21 protocol we see from the memo comes from the Office of 22 the Chief Coroner, an institution -- 23 DR. ERNEST CUTZ: Yes. 24 MS. LUISA RITACCA: -- whose job it is to 25 investigate deaths, --


1 DR. ERNEST CUTZ: Yes. 2 MS. LUISA RITACCA: -- is that -- 3 DR. ERNEST CUTZ: Mm-hm. 4 MS. LUISA RITACCA: And investigation of 5 deaths includes matters beyond the pathologist, is that 6 fair? 7 DR. ERNEST CUTZ: That's correct.. 8 MS. LUISA RITACCA: Okay. And if we 9 could turn to the actual protocol, which is at Tab 43 for 10 you, Dr. Cutz and Commissioner. 11 DR. ERNEST CUTZ: Yes. 12 MS. LUISA RITACCA: And PFP032280. And 13 so if we -- if you look through the protocol, it covers 14 the full death investigation not simply the pathologist's 15 role and the pathology. 16 So there's -- for example, page -- the 17 second page of the protocol deals with the essential 18 components of the coroner's investigation. And the next 19 page, the elements of the police investigation and then 20 the autopsy examination. 21 Do you see that? 22 DR. ERNEST CUTZ: Yes. 23 MS. LUISA RITACCA: And if you look at 24 page -- well, that page that says "Autopsy Examination" 25 on the top?


1 DR. ERNEST CUTZ: Yes. 2 MS. LUISA RITACCA: Right here, yes. It 3 says page 6 but I know it isn't with the document. 4 There's reference to Appendix "D". It's an overview of 5 the pediatric autopsy which has been prepared by Dr. 6 Charles Smith, Director of the Pediatric Forensic Unit. 7 You see that? 8 DR. ERNEST CUTZ: Yes. 9 MS. LUISA RITACCA: Okay. And I have put 10 in front of you, because I -- I didn't realize this 11 Appendix "D" was not attached in your tab, but I've put 12 in front of you, Appendix "D" -- 13 DR. ERNEST CUTZ: Yes. 14 MS. LUISA RITACCA: -- in loose. And, 15 Mr. Registrar, if you go to PFP057584, and go to page 371 16 of that document, please. 17 And so, are you familiar with this 18 Appendix, Dr. Cutz? 19 DR. ERNEST CUTZ: Yeah, I think it -- 20 well, this looks like a, sort of, a handout for a -- for 21 a course or something. I -- I -- I'm not sure if I've -- 22 if I've seen it as part of the protocol. 23 MS. LUISA RITACCA: So you can't -- 24 DR. ERNEST CUTZ: Part -- part of the 25 memo. No.


1 MS. LUISA RITACCA: Oh, you can't recall 2 seeing this attached to the protocol. Is that -- 3 DR. ERNEST CUTZ: No. 4 MS. LUISA RITACCA: -- what you're 5 saying? 6 DR. ERNEST CUTZ: Mm-hm. 7 MS. LUISA RITACCA: All right. If you 8 look at it and I appreciate that it's -- it's a multi- 9 page document, but if you -- 10 DR. ERNEST CUTZ: Yeah. 11 MS. LUISA RITACCA: -- take a quick look 12 at it, can you agree with me that it seems to be dealing 13 with the pediatric autopsy in general and not just 14 forensic issues. 15 Is that -- 16 DR. ERNEST CUTZ: That's correct, yes. 17 MS. LUISA RITACCA: Is that fair? 18 DR. ERNEST CUTZ: Yeah. 19 MS. LUISA RITACCA: And so just as an 20 example, if you go to page -- five (5) pages in. Could 21 we go back a page, Mr. Registrar? One (1) more page. 22 Right. So at the bottom of that page it says: 23 "Heart. Examination -- for example, 24 the examination of the external aspects 25 of the heart must include the size and


1 position of the atria, the shape of the 2 atrial appendages [et cetera]." 3 This is -- 4 DR. ERNEST CUTZ: Yes. 5 MS. LUISA RITACCA: This is pediatric 6 pathology, it's not -- 7 DR. ERNEST CUTZ: Yeah, it's a pretty 8 standard. 9 MS. LUISA RITACCA: Right. It's not 10 forensic pathology? 11 DR. ERNEST CUTZ: No, no. 12 MS. LUISA RITACCA: And would you agree 13 that for a pathologist outside of a pediatric setting, 14 particularly in 1995, this kind of information would be 15 important to have if you're conducting pediatric cases? 16 DR. ERNEST CUTZ: Yes, I agree. Yes. 17 MS. LUISA RITACCA: And you'd agree that 18 a protocol to ensure that certain tests are undertaken 19 and certain -- and the autopsy is done in a certain way 20 is an important protocol to have for people outside of a 21 pediatric setting? 22 DR. ERNEST CUTZ: Yes. 23 MS. LUISA RITACCA: And you indicated, 24 Dr. Cutz, that you had voiced your concerns about the 25 protocol in the memo to Dr. Becker?


1 You recall saying that? 2 DR. ERNEST CUTZ: Well, I don't know if 3 there is a memo but, you know, certainly I personally -- 4 I -- I speak to him about it, yeah. 5 MS. LUISA RITACCA: Okay. And my 6 question was: Did you -- did you document your concerns 7 at all? 8 DR. ERNEST CUTZ: In a written form? I 9 don't think in a written form, no. 10 MS. LUISA RITACCA: Did you tell your 11 path -- your fellow pathologists at the Hospital for Sick 12 Children that they shouldn't follow the protocol? 13 DR. ERNEST CUTZ: No, no, no, that wasn't 14 -- I mean, that wasn't the intention. I mean, the issue 15 -- there were a couple of issues with the protocol. 16 One (1) was that right in the covering 17 letter, it said they consulted, you know, all the experts 18 in Ontario to writing this protocol and I found it 19 curious; they had two (2) biggest experts right there who 20 -- who were not shown this protocol. 21 And so had I been shown the protocol, I 22 would have crossed out the "think dirty" -- 23 MS. LUISA RITACCA: Okay. 24 DR. ERNEST CUTZ: -- for one (1). And I 25 would have streamlined it a little bit -- a little bit


1 differently. 2 It's not to say the protocol is wrong. I 3 mean, there are good features in it, except, you know, 4 it's too heavily one-sided and it doesn't really tell you 5 what to do with a -- with a genuine SIDS case. 6 I mean it -- it tells you what to do in 7 these other type of situations. 8 MS. LUISA RITACCA: Sudden and unexpected 9 death of children under two (2) -- 10 DR. ERNEST CUTZ: That's right, yeah. 11 Right. 12 MS. LUISA RITACCA: -- which is what the 13 protocol is called. 14 DR. ERNEST CUTZ: Well, that -- that's 15 correct -- 16 MS. LUISA RITACCA: Right. 17 DR. ERNEST CUTZ: -- except to say that 18 in that category at -- at 30 percent is going to be SIDS. 19 MS. LUISA RITACCA: All right. And, Dr. 20 Taylor, I'd like to turn to you for a moment. 21 And you've -- you've answered a lot of 22 questions with regard to the difficulties that the 23 hospital had with Dr. Smith's surgical pathology. 24 On December 7th of this year, when Dr. 25 Chiasson was giving evidence, he was shown the same


1 letter that is found at PFP137850, and I have it down as 2 Tab 71, but I don't know what volume that is, and I 3 apologise, but perhaps you can just look at it on the 4 screen and -- 5 DR. GLENN TAYLOR: It's Volume I. 6 MS. LUISA RITACCA: Oh, Volume I. And 7 Dr. Chiasson was asked the following question by Ms. 8 Rothstein: 9 "While turning to the next tab, a 10 letter that may or may not have been 11 sent to Dr. Smith from Dr. Becker dated 12 April 18th, 1997, without suggesting 13 for a moment that you would maintain 14 that ought to have been copied with 15 that letter, is the information set out 16 in that letter something that you would 17 have thought relevant for you to know 18 in your role as the Chief Forensic 19 Pathologist, with oversight 20 responsibility for Dr. Smith and his 21 unit?" 22 And Dr. Chiasson answered: 23 "Well, first let me say -- I mean, to 24 me this is a very significant letter, 25 that, you know, I've worked in


1 pathology departments and if I was to 2 receive such a letter, I would consider 3 this to be a very serious matter, that 4 the Chief is writing and making these 5 indications and especially issues of 6 docking salary. I mean, that's a very 7 serious degree of problem here. 8 And yeah, I wouldn't expect to be 9 copied this, but to perhaps be given 10 some indication that, yes, we're having 11 problems with Dr. Smith." 12 Dr. Taylor, my question to you is: If you 13 were the Chief Forensic Pathologist would you have wanted 14 to know about the competency issues arising from Dr. 15 Smith's surgical work? 16 DR. GLENN TAYLOR: If I was the Chief 17 Forensic Pathologist? It's a bit of a stretch, I guess. 18 But I probably would. Now, what I made out of it is 19 another issue, which I think I discussed yesterday. 20 MS. LUISA RITACCA: And, Dr. Cutz, can I 21 ask you the same question? 22 DR. ERNEST CUTZ: I -- I would overall 23 apro -- agree with Dr. Taylor's approach, that, you 24 know, these are two (2) separate things and not -- not 25 necessarily -- the hospital matters would be communicated


1 because this was a separate activity. And, you know, I - 2 - I think that, you know, that would be Dr. Becker to 3 answer like, you know, what -- what were his intentions. 4 MS. LUISA RITACCA: And, Dr. Taylor, I -- 5 I understand you had a fairly active role in the Chief 6 Coroner's tissue audit in the Spring of 2005. 7 DR. GLENN TAYLOR: It was mostly 8 coordinating the -- gathering of the tissues, and the -- 9 and the records, and the specimens. 10 MS. LUISA RITACCA: And did you speak to 11 Dr. Smith about the audit before it began? 12 DR. GLENN TAYLOR: I can't recall. 13 MS. LUISA RITACCA: Did you speak to him 14 during the audit? 15 DR. GLENN TAYLOR: I don't think so. 16 MS. LUISA RITACCA: He was still employed 17 at the Sick -- at the hospital during the audit, is that 18 correct? 19 DR. GLENN TAYLOR: I'd have to get the 20 dates. 21 MS. LUISA RITACCA: The audit occurs in - 22 - between March and June of '05. 23 DR. GLENN TAYLOR: And he was probably on 24 leave of absence during that period of time, so he wasn't 25 actually at the hospital, but he was still employed.


1 MS. LUISA RITACCA: All right. That's my 2 understanding, as well. 3 DR. GLENN TAYLOR: Yes. 4 COMMISSIONER STEPHEN GOUDGE: When does 5 he go on leave? I have his resignation as happening in 6 July of '05. 7 DR. GLENN TAYLOR: Yes, I can't remember 8 the exact date that he went on leave, Mr. Commissioner, 9 but I think -- 10 COMMISSIONER STEPHEN GOUDGE: Was it 11 several months or six (6) months or -- 12 DR. GLENN TAYLOR: It was several weeks, 13 if not a couple of months, but I can't -- I honestly 14 can't recall the exact timing. 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 17 CONTINUED BY MS. LUISA RITACCA: 18 MS. LUISA RITACCA: And did Dr. Smith 19 have access to his office while the audit was being 20 conducted? 21 DR. GLENN TAYLOR: I believe he did, yes. 22 MS. LUISA RITACCA: Okay. And my final 23 topic of question and I'll be finished in a moment, 24 Commissioner. 25 You talked -- both Dr. Cutz and Dr.


1 Taylor, you spoke a lot about communication between the 2 Coroner's Office and the Hospital for Sick Children, 3 primarily the unit. 4 Would you agree that with Dr. Chiasson as 5 the Director of the unit, and Dr. Pollanen as the Chief 6 Forensic Pathologist, there has been better or more 7 transparent communication between the -- the two (2)? 8 DR. GLENN TAYLOR: I'll give them their 9 credit, but I think with Dr. McLellan as the new Chief 10 Coroner and when I came back to Toronto I think things 11 started there, but certainly it's been increased with -- 12 between Dr. Chiasson and Dr. Pollanen, yes. 13 MS. LUISA RITACCA: And I didn't mean to 14 minimize your role -- 15 DR. GLENN TAYLOR: No, no, but I just -- 16 MS. LUISA RITACCA: -- or Dr. McLellan's 17 role in all that. 18 DR. GLENN TAYLOR: -- I just wanted to 19 get a point -- the point across that it's been since 20 about 2003 -- 21 MS. LUISA RITACCA: All right. 22 DR. GLENN TAYLOR: -- that the 23 communication has been, I think, good. 24 MS. LUISA RITACCA: And does 25 participation in -- well actually I should ask you this


1 first, Dr. Taylor: I understand that you were a member, 2 or may still be a member of the Death Under Five 3 Committee and the PDRC Committee at the Coroner's Office? 4 DR. GLENN TAYLOR: I'm a member of the 5 PDRC Committee. I've resigned from the Death Under Five 6 Committee. 7 MS. LUISA RITACCA: And you've been a 8 member of those Committee's since your arrival back in 9 2003? 10 DR. GLENN TAYLOR: Yes. Approximately, 11 yes. 12 MS. LUISA RITACCA: Okay. And did you 13 replace Dr. Smith as the pediatric pathologist on those 14 Committees? 15 DR. GLENN TAYLOR: Yes, I did. 16 MS. LUISA RITACCA: Okay. And would you 17 say that participation in those Committees, or on those 18 Committees helps foster the relationship or communication 19 between the -- the two (2) Institutions? 20 DR. GLENN TAYLOR: Yes, I think they do. 21 MS. LUISA RITACCA: And how so? 22 DR. GLENN TAYLOR: Well, it -- my sort 23 of take on my role in the PDRC for instance, is to 24 provide pathology input from the point -- perspective of 25 pediatric pathologists, not as a forensic pathologist.


1 And the Corner's -- members of the Coroner's Office -- 2 Office of the Chief Coroner are on that Committee, and 3 there's that avenue for the pediatric pathology point of 4 view to be sort of given. Plus they have the opportunity 5 to give the coroners and perhaps forensic point of view 6 back to the pediatric pathologist. 7 On the Death Under Five Committee, or 8 Death Under Two Committee as it used to be called, 9 there's even more of that give and take, so there's a -- 10 because there's several pediatric pathologists on that 11 Committee and several forensic pathologists on that 12 Committee. So there is opportunity to foster sort of 13 points of view with regards to cases. 14 Plus it does allow the Office of the Chief 15 Coroner have direct face-to-face contact with pediatric 16 pathologists and also gives the opportunity to a 17 pediatric pathologists to have that contact with senior 18 members of the Office of the Chief Coroner. 19 So it is a good venue for communication, 20 getting to know each other, and getting to understand the 21 relative problems that both sides have. 22 MS. LUISA RITACCA: Great. Thank you. 23 Those are my questions, Commissioner. 24 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 25 Ritacca. We'll rise now until five (5) past 2:00 and


1 come back, Ms. Silver, with you. 2 3 --- Upon recessing at 12:47 p.m. 4 --- Upon resuming at 2:07 p.m. 5 6 THE REGISTRAR: All rise. Please be 7 seated. 8 COMMISSIONER STEPHEN GOUDGE: Ms. 9 Silver...? 10 11 CROSS-EXAMINATION BY MS. CAROLYN SILVER: 12 MS. CAROLYN SILVER: Thank you. Good 13 afternoon, Doctors, I'm Carolyn Silver, and I represent 14 the College of Physicians and Surgeons. 15 DR. GLENN TAYLOR: Good afternoon. 16 DR. ERNEST CUTZ: Good afternoon. 17 MS. CAROLYN SILVER: Both of you have 18 given evidence about the concerns you had or the concerns 19 that you were aware of with respect to Dr. Smith's work 20 as a pathologist while he worked at Sick Kids, fair 21 enough? 22 DR. GLENN TAYLOR: Yes. 23 MS. CAROLYN SILVER: And I'll -- I'll 24 just ask one (1) of you to answer and if there's any 25 disagreement from the other, perhaps you could indicate


1 so? And there were concerns with respect to Dr. Smith's 2 surgical pathology, correct? 3 DR. GLENN TAYLOR: Yes. 4 MS. CAROLYN SILVER: And concerns with 5 respect to his opinions regarding cause of death in 6 certain forensic cases, correct? 7 DR. GLENN TAYLOR: Yes. 8 MS. CAROLYN SILVER: And there were 9 certainly concerns about the timeliness of his reports, 10 correct? 11 DR. GLENN TAYLOR: Yes. 12 MS. CAROLYN SILVER: And that's all been 13 gone over in some detail, fair enough? 14 DR. GLENN TAYLOR: Yes. 15 MS. CAROLYN SILVER: And in terms of 16 addressing those concerns, some of those concerns were 17 brought up with Dr. Smith in correspondence by the 18 hospital, correct? 19 DR. GLENN TAYLOR: Yes. 20 MS. CAROLYN SILVER: And certain concerns 21 were brought up at rounds by people, correct? 22 DR. GLENN TAYLOR: Yes. 23 MS. CAROLYN SILVER: And you've heard 24 evidence from the Coroner's Office that they thought some 25 of those concerns were significant, correct?


1 DR. GLENN TAYLOR: Yes. 2 MS. CAROLYN SILVER: And you're aware 3 that -- at least, Dr. Cairns gave evidence that some of 4 that information -- it might have been helpful to share 5 that with the Coroner's Office, fair enough? 6 DR. GLENN TAYLOR: Yes. 7 MS. CAROLYN SILVER: And that much of 8 that information was not shared with the Coroner's 9 Office, fair enough? 10 DR. GLENN TAYLOR: Yes. 11 MS. CAROLYN SILVER: And we've also heard 12 evidence about information that the Coroner's Office had 13 with respect to Dr. Smith that was not shared with Sick 14 Kids, correct? 15 DR. GLENN TAYLOR: Yes. 16 MS. CAROLYN SILVER: And the concerns 17 about Dr. Smith's work as a pathologist at the Hospital 18 for Sick Kids was present from, at least, let's say, 1995 19 through to, at least, the early 2000s, correct? 20 DR. GLENN TAYLOR: Yes. 21 MS. CAROLYN SILVER: And we've looked at, 22 I think, several times now in the evidence, a letter from 23 Dr. Becker to Dr. Smith, July 20th, 1995, and that is 24 PFP137837. I believe that's at Volume I, Tab 35. 25 And I know you've both been taken to it


1 many times about three (3) incomplete cases from early 2 March '95, correct? 3 DR. GLENN TAYLOR: I'm sorry, which? 4 MS. CAROLYN SILVER: Sorry, it's 5 PFP137837. It's Volume I, I believe Tab 35, July 20th, 6 1995. Do you have that? 7 DR. GLENN TAYLOR: My 30 -- 8 COMMISSIONER STEPHEN GOUDGE: Yes, it's 9 not -- 10 11 CONTINUED BY MS. CAROLYN SILVER: 12 MS. CAROLYN SILVER: Tab 44, sorry, I 13 have the wrong tab number. 14 DR. GLENN TAYLOR: Yes, I have it. 15 MS. CAROLYN SILVER: Okay. And Dr. Smith 16 was advised that he failed to meet department standards, 17 correct? 18 DR. GLENN TAYLOR: Correct. 19 MS. CAROLYN SILVER: And I think both of 20 you gave evidence that that was a significant letter, 21 correct? 22 DR. GLENN TAYLOR: Yes. 23 MS. CAROLYN SILVER: And I think you gave 24 evidence, Dr. Taylor, that that letter was significant 25 because it related to patient care, correct?


1 DR. GLENN TAYLOR: Yes. 2 3 (BRIEF PAUSE) 4 5 MS. CAROLYN SILVER: And then we also 6 looked at a letter from Dr. Becker to Dr. Smith, which 7 was April 18th, 1997, PFP137850. 8 And that was the letter where Dr. Smith 9 was advised that his responsibilities would be curtailed? 10 COMMISSIONER STEPHEN GOUDGE: Do you have 11 a tab number for that, Ms. Silver? 12 13 CONTINUED BY MS. CAROLYN SILVER: 14 MS. CAROLYN SILVER: 71? No, I have the 15 wrong tab numbers. Volume I, Tab 71. 16 DR. GLENN TAYLOR: Yes. 17 MS. CAROLYN SILVER: And that letter also 18 raised serious concerns about Dr. Smith's work, correct? 19 DR. GLENN TAYLOR: Yes. 20 MS. CAROLYN SILVER: Both in terms of the 21 reporting time and the accuracy of his reports in the 22 last two (2) years, correct? 23 DR. GLENN TAYLOR: Yes. 24 MS. CAROLYN SILVER: So that would be 25 since 1995, correct?


1 DR. GLENN TAYLOR: Yes. 2 MS. CAROLYN SILVER: And the letter says 3 that there's been no improvement in either of these 4 areas, reporting time or accuracy of his reports, 5 correct? 6 DR. GLENN TAYLOR: Yes. 7 MS. CAROLYN SILVER: And so he is 8 informed in that letter that Dr. Becker said he must 9 curtail his responsibilities in surgical pathology until 10 he demonstrates that he could improve his skills, 11 correct? 12 DR. GLENN TAYLOR: Yes. 13 MS. CAROLYN SILVER: And there was some 14 discussion, in the evidence yesterday, about whether this 15 letter constituted a removal, a restriction on Dr. 16 Smith's privileges at the hospital. 17 Do you remember that, Dr. Taylor? 18 DR. GLENN TAYLOR: Yes, I do. 19 MS. CAROLYN SILVER: Okay. And I think 20 it was Dr. Cutz' initial evidence that you would have 21 viewed it as a removal -- a restriction on his 22 privileges, correct? 23 DR. ERNEST CUTZ: Well, it doesn't 24 explicitly state it. 25 MS. CAROLYN SILVER: Right.


1 DR. ERNEST CUTZ: So, I think, that it 2 depends how the privileges are defined. 3 MS. CAROLYN SILVER: Okay. Fair enough. 4 I -- I guess I was putting to you, Dr. Cutz, initially 5 you thought it might be a restriction of privileges, but 6 it's not necessarily clear from the letter whether it 7 would constitute a restriction of privileges -- 8 DR. ERNEST CUTZ: That's -- 9 MS. CAROLYN SILVER: -- fair enough? 10 DR. ERNEST CUTZ: -- yes. 11 MS. CAROLYN SILVER: Okay. And Dr. 12 Taylor, I think your evidence was, it wouldn't 13 necessarily be affecting his privileges, it would be 14 narrowing the work he did, fair enough? 15 DR. GLENN TAYLOR: That's correct. 16 MS. CAROLYN SILVER: Okay. And I take it 17 you're both aware that a restriction or removal of a 18 physician's privileges by the Hospital triggers certain 19 reporting requirements to the College, correct? 20 DR. GLENN TAYLOR: I don't think I was 21 explicitly aware of that, but I'll accept that, yes. 22 MS. CAROLYN SILVER: Okay. You -- you're 23 not aware of that now? 24 DR. GLENN TAYLOR: No, sorry. 25 MS. CAROLYN SILVER: Okay. I take it


1 then you weren't at the time either? 2 DR. GLENN TAYLOR: No. 3 MS. CAROLYN SILVER: Okay. And 4 regardless of whether -- what those reporting 5 requirements are, you both agree that this was quite a 6 serious letter to Dr. Smith, correct? 7 DR. GLENN TAYLOR: Yes. 8 9 (BRIEF PAUSE) 10 11 COMMISSIONER STEPHEN GOUDGE: This is the 12 letter, I take it, that you're uncertain whether it was 13 sent or not? 14 DR. GLENN TAYLOR: That's correct, sir. 15 COMMISSIONER STEPHEN GOUDGE: What makes 16 you uncertain? 17 DR. GLENN TAYLOR: It's not signed, and I 18 can't recall that there's any discussion amongst the 19 staff that Charles was being removed from surgical 20 service or that there was any cut in his pay. 21 Of course, the last comment, especially, 22 may not be shared amongst other pathologists, but gossip 23 does occur amongst the staff. I wasn't aware of any 24 change in his status. 25 COMMISSIONER STEPHEN GOUDGE: Does


1 anything turn on the fact that, at least looking at the 2 one (1) page we have, there are -- there are no initials 3 indicating that a secretary typed it as there are, for 4 example, in the letter at Tab 73, or is that 5 insignificant? 6 DR. GLENN TAYLOR: No, I -- usually the 7 secretary would include her initials in a -- in a letter. 8 COMMISSIONER STEPHEN GOUDGE: Did Dr. 9 Becker have his letters typed by a secretary? 10 DR. GLENN TAYLOR: Yes, he did. 11 COMMISSIONER STEPHEN GOUDGE: Okay. So 12 does that -- is that a clue that it may not have been 13 sent? 14 DR. GLENN TAYLOR: I can't say for sure, 15 but it -- to ,it's -- it is a bit of a suggestion, yes, 16 that it wasn't sent. 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 Okay, thanks. Thanks, Ms. Silver. 19 20 CONTINUED BY MS. CAROLYN SILVER: 21 MS. CAROLYN SILVER: Would you agree with 22 me, I guess, just following up on the Commissioner's 23 question that, whether sent to Dr. Smith or not, this, at 24 least, reflected the concerns that Dr. Becker had, at the 25 time, regarding Dr. Smith?


1 DR. GLENN TAYLOR: I'm sure it did, yes. 2 MS. CAROLYN SILVER: And then looking at 3 another memo that you've already looked at; it's a memo 4 of March 12th, 2002, and I believe it's at Volume II, Tab 5 13, it's PFP137707. 6 is another memo or email to Dr. Smith 7 regarding his late surgical and autopsy reports, correct? 8 DR. GLENN TAYLOR: Yes. 9 MS. CAROLYN SILVER: And there is a 10 series of other correspondence and lists in between which 11 also deal with delays in Dr. Smith's reports, correct? 12 DR. GLENN TAYLOR: Yes. 13 MS. CAROLYN SILVER: And I put it to you 14 that, in the third line, Dr. Smith is being told by the 15 Hospital for Sick Kids that this represents a fall below 16 the standard of care that is expected at the Hospital for 17 Sick Kids, correct? 18 DR. GLENN TAYLOR: Yes. 19 MS. CAROLYN SILVER: And so the same 20 problem was still ongoing in, at least, March of 2002, 21 correct? 22 DR. GLENN TAYLOR: Yes. 23 MS. CAROLYN SILVER: And I put it to you 24 that regardless of what reporting obligations may or not 25 have been triggered with respect to Dr. Smith's


1 privileges, would you agree with me that given the 2 seriousness of the concerns that were raised at the 3 Hospital for Sick Kids regarding Dr. Smith's work as a 4 pathologist and the length of time over which those 5 concerns persisted, this is information that should have 6 been shared with the College? 7 DR. GLENN TAYLOR: I'm -- except that 8 it's very significant information, I'm not sure what the 9 specific reporting requirements are to the College with 10 regards to this kind of matter, and I apologize for that. 11 MS. CAROLYN SILVER: Right, and that's my 12 question. Regardless of what technical reporting 13 requirements there may be in the legislation, and let's 14 assume that those technical requirements may not have 15 been triggered -- automatic reporting may not have been 16 triggered on the legislation -- would you agree with me 17 that given the seriousness of the concerns that the 18 Hospital for Sick Kids had about Dr. Smith's work and the 19 length of time over which those concerns persisted, that 20 this is information that the hospital should have 21 notified the College about? 22 OBJ MR. WILLIAM CARTER: Mr. Commissioner, 23 the way that question is phrased is objectionable. She - 24 - My Friend is suggesting that irrespective of the 25 statutory obligations, the hospital should...


1 2 (BRIEF PAUSE) 3 4 MR. WILLIAM CARTER: Although this is not 5 my witness, he does come from my client, and My Friend, 6 in her question, is suggesting, notwithstanding, the 7 statutory reporting requirements, that the hospital was 8 other -- under some other kind of obligation, which she 9 hasn't defined -- to report their assessment of Dr. 10 Smith's clinical performance to the College, and I don't 11 think that's a fair question. 12 COMMISSIONER STEPHEN GOUDGE: I think I 13 agree with that, Ms. Silver. I mean, are you suggesting 14 there's an obligation beyond the legal obligation? 15 MS. CAROLYN SILVER: Yes, I'm suggesting 16 that, as it was suggested, that the Hospital for Sick 17 Kids maybe should have shared information with the 18 Coroner's Office about Dr. Smith and the Coroner's Office 19 should have shared information with the Hospital for Sick 20 Children about Dr. Smith. 21 I'm suggesting -- I'm asking these 22 witnesses whether they would agree that the Hospital for 23 Sick Kids should have shared their concerns with the 24 regulatory body of the College? That's the context of my 25 question.


1 COMMISSIONER STEPHEN GOUDGE: What would 2 the standard be for that? I mean... 3 MS. CAROLYN SILVER: Well, that's why I 4 put at these witness that there were serious concerns 5 about Dr. Smith's work as a for -- as a pathologist and 6 that there's several letters and notes and references 7 that I took the witness to in the documents, that refer 8 to Dr. Smith falling below the standard of care. 9 And in that context, where the Hospital 10 for Sick Kids had said on several instances that Dr. 11 Smith's conduct represented falling below the standard of 12 care that was expected at the Hospital for Sick Kids, in 13 that context should the -- 14 COMMISSIONER STEPHEN GOUDGE: Yes. 15 MS. CAROLYN SILVER: -- should the -- 16 COMMISSIONER STEPHEN GOUDGE: That sounds 17 like it triggers a legal obligation. Is that your view? 18 I mean, I do not know. 19 MS. CAROLYN SILVER: I think -- 20 COMMISSIONER STEPHEN GOUDGE: I do not 21 know what the regulatory threshold is 22 MS. CAROLYN SILVER: Right. I -- I'm 23 suggesting that, in the context of the hospital having 24 told a doctor that he falls below the standard of care, 25 didn't the hospital have an obligation to notify the


1 College? 2 COMMISSIONER STEPHEN GOUDGE: What -- a 3 legal obligation or...? 4 MS. CAROLYN SILVER: I'm not asking for a 5 legal opinion from these witnesses, I suppose, but -- 6 COMMISSIONER STEPHEN GOUDGE: Yes, 7 because that is... 8 Well, I mean, I don't know if he can 9 answer that, Dr. Taylor. 10 DR. GLENN TAYLOR: I don't think I can, 11 Mr. Commissioner. 12 COMMISSIONER STEPHEN GOUDGE: Yes. If 13 you want to suggest some other kind of obligation, Ms. 14 Silver. 15 16 CONTINUED BY MS. CAROLYN SILVER: 17 MS. CAROLYN SILVER: Well, did you not 18 feel that there was a professional obligation on the part 19 of the hospital to notify the College that they had a 20 physician that they had identified as falling below the 21 standard of practice? 22 COMMISSIONER STEPHEN GOUDGE: Whatever 23 the legal obligation? 24 MS. CAROLYN SILVER: Whatever the legal 25 obligation.


1 COMMISSIONER STEPHEN GOUDGE: That is 2 okay; I am going to permit that question to be answered. 3 DR. GLENN TAYLOR: Well, notification of 4 the College, in my opinion, is a very serious matter. 5 And -- and I'm speaking for myself. I can't speak for 6 Dr. Becker who was the Division Head and Department Chief 7 at that time. My approach would be to try to rectify the 8 situation as best I can before resorting to calling the 9 Col -- calling the College. And especially in the 10 context of -- of late reports. 11 If the late reports hadn't been impacting 12 upon patient care, meaning that there hadn't been lots of 13 complaints being registered by the families or the 14 Coroner's Office with regards to that, then I may have 15 given it a little bit less -- although it's still an 16 important issue -- less importance than what might be 17 required to call -- contact the College. 18 So, you know, it's a difficult assessment 19 to make. I mean, it's a very serious matter to contact 20 the College. 21 On the other hand, if I felt, with all the 22 information that was available to me, that the 23 practitioner was dangerous to patients, I would have 24 called the College. I'm not sure -- looking at all of 25 these -- all of these things which we've gone through,


1 especially the surgical side of things, which is 2 something I think that is directly under the 3 responsibility of the Division or Department Head -- 4 whether they require contacting the College. 5 The issues with regards to late times on 6 the coroner's cases; when it comes down to the bottom 7 line, I think that's an issue with the Office of the 8 Chief Coroner because those reports are being created for 9 the Office of the Chief Coroner under coroner's warrants. 10 Issues related to hospital autopsy 11 delinquency is another matter, and that comes back to the 12 Chief of the Service. 13 So I'd have -- you know, I'm kind of 14 walking around this, but it is a bit of a tough call so 15 I'm not sure what I would have done in those 16 circumstances unless I had all of this stuff in front of 17 me. 18 19 CONTINUED BY MS. CAROLYN SILVER: 20 MS. CAROLYN SILVER: And just a final 21 question. 22 I take it, as far as you are both aware, 23 this information that I've been discussing wasn't shared 24 with the College as far as you know? 25 DR. GLENN TAYLOR: As far as I know.


1 MS. CAROLYN SILVER: Okay, those are my 2 questions. Thank you very much. 3 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 4 Silver. 5 Mr. Carter...? 6 7 CROSS-EXAMINATION BY MR. WILLIAM CARTER: 8 MR. WILLIAM CARTER: Thank you, 9 Commissioner. 10 If I might just begin, Dr. Cutz, with a 11 question directed to you. In your brief curriculum vitae 12 at the beginning of your evidence, you indicated that you 13 received your initial medical training in Prague. 14 DR. ERNEST CUTZ: That's correct, yes. 15 MR. WILLIAM CARTER: And that included 16 some forensic training as well? 17 DR. ERNEST CUTZ: Yes. 18 MR. WILLIAM CARTER: And that was part of 19 the regular medical school curriculum? 20 DR. ERNEST CUTZ: That's correct. 21 MR. WILLIAM CARTER: And I understand 22 there are significant differences between -- and I 23 appreciate we're talking back in the mid 1960s, and I 24 don't know whether these observations are relevant today, 25 but it -- as I understand it, there are significant


1 differences in the treatment of forensic medicine in 2 European tradition from those that we find in Canada and 3 North America, is that fair? 4 DR. ERNEST CUTZ: Yes, that's fair. I 5 think the -- 6 MR. WILLIAM CARTER: Would -- would it -- 7 would it -- 8 DR. ERNEST CUTZ: Sorry. 9 MR. WILLIAM CARTER: -- be of help, do 10 you think, for the Commissioner to hear something about 11 this? 12 DR. ERNEST CUTZ: Perhaps in terms of the 13 organization, but I think the -- the main difference is - 14 - is that if the patient dies in hospital -- all the 15 patients dying in hospital regardless, the -- there's no 16 need for a consent. All patients get autopsied. 17 In other words, this is to maintain a -- 18 quality control, get a feedback on the treatment that the 19 patient received, and then determine why the patient 20 died. So there's a huge volume of -- of cases. And so 21 the way it was organized, Charles University in Prague 22 was -- was a building which was called Institute of 23 Pathology. 24 And it has three (3) sections which headed 25 by a separate professor and is -- is one who was -- who


1 was in charge. One (1) branch was pediatric pathology, 2 the major part was this kind of general adult pathology, 3 and the third branch was legal medicine or what would be 4 here called forensic pathology. 5 But there it's part of the medical faculty 6 rather than Coroner's Office or some law enforcement 7 agency. And they provide inde -- independent medical 8 opinion on forensic issues. 9 MR. WILLIAM CARTER: Okay. So the 10 Institute of Pathology was the centre within the 11 university setting? 12 DR. ERNEST CUTZ: That's correct. 13 MR. WILLIAM CARTER: And they would 14 conduct, depending on the nature of the case whether it 15 be adult, pediatric, or forensic, -- 16 DR. ERNEST CUTZ: That's right. 17 MR. WILLIAM CARTER: -- there would be a 18 triaging in process of some kind? 19 DR. ERNEST CUTZ: Yes, it would be based 20 on -- yeah, those kind of criteria. 21 MR. WILLIAM CARTER: And it would cover 22 all in-hospital deaths? 23 DR. ERNEST CUTZ: Well, the forensic 24 would cover both in-hospital and out of hospital. The -- 25 the other section, those would be mostly in-hospital.


1 MR. WILLIAM CARTER: Okay. Well, I guess 2 what I meant to say was that the -- the Institute of 3 Pathology whether -- irrespective of which of the three 4 (3) divisions was engaged, would cover all hospital 5 deaths in total? 6 DR. ERNEST CUTZ: That's correct, yes. 7 MR. WILLIAM CARTER: Okay. Would they 8 also cover deaths from the wider community? 9 DR. ERNEST CUTZ: Yes, under the 10 forensic. 11 MR. WILLIAM CARTER: I see, okay. And 12 how much of your time was spent in the Institute of 13 Pathology when you were in medical school? 14 DR. ERNEST CUTZ: Well, pathology was a 15 very demanding -- and also in terms of time -- exposure, 16 quite -- quite demanding discipline -- pre -- preclinical 17 discipline. So that we -- we are receive, I believe, one 18 and a half (1-1/2) year of -- of training. 19 MR. WILLIAM CARTER: In pathology? 20 DR. ERNEST CUTZ: In pathology. 21 MR. WILLIAM CARTER: And you say 22 preclinical, that's before you're turned loose on 23 patients? 24 DR. ERNEST CUTZ: Before -- that's right, 25 before we are -- yeah.


1 MR. WILLIAM CARTER: As part of your 2 medical training? 3 DR. ERNEST CUTZ: That's correct. 4 MR. WILLIAM CARTER: Okay. And you told 5 us that you entered this program, in effect, out of high 6 school; that's a six (6) year program? 7 DR. ERNEST CUTZ: That's correct, yeah. 8 MR. WILLIAM CARTER: Yeah, okay. Also, 9 Dr. Cutz, you spent some considerable time talking to us 10 about cases you recall where you had professional 11 differences of opinion with Dr. Smith at a time when he 12 was Director of the Unit. 13 DR. ERNEST CUTZ: That's correct. 14 MR. WILLIAM CARTER: You'll recall some 15 of that dialogue? 16 DR. ERNEST CUTZ: Yes. 17 MR. WILLIAM CARTER: And as I understand 18 it, in a -- in a couple of those cases, the -- the cases 19 you had prepared were -- in fact, I think in all of the 20 cases, they were your coroner's cases, is that fair? 21 DR. ERNEST CUTZ: That's correct, yes. 22 MR. WILLIAM CARTER: And you recognized 23 that as a pathologist engaged to perform a coroner's 24 autopsy, your direct professional responsibility was to 25 the coroner to do the best job you could to assist the


1 coroner in answering the legal questions the coroner is 2 required to do under the Coroner's Act? 3 DR. ERNEST CUTZ: That's correct, yes. 4 MR. WILLIAM CARTER: And -- so in effect, 5 he's your client, as it were, is that fair? 6 DR. ERNEST CUTZ: That's how I 7 interpreted it, yes. 8 MR. WILLIAM CARTER: Yeah. And in the 9 context of the Pediatric Forensic Pathology Unit under 10 the direction of -- of Dr. Smith. You were obliged to 11 have your final autopsy report or form 12 of reviewed by 12 him for forwarding to the Coroner's Office? 13 DR. ERNEST CUTZ: That's correct, yes. 14 MR. WILLIAM CARTER: And in the context 15 of that process, on a couple of occasions, Dr. Smith 16 suggested to you that there might be alternative 17 explanations for what you were looking at, is that fair? 18 DR. ERNEST CUTZ: Well, those instances 19 were not at this stage of the report. This was the stage 20 where the -- where the cases were discussed. 21 MR. WILLIAM CARTER: Yes. 22 DR. ERNEST CUTZ: This is before the 23 reports were completed. 24 MR. WILLIAM CARTER: I see. Okay. So it 25 was in the process of the formulation of your report that


1 you discussed them with Dr. Smith? 2 DR. ERNEST CUTZ: That's right. 3 MR. WILLIAM CARTER: Okay. And that, -- 4 I think, in a couple of cases, included rounds? 5 DR. ERNEST CUTZ: Yes. 6 MR. WILLIAM CARTER: Okay. And as I 7 understand your evidence, you listened to Dr. Smith's 8 views? 9 DR. ERNEST CUTZ: Yes. 10 MR. WILLIAM CARTER: And you considered 11 them? 12 DR. ERNEST CUTZ: Yes. 13 MR. WILLIAM CARTER: Some of them you had 14 already considered before he expressed them? 15 DR. ERNEST CUTZ: That's right. 16 MR. WILLIAM CARTER: Right. And at the 17 conclusion of these discussions, you maintained your 18 view, and you submitted your report unaltered? 19 DR. ERNEST CUTZ: That's right. 20 MR. WILLIAM CARTER: Right. And in doing 21 that, you were fulfilling your professional 22 responsibility of integrity to the Coroner's System? 23 DR. ERNEST CUTZ: That's correct. 24 MR. WILLIAM CARTER: And you were not 25 unduly influenced by the views of Dr. Smith, whatever


1 they were -- you just simply took them on board as the 2 views of a -- an experienced colleague? 3 DR. ERNEST CUTZ: That -- that's right. 4 MR. WILLIAM CARTER: Okay. And that's a 5 normal and healthy part of the system -- is it not, in 6 the development of medical opinions -- discussion with 7 colleagues? 8 DR. ERNEST CUTZ: Yes. We -- we always - 9 - always discuss matters. The -- the only thing I like 10 to mention is that it seemed kind of out of context in 11 that they -- you know, if -- if there was any criminal or 12 other evidence that we -- we may suspect it, but there -- 13 there was nothing to -- to suggest then, so I find it 14 very curious that this -- this question would even be 15 thought of. 16 You know, anybody's free to have his 17 opinions, and you know, I accept that, except I find it 18 in those particular cases to be, you know, not very 19 useful. 20 MR. WILLIAM CARTER: I understand. But 21 what I -- what I'm focussing on -- 22 DR. ERNEST CUTZ: Yes. 23 MR. WILLIAM CARTER: -- is a broader 24 question; is that is the extent to which you permitted 25 Dr. Smith's views to influence your judgment in these


1 matters? I take it, you didn't? 2 DR. ERNEST CUTZ: Well I rea -- again, 3 re-looked at the whole issue, looked at if there was 4 anything suspicious to consider and then so there wasn't, 5 and so this why -- this is why I concluded the case, and 6 it was sent to the Coroner's Office. 7 MR. WILLIAM CARTER: Right. 8 DR. ERNEST CUTZ: And I didn't hear 9 anything back. 10 MR. WILLIAM CARTER: Right. And that's - 11 - if similar kinds of discussions took place with your 12 colleagues in the Department or Division of Pathology who 13 are also doing coroner's autopsies -- similar discussions 14 with Dr. Smith -- you'd expect them, if they were 15 unpersuaded by Dr. Smith, to submit reports consistent 16 with their own opinions, wouldn't you? 17 DR. ERNEST CUTZ: That would be dependent 18 on each pathologist. 19 MR. WILLIAM CARTER: Yes. But that's -- 20 that would be -- 21 DR. ERNEST CUTZ: Yes. 22 MR. WILLIAM CARTER: -- that's what the 23 expectation is of an independent professional? 24 DR. ERNEST CUTZ: That's correct. 25


1 (BRIEF PAUSE) 2 3 MR. WILLIAM CARTER: Now I have some 4 questions for Dr. Taylor, and I'm going to go into the -- 5 the area of surgical pathology. I'd like to start with 6 the general and then move to the particular, and the 7 particular is Dr. Smith. 8 So let me just start with the general. As 9 I understand it, in the Division of Surgical Pathology at 10 the Hospital for Sick Children, there are a number of 11 services, to use a term that has meaning within the 12 context of the Hospital. 13 We have seen these portrayed. If I could 14 ask for a -- a document, PFP117053. This is a 1995 15 roster. And this is, I think, typical, is it not, Dr. 16 Taylor, of the kind of roster one saw generated in the 17 mid to late '90s at the hospital? 18 DR. GLENN TAYLOR: Yes, it is. 19 MR. WILLIAM CARTER: And the -- I'd just 20 like to start with these classifications. 21 "Surgical" we know includes surgical 22 pathology, and we've heard something about that. I'm 23 going to return to it. 24 "Autopsy" means hospital autopsy; that's 25 the post-mortem examination of patients who die in the


1 hospital. Is that correct? 2 DR. GLENN TAYLOR: Or autopsies performed 3 on children that had been sent to the hospital for 4 autopsy. But basically the difference from medicolegal 5 is that these autopsies are done under consent of the 6 parents or the legal guardian rather than the coroner. 7 MR. WILLIAM CARTER: Fair enough. So 8 these would be hospital patients, is that -- 9 DR. GLENN TAYLOR: Correct. 10 MR. WILLIAM CARTER: -- a fair... 11 And -- but of course that could be true of 12 the coroner's cases as well? 13 DR. GLENN TAYLOR: Correct. 14 MR. WILLIAM CARTER: Okay. 15 And "the weekend," I take it, refers to 16 weekend coverage; to take call for the Department or 17 Division? 18 DR. GLENN TAYLOR: That's correct. 19 MR. WILLIAM CARTER: And so whoever is on 20 the weekend may be expected to respond to any area. Is 21 that fair? 22 DR. GLENN TAYLOR: That's correct. 23 MR. WILLIAM CARTER: Okay. So that could 24 include surgical, autopsy or medicolegal? 25 DR. GLENN TAYLOR: Well, some of them are


1 split, and there may be a designated person who is 2 covering surgical and another person who is covering the 3 autopsies, both hospital and medicolegal. 4 MR. WILLIAM CARTER: I understand but in 5 -- there are some circumstances where there's one (1) 6 individual -- 7 DR. GLENN TAYLOR: Who would be covering 8 everything, yes. 9 MR. WILLIAM CARTER: -- and there's some 10 circumstances where, as you suggest, there's a team? 11 DR. GLENN TAYLOR: Correct. 12 MR. WILLIAM CARTER: A small team of two 13 (2). I think I've seen some cases where there are as 14 many as three (3) on the weekends but typically, they're 15 two (2) or one (1). 16 Is that fair? 17 DR. GLENN TAYLOR: At present up to four 18 (4), if you include the neuropathologist sometimes. 19 MR. WILLIAM CARTER: Okay. I don't see 20 the neuropathologist mentioned on here, but that takes me 21 to my next question. 22 As I understand it, the surgical is 23 subdivided into a number of areas, and there are other 24 areas outside of surgical that are covered by the 25 pathologist.


1 Is that right? 2 DR. GLENN TAYLOR: That's correct. 3 MR. WILLIAM CARTER: Could you give us 4 some idea of how much, in terms of sub-specialization, 5 there is within the division? 6 DR. GLENN TAYLOR: The sub-specialization 7 is driven by the clinical services that we are providing 8 diagnostic services for. And the reason for sub- 9 specializing is because those clinical services are very 10 sophisticated and have high expectations and high 11 academic demands as well as high clinical demands on the 12 sort of the general surgical pathology of the division. 13 So they've been -- they've been recognized by subdividing 14 it. 15 So, for instance, at present we have what 16 are called the sub-speciality services, including kidney 17 pathology, cardiovascular pathology, GI pathology, liver 18 pathology, placental pathology, lung pathology. I think 19 that's it. I think that's our current spectrum. 20 MR. WILLIAM CARTER: Neuropathology? 21 DR. GLENN TAYLOR: Neuropathology, and I 22 apologize to my neuropathology colleagues, is off by 23 itself. 24 MR. WILLIAM CARTER: Okay. 25 COMMISSIONER STEPHEN GOUDGE: That is


1 history? 2 DR. GLENN TAYLOR: They have a different 3 -- diff -- it's a different discipline, really. And our 4 two (2) neuropathologists are trained in pediatric 5 neuropathology which is a sub-speciality of 6 neuropathology. And they have enough trouble dealing 7 with the neurosurgeons and neurologists at the hospital, 8 so I kind of leave them alone. 9 10 CONTINUED BY MR. WILLIAM CARTER: 11 MR. WILLIAM CARTER: Well, if -- if 12 you're on the roster and on call for surgical pathology, 13 you may be called upon to cover -- leaving aside 14 neuropathology, you may be covered -- called upon to 15 answer in any of the areas you've indicated? 16 DR. GLENN TAYLOR: Yes, except 17 neuropathology. 18 MR. WILLIAM CARTER: Yeah. And you've 19 indicated to us that your pathologists develop an 20 interest in and an infinity towards one (1) or more of 21 the sub-specialities, depending on the clinical demands 22 and their own interests and studies? 23 DR. GLENN TAYLOR: That's correct. 24 MR. WILLIAM CARTER: So some of your 25 pathologists would have more or less experience with the


1 cardiovascular side of things. 2 Is that fair? 3 DR. GLENN TAYLOR: That's fair, yes. 4 MR. WILLIAM CARTER: And some with the 5 kidney side of things? 6 DR. GLENN TAYLOR: Correct. 7 MR. WILLIAM CARTER: And some with the 8 gastrointestinal side? 9 DR. GLENN TAYLOR: Correct. 10 MR. WILLIAM CARTER: Which is an area 11 where Dr. Cutz is -- has sub-specialized? 12 DR. GLENN TAYLOR: Correct. 13 MR. WILLIAM CARTER: And if one is on the 14 surgical rotation, one may be called upon to provide 15 surgical consultation during the course of an operation 16 or some other real-time investigation in the hospital in 17 any of the areas irrespective of your particular forte. 18 DR. GLENN TAYLOR: That's true except if 19 it's through regular work hours then -- and a specific 20 case comes up, that is, in an area of interest to one (1) 21 of the other members of the division and the person 22 that's on is not that familiar with that area there may 23 be some consul -- there should be consultation, actually. 24 MR. WILLIAM CARTER: Right. No -- and -- 25 and that's in -- in the ordinary course of things, you


1 expect a certain amount of interplay among your 2 colleagues, depending on their level and degree of -- of 3 comfort with the question that's being posed to them -- 4 DR. GLENN TAYLOR: Yes. 5 MR. WILLIAM CARTER: -- in the clinical 6 context? 7 DR. GLENN TAYLOR: Yes. 8 MR. WILLIAM CARTER: All right. And so I 9 don't know want to go through four (4) or five (5) years 10 of rotations and take the time of the Commission to do 11 this, but I have done it myself, and I just want you to - 12 - we'll start with 1995 and I want to focus just on Dr. 13 Smith, for a moment, in surgery. 14 He was between slot 2, January 2, 1995 and 15 the end of May, beginning of June, on-call one (1), two 16 (2), three (3) weeks. And although he appears to have 17 done considerably more work in the medicolegal side. 18 Does that surprise you? 19 DR. GLENN TAYLOR: No, not -- not really. 20 It -- the distribution of workload depends upon people's 21 interest and availability of others to provide the 22 service. It looks like -- 23 MR. WILLIAM CARTER: And if we -- 24 sorry, I don't meant to interrupt you, but I'd just like 25 to go to the following page. So that would be page 2 of


1 the same document. 2 You'll see that he was on-call twice 3 between June and Oct -- the end of October, if I'm not 4 mistaken; August and September. 5 Do you see those? 6 DR. GLENN TAYLOR: Yes. 7 MR. WILLIAM CARTER: And if you go to the 8 third page, you'll see that he was on-call just the first 9 -- or second week of November in the surgical side, fair 10 enough? 11 DR. GLENN TAYLOR: Yes. Yes. 12 MR. WILLIAM CARTER: So in the year 1995, 13 he took surgical rotation six (6) times? 14 DR. GLENN TAYLOR: Yes. 15 MR. WILLIAM CARTER: Okay. Now, it 16 appears from my calculations that he was -- he did the 17 medicolegal about twenty-nine (29) weeks, as opposed the 18 six (6) he did at surgical. 19 And you'd agree with me that's a -- a 20 preponderance of his pathology work was in the 21 medicolegal in 1995? 22 DR. GLENN TAYLOR: Yes. 23 MR. WILLIAM CARTER: Okay. And if we 24 could go to the next year -- in fact, I'd like to stop 25 just there and go back to another document, PFP137698. I


1 don't think it's in your bundle, Dr. Taylor. This is a 2 performance evaluation covering the period '94/'95. 3 It's dated October 12th, 1995, and it 4 appears to be signed by Dr. Becker. That would be Dr. 5 Smith's supervisor at the time? 6 DR. GLENN TAYLOR: Yes. 7 MR. WILLIAM CARTER: And it would cover 8 some of the period covered by the surgical rotation I 9 just took you through, which was the calendar year '95. 10 And could I just take you to the third box that has the 11 checkmark. 12 DR. GLENN TAYLOR: Yes. 13 MR. WILLIAM CARTER: This is apparently 14 the evaluation of Dr. Becker, that he is -- achieves 15 expectations. 16 DR. GLENN TAYLOR: Yes. 17 MR. WILLIAM CARTER: And he notes that 18 there's an attached summary. 19 DR. GLENN TAYLOR: Yes, I see that. 20 MR. WILLIAM CARTER: And that is the next 21 document, Mr. Registrar, 137699. Thank you. 22 This appears to be a -- a memorandum, the 23 circumstances would suggest dictated by Dr. Becker 24 summarizing his performance appraisal of Dr. Smith. 25 Would you agree with that?


1 DR. GLENN TAYLOR: Yes. 2 MR. WILLIAM CARTER: And I'd just like to 3 read part of it. 4 "I indicated to Dr. Smith my 5 satisfaction with the fact that he had 6 submitted an excellent application for 7 promotion from assistant to associate 8 professor and express my confidence 9 that this promotion would be 10 forthcoming." 11 Could we stop there. And would you agree 12 with me that that's an indication that Dr. Smith is 13 progressing up the academic ladder in the ordinary course 14 of things? 15 DR. GLENN TAYLOR: Yes. 16 MR. WILLIAM CARTER: And a positive 17 report from his clinical supervisor as was Dr. Becker, 18 would be an important contribution towards the success of 19 that enterprise? 20 DR. GLENN TAYLOR: That's correct, yes. 21 MR. WILLIAM CARTER: I'll continue. 22 "I expressed my confidence that this 23 promotion would be forthcoming. I also 24 indicated that my impression was that 25 the forensic -- [excuse me] pediatric


1 forensic pathology unit was working 2 well and that collegiality had improved 3 over the past few months. The forensic 4 rounds, which have been initiated, I 5 feel are a success." 6 I guess that gives us some clue as to when 7 the rounds were initiated. 8 "Charles pointed out that he had made a 9 concerted effort to update his autopsy 10 and surgical cases. This has been very 11 successful and I complimented him on 12 the improvement in the turnaround times 13 for case completion." 14 I'm just going to read a little bit more 15 of this, but would you agree with me so far that this 16 sounds like a reasonable degree of satisfaction with the 17 performance of Dr. Becker -- or Dr. Smith, rather? 18 DR. GLENN TAYLOR: Yes, I do. 19 MR. WILLIAM CARTER: 20 "Because of the success that Charles 21 has had with teaching, we mutually 22 agreed that the educational field would 23 become an important area for his 24 specialization within the Department." 25 And then he goes on to amplify that and I


1 needn't do that for my purposes. 2 But would you agree with me that it 3 appears that there's been a discussion between Dr. Smith 4 and his clinical supervisor about how he might enhance 5 his role in the hospital and make a positive contribution 6 to the team here? 7 DR. GLENN TAYLOR: Yes. Yes. 8 MR. WILLIAM CARTER: And education has 9 been -- and that's one (1) of the three (3) missions of 10 the hospital, is it not? 11 DR. GLENN TAYLOR: Yes, it is. 12 MR. WILLIAM CARTER: Apart from research 13 and of course, clinical care it's education. So that's a 14 -- that's an appropriate thing for Dr. Smith and Dr. 15 Becker to agree upon? 16 DR. GLENN TAYLOR: Yes, it is. 17 MR. WILLIAM CARTER: Okay. And as a 18 division chief, this is the sort of conversation you have 19 with your colleagues from time to time? 20 DR. GLENN TAYLOR: Yes, it is. 21 MR. WILLIAM CARTER: It's part of your 22 job, in fact, isn't it? 23 DR. GLENN TAYLOR: Yes. 24 MR. WILLIAM CARTER: To try to identify 25 the strengths and weaknesses and enhance the performance


1 of your colleagues as an individual working within a 2 team? 3 DR. GLENN TAYLOR: Correct. 4 MR. WILLIAM CARTER: And I'll just go to 5 the last paragraph, it says: 6 "In summary, Dr. Smith has focussed on 7 the forensic aspects of pediatric 8 pathology and has been successful in 9 establishing a centre of expertise at 10 the Hospital for Sick Children." 11 That would be the unit, I assume? 12 DR. GLENN TAYLOR: Yes. 13 MR. WILLIAM CARTER: 14 "Charles has an excellent track record 15 in teaching, education, and I would 16 like to see this area further developed 17 by incorporating new teaching 18 modalities into our armamentarium." 19 Would you agree with me that it would 20 appear that that was a satisfactory evaluation by Dr. 21 Becker? 22 DR. GLENN TAYLOR: It looks to be 23 satisfactory, yes. 24 MR. WILLIAM CARTER: Okay. Now I'd just 25 like to move on to the next year, 1996. This is document


1 PFP117050. 2 Now, in 1996, on the first page here, we 3 see Dr. Smith's name appearing -- name appears three (3) 4 times before mid-June at the bottom. 5 Would you agree with me that that suggests 6 that his surgical rotation was again three (3) times in 7 the first five (5) or six (6) months of the year? 8 DR. GLENN TAYLOR: Yes. 9 MR. WILLIAM CARTER: Which is pretty 10 similar to the previous year -- 11 DR. GLENN TAYLOR: Yes. 12 MR. WILLIAM CARTER: -- as I recall. And 13 in -- I'm going to come back to this document but I'd 14 like to cut now to another document, it's PFP137695. 15 This is a memorandum dated July 23, '96, to Dr. Becker 16 from Dr. Smith, and it relates to his performance 17 evaluation. 18 Am I right in understanding that as part 19 of the performance evaluation at the time at Sick Kids 20 there was two-way communication, one (1) from the 21 supervisor to the physician and the other from the 22 physician to the supervisor? 23 DR. GLENN TAYLOR: That's correct, yes. 24 MR. WILLIAM CARTER: And so this would 25 appear to be the communication from Dr. Smith to Dr.


1 Becker in the summer of 1996. And I just want to draw 2 your attention to the first paragraph under the caption 3 "Clinical Service", he says: 4 "During the past year my service 5 responsibilities included autopsy and 6 surgical pathology. On the autopsy 7 service I performed 35 percent of the 8 non-fatal cases in the last six (6) 9 months of '95 and 31 percent of such 10 cases in the first half of '96. In 11 surgical pathology my responsibilities 12 having increased to 30 percent of 13 routine coverage and I have taken on 14 added responsibility in 15 nephropathology." 16 And that is what, Doctor? 17 DR. GLENN TAYLOR: That's kidney biopsy 18 service. 19 MR. WILLIAM CARTER: Okay. And so am I 20 right in taking from this that Dr. Patholo -- Dr. Smith, 21 in conjunction with Dr. Becker, agreed that he was going 22 to take on an additional workload in the kidney service? 23 DR. GLENN TAYLOR: Yes. 24 MR. WILLIAM CARTER: And I take it that 25 in fact he did that and he sub-specialised in the kidney


1 service over the next number of years. 2 DR. GLENN TAYLOR: That's correct, yes. 3 MR. WILLIAM CARTER: And I understand he 4 -- well, in your opinion, what was the -- the -- what was 5 his performance level in that area? 6 DR. GLENN TAYLOR: His performance level 7 was satisfactory. The nephrologists are a very 8 demanding, and appropriately so, demanding clinical 9 service, and he had some difficulties with some 10 turnaround time issues, but generally functioned okay. 11 MR. WILLIAM CARTER: Okay, well, just 12 dealing with the interpretation, would he be doing 13 biopsies? 14 DR. GLENN TAYLOR: Yes. 15 MR. WILLIAM CARTER: So he'd be looking 16 at slides and things of that kind? 17 DR. GLENN TAYLOR: Correct, yes. 18 MR. WILLIAM CARTER: And in terms of his 19 reading of those slides and the interpretation of the 20 pathology was it satisfactory? 21 DR. GLENN TAYLOR: It was satisfactory; 22 there were a few instances that Dr. Thorner was asked to 23 look at his work. Dr. Thorner being the sort of major -- 24 MR. WILLIAM CARTER: Right. 25 DR. GLENN TAYLOR: -- consultant for the


1 renal service and so on occasion the nephrologist would 2 ask Dr. Thorner to review slides. 3 MR. WILLIAM CARTER: Right. Well, that's 4 what you'd expect when an -- a person's entering a new 5 area and there's somebody with greater expertise 6 supervising them, isn't it? 7 DR. GLENN TAYLOR: Yes. 8 MR. WILLIAM CARTER: Yeah. So we here 9 that in the summer of 1995 we -- Dr. Smith is describing 10 his practice and caseload, and I'd like to take you to 11 the -- another document, PFP137689. 12 Okay. This -- if we could just have a 13 look at the bottom, Mr. Registrar, is a -- just -- I just 14 want to get the date of the author. It's prepared by 15 again Dr. Becker and is dated October 3, '96. And could 16 we just go to the top. 17 You'll see that the performance has been 18 rated "meets expectations". 19 DR. GLENN TAYLOR: Yes. 20 MR. WILLIAM CARTER: Okay. And I don't - 21 - I don't have the attachment, I'm sorry, but -- so I -- 22 I don't know what's contained in it, but you would agree 23 with me that at first blush this appears to be a 24 satisfactory performance appraisal; he's met expectations 25 in all of the categories?


1 DR. GLENN TAYLOR: Yes. 2 MR. WILLIAM CARTER: Thank you. Now, if 3 we could just go back to the pathology rotation at 4 document 117050, this is the roster for 1996. 5 And if we could go to the second page. 6 The first page we've noticed that Dr. Smith was on 7 service in the surgical area for three (3) weeks. His 8 frequency of service in surgical seems to have increased 9 here. He's on for one (1), two (2), three (3), four (4), 10 five (5), six (6) more weeks, you'll see that? 11 DR. GLENN TAYLOR: Yes. 12 MR. WILLIAM CARTER: So that's a total of 13 nine (9) to the end of -- or to the beginning of 14 November? 15 DR. GLENN TAYLOR: Yes. 16 MR. WILLIAM CARTER: And if we could just 17 go to the last page of this document. You'll see that he 18 was on two (2) more weeks plus a -- Boxing Day. So we're 19 looking at a total of eleven (11) weeks and a day? 20 DR. GLENN TAYLOR: Yes. 21 MR. WILLIAM CARTER: That's a 22 considerable increase in his surgical service over the 23 previous year, which was, I think, six (6) if I recall 24 correctly? 25 DR. GLENN TAYLOR: Yes.


1 MR. WILLIAM CARTER: Okay. And... 2 3 (BRIEF PAUSE) 4 5 MR. WILLIAM CARTER: I'd like to -- I'd 6 like to take you to document 137691. This document 7 appears to be a performance appraisal for '95/'96 and 8 might well have been the document that was attached to 9 the one (1) that we referred to earlier; it just -- it 10 isn't clear that it was, from the date of the document. 11 But in any event it -- it appears, does it 12 not, to be Dr. Becker's -- a summary of his discussion 13 with Dr. Smith about his '95/'96 performance? 14 DR. GLENN TAYLOR: Yes. 15 MR. WILLIAM CARTER: And I'd just like to 16 take you through a -- a couple of points. If I could 17 just read the first paragraph. And -- and why I'm doing 18 this, Dr. Taylor, is I'm trying to -- the extent we can, 19 in the absence of Dr. Becker, and as a -- as a person 20 with -- charged with the same sort of responsibilities 21 now, that Dr. Becker had then -- trying to put you as 22 much as possible into Dr. Becker's shoes for evaluating 23 the significance of any deficiencies we're encountering 24 and we're hearing so much about in Dr. Smith's surgical 25 pathology.


1 Do you appreciate that? 2 DR. GLENN TAYLOR: Yes, I understand. 3 MR. WILLIAM CARTER: Okay. So if I could 4 just read the first paragraph: 5 "Using the annual professional review 6 form together with Dr. Smith's 7 curriculum vitae, discussion included 8 highlights from the previous years 9 accomplishments and major goals for the 10 forthcoming year under the general 11 headings: patient clinical care, 12 education, research, administration, 13 national and external activities, 14 leadership and collegiality." 15 So that's kind of the spectrum over which 16 your performance or one's performance is evaluated for 17 the past year. 18 Is that fair? 19 DR. GLENN TAYLOR: That's correct, yes. 20 MR. WILLIAM CARTER: And if I could go 21 on. During the discussion with Dr. Smith he was 22 congratulated for achieving associate professor status. 23 "This requires academic activity. 24 Charles has devoted much time to 25 directing a variety of educational


1 endeavours at the University of 2 Toronto, for which he has received 3 deserved recognition. Charles has also 4 been successful in running the 5 Provincial Pediatric Forensic Unit at 6 the Hospital for Sick Children. This 7 is recognized as a successful venture 8 and has been touted as an example for 9 other jurisdictions. 10 Over the past year Charles mentioned 11 some frustrations about the ability to 12 develop effective CD ROMS due to the 13 limitation of resources. In the next 14 [that would be 1997 -- or '96/'97] 15 Charles indicated there will likely be 16 a greater focus on pediatric forensic 17 autopsies for a number of reasons." 18 Then he just talks about some work he's 19 planning to do outside of the country. If I could just 20 drop down to the last paragraph on this page: 21 "Though not discussed during the formal 22 time set aside for performance 23 appraisal, a number of discussions have 24 occurred throughout the year related to 25 completion of surgical and autopsy


1 reports. Timely finalization of 2 reports is an important part of quality 3 control and a requirement of the 4 Hospital accreditation process. Over 5 the past two (2) years, I've 6 consistently indicated that there will 7 be greater scrutiny of turn-around 8 times for service activities for 9 pathologists. And all members of the 10 division have agreed that cases must be 11 signed out consistent with consensually 12 approved departmental standards. It 13 has been understood that failure to do 14 so may in the future create obstacles 15 to annual reappointment processes." 16 We're talking here, are we not, about the 17 development of departmental standards at the Hospital for 18 Sick Children? 19 DR. GLENN TAYLOR: In the division of 20 pathology -- 21 MR. WILLIAM CARTER: In the -- in the -- 22 yes. 23 DR. GLENN TAYLOR: In the division of 24 pathology, yes. 25 MR. WILLIAM CARTER: Yeah. Yeah, we're


1 not talking about a standards of the profession as they 2 relate to the wider practice as might be of interest to 3 the College of Physicians and Surgeons, we're talking 4 about Sick Kids standards for this type of work? 5 DR. GLENN TAYLOR: Correct. 6 MR. WILLIAM CARTER: Right. 7 "In summary, Charles is a valuable 8 member of our department, has 9 significantly contributed to the 10 success of the division of pathology. 11 I look forward to working with Dr. 12 Smith to improve the turnaround times 13 for all autopsies, but particularly for 14 those autopsies that are performed on 15 patients at the Hospital for Sick 16 Children." 17 So would you agree with me that it appears 18 as of the end of 1995, Dr. Becker considered Dr. Smith a 19 -- a contributing member to the team at the hospital in 20 the division of pathology, or the department as it may 21 have been then? 22 DR. GLENN TAYLOR: Yes, I do. 23 MR. WILLIAM CARTER: Okay. Now, in 1997, 24 I understand that the Coroner's office indicated that 25 they -- they wanted Dr. Smith to devote more of his time


1 and energy to forensic autopsies and particularly the 2 more challenging criminal cases. 3 DR. GLENN TAYLOR: That's my 4 understanding, yes. 5 MR. WILLIAM CARTER: Could you go to 6 document 117913, please? 7 DR. GLENN TAYLOR: Okay. 8 MR. WILLIAM CARTER: And this is a letter 9 from Dr. Chiasson. We've seen this before, so I -- I 10 needn't dwell on it, but if we could halfway through the 11 first paragraph, it begins "specifically". 12 Do you see that? It's about four (4) 13 lines down. 14 "Specifically, we want to see changes 15 in the way the coroner's cases are 16 distributed, 'triaged' [in quotes] 17 among pathologists. We expect..." 18 Now, this is a letter from the Chief 19 Forensic Pathologist to the Director of the unit, so 20 would you agree with me this is more than a suggestion? 21 This is somebody to whom he has some reporting 22 responsibility in the Coroner's office? 23 DR. GLENN TAYLOR: Yes, I agree. 24 MR. WILLIAM CARTER: Okay. 25 "We expect you to be available to


1 perform the majority the forensically 2 complex cases including homicides and 3 spec -- suspicious deaths with Dr. 4 Glenn Taylor providing backup, 5 especially during the periods of time 6 that you are away from the hospital. 7 This implies that your work schedule 8 allows you the time to perform forensic 9 autopsies in a comprehensive manner, 10 generate the necessary documentation, 11 and testify in court as required. And 12 also permits you to be actively 13 involved in pediatric forensic pathol - 14 - pathologic consultative work." 15 And then he suggests that he attend 16 regularly the Coroner's office. The next paragraph: 17 "I understand that Dr. Becker is away 18 for the remainder of the month, so I 19 will await mid-March to follow up with 20 you regarding this matter. I am 21 hopeful that the propos -- a proposal 22 that will address the needs of your 23 hospital department and the concerns of 24 this office will be available at that 25 time."


1 Would you agree with me that what is being 2 suggested, in fact, requires Dr. Smith, to the extent 3 it's possible in the context where he works, to increase 4 the amount of involvement he has in the forensic 5 pathology work that he's doing? 6 DR. GLENN TAYLOR: I agree, yes. 7 MR. WILLIAM CARTER: And that he is to 8 talk to Dr. Becker, his supervisor, to try to make 9 arrangements for this to be possible? 10 DR. GLENN TAYLOR: Yes. 11 MR. WILLIAM CARTER: Okay. And -- 12 COMMISSIONER STEPHEN GOUDGE: Can I just 13 ask a question -- 14 MR. WILLIAM CARTER: Yes, of course. 15 COMMISSIONER STEPHEN GOUDGE: -- arising 16 out of that, unless you are going to cover it, Mr. 17 Carter. 18 I do not think we have seen, Dr. Taylor, 19 anywhere documented understanding between the two (2) 20 organizations -- the hospital and the Coroner's office -- 21 of the amount of time that one expects of the Director of 22 the unit to be devoted to its service, i.e., the 23 Coroner's Office? 24 DR. GLENN TAYLOR: Yeah, I'm not aware of 25 such a statement, either, Commissioner.


1 COMMISSIONER STEPHEN GOUDGE: Was that a 2 gap or should it be left flexible? 3 DR. GLENN TAYLOR: I think it needs to be 4 left flexible. I certainly -- I mean I -- I can't speak 5 for Dr. Chiasson, but I would think that he would not 6 want to be 100 percent dedicated to the forensic 7 pathology unit as director, you would want opportunities 8 to do other things within the division of pathology. He 9 is -- 10 COMMISSIONER STEPHEN GOUDGE: And you 11 presume they need him to do other things in -- 12 DR. GLENN TAYLOR: I -- I need him to 13 other things and I would like him to do other things. 14 Those other things involve learning more pediatric 15 pathology -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. GLENN TAYLOR: -- so that would help 18 his job as a pediatric forensic pathologist. 19 COMMISSIONER STEPHEN GOUDGE: Right. I 20 guess what I'm getting at is, this letter has at least a 21 possible implication of we're not getting enough of your 22 time, we need more of it. 23 DR. GLENN TAYLOR: Yeah. So that would 24 need to be discussed between Dr. Becker, Smith, and 25 Chiasson with or without the Office of the Chief Coroner


1 representative to work out the arrangements. And I'm not 2 sure if that was done or not; I can't recall any 3 specific -- 4 COMMISSIONER STEPHEN GOUDGE: But I hear 5 you saying as the Chair of the department, it's probably 6 best to leave that un-codified. 7 Am I reading you right or...? 8 DR. GLENN TAYLOR: Yeah, I think it could 9 be handled without having to say, Okay, 75 percent -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. GLENN TAYLOR: -- of Dr. Chiasson is 12 devoted to the Pediatric Forensic Pathology Unit. 13 COMMISSIONER STEPHEN GOUDGE: And I don't 14 mean to personalise it with Dr. Chiasson, at all but -- 15 DR. GLENN TAYLOR: No, but I'm just using 16 the current -- 17 COMMISSIONER STEPHEN GOUDGE: -- 18 personalise it with Dr. Smith, too. And what I'm getting 19 at is sort of the institutional arrangement and what 20 would work best going forward. 21 DR. GLENN TAYLOR: Yeah. Well, maybe 22 that needs to be looked at and -- 23 COMMISSIONER STEPHEN GOUDGE: Do you have 24 any views on how tight that -- that blueprint ought to 25 be, as somebody responsible for the department in which


1 the director serves, at least at the moment? 2 DR. GLENN TAYLOR: Yeah, I kind of leave 3 it up to Dr. Chiasson and how the service is being 4 perceived to be provided to the Coroner's Office. If the 5 provision of that service is in -- in somehow hindered by 6 Dr. Chiasson not being available enough to do the 7 director's job, then it certainly needs to be looked at. 8 And perhaps then there needs to be a more sort of 9 specific proportioning of his time to that position. 10 At the present time, I think it's working 11 okay. I haven't -- Dr. Chiasson's not here to dis -- 12 discuss this or debate me about -- 13 COMMISSIONER STEPHEN GOUDGE: But from 14 your perspective as the responsible for that part of it? 15 DR. GLENN TAYLOR: From my perspective, 16 I'm letting Dr. Chiasson kind of drive this right now, 17 and if he says to me and look -- and the Office of the 18 Chief Coroner says to me that we really need him to have 19 more -- more time doing his -- I mean he's basically 20 doing at least 75 percent now -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. GLENN TAYLOR: -- in that role. If 23 they need 100 percent, then I'm willing to look at that. 24 But I think it's working out right now, 25 with kind of leaving it a little bit flexible. It allows


1 Dr. Chiasson to develop his other interests and it allows 2 him to parti -- participate in some of the other 3 activities within the Department of Pathology, Division 4 of Pathology. 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 Sorry for prolonging this, Mr. Carter, but I want to ask 7 a question that I've been wanting to ask at some point. 8 Going back to the time when you were there 9 in the second half of the '90s, Dr. Taylor, as somebody 10 who was obviously integrally involved in the department 11 then as a staff pathologist, did you ever get the sense 12 that Dr. Smith was in effect being taken away from his 13 surgical pathology or hospital autopsy responsibilities 14 because of the demands of Court appearances which can 15 tend to be indeterminate sometimes? 16 DR. GLENN TAYLOR: Yeah. There was -- I 17 did have that impression at times. Yes, he was at Court 18 and travelling quite a bit. 19 COMMISSIONER STEPHEN GOUDGE: How would 20 the schedules that Mr. Carter has taken you to, 21 accommodate that kind of pull and tug? 22 DR. GLENN TAYLOR: In -- in general, the 23 Court dates are known reasonably far enough in advance 24 that the scheduling can be done around those dates, but 25 on occasion there would be instances when he was


1 scheduled to be on surgicals, if I remember correctly, 2 and was -- could not be available because he had to go to 3 Court. 4 COMMISSIONER STEPHEN GOUDGE: And what 5 would happen? 6 DR. GLENN TAYLOR: Somebody else would 7 pick up the responsibilities for those days. 8 COMMISSIONER STEPHEN GOUDGE: And he'd 9 swap a week or something? 10 DR. GLENN TAYLOR: Sometimes, yes. 11 COMMISSIONER STEPHEN GOUDGE: Was that an 12 issue, as you experienced it back then. I mean, I -- 13 DR. GLENN TAYLOR: Since it was often me 14 doing the swapping with him, it was an issue on -- on 15 occasion, but it wasn't a big issue. 16 COMMISSIONER STEPHEN GOUDGE: A tolerable 17 irritant, if I can put it. 18 DR. GLENN TAYLOR: Yes. Usually the 19 scheduling could accommodate his court days. 20 COMMISSIONER STEPHEN GOUDGE: Okay, 21 thanks. 22 Thanks, Mr. Carter. Sorry. 23 24 CONTINUED BY MR. WILLIAM CARTER: 25 MR. WILLIAM CARTER: Just to take a


1 slight departure from that for a moment. 2 I take it that the questions the 3 Commissioner had around the allocation of time to the job 4 of running the Unit is really something that would be an 5 appropriate agenda item for this executive committee that 6 you've told us a little bit about? 7 DR. GLENN TAYLOR: Yes, of course, it 8 would be. Yes. 9 MR. WILLIAM CARTER: And so the purpose 10 of this executive -- as I understand, and we're going to 11 get you the document at some point. 12 COMMISSIONER STEPHEN GOUDGE: Yes, we 13 would appreciate that -- 14 MR. WILLIAM CARTER: Yeah. 15 COMMISSIONER STEPHEN GOUDGE: -- Mr. 16 Carter. 17 MR. WILLIAM CARTER: It's quite -- a very 18 recent vintage, I understand. Like August -- 19 COMMISSIONER STEPHEN GOUDGE: Yeah, I 20 heard about him for the first time with Dr. Taylor's 21 evidence. 22 23 CONTINUED BY MR. WILLIAM CARTER: 24 MR. WILLIAM CARTER: Right. But -- but 25 as I understand it, and not to belabour this because we


1 will have more time for it later. As I understand it, 2 the purpose of the executive committee is to bring 3 forward an agenda of items that are of common interest to 4 the Coroner's Office and the hospital and the Division of 5 Pathology? 6 DR. GLENN TAYLOR: That's correct, yes. 7 MR. WILLIAM CARTER: Okay. And there are 8 senior representatives of each of those bodies on the 9 commit -- on the committee? 10 DR. GLENN TAYLOR: Yes, there are. 11 COMMISSIONER STEPHEN GOUDGE: Just to 12 confirm what is, sort of, the initial understanding I 13 formed in the conversation you and I had this morning, 14 Dr. Taylor. I got the sense that the terms of reference 15 were sort of restructured last summer? That is... 16 DR. GLENN TAYLOR: Yes. 17 COMMISSIONER STEPHEN GOUDGE: And that -- 18 if I can put it this way, before that, the executive team 19 had not really done a whole lot, and it is now populated 20 with the people you discussed and is moving forward? 21 DR. GLENN TAYLOR: That's correct. 22 COMMISSIONER STEPHEN GOUDGE: Is that 23 sort of a general impression that is, generally speaking, 24 accurate? 25 DR. GLENN TAYLOR: That's correct, yes.


1 COMMISSIONER STEPHEN GOUDGE: Okay, 2 thanks. Thanks, Mr. Carter. 3 4 CONTINUED BY MR. WILLIAM CARTER: 5 MR. WILLIAM CARTER: Not at all. 6 So I've -- I've brought you to the early 7 part of '97 when we have a letter from Dr. Chiasson 8 asking Dr. Smith to devote more of his time and energy to 9 the forensic work and understanding that this will 10 involve some discussion with Dr. Becker in due course. 11 Okay? 12 DR. GLENN TAYLOR: Yes. 13 MR. WILLIAM CARTER: Now we know from 14 other evidence that in -- shortly after, in fact, this 15 letter of February -- I think it was April -- we might as 16 well have the document, it's 137850. This is a letter 17 dated April 18, 1997, the one (1) without the typist's 18 initials; the one (1) that we wonder whether it was ever 19 delivered. 20 Have I -- have I given you the wrong 21 number? 22 MS. JENNIFER MCALEER: It's Tab -- 23 MR. WILLIAM CARTER: We have a systemic, 24 I've heard. 25 MS. JENNIFER MCALEER: -- 71, of Volume


1 I. 2 COMMISSIONER STEPHEN GOUDGE: I think our 3 equipment is getting tired. Is it coming? 4 MR. WILLIAM CARTER: I'll try not to take 5 that personally. 6 7 CONTINUED BY MR. WILLIAM CARTER: 8 MR. WILLIAM CARTER: Well, you'll recall 9 -- we'll get it on the screen, but you'll recall on more 10 than one (1) occasion, Dr. Taylor, in your evidence, 11 you've been taken to the letter of questionable 12 provenance that has the date of April 18th, '97, in which 13 there's a discussion about Charles' performance, both in 14 terms of turnaround times for surgical pathology and the 15 quality of the interpretation of the surgical pathology 16 cases. 17 DR. GLENN TAYLOR: Yes. 18 MR. WILLIAM CARTER: Okay. And I did 19 want to actually read the line in the letter, but I -- 20 COMMISSIONER STEPHEN GOUDGE: How much 21 longer are you going to be, Mr. Carter? You have about 22 thirty-five (35) more minutes. 23 MR. WILLIAM CARTER: I'll be thirty-four 24 and a half (34 1/2). 25 COMMISSIONER STEPHEN GOUDGE: Okay.


1 Well, do you want to break now then you can go get the 2 letter. 3 MR. WILLIAM CARTER: Yeah, the -- the 4 letter. I just -- I just -- 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 Because we are at 3:15, or virtually. 7 MR. WILLIAM CARTER: Well, it's -- I'm 8 quite happy to -- 9 COMMISSIONER STEPHEN GOUDGE: Okay, why 10 don't you finish with the letter and then we will take a 11 short break -- 12 MR. WILLIAM CARTER: Okay. 13 COMMISSIONER STEPHEN GOUDGE: -- and come 14 back and you can finish. 15 MR. WILLIAM CARTER: That's good timing. 16 I just -- 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 MR. WILLIAM CARTER: We don't have it. 19 Do you have it available to you in your binder? 20 DR. GLENN TAYLOR: Yes, we do. 21 MR. WILLIAM CARTER: Okay. And do you 22 have it, Commissioner -- 23 COMMISSIONER STEPHEN GOUDGE: Yes, I have 24 it. 25 MR. WILLIAM CARTER: -- or have you


1 memorized it? 2 COMMISSIONER STEPHEN GOUDGE: Yes. No, I 3 have seen it enough that I kind of know what it says. 4 5 CONTINUED BY MR. WILLIAM CARTER: 6 MR. WILLIAM CARTER: I just want to find 7 the operative phrase here. 8 9 (BRIEF PAUSE) 10 11 MR. WILLIAM CARTER: Maybe this is the 12 time to break because there's no point in me standing 13 here. We're going to break -- 14 COMMISSIONER STEPHEN GOUDGE: Yeah. 15 Okay, we will break then until -- 16 MR. WILLIAM CARTER: Thank you. 17 COMMISSIONER STEPHEN GOUDGE: -- 3:30. 18 And you have, by my calculation, about thirty-five (35) 19 minutes. 20 MR. WILLIAM CARTER: Thank you, that 21 should be sufficient. 22 COMMISSIONER STEPHEN GOUDGE: Okay. 23 Actually, it will be sufficient. 24 25 --- Upon recessing at 3:15 p.m.


1 --- Upon resuming at 3:30 p.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Mr. 6 Carter...? 7 8 CONTINUED BY MR. WILLIAM CARTER: 9 MR. WILLIAM CARTER: Dr. Taylor, if I 10 could just take you to the letter of April 18th, 1997, 11 which you have available to you. And at the second 12 paragraph in which Dr. Becker says: 13 "Neither Paul nor I can see any 14 improvement in the reporting time or 15 the accuracy of the reports over the 16 past two (2) years; therefore, I regret 17 to inform you that I must curtail your 18 responsibilities in surgical 19 pathology." 20 Would you agree with me that the word 21 "curtail" means to limit? 22 DR. GLENN TAYLOR: It could mean to 23 limit, yes. 24 MR. WILLIAM CARTER: Yeah. And we know 25 that the amount of surgical pathology that Dr. Smith did


1 in 1997 -- 'cause I think we've been taken to this -- 2 was reduced to -- if I can just -- well, in 1997, he did 3 ten (10) rotations in surgical pathology. 4 He did -- there was a period of time 5 between the end of April and the middle of September when 6 he wasn't on the rotation, but in total, he did ten (10) 7 weeks, which, in fact, exceeded the amount of time he'd 8 done the year before, -- 9 DR. GLENN TAYLOR: Yes. 10 MR. WILLIAM CARTER: -- would you agree 11 with that? 12 DR. GLENN TAYLOR: Yes. 13 MR. WILLIAM CARTER: And I note that Dr. 14 Cutz' name does not appear on the surgical rotation list. 15 I guess I should look to him for an explanation. 16 DR. ERNEST CUTZ: Yes. The explanation 17 is that -- as Dr. Taylor explained, is these 18 subspecialities. So I, for example, would be doing 19 gastrointestinal, liver, and -- and pulmonary pathology. 20 But it wouldn't be on the list because the surgical 21 pathology on the list are pathologists who cover the 22 quick section or the frozen section service. 23 So I -- I would be doing -- all the time I 24 would be on, practically, every day -- 25 MR. WILLIAM CARTER: Okay.


1 DR. ERNEST CUTZ: -- covering these four 2 (4) -- three (3) services. 3 MR. WILLIAM CARTER: Okay. Now, back to 4 this letter of April 18th, Dr. Taylor, as the 5 Commissioner observed, there's no typist initials; indeed 6 it's not on the letterhead either, right? 7 DR. GLENN TAYLOR: Yes. 8 MR. WILLIAM CARTER: So this might 9 suggest that Dr. Becker had personally prepared this 10 letter? 11 DR. GLENN TAYLOR: Perhaps, yes. 12 MR. WILLIAM CARTER: This might be the 13 sort of letter that he felt was sensitive and the 14 contents of which he wouldn't want to share with somebody 15 other than the person to whom it's addressed? 16 DR. GLENN TAYLOR: Yes, that's possible. 17 MR. WILLIAM CARTER: Okay. And just tell 18 us a little bit about Dr. Becker. I understand he was a 19 fairly hard marker; tough but fair sort of person? 20 DR. GLENN TAYLOR: I think that's a fair 21 assessment. He was certainly always fair with me, but he 22 did have a tough mind at times with dealing with -- with 23 issues. 24 MR. WILLIAM CARTER: Okay. And I'm going 25 to suggest to you that it's possible that he was


1 concerned and indeed, frustrated with Dr. Smith's 2 performance at -- at and around April of 1997? 3 DR. GLENN TAYLOR: I think it's quite 4 possible he was frustrated with Dr. Smith's performance, 5 yes. 6 MR. WILLIAM CARTER: And getting some bad 7 news about the quality of some of the surgical work would 8 have upset him? 9 DR. GLENN TAYLOR: I think that's a 10 reasonable assumption, yes. 11 MR. WILLIAM CARTER: All right. And one 12 (1) possible explanation for some of this deficiency is 13 that Dr. Smith might have been getting overextended in 14 the amount of work he was doing on a number of fronts? 15 DR. GLENN TAYLOR: I think that's 16 possible, yes. 17 MR. WILLIAM CARTER: And he might have 18 been distracted from the proper exercise of his clinical 19 judgment? 20 DR. GLENN TAYLOR: I -- I think that's a 21 possibility, as well, yes. 22 MR. WILLIAM CARTER: Yeah. And would it 23 be consistent -- to use a phrase that's falling into 24 disuse, but nonetheless has some place in the vernacular. 25 Would it be consistent with your impression of Dr. Becker


1 for him to write a letter like this one we have in front 2 of us, and show it to Dr. Smith without actually sending 3 it to him? 4 DR. GLENN TAYLOR: I think that's 5 possible. And it's also possible I think that he could 6 have had the letter done and put it in a file and sort of 7 hold on to it and see how things went, if he was at a 8 particularly vexed phase with Dr. Smith. I've certainly 9 written some letters that I decided it would be better if 10 I slept on them for a little while. I usually shred 11 those one's though. 12 MR. WILLIAM CARTER: Well, I -- I think 13 there -- we all know there's some therapeutic value in 14 putting thoughts to paper sometimes without executing the 15 delivery. 16 Is that fair? 17 DR. GLENN TAYLOR: Yes. 18 MR. WILLIAM CARTER: Okay. But if you 19 could just go to the document 138035. This will come up 20 on the screen, Dr. Taylor. This is a letter addressed to 21 Dr. Smith and it does have typists initials at the 22 bottom, but you'll note -- is that Dr. Becker's 23 handwriting in the top right? 24 DR. GLENN TAYLOR: I think it's his 25 writing, yes.


1 MR. WILLIAM CARTER: Yeah, and it says, 2 "discussed August 7th, but not sent". 3 So you'd agree with me that there seems to 4 be some support for the suggestion that Dr. Becker was in 5 the practice of discussing some documents without 6 actually sending them? 7 DR. GLENN TAYLOR: Yes. 8 MR. WILLIAM CARTER: Okay. And I 9 appreciate, you don't know whether in fact that's the 10 case in respect of the April 18th, '97 letter? In fact 11 you don't even know if it was shown to Dr. Smith? We'll 12 have to ask him I guess. 13 DR. GLENN TAYLOR: That's correct. 14 MR. WILLIAM CARTER: But we -- we do know 15 that Dr. Smith's involvement in surgical rotation 16 followed this period of time and this punitive discussion 17 with Dr. Becker, and followed the February 17th request 18 of the Coroner's Office -- or Dr. Chiasson, the Chief 19 Forensic Pathologist, that he devote more time to the 20 forensic autopsies? 21 DR. GLENN TAYLOR: Yes. 22 MR. WILLIAM CARTER: Okay. And if I 23 could just take you to document 137574. 24 Do you have that, Doctor? 25 DR. GLENN TAYLOR: Yes, I do.


1 MR. WILLIAM CARTER: This appears to be 2 another one of these annual performance exchanges. This 3 is the one from Dr. Smith to Dr. Becker, dated May 14th, 4 '97. And in the first couple of paragraphs he summarizes 5 his past twelve (12) months in review. 6 Is that fair? 7 DR. GLENN TAYLOR: Yes. 8 MR. WILLIAM CARTER: And if I could just 9 read some of this to you: 10 "In the past twelve (12) months there 11 was a substantial increase in my 12 service workload because of added 13 surgical pathology, and nephropathology 14 rotations. While this was to be 15 accompanied by a modest decrease in 16 autopsy work, such did not occur. 17 Indeed the autopsy service in '96 18 reversed a many year downward trend 19 with a substantial increase in the case 20 load. This was continued -- [or] has 21 continued into the 1997 time frame. 22 The forensic cases have been 23 accompanied by substantial increase in 24 time demands related to case 25 investigation, conferences and court


1 time." 2 I don't know that I need to read the rest, 3 but would you agree with me that Dr. Smith is explaining 4 to his supervisor how he's getting somewhat stretched? 5 DR. GLENN TAYLOR: Yes, I agree. 6 MR. WILLIAM CARTER: Okay. And in all of 7 the circumstances, given some concerns about the quality 8 of the surgical work, and recognizing the -- the request 9 of the Chief Forensic Pathologist for Ontario, that he 10 increases service in the forensic autopsy area, it would 11 be a reasonable thing for Dr. Becker to free him up from 12 some of the surgical work, would it not? 13 DR. GLENN TAYLOR: Yes, it would. 14 MR. WILLIAM CARTER: That would be an 15 appropriate management response? 16 DR. GLENN TAYLOR: Yes, I think it would 17 be. 18 MR. WILLIAM CARTER: And it would be one 19 that would be appreciated by Dr. Smith? 20 DR. GLENN TAYLOR: I would think so, yes. 21 MR. WILLIAM CARTER: Would you go to 22 document 137577, and this is his June 1998 performance 23 appraisal. And if I could just take you to the last 24 sentence of the first paragraph. 25 COMMISSIONER STEPHEN GOUDGE: This is his


1 response? 2 3 CONTINUED BY MR. WILLIAM CARTER: 4 MR. WILLIAM CARTER: This is Dr. Smith to 5 Dr. Becker. 6 "The reduction in my workload of 7 surgical pathology has been 8 appreciated." 9 DR. GLENN TAYLOR: Yes. 10 MR. WILLIAM CARTER: So that would be in 11 keeping with the analysis of events as I portrayed them 12 in our discussion so far? 13 DR. GLENN TAYLOR: Yes, it would. 14 MR. WILLIAM CARTER: Yeah. And we know 15 that in 1999, Dr. Smith gained the accreditation of the 16 American Board of Pathology in Pediatric Pathology, did 17 he not? 18 DR. GLENN TAYLOR: Yes, he did. 19 MR. WILLIAM CARTER: He'd already had the 20 board certification in Anatomic Pathology back in 1980, 21 did he not? 22 DR. GLENN TAYLOR: Yes, he did. 23 MR. WILLIAM CARTER: But he took the time 24 and study and wrote the exam and passed and was certified 25 in Pediatric Pathology in 1999?


1 DR. GLENN TAYLOR: Yes. 2 MR. WILLIAM CARTER: And that would be a 3 step designed, I suggest to you, to ensure that those who 4 supervised his work in the clinical setting had every 5 assurance that he was up to par? 6 DR. GLENN TAYLOR: That is sort of a 7 benchmark, yes. 8 MR. WILLIAM CARTER: And we know, because 9 Mr. Wardle took us to some of these evaluations, that in 10 '99 and 2000 and 2000 and 2001, Dr. Becker -- and I don't 11 plan to take you to these but I will if you require it -- 12 you may recall he received very good evaluations for his 13 clinical work? 14 DR. GLENN TAYLOR: Yes. 15 MR. WILLIAM CARTER: Okay. And indeed, 16 some years later, when you were on the scene, you gave 17 him good evaluations too? 18 DR. GLENN TAYLOR: Yes. 19 MR. WILLIAM CARTER: And you did that, 20 and I suggest Dr. Becker did that because he had -- he 21 merited that -- 22 DR. GLENN TAYLOR: Yes. 23 MR. WILLIAM CARTER: -- in your 24 assessment? 25 DR. GLENN TAYLOR: Yes.


1 MR. WILLIAM CARTER: And at no time in 2 your assessment did his performance warrant reporting to 3 the College of Physicians and Surgeons? 4 DR. GLENN TAYLOR: Not in my time, no. 5 MR. WILLIAM CARTER: No. 6 COMMISSIONER STEPHEN GOUDGE: Sorry, Mr. 7 Carter, can I just go back and ask a question of Dr. 8 Taylor about the qualification Dr. Smith received from 9 the American Board in 1999. 10 How did you refer it? The certification 11 in...? 12 DR. GLENN TAYLOR: It's a specialty 13 qualification. 14 COMMISSIONER STEPHEN GOUDGE: So it is 15 what you have? 16 DR. GLENN TAYLOR: Yes. 17 COMMISSIONER STEPHEN GOUDGE: And you 18 described this morning in answer to some questions about 19 how that requires some self-study and then an 20 examination? 21 DR. GLENN TAYLOR: Correct. 22 COMMISSIONER STEPHEN GOUDGE: Is there a 23 curriculum for it that one studies for? Is -- 24 DR. GLENN TAYLOR: No. 25 COMMISSIONER STEPHEN GOUDGE: -- there a


1 body of -- 2 DR. GLENN TAYLOR: No, no, no, no. 3 COMMISSIONER STEPHEN GOUDGE: -- work one 4 has to look at? Give me some sense of what is involved 5 and then how long is the exam and what does it consist 6 of. 7 DR. GLENN TAYLOR: The current 8 qualifications are different from the qualifications that 9 were necessary in 1999. The current qualifications 10 require that the candidates complete an accredited 11 Fellowship program of one (1) year's duration in 12 pediatric pathology. 13 COMMISSIONER STEPHEN GOUDGE: At that 14 point in 1999, it was experience-based? That was 15 sufficient -- 16 DR. GLENN TAYLOR: One could go -- one 17 could go through either a Fellowship program or 18 experience was accepted as qualification for the 19 training. 20 There still is an examination that has to 21 be passed and I'm trying to remember how many days it 22 was. I think it was two (2) days or maybe -- maybe just 23 one (1) day. But it was -- if it was one (1) day, it was 24 all day long. It was -- the examination involves not 25 just anatomical pathology but also clinical pathology,


1 biochemistry, microbiology, hematology related to 2 pediatrics. So it's -- 3 COMMISSIONER STEPHEN GOUDGE: Were they 4 written exams -- 5 DR. GLENN TAYLOR: They -- 6 COMMISSIONER STEPHEN GOUDGE: -- or 7 demonstration of skills? 8 DR. GLENN TAYLOR: They were a 9 combination of written exams and analysis of slides and 10 other images for diagnostic purposes. 11 The current state of those exams is that - 12 - and for many institutions in the United States that do 13 pediatric pathology, the requirement for employment is 14 either board certified or board eligible. And it's 15 usually board certified that people will request. 16 So it's now become, as I said, a benchmark 17 for kind of entry into pediatric pathology. As are the 18 speciality qualification exams in either disciplines, in 19 -- in many places. 20 COMMISSIONER STEPHEN GOUDGE: How would 21 one prepare oneself for this day long or two (2) day long 22 examination? 23 DR. GLENN TAYLOR: Making oneself 24 familiar with the -- with the current standard textbooks 25 in pediatric pathology, probably doing a little bit of


1 reading in obstetrics because perinatal pathology with is 2 -- relates to children at the time of birth plus the 3 placenta is -- is part of the -- of the examinable 4 material; reviewing some of the clinical pathology, 5 that's the microbiology, chemistry, and hematology 6 related to children. 7 So the -- there are standard textbooks and 8 those would be the first avenue. They -- the way the 9 exam is structured is that it has a basic knowledge sort 10 of requirement plus there's examinable questions on kind 11 of current trends in pediatric pathology. So up-to-date 12 literature's also required, as well as the standard 13 textbooks. 14 COMMISSIONER STEPHEN GOUDGE: Thanks. 15 That is helpful, Dr. Taylor. Sorry, Mr. Carter. 16 17 CONTINUED BY MR. WILLIAM CARTER: 18 MR. WILLIAM CARTER: No, not at all. So 19 this is a serious exam? 20 DR. GLENN TAYLOR: Yes, it is. 21 MR. WILLIAM CARTER: I think that's 22 what's at the heart of the question. So it would appear 23 that whatever the reasons were for Dr. Smith's problems 24 related to the surgical realm may have been -- well, 25 first of all, they were identified, were they not, by


1 Doctors Thorner and Becker? 2 DR. GLENN TAYLOR: Yes. 3 MR. WILLIAM CARTER: And that's -- that's 4 important, isn't it, because in a -- in a setting like 5 Sick Kids -- but it's true of most clinical settings, 6 it's important that problems get identified by the 7 appropriate people -- 8 DR. GLENN TAYLOR: Yes. 9 MR. WILLIAM CARTER: -- and they get 10 addressed by the appropriate people? 11 DR. GLENN TAYLOR: Yes. 12 MR. WILLIAM CARTER: And that occurred 13 here? 14 DR. GLENN TAYLOR: Yes. 15 MR. WILLIAM CARTER: And that 16 demonstrates the operation of -- of an appropriate 17 quality assurance/risk management system? 18 DR. GLENN TAYLOR: Yes. 19 MR. WILLIAM CARTER: Okay. And it would 20 appear that whatever the problems were they got turned 21 around, didn't they, because both you and Dr. Becker were 22 giving him passing grades on the surgical side of things, 23 subsequently? 24 DR. GLENN TAYLOR: Yes. 25 MR. WILLIAM CARTER: Okay. And we know


1 that in 2005, you asked Dr. Dimmick, your mentor, to take 2 an independent review of sixty (60) cases -- 3 DR. GLENN TAYLOR: Yes. 4 MR. WILLIAM CARTER: -- of Dr. Smith's. 5 Now, you said to us, fairly, that it wasn't so much that 6 you personally were concerned; you felt that it was an -- 7 an appropriate move to find independent verification or 8 external verification for your judgment of Dr. Smith? 9 DR. GLENN TAYLOR: Yes. 10 MR. WILLIAM CARTER: And why did you 11 chose Dr. Dimmick? 12 DR. GLENN TAYLOR: Well, I knew Dr. 13 Dimmick -- I know Dr. Dimmick very well. I know his 14 abilities as a surgical pathologist. I worked with him 15 for many years. Dr. Dimmick is a highly respected 16 pediatric pathologist in the pediatric pathology world. 17 He, at that time, was in a -- in an 18 administrative position, in a sense. He was -- I think 19 he had just finished as being the chairman of the 20 Department of Pathology at the University of British 21 Columbia. 22 He was available, and he was willing to 23 come to Toronto -- I'm not sure what the financial 24 transactions for his retainer were, but he was willing to 25 do it, and he was willing to accept that the, sort of,


1 parameters of the review that I had set up. 2 MR. WILLIAM CARTER: But I take it that 3 he wasn't just a senior colleague, that he, in fact, was 4 a preeminent pediatric pathologist? 5 DR. GLENN TAYLOR: That's correct. He's 6 past president of the Society for Pediatric Pathology, 7 and he's certainly well known throughout the world as a 8 pediatric pathologist. 9 MR. WILLIAM CARTER: And someone who's 10 imprimatur on this task would be of, you thought, 11 indisputed repute? 12 DR. GLENN TAYLOR: I had my full 13 confidence in him providing a reliable, unbiassed and 14 appropriate judgment. 15 MR. WILLIAM CARTER: And what, in fact, 16 was done was you didn't sel -- you didn't, unlike some of 17 these other quality assurance programs, do a random 18 sample, you, in fact, selected sixty (60) tough cases 19 that had important significant implications for patients? 20 DR. GLENN TAYLOR: Yes, I went through 21 six (6) months surgicals that were signed out by Dr. 22 Smith, and I reviewed the reports, and I selected cases 23 that were either of a diagnosis that involved cancer of 24 had some other important implication for the treatment of 25 patients.


1 I ignored cases that sort of didn't really 2 matter in a sense, but I -- I wanted to get the cases 3 where, if there was -- if there were mis-diagnoses, there 4 could have BEEN trouble. 5 MR. WILLIAM CARTER: You didn't want to 6 just test; you wanted a very critical evaluation, is that 7 fair? 8 DR. GLENN TAYLOR: Yes, right. 9 MR. WILLIAM CARTER: Because a random 10 sample might have randomly produced some easy stuff, too. 11 DR. GLENN TAYLOR: Yes. 12 MR. WILLIAM CARTER: This -- this was 13 more difficult stuff; this was what you felt was a fair 14 acute analysis of what -- what really matters to a 15 surgical pathologist. 16 DR. GLENN TAYLOR: Yes. 17 MR. WILLIAM CARTER: Okay. And in fact, 18 there were no cases in which he disagreed in any 19 significant way with Dr. Smith. 20 DR. GLENN TAYLOR: There were three (3) 21 that he disagreed, but which didn't -- and I haven't 22 reviewed those cases -- 23 MR. WILLIAM CARTER: Right. 24 DR. GLENN TAYLOR: -- to find out what, 25 but it was without any consequence to the patient.


1 MR. WILLIAM CARTER: Though he disagreed 2 in a minor way. 3 DR. GLENN TAYLOR: Correct. 4 MR. WILLIAM CARTER: So they -- they 5 weren't in a significant way. 6 DR. GLENN TAYLOR: Sorry? Yes. 7 MR. WILLIAM CARTER: So that was -- that 8 was my point. 9 DR. GLENN TAYLOR: Okay. 10 MR. WILLIAM CARTER: Among a selection of 11 sixty (60) cases in a room full of pathologists, do you 12 think there would be some minor disagreement? 13 DR. GLENN TAYLOR: Probably some minor 14 disagreement, yes. 15 MR. WILLIAM CARTER: Maybe on three (3) 16 out of sixty (60) cases? 17 DR. GLENN TAYLOR: Perhaps, depending 18 upon the pathologists. 19 MR. WILLIAM CARTER: What I'm suggesting 20 to you is this is actually a pretty good outcome, isn't 21 it? 22 DR. GLENN TAYLOR: I think it's a good 23 outcome, yes. 24 MR. WILLIAM CARTER: Okay. And you 25 certainly found it reassuring.


1 DR. GLENN TAYLOR: Yes, I did. 2 MR. WILLIAM CARTER: Okay. Now, just a 3 couple of points; I'd like to move into the present a 4 little bit. Can you -- can you find the Institutional 5 Report? It's -- 6 DR. GLENN TAYLOR: Yes. 7 MR. WILLIAM CARTER: -- for those of us 8 tied to the monitor, it's 301353. I'd like to take you 9 to the very back page. 10 COMMISSIONER STEPHEN GOUDGE: Of the 11 appendices or the report? 12 MR. WILLIAM CARTER: Of the appendices, 13 thank you, Commissioner. I don't know the last page 14 number, but -- in fact, it doesn't -- my copy -- 15 COMMISSIONER STEPHEN GOUDGE: It doesn't 16 have a number. 17 MR. WILLIAM CARTER: -- doesn't have a 18 number, but if we -- do you see that? 19 COMMISSIONER STEPHEN GOUDGE: It's the 20 form. 21 22 CONTINUED BY MR. WILLIAM CARTER: 23 MR. WILLIAM CARTER: It's a form. 24 DR. GLENN TAYLOR: Yes. 25 MR. WILLIAM CARTER: Are you familiar


1 with this document? 2 DR. GLENN TAYLOR: Yes, I am. 3 MR. WILLIAM CARTER: Can you tell us what 4 it is, please? 5 DR. GLENN TAYLOR: This is our internal 6 form for second review of either initial diagnosis of 7 malignancy cases or cases that have a significant 8 clinical concern. So it's -- it's an -- it's a form that 9 is distributed when a formal request by a member of the 10 division is made to another member of the division to 11 review a case. 12 This form also allows for the cases to be 13 reviewed at our weekly surgical pathology rounds for 14 confirmation of diagnoses or for suggestions as to 15 additional testing that should be done. 16 The form tracks who was there and who did 17 the review and this is more -- is flagged in our computer 18 system so that cases that are subjected to an internal 19 formal review are identified in the computer system. 20 MR. WILLIAM CARTER: Okay. Now I -- I 21 take it this -- this form is a fairly recent innovation. 22 DR. GLENN TAYLOR: Yes. 23 MR. WILLIAM CARTER: When did it come 24 into use? 25 DR. GLENN TAYLOR: I can't recall; it's -


1 - I think it's at least two years old. 2 MR. WILLIAM CARTER: It's under your 3 leadership. 4 DR. GLENN TAYLOR: Yes. 5 MR. WILLIAM CARTER: And I take it the 6 purpose of this was to create a tracking system which 7 left a documentary trail and increased the accountability 8 for surgical out -- pathological outcomes. 9 DR. GLENN TAYLOR: Yes. 10 MR. WILLIAM CARTER: Okay. And can we 11 just, in the short time left to me, address a couple of 12 the systemic issues that we have had summarized for us by 13 the Commission? 14 I'm not sure you have the systemic issues 15 document. I'm not -- I think it may have a BEGDOC 16 number. I'm sorry, one (1) moment. 17 18 (BRIEF PAUSE) 19 20 MR. WILLIAM CARTER: I -- I'm going to 21 read it to you. I don't want to take the time. There's 22 just a couple of them; I thought it might be of 23 assistance for the Commissioner just to get your views on 24 these. 25 Item number 11: This is under the caption


1 "Institutional considerations"; systemic issue number 11: 2 "Does Ontario have a sufficient supply 3 of pediatric forensic pathology 4 services and how can that be assured in 5 future?" 6 And let me just try to contextualize this, 7 although this Commission has, and is, devoted to this 8 particular subject in the scheme of things, we're dealing 9 with ten (10) to fifteen (15) cases a year, I think, are 10 we not? 11 DR. GLENN TAYLOR: Yes. 12 MR. WILLIAM CARTER: Okay. So just so 13 we've got that in a -- in a population of 5 or 6 million, 14 I suppose is the catchment for Sick Kids. 15 Is that fair? 16 DR. GLENN TAYLOR: Yes. 17 MR. WILLIAM CARTER: So in that context, 18 can you assist the Commissioner with your views? 19 DR. GLENN TAYLOR: Well, it would only 20 take one (1) person to deal with ten (10) or fifteen (15) 21 cases. But the issue is the other 95 percent of cases 22 which bumps things up to probably two-fifty (250) or 23 three hundred (300) cases and how many people do you need 24 to deal with that in an appropriate way. 25 And at the present time, Sick Kids, with


1 the current resources we have, could not handle three 2 hundred (300) cases. I don't think the Office of the 3 Chief Coroner if they elected to do all of -- all of -- 4 the whole blanket of pediatric forensic pathology cases 5 could handle that. 6 So a distributed system, I think, is still 7 logistically most reasonable. The question is the 8 training and the interaction with the coroner's service 9 and all of the other issues that have been raised at 10 those different regions to deal with these cases. 11 If there was a decision made to 12 institutionalize or centralize all of those, and there 13 would have to be the appropriate resources and manpower 14 available, and I'm not sure where pediatric forensic 15 pathologists might come from in order to staff such a 16 place. Because most of the pediatric forensic 17 pathologists are pediatric pathologists working in 18 hospitals and doing hospital-based pediatric pathology as 19 well as the coroner's cases. 20 MR. WILLIAM CARTER: That's driven by 21 supply considerations -- 22 DR. GLENN TAYLOR: That's -- 23 MR. WILLIAM CARTER: -- really, isn't it? 24 DR. GLENN TAYLOR: That's driven by 25 supply considerations, yes.


1 So how can it be assured in the future? I 2 think there has to be a training program in place that's 3 a joint venture between pediatric pathology and forensic 4 pathology so that there is appropriate cross-pollination 5 between those two (2) disciplines. There may be an 6 individual who has aptitude and interest in both. 7 And there are some double-boarded people 8 in the United States that have both pediatric pathology 9 and forensic pathology, but there are not very many. 10 Most of the pediatric forensic pathology is done through 11 Medical Examiners or Coroner's Systems. Some places 12 still do some pediatric -- some pediatric pathology and 13 places still do some forensic, but they're in a major -- 14 minority in the United States. 15 In the United Kingdom, it's a bit 16 different. Many of the pediatric pathology services also 17 do forensic cases. 18 Regardless, if we wanted to ensure 19 pediatric -- appropriate pediatric forensic pathology 20 services in Ontario, there needs to be a training venue, 21 and it needs to involve both the coroner's service and 22 the academic pediatric pathology services. Whether 23 that's centred at the -- say, the Office of the Chief 24 Coroner or at a place like the PFPU at Sick Kids is open 25 for debate, I think, as long as the resources are there


1 and the very important communication between those two 2 (2) services and, sort of, joint development of the 3 curriculum and so on. 4 MR. WILLIAM CARTER: Okay. As things 5 currently stand, the resources are located at the 6 Hospital for Sick Children for at least 95 percent of the 7 cases that are part of our concern? 8 DR. GLENN TAYLOR: Yes. 9 MR. WILLIAM CARTER: Okay. And I 10 appreciate it's that other group that we're concerned 11 about delineating who should be the gatekeeper for those. 12 DR. GLENN TAYLOR: Right. 13 MR. WILLIAM CARTER: Whether they start 14 out in the coronial system or whether they start in -- 15 out in the hospital system. 16 DR. GLENN TAYLOR: Correct. But 17 regardless of where they go, there still needs to be 18 close communication and collaboration between forensic 19 pathologists and pediatric pathologists. 20 Now, who takes the lead in those -- 21 forensic pathology or pediatric pathology -- is -- you 22 know, is still open to discussion. I tend to think that 23 forensic pathologists should take the lead in those with 24 some input, if necessary, from the pediatric 25 pathologists. But there should be open lines of


1 communication, and there should be an understanding as to 2 the best way to investigate these cases. 3 MR. WILLIAM CARTER: So the -- just 4 exploring the ideas of open lines of communication. An 5 institutional-to-institution -- institution-to- 6 institution framework within which these cases are 7 evaluated and managed, such as the framework between the 8 Hospital for Sick Children and the Coroner's Office 9 constitutes the ideal framework for addressing the 10 problem. 11 DR. GLENN TAYLOR: All right, I think -- 12 I don't know about ideal; we're still testing it. But I 13 think it's a very good start, yes. 14 MR. WILLIAM CARTER: Well, when I say 15 ideal, I wasn't suggesting you've -- you've reached the 16 ideal point. I was suggesting that the framework 17 encompasses the elements for success. It has the 18 forensic pathologist focussed at the Coroner's Office, 19 and it has the pediatric pathologist focussed at the 20 Hospital, so those are important elements? 21 DR. GLENN TAYLOR: Yes. 22 MR. WILLIAM CARTER: And it has bridging 23 mechanisms in that there are cross-appointments; for 24 instance, the Chief Forensic Pathologist is also a member 25 of your medical staff and your Division?


1 DR. GLENN TAYLOR: Correct. 2 MR. WILLIAM CARTER: And he actually 3 takes an active role to the extent his duties permit, in 4 the -- in the conduct of cases at the hospital? 5 DR. GLENN TAYLOR: That's correct, and 6 unfortunately, he's getting busier and busier so we're 7 seeing less and less of him which is to my regret. 8 MR. WILLIAM CARTER: Right, but the -- 9 the -- that -- forgetting the incumbent, that that 10 position of Chief Forensic Pathologist with a staff 11 appointment at the hospital and an academic appointment 12 at the University, is another important element in the 13 framework for success? 14 DR. GLENN TAYLOR: Yes. 15 MR. WILLIAM CARTER: And having a fully 16 trained certified -- board certified forensic pathologist 17 on staff at the Hospital for Sick Children, in the person 18 of Dr. Chiasson -- but just take the position without the 19 individual for the purpose of my question -- having 20 somebody with those credentials working in a pediatric 21 setting, conducting pediatric forensic pathology in close 22 contact with the Coroner's Office and the Chief Forensic 23 Pathologist is another important ingredient in the 24 framework for success? 25 DR. GLENN TAYLOR: I -- I think it's a


1 very important part of that. It's kind of a bit of a 2 unique situation right now, because there are not very 3 many people around like Dr. Chiasson that has board 4 certification plus experience and interest in pediatric 5 pathology. 6 I know of a few people, sort of, floating 7 around in the background at various stages of the 8 training that have similar interests, but there are very 9 few people like that. 10 MR. WILLIAM CARTER: Okay. Those are my 11 questions, thank you, Commissioner. 12 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 13 Carter. Let me just ask, and if anything arises from 14 this, Mr. Carter -- 15 MR. WILLIAM CARTER: Thank you. 16 COMMISSIONER STEPHEN GOUDGE: -- you can 17 ask about it. Just to come at the -- Mr. Carter called 18 the supply question in a complimentary way, this way, Dr. 19 Taylor. I get the sense from the last paragraph of your 20 Institutional Report, paragraph 171, that your view as 21 the Chair of the Department is we probably, as a 22 component of the Health Care System, could profit from 23 more pediatric pathologists? 24 That is, they're in short supply? 25 DR. GLENN TAYLOR: They're in short


1 supply. It's a difficult position to kind of fill, 2 because there are many opportunities for a pathologist in 3 other areas -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. GLENN TAYLOR: -- that allow them a 6 lot more flexibility in where they can live, for 7 instance. If you're a pediatric pathologist, you're 8 basically committing to working in a -- 9 COMMISSIONER STEPHEN GOUDGE: Toronto, 10 Vancouver? 11 DR. GLENN TAYLOR: -- in a large city 12 with a University and large academic based hospital, yes. 13 COMMISSIONER STEPHEN GOUDGE: As opposed 14 to a general anatomical pathologist who could live in a 15 variety of centres? 16 DR. GLENN TAYLOR: That's correct. 17 COMMISSIONER STEPHEN GOUDGE: Ok. That's 18 a given, I would assume? 19 DR. GLENN TAYLOR: Yes. 20 COMMISSIONER STEPHEN GOUDGE: But we've 21 heard the same sort of refrain about shortage of supply 22 concerning forensic pathology as well, so those two (2) 23 sub-specialities have the same interest in enhancing 24 their supply lines so to speak? 25 DR. GLENN TAYLOR: Yes.


1 COMMISSIONER STEPHEN GOUDGE: How do you 2 do that? 3 DR. GLENN TAYLOR: The only way that I 4 know to do it is to find somebody through the trai -- 5 through the medical school or through their residency 6 training program that has -- that demonstrates an 7 interest in those areas, and gently mentor them -- well, 8 not so gently, maybe, but mentor them toward that career 9 choice. 10 In part, this is how I ended up in the 11 field, and it's certainly how other people that I know 12 that are in pediatric pathology ended up in the field. 13 They -- they were encouraged and directed and mentored by 14 other pediatric pathologists. 15 And I think it's the same in forensic 16 pathology. 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. GLENN TAYLOR: You find somebody 19 who's -- who looks good, who has interest, and you help 20 to blossom that interest, and then support them as they 21 get the additional training required. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 Does enhancing the residency exposure of the sub- 24 specialty help? 25 DR. GLENN TAYLOR: That helps, and also


1 enhancing exposure in medical school. There's an issue-- 2 COMMISSIONER STEPHEN GOUDGE: Are there 3 any courses in pediatric pathology as part of the 4 undergraduate MD program in Canada? 5 DR. GLENN TAYLOR: There are no full 6 courses in the U of T. Recently, I started giving 7 lectures in pediatric pathology to the second year 8 medical students as part of the Pathology Lecture 9 Program. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. GLENN TAYLOR: And basically, that's 12 it except for other exposure that may be derived from my 13 being involved in, what they call, the "Problem-Based 14 Learning Seminar Series" with medical students. 15 So it gives an opportunity to kind of 16 influence people's interest. 17 COMMISSIONER STEPHEN GOUDGE: Do you have 18 to do outreach, in effect, to get into the medical 19 curriculum in both those ways? 20 DR. GLENN TAYLOR: Well, they're always 21 looking for volum -- the University's always looking for 22 teachers, but in a sense, yes. There used to be lectures 23 in pediatric pathology back in the '90s that I was 24 involved with, and I think they kind of fell when I -- 25 when I left and one (1) of the other --


1 COMMISSIONER STEPHEN GOUDGE: This is 2 when you -- 3 DR. GLENN TAYLOR: In Toronto, U of T. 4 COMMISSIONER STEPHEN GOUDGE: Okay. 5 DR. GLENN TAYLOR: When I left and one 6 (1) of the other pathologists that was doing them, kind 7 of, left or -- or dropped doing the -- that particular 8 curriculum component kind of stalled. And then when I 9 came back, I wanted to get some more pediatric pathology 10 back into the University curriculum. 11 And that's happened. And so far -- 12 COMMISSIONER STEPHEN GOUDGE: What did 13 you do, go to the Dean and say, I would like to give some 14 lectures -- 15 DR. GLENN TAYLOR: I went -- 16 COMMISSIONER STEPHEN GOUDGE: -- within 17 your pathology course? 18 DR. GLENN TAYLOR: I went -- I went to 19 the Head of the Department at the University in Pathology 20 and to the -- the Program Coordinator for the lecture 21 series and made the suggestion. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. GLENN TAYLOR: And they were well 24 received because they were -- they were -- it was hole in 25 -- in the curriculum.


1 COMMISSIONER STEPHEN GOUDGE: Okay. Now, 2 moving on to the residency, the general residency. I 3 take it, where the pediatric component you speak of in 4 paragraph 171 arises, is in the anatomical pathology 5 residency? 6 DR. GLENN TAYLOR: Yes. 7 COMMISSIONER STEPHEN GOUDGE: And it's -- 8 what do you say here: 9 "I was surprised at how short a period 10 of time it is, within that." 11 DR. GLENN TAYLOR: Well, it used to be 12 three (3) months required by the Royal College. And I'm 13 not sure now that that three (3) months is still a hard 14 requirement or if it's a requirement at all. We have 15 been getting residents for one (1) month and two (2) 16 months which is not an adequate time to fully expose them 17 to -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. GLENN TAYLOR: -- to the 20 subspecialty. 21 COMMISSIONER STEPHEN GOUDGE: Let alone 22 create the kind of mentoring relationship that you say is 23 an important component of attracting young doctors into 24 this field? 25 DR. GLENN TAYLOR: Correct. So what our


1 strategies have been is to identify those that show some 2 interest, get them involved in, perhaps, publishing a 3 case report or getting their feet wet in the academic 4 aspect, supporting them, and hopefully being able -- if 5 they make the career choice -- hopefully, being able to 6 support further training. 7 Most of the -- we have a Fellowship 8 program at the U of -- at the Hospital for Sick Children 9 in pediatric pathology. Our problem is in -- in training 10 people so that they are qualified for the American Board 11 exams. 12 And the -- the issue there is the American 13 Board of Pathology now requires that the candidates be 14 trained in a -- an accredited program. And accreditation 15 that they accept is done by the Accreditation Council and 16 Graduate Medical Education in the United States which 17 does not accredit programs in Canada. 18 So immediately all of the Canadian 19 Fellowship programs lost -- 20 COMMISSIONER STEPHEN GOUDGE: Lose value. 21 DR. GLENN TAYLOR: -- lost value, in a 22 sense, because training in Canada does not qualify you to 23 sit for the American Board -- 24 COMMISSIONER STEPHEN GOUDGE: So it is a 25 wasted year if you are trying to get to the American --


1 DR. GLENN TAYLOR: Well, I wouldn't 2 consider it a wasted year, but -- 3 COMMISSIONER STEPHEN GOUDGE: No, but if 4 you are trying to get your American cert -- 5 DR. GLENN TAYLOR: And if you ever have 6 intention of going to the United States to practice, you 7 won't be qualified. And as I mentioned, more and more 8 institutions are requiring either board qualification or 9 board certification for employment purposes. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. GLENN TAYLOR: So even getting 12 Fellows, which are physicians which have completed a 13 residency and are doing additional training, primarily 14 from the United Kingdom, and from Australia, and Asia. 15 COMMISSIONER STEPHEN GOUDGE: Okay. Now 16 -- sorry. 17 DR. GLENN TAYLOR: So -- and one (1) -- 18 one (1) route for us to increase our -- our population or 19 to make replacements is to swipe those people if they 20 come to -- train at our place, if they look good, and 21 they're interested in staying, to try to accommodate them 22 staying here. 23 COMMISSIONER STEPHEN GOUDGE: All right. 24 Right. There, at present, is no Canadian certificate in 25 pediatric pathology?


1 DR. GLENN TAYLOR: That's correct. 2 COMMISSIONER STEPHEN GOUDGE: Is there 3 any move in that direction? 4 DR. GLENN TAYLOR: There has been some 5 movement towards that, and it's one (1) of the projects 6 that's been on my, kind of, back shelf for some time. 7 The problem is the Royal College has been trying to cut 8 back on the number of sub-specialties that they certify, 9 for a variety of reasons. 10 In fact, recently neuropathology was 11 threatened with losing its full certification. It's now 12 still considered to be a sub-specialty, so there is a 13 certification process for neuropathology in Canada. But 14 there was a time when it was cons -- it was being 15 considered to be dropped and just fold it into pathology, 16 in general, with the recognition perhaps of -- of some 17 special qualifications, but not a full certification 18 process. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. GLENN TAYLOR: Forensic pathology has 21 just been accepted for certification in Canada, and it 22 took several years for that to happen. The process could 23 be similar for pediatric pathology, given sort of an 24 agreeable college to consider it. 25 And then there is a potential route for


1 going for -- for people to sit for the American Board 2 exams because there are precedents for reciprocal 3 acknowledgement of accredited programs -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. GLENN TAYLOR: -- so the college has 6 an accredited program in a sub-specialty. 7 COMMISSIONER STEPHEN GOUDGE: That will 8 satisfy the American requirement. 9 DR. GLENN TAYLOR: It may satisfy the 10 ACGME, and therefore, satisfy the American Board of 11 Pathology. 12 COMMISSIONER STEPHEN GOUDGE: Right, 13 okay. The last element to my questions about this, is 14 relative rate of remuneration of pediatric pathologists, 15 an issue at all -- 16 DR. GLENN TAYLOR: Well -- 17 COMMISSIONER STEPHEN GOUDGE: -- in terms 18 of making it an attractive sub-specialty? 19 DR. GLENN TAYLOR: I'd like more money, 20 yes, but no, I -- I -- in Ontario, it's a bit of an 21 anomaly right now because with the funding agreement 22 that's in place -- although that's due to end soon -- 23 there's a base level for all pathologists that includes 24 pediatric pathologists in the Province, and it's supposed 25 to be a base level and the Institution is supposed to top


1 it up to kind of attract people, but basically, the 2 salary is at the base level, which is -- it's a good -- 3 it's a good salary, but for pediatric pathology to 4 compete with other disciplines in pathology, it's -- 5 we're at a bit of a disadvantage. 6 If we were paid more, would it have -- 7 COMMISSIONER STEPHEN GOUDGE: A bit of a 8 disadvantage why; because of the geographical issue you 9 described? 10 DR. GLENN TAYLOR: The geographical 11 issue, the fact that you need extra -- a Fellowship 12 training -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. GLENN TAYLOR: -- and so you spend 15 the extra time and you commit yourself to working in a 16 large university centre -- 17 COMMISSIONER STEPHEN GOUDGE: For no more 18 money. 19 DR. GLENN TAYLOR: -- for no more money, 20 correct, so you really have to like what you do which we 21 do. 22 COMMISSIONER STEPHEN GOUDGE: Okay, 23 thanks. Thanks, Dr. Taylor. That's all about supply, 24 Mr. Carter. 25 MR. WILLIAM CARTER: Thank you.


1 COMMISSIONER STEPHEN GOUDGE: I don't 2 know if any questions arise out of that. 3 MR. WILLIAM CARTER: No, thank you. 4 COMMISSIONER STEPHEN GOUDGE: I just have 5 a couple more really housekeeping questions, anyway. You 6 can stay there if you want and see if there's anything 7 that arises and then I'll call on Ms. McAleer. 8 Can you turn back in -- in your 9 institutional report, Dr. Taylor, to paragraph 113? This 10 is a little sort of paperwork thing, but Ms. Johnson went 11 through, very carefully, for us the other day the various 12 forms involved in an autopsy, and I'm not quite sure I 13 understand where this fits in. 14 There is now a form called "The 15 Preliminary Cause of Death Document" that is completed 16 right at the end of the autopsy -- 17 DR. GLENN TAYLOR: Yes. 18 COMMISSIONER STEPHEN GOUDGE: -- that 19 goes -- and that's for all medicolegal autopsies? 20 DR. GLENN TAYLOR: Yes. 21 COMMISSIONER STEPHEN GOUDGE: And it goes 22 to the Coroner's Office. 23 DR. GLENN TAYLOR: No, what go -- it goes 24 to the Director of the OPFPU. For homicide cases, 25 they're forwarded on to the -- the Office of the Chief


1 Coroner and Chief Forensic Pathologist. 2 COMMISSIONER STEPHEN GOUDGE: Okay, now 3 do we have a copy of that form somewhere, Mr. Carter? 4 I'm sure we do. 5 MR. WILLIAM CARTER: I don't have any on 6 the screen so -- 7 COMMISSIONER STEPHEN GOUDGE: The 8 Preliminary Cause of Death Document. I -- I understood 9 Ms. Johnson, because we went through this carefully with 10 her the other day, and she, sort of, said the first form 11 that gets filled out is the CF 12. 12 DR. GLENN TAYLOR: The -- this form is 13 filled out by the pathologist in the autopsy room, and it 14 doesn't necessarily even go to the secretaries. So my -- 15 my practice is I -- I fill it out, make a copy -- a copy 16 for my records -- and then I -- the copy goes to Dr. 17 Chiasson. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 DR. GLENN TAYLOR: So it doesn't even see 20 the secretary. 21 COMMISSIONER STEPHEN GOUDGE: Okay. And 22 so when you do a medicolegal autopsy, this is the first 23 piece of paper that you complete. 24 DR. GLENN TAYLOR: Yes. 25 COMMISSIONER STEPHEN GOUDGE: And is the


1 next piece of paper the CF 12? 2 DR. GLENN TAYLOR: Yes. 3 COMMISSIONER STEPHEN GOUDGE: Okay. And 4 then I think we pick up the trail that Ms. Johnson 5 outlined. How long has "The Preliminary Cause of Death 6 Document" been used? 7 DR. GLENN TAYLOR: I think it's less than 8 a year. It's -- it's recent. It's one of Dr. Chiasson's 9 initiatives. 10 COMMISSIONER STEPHEN GOUDGE: And what 11 was the philosophy for putting it in place? 12 DR. GLENN TAYLOR: There are a couple of 13 reasons. The main one (1) was that when we complete a 14 case done under coroner's warrant, we call the coroner to 15 inform the coroner of the cause of death as we understand 16 it at the time. If we don't know, we just say 17 undetermined. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. GLENN TAYLOR: But sometimes we -- we 20 do have a good idea, and this is a form to document what 21 was said to the coroner. 22 In addition, for -- for the investigation 23 of children that were under five (5) years of age, the 24 police are often in attendance, and this is a way to 25 document what's exactly said to the police at the end of


1 the autopsy. 2 COMMISSIONER STEPHEN GOUDGE: Okay. 3 DR. GLENN TAYLOR: And the form also 4 includes some indication as to whether there's been 5 retention of whole organs, like the brain or the heart, 6 which is an important component of the autopsy that needs 7 to be appropriately documented. 8 COMMISSIONER STEPHEN GOUDGE: Prior to 9 its introduction -- prior to the introduction of this 10 form, there was nothing before the CF 12? 11 DR. GLENN TAYLOR: I can't recall 12 anything that was done at -- 13 COMMISSIONER STEPHEN GOUDGE: She 14 described at one (1) earlier stage, there was a document 15 that had, sort of, a history in it and -- 16 DR. GLENN TAYLOR: Oh, that's -- 17 COMMISSIONER STEPHEN GOUDGE: -- that -- 18 DR. GLENN TAYLOR: -- yeah, that's really 19 part of the -- the previous policy or -- 20 COMMISSIONER STEPHEN GOUDGE: Yes -- 21 DR. GLENN TAYLOR: -- previous system -- 22 COMMISSIONER STEPHEN GOUDGE: -- the 23 previous regime. 24 DR. GLENN TAYLOR: -- that was in place. 25 COMMISSIONER STEPHEN GOUDGE: Yes.


1 DR. GLENN TAYLOR: Correct. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. GLENN TAYLOR: We don't do that 4 anymore. 5 COMMISSIONER STEPHEN GOUDGE: Right. And 6 she made that clear to us. 7 DR. GLENN TAYLOR: Yes. 8 COMMISSIONER STEPHEN GOUDGE: Okay. That 9 is helpful. 10 Then the last question I have has to do 11 with -- you may not be able to answer this -- Dr. 12 Phillips' evidence, I don't know. It is the loose thing, 13 and I just did not understand something in it. And I do 14 not know, since it is not your evidence. It is this 15 loose thing. I do not know that it has a PFP number. 16 DR. GLENN TAYLOR: It should have. 17 MS. JENNIFER MCALEER: Mr. Commissioner, 18 the witnesses don't have a copy of that. 19 COMMISSIONER STEPHEN GOUDGE: Oh. Let me 20 just show it to you. I just did not understand what he 21 is talking about there. 22 I don't know if either of you can clarify 23 that? 24 DR. GLENN TAYLOR: I think I can make a 25 comment, sir.


1 COMMISSIONER STEPHEN GOUDGE: What do you 2 think that refers to, Dr. Taylor? 3 DR. GLENN TAYLOR: I think that refers to 4 the hospital autopsy rate. In the '80s and early '90s, 5 the rate was very high. And this is the percentage of 6 hospital deaths that had permission for autopsy. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. GLENN TAYLOR: Permission given by -- 9 COMMISSIONER STEPHEN GOUDGE: What would 10 it have been at its height? 11 DR. GLENN TAYLOR: It probably was close 12 to what Dr. Phillips says. At Sick Kids, it was probably 13 around 70 percent and certainly, at BC Children's 14 Hospital at one (1) time, it was around 60 to 70 percent. 15 But -- 16 COMMISSIONER STEPHEN GOUDGE: Getting 17 within sight of Dr. Cutz' experience in Czechoslovakia 18 of -- 19 DR. GLENN TAYLOR: Correct. 20 COMMISSIONER STEPHEN GOUDGE: -- 100 21 percent? 22 DR. ERNEST CUTZ: Right. 23 DR. GLENN TAYLOR: Correct. But in 24 recent years, it has fallen to 30 percent. 25 And we keep track of those statistics; I


1 just can't recall the exact numbers off the top of my 2 head, but it's -- it's probably in the 30 to 40 percent 3 range right now. 4 COMMISSIONER STEPHEN GOUDGE: I see. And 5 it looks to me as if Dr. Phillips' explanation for that 6 is not that consents are harder to get but the felt-need 7 on the part of the hospital to do an autopsy in a 8 hospital death has diminished. 9 DR. GLENN TAYLOR: I -- I think that's -- 10 COMMISSIONER STEPHEN GOUDGE: Because of 11 the other techniques that are available to explain the 12 cause. 13 DR. GLENN TAYLOR: I -- I think that's 14 partly right, but I think there is a component of change 15 in culture; a change in attitudes towards autopsy; change 16 in ethnic populations. There's -- 17 COMMISSIONER STEPHEN GOUDGE: Consent may 18 be a little more difficult -- 19 DR. GLENN TAYLOR: Consent -- 20 COMMISSIONER STEPHEN GOUDGE: -- to come 21 by? 22 DR. GLENN TAYLOR: I think consent is an 23 issue. I don't -- I don't think we can blame our 24 clinicians totally for that. 25 COMMISSIONER STEPHEN GOUDGE: Yeah. No.


1 And I am not suggesting it is blame at all. I mean, it 2 looks as if Dr. Phillips is saying, We have a whole lot 3 of other investigative tools that allow us to determine 4 what we need to know in order to ensure quality going 5 forward. 6 DR. GLENN TAYLOR: That's a true 7 statement. But there have been many studies in the 8 various errors of diagnostic modalities -- clinical 9 diagnostic modalities -- that have shown a pretty similar 10 error rate in diagnoses once an autopsy is done and to 11 confirm the clinical diagnoses. So, yes, more and more 12 sophisticated things are done but -- 13 COMMISSIONER STEPHEN GOUDGE: The autopsy 14 is -- 15 DR. GLENN TAYLOR: -- yes -- 16 COMMISSIONER STEPHEN GOUDGE: -- still 17 the best? 18 DR. GLENN TAYLOR: Well, you can argue 19 some -- the diagnostic imaging people would argue with 20 that, but it still finds -- it still finds errors in 21 diagnoses, yes. 22 COMMISSIONER STEPHEN GOUDGE: Okay, 23 thanks. Those are the questions I have. Thanks, Mr. 24 Carter. 25 Ms. McAleer...?


1 MS. JENNIFER MCALEER: Mr. Commissioner, 2 just one (1) brief point of clarification. You may 3 recall that you had posed a question during Ms. Ritacca's 4 cross-examination with respect to when Dr. Smith 5 commenced his leave of absence? 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 8 RE-DIRECT EXAMINATION BY MS. JENNIFER MCALEER: 9 MS. JENNIFER MCALEER: And, Dr. Taylor, 10 you couldn't recall the exact date. But if you look at 11 Volume II, Tab 35. 12 13 (BRIEF PAUSE) 14 15 DR. GLENN TAYLOR: Yes. 16 MS. JENNIFER MCALEER: There's reference 17 -- this is an email exchange between Dorothy Zwolakowski 18 at the Office of the Chief Coroner, and Dr. Barry 19 McLellan. But it refers to a phone call that's been 20 received from you on April 18th, 2005, indicating that as 21 of that date, effective immediately, Dr. Smith was going 22 to be on leave of absence. 23 DR. GLENN TAYLOR: Yes. 24 MS. JENNIFER MCALEER: So that's the date 25 that he --


1 DR. GLENN TAYLOR: That's the date -- 2 MS. JENNIFER MCALEER: -- commenced his 3 leave of absence? 4 DR. GLENN TAYLOR: Yes. Yes. 5 MS. JENNIFER MCALEER: Thank you. Thank 6 you, Mr. Commissioner. 7 COMMISSIONER STEPHEN GOUDGE: Well 8 gentlemen, thank you very much, that concludes your being 9 in our presence and may be delighted to leave us. But 10 thank you for the time you've spent and the information 11 you've given. It's very helpful for what we're trying to 12 do, so we're very grateful. 13 DR. GLENN TAYLOR: Thank you, Mr. 14 Commissioner. 15 16 (WITNESSES STAND DOWN) 17 18 COMMISSIONER STEPHEN GOUDGE: We'll rise 19 until 9:30 tomorrow morning. 20 21 --- Upon adjourning at 4:20 p.m. 22 23 24 25


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