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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 20th, 2007 25

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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 (np) ) 20 21 William Carter ) Hospital for Sick Children 22 Barbara Walker-Renshaw(np) ) 23 Kate Crawford ) 24 Paul Cavalluzzo (np) ) Ontario Crown Attorneys' 25 Association

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

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

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1 TABLE OF CONTENTS Page No. 2 3 JEAN MICHAUD, Sworn 4 JOSEPH de NANASSY, Sworn 5 BLAIR CARPENTER, Sworn 6 7 Examination-In-Chief by Ms. Jennifer McAleer 7 8 9 10 Certificate of transcript 256 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

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1 --- Upon commencing at 9:31 a.m. 2 3 THE REGISTRAR: All Rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Good 6 morning. 7 Ms. McAleer...? 8 MS. JENNIFER MCALEER: Good morning, Mr. 9 Commissioner. This morning we have three (3) doctors 10 with us from Ottawa. We're joined by Dr. Carpenter, Dr. 11 De Nanassy, and Dr. Michaud. All three (3) of these 12 doctors either have or are currently practising out of 13 the Children's Hospital of Eastern Ontario in Ottawa. 14 I'd like to begin this morning by 15 reviewing briefly the backgrounds of the three (3) 16 witnesses beginning with Dr. Carpenter. Good morning, 17 Dr. Carpenter. 18 DR. BLAIR CARPENTER: Good morning. 19 MS. JENNIFER MCALEER: Dr. Carpenter, you 20 will find your resume at Tab 1 of the brief that's before 21 you. It's PFP301515. 22 Do you have that, Dr. Carpenter? 23 DR. BLAIR CARPENTER: I have. 24 MS. JENNIFER MCALEER: Good. Oh, I'm 25 sorry, we haven't sworn in the witnesses. Mr. Registrar,

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1 if you'll swear in the witnesses, please? 2 3 JEAN MICHAUD, Sworn 4 JOSEPH De NANASSY, Sworn 5 BLAIR CARPENTER, Sworn 6 7 MS. JENNIFER MCALEER: Thank you, Mr. 8 Registrar. 9 10 EXAMINATION-IN-CHIEF BY MS. JENNIFER MCALEER: 11 MS. JENNIFER MCALEER: Dr. Carpenter, at 12 Tab 1 of Volume I you'll find your resume. 13 DR. BLAIR CARPENTER: Yes. 14 MS. JENNIFER MCALEER: You obtained your 15 medical degree from the University of Laval in 1970? 16 DR. BLAIR CARPENTER: Yes. 17 MS. JENNIFER MCALEER: You then did an 18 internship at the Hotel Dieu Grace Hospital in Chicoutimi 19 between 1965 and 1970? 20 DR. BLAIR CARPENTER: Yes. 21 MS. JENNIFER MCALEER: And then you did 22 residency at the l'Hopital St-Sacrement in Quebec City 23 from 1970 to 1972. 24 And you did part of that -- your residency 25 in pathology, correct?

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1 DR. BLAIR CARPENTER: Yes. 2 MS. JENNIFER MCALEER: And then you did a 3 year at the Hospital for Sick Children in Toronto between 4 1973 and 1974? 5 DR. BLAIR CARPENTER: Yes. 6 MS. JENNIFER MCALEER: And then I 7 understand you did a -- another year at the Hospital for 8 Sick Children, a fellowship -- 9 DR. BLAIR CARPENTER: Yes. 10 MS. JENNIFER MCALEER: -- between 1974 11 and 1975? 12 DR. BLAIR CARPENTER: Yes. 13 MS. JENNIFER MCALEER: And as part of 14 your university studies, your medical degree, was there 15 any component of forensic training when you were doing 16 your university studies? 17 DR. BLAIR CARPENTER: There was forensic 18 involvement as part of the overall training in pediatric 19 pathology. At the time, there was not a structured 20 immediate forensic pathology program, as such, but it was 21 part on an overall view of pediatric pathology. 22 MS. JENNIFER MCALEER: So does that mean, 23 Dr. Carpenter, that there would be occasional lectures in 24 medical school on forensic matters? 25 DR. BLAIR CARPENTER: There was some

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1 lectures as part of the overall curriculum. 2 MS. JENNIFER MCALEER: And when you were 3 doing your residency either in Quebec or in Toronto at 4 the Hospital for Sick Children did you have any exposure 5 to forensic pathology? 6 DR. BLAIR CARPENTER: Not in Quebec, but 7 in Toronto, yes. 8 MS. JENNIFER MCALEER: And what was the 9 nature of your exposure at the Hospital for Sick 10 Children? 11 DR. BLAIR CARPENTER: Well, it was 12 pediatric forensic pathology as a whole including every 13 aspect, whenever it occurred and I -- we were available. 14 MS. JENNIFER MCALEER: So the Hospital 15 for Sick Children at the time was doing medicolegal 16 autopsies, and as part of your residency -- excuse me -- 17 you would participate in those medicolegal autopsies? 18 DR. BLAIR CARPENTER: Yes. 19 MS. JENNIFER MCALEER: And would you be 20 exposed to criminally suspicious cases? 21 DR. BLAIR CARPENTER: These were usually 22 done by the staff people. We had access indirectly as 23 being available on the department. 24 MS. JENNIFER MCALEER: And I understand 25 that your first staff position was at the Hospital for

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1 Children -- the Children's Hospital of Eastern Ontario, 2 in Ottawa, in 1975 as the Staff Pediatric Pathologist? 3 DR. BLAIR CARPENTER: Yes. 4 MS. JENNIFER MCALEER: And can you 5 explain to Mr. Commissioner how it is you came to be at 6 CHEO? 7 DR. BLAIR CARPENTER: Well I was a 8 resident and fellow at the Children's Hospital -- at Sick 9 Kid in Toronto. I was planning to go back to Quebec city 10 as a Pediatric Pathologist. At the time the Hospital for 11 -- Pediatric Hospital in Quebec was still not fully -- or 12 structured, it was still in the planning. And Dr. 13 Norman, which was a neuropathologist at the Sick Kid 14 Hospital became head at CHEO in Ottawa when it opened. 15 I had been a fellow with her, and she 16 offered me, if I wish to come to Ottawa to work with her 17 would be available -- the job was available, which I 18 accepted and became a staff pathologist in -- in Ottawa 19 rather than going back to Quebec City. 20 MS. JENNIFER MCALEER: And CHEO opened in 21 1975, is that correct? 22 DR. BLAIR CARPENTER: I think officially 23 was '75, but it might be towards the end of '74 that it 24 started to -- to function. This has to be confirmed, but 25 I think it's the end of '74.

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1 MS. JENNIFER MCALEER: And I understand 2 that you worked with Dr. Norman at CHEO for five (5) 3 years, and then in or around 1980 you assumed the 4 position of Director of the Pediatric Pathology Division? 5 DR. BLAIR CARPENTER: Yes. 6 MS. JENNIFER MCALEER: And you held that 7 position until your retirement at the end of 2004, is 8 that correct? 9 DR. BLAIR CARPENTER: That is correct. 10 MS. JENNIFER MCALEER: And we'll come 11 back to your resume a little bit later, Dr. Carpenter, to 12 talk in particular about the forensic experience you've 13 had over the time that you were at CHEO. 14 But for now I'd like to move to Dr. de 15 Nanassy. Dr. de Nanassy, you will find your CV at Tab 3 16 of the volume before you. 17 DR. JOSEPH DE NANASSY: Yes. 18 MS. JENNIFER MCALEER: And, Dr. de 19 Nanassy, you are a graduate of Szeged University in 20 Hungary? 21 DR. JOSEPH DE NANASSY: Yes. 22 MS. JENNIFER MCALEER: And you obtained 23 your medical degree in 1980? 24 DR. JOSEPH DE NANASSY: Yes. 25 MS. JENNIFER MCALEER: And I understand

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1 that you then did residency in Hungary before moving to 2 Canada, is that correct? 3 DR. JOSEPH DE NANASSY: I did one (1) 4 year of residency in Hungary before leaving for France. 5 I did an additional six (6) months of residency in France 6 before arriving to Canada. 7 MS. JENNIFER MCALEER: And your one (1) 8 year residency in -- in -- or your six (6) months 9 residency in France was in general and thoracic surgery, 10 is that correct? 11 DR. JOSEPH DE NANASSY: That's correct. 12 MS. JENNIFER MCALEER: And then you did 13 residency -- well actually you worked as a pathology 14 assistant for three (3) years when you came to Canada, 15 correct? 16 DR. JOSEPH DE NANASSY: Yes. 17 MS. JENNIFER MCALEER: And then between 18 1986 and 1991 you did your residency in anatomical 19 pathology at the University of Toronto? 20 DR. JOSEPH DE NANASSY: Yes. 21 MS. JENNIFER MCALEER: And were you 22 affiliated with a particular hospital doing that 23 residency? 24 DR. JOSEPH DE NANASSY: No, because there 25 are several teaching hospitals in the Toronto system, so

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1 residents rotated among those hospitals. 2 MS. JENNIFER MCALEER: And which 3 hospitals did you rotate through? 4 DR. JOSEPH DE NANASSY: The Mt. Sinai 5 Hospital, the Toronto Western Hospital, the Women's 6 College Hospital, the Toronto General Hospital, and the 7 Hospital for Sick Children. 8 MS. JENNIFER MCALEER: All right. And 9 then between 1991 and 1993 you did a clinical fellowship 10 in pediatric pathology at the Hospital for Sick Children? 11 DR. JOSEPH DE NANASSY: That's correct. 12 MS. JENNIFER MCALEER: And then you moved 13 from there to Manitoba? 14 DR. JOSEPH DE NANASSY: Yes. 15 MS. JENNIFER MCALEER: And what was your 16 experience in Manitoba? 17 DR. JOSEPH DE NANASSY: In terms of...? 18 MS. JENNIFER MCALEER: You -- did you 19 obtain a staff position at a hospital in Manitoba? 20 DR. JOSEPH DE NANASSY: Yes, I was a 21 staff pathologist in pediatric pathology at the Health 22 Sciences Centre in Winnipeg, Manitoba. 23 MS. JENNIFER MCALEER: And how long did 24 you maintain that position for? 25 DR. JOSEPH DE NANASSY: I was a staff

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1 pathologist there for eleven (11) years. 2 MS. JENNIFER MCALEER: And you eventually 3 became the head of the section of Pediatric and Perinatal 4 Pathology in 2000 at the Heath Sciences Centre at the 5 Winnipeg Children's Hospital? 6 DR. JOSEPH DE NANASSY: That's correct. 7 MS. JENNIFER MCALEER: And then in 2004 8 you moved to Ottawa and you became the head of the 9 Division of Anatomical Pathology at CHEO? 10 DR. JOSEPH DE NANASSY: I moved to Ottawa 11 and eventually became the head, yes. 12 MS. JENNIFER MCALEER: Did you become the 13 head in 2004? 14 DR. JOSEPH DE NANASSY: No, I am the head 15 officially as of 2005. 16 MS. JENNIFER MCALEER: I see. And did 17 you move to Ottawa in 2004? 18 DR. JOSEPH DE NANASSY: I did. 19 MS. JENNIFER MCALEER: I see. And as a 20 result, just going back to your medical studies, did you 21 have any exposure to forensic pathology when you were 22 doing your medical degree? 23 DR. JOSEPH DE NANASSY: In medical school 24 the curriculum in that part of the world in those days 25 included two (2) or three (3) semesters of medicolegal

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1 medicine. 2 MS. JENNIFER MCALEER: And that included 3 exposure to forensic pathology, as well? 4 DR. JOSEPH DE NANASSY: That's correct. 5 MS. JENNIFER MCALEER: And then when you 6 working -- actually, before you started working, when you 7 were doing your residency in Toronto, did you have 8 exposure to forensic pathology at any of the hospitals 9 that you were working at while you were doing your 10 residency? 11 DR. JOSEPH DE NANASSY: Not specifically 12 at any one (1) of those particular hospitals I listed, 13 but rather the residency curriculum included a month or 14 two (2) of rotation at the -- at the coroner's building 15 on Grenville Street. So I spent a couple of months there 16 observing medicolegal autopsies. 17 MS. JENNIFER MCALEER: And is that while 18 you were doing your clinical fellowship at the Hospital 19 for Sick Children? 20 DR. JOSEPH DE NANASSY: NO, it's during 21 my residency. 22 MS. JENNIFER MCALEER: I see. And while 23 you were doing -- while you had that month or two (2) 24 months at the Office of the Chief Coroner did you have 25 exposure to a wide variety of medicolegal cases?

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1 DR. JOSEPH DE NANASSY: Yes, I did. 2 MS. JENNIFER MCALEER: Including cases 3 that were of a criminally suspicious or homicide nature? 4 DR. JOSEPH DE NANASSY: Yes. 5 MS. JENNIFER MCALEER: And then with 6 respect to your work in Manitoba, did you have further 7 exposure to forensic pathology? 8 DR. JOSEPH DE NANASSY: There were two 9 (2) of us pediatric pathologists in Winnipeg and we 10 alternated doing medicolegal cases, irrespective of their 11 nature, yes. 12 MS. JENNIFER MCALEER: Including 13 criminally suspicious cases? 14 DR. JOSEPH DE NANASSY: Including 15 criminally suspicious cases. 16 MS. JENNIFER MCALEER: And who was the 17 other doctor at the time? 18 DR. JOSEPH DE NANASSY: Dr. Susan 19 Phillips. 20 MS. JENNIFER MCALEER: And what 21 percentage of your practice would have been devoted to 22 doing medicolegal autopsies when you were in Manitoba? 23 DR. JOSEPH DE NANASSY: I have to guess 24 here, 10 to 20 percent of the cases were medicolegal -- 25 were -- were homicidal suspicious in nature.

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1 MS. JENNIFER MCALEER: To -- so 20 to 30 2 percent were -- 3 DR. JOSEPH DE NANASSY: 20 to -- 10 to 20 4 percent. 5 MS. JENNIFER MCALEER: Were criminally 6 suspicious? 7 DR. JOSEPH DE NANASSY: I'm guessing 8 here. 9 MS. JENNIFER MCALEER: All right. And 10 then there would be a larger subset that would be 11 medicolegal autopsies. 12 DR. JOSEPH DE NANASSY: There would be 13 about 30 to 40 percent which were medicolegal cases, not 14 necessarily high profile. 15 MS. JENNIFER MCALEER: Not -- not 16 necessarily criminally suspicious cases. 17 DR. JOSEPH DE NANASSY: Correct. 18 MS. JENNIFER MCALEER: And I see by 19 looking at your resume at page 6, that between 1996 and 20 2000 you were a member of -- it says "a pediatric 21 pathologist member" --I'm not quite sure what that means 22 -- the Manitoba Chief Medical Examiner's Children's 23 Inquest Review Committee. 24 Can you explain to the Commissioner what 25 your involvement was with the Children's Inquest Review

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1 Committee? 2 DR. JOSEPH DE NANASSY: The Chief Medical 3 Examiner for Manitoba had organised a committee which 4 examined medicolegal cases of pediatric patients who had 5 come to autopsy and around the table there were police 6 officers, socials workers, the Children's Aid Society 7 present at these then so on and so forth. 8 I was the pathologist on the -- on that 9 committee. We discussed those cases that we felt might 10 have some merit in coming to an inquest and then a 11 decision was made to proceed to an inquest or not. 12 MS. JENNIFER MCALEER: I see. And you 13 were on that committee for four (4) years? 14 DR. JOSEPH DE NANASSY: Yes. 15 MS. JENNIFER MCALEER: And the Chief 16 Medical Examiner at the time, was that Dr. Markesteyn? 17 DR. JOSEPH DE NANASSY: Initially it was 18 Dr. Markesteyn, and then when he retired Dr. Balachandra 19 became the Chief Medical Examiner. 20 MS. JENNIFER MCALEER: And did you 21 actually have experience on coroner's inquests, as well, 22 during that time period? 23 DR. JOSEPH DE NANASSY: I did, yes. 24 MS. JENNIFER MCALEER: And what was the 25 nature of that experience?

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1 DR. JOSEPH DE NANASSY: I would be the 2 expert witness testifying at -- at an inquest. 3 MS. JENNIFER MCALEER: And -- and how 4 many of those did you do, Dr. de Nanassy? 5 DR. JOSEPH DE NANASSY: Again, I'm 6 guessing, not that many, a couple maybe. 7 MS. JENNIFER MCALEER: All right. And 8 then, Dr. Michaud, if we could turn to your resume, which 9 is at Tab 2 of the brief before you. 10 Do you have that before you? 11 DR. JEAN MICHAUD: I do. Thank you. 12 MS. JENNIFER MCALEER: All right. So you 13 obtained your medical degree from Laval University 14 between 1968 and 1971? 15 DR. JEAN MICHAUD: That's correct. 16 MS. JENNIFER MCALEER: And did you have 17 any exposure to forensic courses in -- or courses in 18 forensic pathology during your medical school? 19 DR. JEAN MICHAUD: I'm sorry, 1972. The 20 last year was the externship, so I got -- I got my MD 21 degree in 1972. 22 MS. JENNIFER MCALEER: All right. And 23 did you -- that's the externship? 24 DR. JEAN MICHAUD: Yeah. 25 MS. JENNIFER MCALEER: And did you have

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1 any exposure to medical -- or -- or sorry, forensic 2 courses during your medical degree? 3 DR. JEAN MICHAUD: No, during medical 4 school there is no specific courses on forensic pathology 5 or medicine in general, at that time at least. 6 MS. JENNIFER MCALEER: Would there be -- 7 you may want to move the microphone forward a little, Dr. 8 Michaud. Thank you. 9 Were there forensic lectures or guest 10 lectures, perhaps, on matters of forensic science or 11 forensic pathology? 12 DR. JEAN MICHAUD: During my medical 13 school training, no, there was none of that. 14 MS. JENNIFER MCALEER: Okay. And then 15 you did an internship at l'Hopital de l'Enfant-Jesus 16 between 1972 and 1973? 17 DR. JEAN MICHAUD: That's correct. 18 MS. JENNIFER MCALEER: Any exposure to 19 forensic pathology or forensic sciences during that 20 internship? 21 DR. JEAN MICHAUD: The l'Hopital de 22 l'Enfant-Jesus was the major trauma centre in the Quebec 23 City area. In fact, this centre was receiving more 24 trauma case than all the other hospitals of the region. 25 So through on-call duties at the emergency room and also

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1 through my on-call duties in surgery and during some of 2 the rotations we were in contact with patients with 3 trauma, but there were none I would call the hardcore 4 forensic cases. 5 MS. JENNIFER MCALEER: And you also began 6 your residency there between 1973 and 1974. 7 DR. JEAN MICHAUD: Yes. 8 MS. JENNIFER MCALEER: Was l'Hopital de 9 l'Enfant-Jesus, was that a -- a children's hospital? 10 DR. JEAN MICHAUD: No, this is a -- well, 11 it was adult and children hospital. 12 MS. JENNIFER MCALEER: And then you 13 continued your residency at L Hotel-Dieu de Quebec 14 between 1974 and 1975? 15 DR. JEAN MICHAUD: Correct. 16 MS. JENNIFER MCALEER: Did you have 17 exposure to forensic pathology at that hospital? 18 DR. JEAN MICHAUD: This hospital was in 19 the inner part of the Old Quebec, and we had at times 20 death occurring in the area, itinerants and so on, so we 21 had some of those cases. But the system at that time did 22 not include, within regular pathology department, 23 homicides or highly suspicious deaths. 24 MS. JENNIFER MCALEER: So -- 25 DR. JEAN MICHAUD: But we had some cases

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1 that were perhaps suspicious, but on the lower degree of 2 certify -- 3 MS. JENNIFER MCALEER: So you would do 4 some cases pursuant to a -- a corner's warrant, -- 5 DR. JEAN MICHAUD: Yes. 6 MS. JENNIFER MCALEER: -- but the 7 criminally suspicious were being done somewhere else? 8 DR. JEAN MICHAUD: Yes, they were. 9 MS. JENNIFER MCALEER: And then you 10 continued your residency in the Unites States at 11 Deaconess Hospital in New England between 1975 and 1977. 12 Again, did you have any exposure to 13 forensic pathology in New England? 14 DR. JEAN MICHAUD: In Massachusetts, I 15 did not have any exposure to forensic pathology during 16 these two (2) years of training. 17 MS. JENNIFER MCALEER: And I see, by 18 looking at your resume, that in 1976 you obtained your 19 American Boards of Anatomic Pathology? 20 DR. JEAN MICHAUD: Mm-hm. 21 MS. JENNIFER MCALEER: And that you were 22 certified in anatomic pathology in the Province of Quebec 23 in 1977? 24 DR. JEAN MICHAUD: Yes. 25 MS. JENNIFER MCALEER: And then you also

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1 obtained in 1977 your Certificate of Anatomic Pathology 2 from the Royal College of Surgeons? 3 DR. JEAN MICHAUD: Yes. 4 MS. JENNIFER MCALEER: With respect to 5 your practice -- turning to page 3 of your resume -- you 6 began practising in 1977 at l'Hopital de l'Enfant-Jesus? 7 DR. JEAN MICHAUD: Yes. 8 MS. JENNIFER MCALEER: And again, as an 9 anatomic pathologist, did you at that point have more or 10 less exposure to forensic matter or forensic pathology? 11 DR. JEAN MICHAUD: Well, as I explained 12 earlier, the centre was a major trauma centre so we were 13 exposed to a good number of trauma cases at autopsy. 14 Motor vehicles accidents. There were, at that time, less 15 regulations for snowmobiles, so a lot of snowmobile 16 accidents, ski, and so on. But again, the hard cases of 17 forensic, none. 18 MS. JENNIFER MCALEER: And then I see 19 beginning in 1979 you decided to switch paths a little 20 bit and go into neuropathology? 21 DR. JEAN MICHAUD: Yes. 22 MS. JENNIFER MCALEER: And you did that 23 by attending Western University between 1979 and 1980? 24 DR. JEAN MICHAUD: University of Western 25 Ontario here, yes.

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1 MS. JENNIFER MCALEER: And then continued 2 at Stanford University between 1980 and 1981? 3 DR. JEAN MICHAUD: Yes. 4 MS. JENNIFER MCALEER: And at the 5 University of Western or at Stanford, when you were 6 studying neuropathology, were there elements of forensic 7 pathology or forensic neuropathology as part of your 8 courses? 9 DR. JEAN MICHAUD: Well, University of 10 Western Ontario is in Ontario, so we were having cases 11 similar to any other centres in Ontario, and so we were 12 exposed to some cases of forensic pathology including 13 homicides and, you know, hard cases -- hard or difficult 14 or suspicious cases. But London being what it is, the 15 number of cases was very low. 16 MS. JENNIFER MCALEER: All right. And 17 then you obtained you competent certificate in 18 neuropathology. Again, in -- that was an American Board 19 of Pathology certification in 1981? 20 DR. JEAN MICHAUD: I did, yes. 21 MS. JENNIFER MCALEER: And then you began 22 to actually practice neuropathology between 1981 and -- 23 1997 you were the Hospital Sainte-Justine. 24 DR. JEAN MICHAUD: In Montreal. 25 MS. JENNIFER MCALEER: Right. And what

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1 was your exposure at l'Hopital Sainte-Justine with 2 respect to forensic neuropathology? 3 DR. JEAN MICHAUD: In -- in the Province 4 of Quebec, in the initial years we would have a number of 5 cases of unex -- sudden unexpected death in children, and 6 sometimes suspicious suicide cases. Homicides were very 7 -- you know, very obvious child abuse cases were 8 beginning to be done in the medicolegal laboratory 9 institute in Montreal, but at times we would have some of 10 those cases, but not many. 11 Over the years there was a trend in the 12 Province of Quebec that all pediatric cases should be 13 done in pediatric institutions. This began very slowly 14 around mid 1980's, you know, in the mid '80's, but it 15 became compulsory essentially in 1992, if I recall 16 correctly, and then all those cases would be done. The 17 uneven month were done at the Montreal Children's 18 Hospital and the even months were done at the l'Hopital 19 Sainte-Justine where we were. 20 However, during that same period the trend 21 was also to bring the cases of obvious child abuse, 22 Shaken Baby Syndromes, and so on to the medicolegal 23 laboratory in Montreal, so we were not exposed to those 24 cases on the first hand. 25 However, in view of my expertise --

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1 although, between 1981 and 1988 I was doing regular 2 autopsies of all kinds. I was concentrating on 3 neuropathology with interest, and also as a consultant 4 for numerous centres in the Province. I was beginning to 5 receive consultations from the medicolegal laboratory. 6 This began around 1995/1996 -- 1986, and I was receiving 7 the brains of suspicious child abuse, Shaken Baby 8 Syndrome cases, and so on. 9 And I became gradually more involved with 10 them and I -- for safety and administrative reasons, they 11 put me under an official contract I think in 1994, if I 12 recall correctly. 1994. 13 MS. JENNIFER MCALEER: All right. So 14 between 1981 and 1997 you're working at numerous 15 hospitals in and around the Montreal area. You were at 16 l'Hopital Sainte-Justine. 17 DR. JEAN MICHAUD: Yes. 18 MS. JENNIFER MCALEER: You're at -- 19 you're at Hotel-Dieu de Montreal. 20 DR. JEAN MICHAUD: Yeah. 21 MS. JENNIFER MCALEER: You're at the 22 Montreal Cardiology Institute. 23 DR. JEAN MICHAUD: Yes. 24 MS. JENNIFER MCALEER: And then in -- 25 starting in 1994 you have a position at the medicolegal

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1 laboratory. 2 DR. JEAN MICHAUD: Yes. And on top of 3 this I was receiving more that one hundred (100) 4 consultations from all over the Province. 5 MS. JENNIFER MCALEER: From all over 6 Quebec in matters of neuropathology. 7 DR. JEAN MICHAUD: Neuropathology. 8 Brains mostly, but also biopsies: tumour biopsies, muscle 9 biopsies, things like this. 10 MS. JENNIFER MCALEER: And those 11 consultations, Doctor, were they all medicolegal cases or 12 was that -- 13 DR. JEAN MICHAUD: No. 14 MS. JENNIFER MCALEER: -- a variety of 15 cases? 16 DR. JEAN MICHAUD: No, most of them -- 17 most of them were not medicolegal, they were various 18 diseases in children and adults; a lot of dementia cases 19 and so on. But I had re -- I was receiving forensic 20 cases, as well. 21 MS. JENNIFER MCALEER: Now you indicated 22 that there was a decision in and around 1992 that all 23 medicolegal autopsies would be done in pediatric 24 facilities, but with the exception of high profile 25 criminally suspicious cases.

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1 Did I understand that correctly? 2 DR. JEAN MICHAUD: Yes. I think it was 3 more than just all medicolegal. Essen -- essentially it 4 was a sen -- all pediatric death. It was strongly 5 recommended that all pediatric death occurring in the 6 Province would be done in these two (2) pediatric 7 centres, and so we would receive, you know, dead child 8 and babies from all over, up -- up to the Ungava. 9 MS. JENNIFER MCALEER: I'm sorry, up from 10 where? 11 DR. JEAN MICHAUD: Ungava, the northern 12 part of the Province. 13 MS. JENNIFER MCALEER: All right. 14 DR. JEAN MICHAUD: Everywhere. So I 15 think there were exceptions. You know, some of these 16 baby cases I think probably continue to be done in some 17 centres, but we were receiving most, if not all, 18 pediatric death cases from -- in the Province. 19 MS. JENNIFER MCALEER: Now, you also 20 mentioned the -- the medicolegal laboratory. What 21 exactly is the medicolegal laboratory? 22 DR. JEAN MICHAUD: Well, listen, I may -- 23 I may be inexact in my terminology because it's -- it's 24 in French, but this is the -- the equivalent of the 25 Toronto medical laboratory here. This was the place

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1 where all the homicides, suicides, fire death, stabbing, 2 and so on; bodies found, you know, when the snow goes in 3 the spring, and so on and so on. 4 So these are the -- these cases were going 5 there, most of them. 6 MS. JENNIFER MCALEER: So it would be the 7 -- the equivalent of the Toronto Forensic -- 8 DR. JEAN MICHAUD: Exactly. 9 MS. JENNIFER MCALEER: -- Pathology Unit? 10 COMMISSIONER STEPHEN GOUDGE: Was it run 11 by the Province? 12 DR. JEAN MICHAUD: It was run by the 13 Province, yes. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: All right. So 17 then you started doing work there and while you were 18 doing that, that's when you started to get more exposure 19 to the criminally suspicious cases? 20 DR. JEAN MICHAUD: Well I had the 21 possibility to really get exposure to neuropathological 22 suspicious cases, you know, when there were significant 23 involvement with brain, and again, pediatrics and adults. 24 MS. JENNIFER MCALEER: And while you were 25 in Quebec -- I understand you left Quebec in 1998 and

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1 moved to Ottawa, but the time you were in Quebec, did you 2 testify very often? 3 DR. JEAN MICHAUD: Correction, I moved 4 out of Montreal in 1997. I did one (1) sabbatical year 5 in Paris. 6 MS. JENNIFER MCALEER: Correct, right. 7 DR. JEAN MICHAUD: And I came back in 8 1998 here in Ottawa. I was involved in a number of cases 9 with dis -- with Crown attorneys and sometimes defence 10 consults, reviewing cases or, you know, testifying and so 11 on. 12 I went to a number of inquiries or 13 preliminary inquiry. I never went to trial very often. 14 It happened that frequently, you know, there was 15 resolution after the inquiry, and so I went to trial just 16 a few times in Quebec, but I did a good number of review 17 for Crown attorneys and sometimes defence counsel. 18 MS. JENNIFER MCALEER: So when you say 19 often there was resolution after the inquiry, you mean 20 the preliminary inquiry in the criminal proceedings -- 21 DR. JEAN MICHAUD: Yes. 22 MS. JENNIFER MCALEER: -- or are you 23 talking about coroner's inquests? 24 DR. JEAN MICHAUD: Preliminary inquiry, 25 yes.

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1 MS. JENNIFER MCALEER: Okay. And then, 2 as -- as you pointed out, you did a sabbatical year and 3 then came to Ottawa and obtained a position at the 4 Children's Hospital of Eastern Ontario, and at the Ottawa 5 Hospital, as I understand it? 6 DR. JEAN MICHAUD: Well the position I 7 took in Ottawa was an administrative position. Okay, I 8 was offered a position of Chair at the University of 9 Ottawa of the Department of Pathology and Laboratory 10 Medicine; Head of Pathology and Laboratory Medicine at 11 the Ottawa Hospital and at CHEO. 12 At that time you have to recall that there 13 was the Health Restructuring Commission that had to issue 14 reports, there were mergers and so on, and so they wanted 15 a head of department -- and in fact other departments had 16 the same -- with at least dual or sometimes three (3) 17 responsibilities to cover the -- the range of the 18 disciplines across the academic centres. 19 So my position is Ottawa first and 20 foremost an administrative position. But I wanted to 21 continue to do some clinical work and I made a decision 22 to go and -- and do only pediatric neuropathology at 23 CHEO. 24 MS. JENNIFER MCALEER: So prior to that 25 you had been doing adult and children's cases?

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1 DR. JEAN MICHAUD: Yes. 2 MS. JENNIFER MCALEER: And now you limit 3 your clinical practice simply to children's cases? 4 DR. JEAN MICHAUD: Yes. 5 MS. JENNIFER MCALEER: And as the head of 6 the Department of Pathology and Laboratory Medicine at 7 the Ottawa Hospital, can you explain to the Commission 8 what exactly the Ottawa Hospital is? As I understand it, 9 it's a amalgamation of number of -- number of hospitals 10 in the Ottawa area? 11 DR. JEAN MICHAUD: The -- the Ottawa 12 Hospital is a result of the merger of four (4) hospitals, 13 the Civic Hospital, the General Hospital, the Riverside 14 Hospital and Grace Hospital. Grace was demolished and 15 replaced by a long term care facility. Riverside became 16 an ambulatory care centre. 17 And the Civic and General are now two (2) 18 major campuses with some specialties. But the -- the 19 three (3) campuses now form the Ottawa Hospital, which is 20 in -- in a way -- although there is some pediatric done 21 there and some deliveries are done there, it's -- we -- 22 we quote it as the adult hospital, affiliated with the 23 University of Ottawa -- of Ottawa. And CHEO is the 24 pediatric hospital affiliated to University of Ottawa. 25 MS. JENNIFER MCALEER: So essentially in

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1 Ottawa right now you have the Ottawa Hospital which takes 2 in the -- the former hospitals that you mentioned, and 3 then you have CHEO, which is administratively separate. 4 Is that correct? 5 DR. JEAN MICHAUD: Yes. 6 MS. JENNIFER MCALEER: And then both of 7 those fall under the umbrella, to some extent, of the 8 University of Ottawa? 9 DR. JEAN MICHAUD: For the academic 10 activities, they are affiliated with the University of 11 Ottawa. 12 MS. JENNIFER MCALEER: All right. Thank 13 you for providing that background. 14 Dr. Carpenter, if we could turn back to 15 you please. When you joined CHEO in 1975, you've already 16 explained that you came as a result of the fact that Dr. 17 Norman was moving to CHEO. 18 What was Dr. Norman's background with 19 respect to forensic pathology, as you understood it? 20 DR. BLAIR CARPENTER: I have very little 21 understanding of how she was at Sick Kids before she 22 came. She was doing all the brains, the neuropathology, 23 at CHEO, but you have remember I was a -- a resident, I 24 was a newcomer, in the big hospital and all the 25 administration, these things were very nebulous to me and

34

1 I wouldn't even think of challenging or trying to 2 understand. 3 Then -- but I'm sure she was doing 4 medicolegal because she kept on doing some, and it was 5 being done by somebody and she was doing all the brains. 6 At that time, as I said, these things were not clear cut 7 in my mind all that well. 8 When she left for -- for Ottawa, she 9 became a neuropathologist as well as a pediatric 10 pathologist doing all the work. And she was doing all 11 the medicolegal on children that were sent to her by the 12 coroners. Then it was a new kid on the block; coroners 13 were not all that accustomed to having a pediatric 14 hospital, things were done differently. So it had to 15 show its -- its place, its knowledge, its responsibility 16 and accountability. 17 Dr. Norman did that for -- for a year and 18 six (6) months before I arrived in July of -- of '75. 19 MS. JENNIFER MCALEER: Can I just stop 20 you there, Dr. Carpenter. So it's your understanding 21 that prior to your arro -- arrival at CHEO, Dr. Norman 22 has established some relationship with the Coroner's 23 office and was starting to do medicolegal pediatric 24 autopsies at CHEO -- 25 DR. BLAIR CARPENTER: Yes.

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1 MS. JENNIFER MCALEER: -- is that 2 correct? 3 DR. BLAIR CARPENTER: Correct. 4 MS. JENNIFER MCALEER: All right. And 5 then you joined and she continued to do medicolegal 6 autopsies and you worked with her, is that correct? 7 DR. BLAIR CARPENTER: Well, I worked as 8 staff and we divided the work including the medicolegals. 9 MS. JENNIFER MCALEER: All right. And 10 then over the -- the time period that you were at CHEO, I 11 understand that two (2) more people added -- or joined 12 your group, Dr. Jimenez and Dr. Nizalik? 13 DR. BLAIR CARPENTER: Yes. 14 MS. JENNIFER MCALEER: All right. And 15 Dr. Jimenez's resume is at Tab 4. We're not going to go 16 through it in -- in any great detail, but it's my 17 understanding that Dr. Jimenez joined your staff in 1981. 18 If we look at her resume, page 2 -- 19 DR. BLAIR CARPENTER: Yes. 20 MS. JENNIFER MCALEER: -- we can see that 21 she was a fellow. 22 DR. BLAIR CARPENTER: Yes. She was a 23 fellow to start with. 24 MS. JENNIFER MCALEER: Right. And then 25 she obtained a staff position.

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1 DR. BLAIR CARPENTER: And then she came 2 on staff that was -- she puts down her February '82, 3 staff pediatric pathologist. 4 MS. JENNIFER MCALEER: And her background 5 training was in the Philippines, as I understand it. 6 DR. BLAIR CARPENTER: Yes. 7 MS. JENNIFER MCALEER: And for a short 8 period of time in the States? 9 DR. BLAIR CARPENTER: Yes. 10 MS. JENNIFER MCALEER: And I understand 11 she also had some training in neuropathology. 12 Was that your understanding? 13 DR. BLAIR CARPENTER: That was my 14 understanding. 15 MS. JENNIFER MCALEER: And that her work 16 with your CHEO, before Dr. Michaud joined you in 1998, 17 that Dr. Jimenez was actually essentially performing the 18 work of a neuropathologist, with respect to some of the 19 cases? 20 DR. BLAIR CARPENTER: She -- she -- when 21 she joined with me we were dividing the work, like I was 22 doing before with Dr. Norman. I was also doing my own 23 neuropathology because I had trained with Dr. Norman -- 24 was a neuropathologist. 25 Dr. Jimenez did her case, I did my case,

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1 we consulted one another on a -- on a regular basis 2 whether they be medicolegal or just hospital work. There 3 were only two (2) of us with offices close by. It was 4 extremely easy to communicate on a daily basis on the 5 various work we were doing, which we did because we went 6 along very well together and were quite happy to have 7 that type of consultation. 8 But the work was divided half and half and 9 the neuropathology was also divided half and half. 10 MS. JENNIFER MCALEER: All right. And 11 then Dr. Nizalik joined you, and her resume is at Tab 5 12 of the binder. 13 DR. BLAIR CARPENTER: Yes. 14 MS. JENNIFER MCALEER: And Dr. Nizalik, 15 as I understand, joined you in 1990. Again, looking at 16 page 2 of her resume -- 17 DR. BLAIR CARPENTER: Yes. 18 MS. JENNIFER MCALEER: -- July 1st, 1990, 19 staff pathologist. 20 DR. BLAIR CARPENTER: Staff -- yes. 21 MS. JENNIFER MCALEER: That -- that 22 accords with your general recollection? 23 DR. BLAIR CARPENTER: Yes, because I -- 24 she's written it down there -- it fits in that ballpark. 25 MS. JENNIFER MCALEER: All right. So

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1 then you had the three (3) of you were essentially the 2 staff within the Department of Pathology at CHEO. 3 DR. BLAIR CARPENTER: Yes. 4 MS. JENNIFER MCALEER: And how did you 5 divide the work up amongst the three (3) of you? 6 DR. BLAIR CARPENTER: The medical work up 7 was now divided among the three (3) of us. At this point 8 the -- the clinical neuropathology -- tumours, medical 9 disease, were now mostly done by Dr. Jimenez. 10 Now that we were three (3), we decided 11 that each of us should have a special area of interest 12 because there was more time to work in that are -- 13 sphere, so that -- the neuropathology was done by Dr. 14 Jimenez, but the brains of our autopsies were still done 15 by ourselves, not by Dr. Jimenez. 16 Dr. Nizalik was just doing the same thing 17 as us overall, except divided into three (3), rather than 18 being divided into two (2). It gave me more time to do 19 administrative work, which I was already doing. 20 But it gave me more time and freed some -- 21 some time for that; also for teaching, because we were 22 having residents as part of the overall workload, and 23 teaching at the University, also, at that point, and 24 permit to have some common-ty (phonetic). So it gave it 25 gave us more free time to do other work than the routine,

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1 specialty teaching, specialty administration, and 2 specializing more in-depth in certain area. 3 MS. JENNIFER MCALEER: All right. And 4 with respect to specialization -- specialization, I 5 understand that Dr. Jimenez eventually specialized in the 6 area of bone marrow and Dr. Nizalik also specialized in 7 the area of bone marrow and liver. 8 Does that accord with your understanding? 9 DR. BLAIR CARPENTER: Yes. 10 MS. JENNIFER MCALEER: All right. 11 DR. BLAIR CARPENTER: Yes, because we 12 were trying to concentrate with those cases into a 13 certain area and there weren't all that many of those 14 cases, so it permitted to do the rest of the routine -- 15 MS. JENNIFER MCALEER: All right. And 16 you and Dr. Jimenez would do the neuropathology aspect of 17 the cases when required, and Dr. Nizalik didn't do that, 18 is that correct? 19 DR. BLAIR CARPENTER: Dr. Nizalik did her 20 brain -- 21 MS. JENNIFER MCALEER: Oh, she did all of 22 them. 23 DR. BLAIR CARPENTER: -- also all of the 24 autopsies then. 25 MS. JENNIFER MCALEER: All right, so all

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1 three (3) of you would do -- 2 DR. BLAIR CARPENTER: Yes. 3 MS. JENNIFER MCALEER: -- whatever 4 neuropathology aspect was required. 5 DR. BLAIR CARPENTER: Yes. 6 MS. JENNIFER MCALEER: Okay. And I 7 understand that, with respect to the scope of the work 8 you're doing, you're doing surgical pathology and then 9 you're also doing autopsy pathology, correct? 10 DR. BLAIR CARPENTER: Correct. 11 MS. JENNIFER MCALEER: And that the 12 surgical component was approximately 75 of your practice. 13 DR. BLAIR CARPENTER: This is a rough 14 estimate variable from week to week, and we were teaching 15 -- administration would move up and move down. Let's say 16 that if we divide equally at the end of the year, it 17 should balance somewhere -- 18 MS. JENNIFER MCALEER: Around 75 percent. 19 DR. BLAIR CARPENTER: Yeah. 20 MS. JENNIFER MCALEER: And that applied 21 to all three (3) of you. 22 DR. BLAIR CARPENTER: Yes. 23 MS. JENNIFER MCALEER: And then of the 25 24 percent of your work that was autopsy work, is it correct 25 that approximately 50 percent of that was medicolegal

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1 work? 2 DR. BLAIR CARPENTER: We do have datas on 3 that and I think you're right; I'd have to go back, but 4 it fits pretty well with that. 5 MS. JENNIFER MCALEER: All right. And 6 then if we could go back to your resume, which is at Tab 7 1, PFP301515, you've actually done a section of your 8 resume that you've titled "Forensic Pathology Curriculum 9 Vitae". 10 DR. BLAIR CARPENTER: Yes. 11 MS. JENNIFER MCALEER: And you've -- what 12 is the purpose of segregating this information, Dr. 13 Carpenter? 14 DR. BLAIR CARPENTER: By then, I was 15 asked to be the -- what they call the coroner's 16 pathologist, I think was the term. 17 MS. JENNIFER MCALEER: All right, and 18 we'll get to that a little bit later, but at some point 19 when you were asked to become -- 20 DR. BLAIR CARPENTER: Well, that's what - 21 - yeah, well, that's what triggered doing this. 22 MS. JENNIFER MCALEER: I see. 23 DR. BLAIR CARPENTER: At that point, most 24 of the suspicious case were now coming to me, even if it 25 was not my week on -- on autopsies because I had more

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1 experience that the other two (2) pathologists and they 2 didn't mind me doing it. The coroner -- then Dr. Bechard 3 -- and I had good communication and -- and I had no 4 objection to doing that. 5 So, because I was expected to go probably 6 more to Court and so on, after discussion -- I decided 7 with advice or not -- I can't remember the exact setting 8 -- to do this type of resume. Because I had all my cases 9 since I've been at CHEO, all in a segregated area -- 10 files of all my medicolegal -- it was quite easy to bring 11 that out, pass a couple of hours a day or so, and do a -- 12 a resume which I -- I did here, and break it down and put 13 it available, so when we went to court, I would have the 14 resume, and it was quite simple for everybody to look at 15 it. 16 MS. JENNIFER MCALEER: All right. So out 17 of that answer, a couple of follow up questions. You 18 indicated that you started to do more of the criminally 19 suspicious work than your colleagues -- 20 DR. BLAIR CARPENTER: Yes. 21 MS. JENNIFER MCALEER: -- is that 22 correct? 23 DR. BLAIR CARPENTER: Correct. 24 MS. JENNIFER MCALEER: And is it true 25 that -- that you did actually most of the criminally

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1 suspicious cases? 2 DR. BLAIR CARPENTER: Yes. 3 MS. JENNIFER MCALEER: Did you do all of 4 the criminally suspicious cases? 5 DR. BLAIR CARPENTER: I can't say no -- 6 yes or no, but probably the greater majority. There must 7 have been some that slipped by when I was on holiday or 8 sick or something, but I'd -- I don't have track of that. 9 But let's say that the greater majority of 10 the sus -- the clini -- the clinically suspicious case, I 11 would take over. 12 MS. JENNIFER MCALEER: All right. And 13 then you also indicated that you had a -- a separate 14 place you segregated your medicolegal files? 15 DR. BLAIR CARPENTER: Well, I put all my 16 -- sorry. Yes, I -- well, I didn't segregate them. I 17 had boxes and they were all in -- all the files were in 18 order so I could go and pick them up on a few minutes 19 basis. 20 It was easy to -- to go back and get a 21 case of five (5), ten (10), fifteen (15) years ago. It 22 was just available. 23 MS. JENNIFER MCALEER: All right. And -- 24 and looking at your resume, under num -- point number 5 25 where you have workload, --

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1 DR. BLAIR CARPENTER: Yes. 2 MS. JENNIFER MCALEER: -- do you see 3 that? 4 DR. BLAIR CARPENTER: Yes. 5 MS. JENNIFER MCALEER: And you have total 6 number of autopsies, two thousand two hundred and 7 seventy-five (2,275)? 8 DR. BLAIR CARPENTER: Yeah. More or 9 less, you can add a few here. 10 MS. JENNIFER MCALEER: And what time 11 period is that over then, Dr. Carpenter? 12 DR. BLAIR CARPENTER: Well, it's twenty-- 13 MS. JENNIFER MCALEER: Approximately? 14 DR. BLAIR CARPENTER: -- twenty-eight 15 (28) years. I -- we should put 2004. I guess that was 16 my last year I worked. Because I retired -- I usually do 17 that at the end of the year to do the resume -- and I -- 18 I didn't update it because I was retiring. I didn't have 19 no more purpose. I didn't know I was coming to a 20 Commission three (3) years later. 21 COMMISSIONER STEPHEN GOUDGE: We'll 22 forgive you for that, Dr. Carpenter. 23 24 CONTINUED BY MS. JENNIFER MCALEER: 25 MS. JENNIFER MCALEER: All right. So as

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1 you've quite correctly pointed out, it actually says 1975 2 to 2003, so those are the numbers between those years? 3 DR. BLAIR CARPENTER: So you can add all 4 the case I did in 2004, which I can't remember how many, 5 but probably proportionate. 6 MS. JENNIFER MCALEER: All right. And of 7 those five hundred and fifty-two (552) you said are 8 forensic autopsies, is that medicolegal autopsies? 9 DR. BLAIR CARPENTER: No. The two 10 thousand two hundred and seventy-five (2,275) I think is 11 -- is the total number of autopsies including both side, 12 medicolegal and hospital autopsy cases. 13 MS. JENNIFER MCALEER: Right, but the 14 line just below it, for -- 15 DR. BLAIR CARPENTER: It's five hundred 16 and fifty-two (552), these are the forensic -- well, the 17 one (1) that were done with a coroner's warrant. 18 MS. JENNIFER MCALEER: Right. Not 19 necessarily criminally suspicious? 20 DR. BLAIR CARPENTER: No. 21 MS. JENNIFER MCALEER: But including the 22 criminally suspicious cases? 23 DR. BLAIR CARPENTER: Yes. 24 MS. JENNIFER MCALEER: All right. And 25 then you've done a further breakdown, total number of

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1 child abuse cases you have twenty-six (26), total number 2 of non-accidental injury cases, nine (9), and under that 3 you have cases such as gunshot injuries, knives, sharp 4 injuries, blunt injuries, infanticides. 5 Then you have total number of accidental 6 injury cases, fifty-one (51). Are those cases such as 7 falls, motor vehicle accidents? 8 DR. BLAIR CARPENTER: Or fall from height 9 or from a window or... 10 MS. JENNIFER MCALEER: All right. And 11 this -- this breakdown is all the forensic autopsies, 12 correct? 13 DR. BLAIR CARPENTER: Correct. 14 MS. JENNIFER MCALEER: That we're going 15 through? 16 DR. BLAIR CARPENTER: Correct. 17 MS. JENNIFER MCALEER: Okay. And then 18 you've included suicides, burn cases, and then a category 19 that you've called asphyxial cases, two hundred and one 20 (201)? 21 DR. BLAIR CARPENTER: Yes. These all 22 include -- well I've included the SIDS underneath that, 23 because I doubt at that time it was taught that SID -- 24 still believe it by many people -- that it has an 25 asphyxial component.

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1 You stop breathing; it's a central 2 asphyxia if you wish. 3 MS. JENNIFER MCALEER: So you've 4 categorized it in there? 5 DR. BLAIR CARPENTER: So I included those 6 there. I've also -- sorry -- also included the perinatal 7 asphyxia's; the one's that babies die at birth due to 8 suffocation for any -- whatever cause. 9 MS. JENNIFER MCALEER: And -- and 10 generally speaking, Dr. Carpenter, is it correct that the 11 Unit was doing approximately a hundred (100) to a hundred 12 and fifty (150) autopsies per -- per year? 13 DR. BLAIR CARPENTER: I would say that a 14 good figure would be hundred and fifty (150), more or 15 less ten (10). I remember one (1) year which was the 16 worst, if you call it worst by number. We -- we did up 17 to a hundred and eight-five (185) or a hundred and 18 eighty-six (186) case. 19 And there were a few years where it went 20 down to maybe a hundred and ten (110) -- hundred and 21 five/hundred and ten (105/110). The greater majority was 22 around a hundred and fifty (150) more or less then. 23 MS. JENNIFER MCALEER: And what was the - 24 - the catchment area for CHEO? Where -- where were cases 25 coming from?

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1 DR. BLAIR CARPENTER: That varied. It -- 2 it included, obviously, Ottawa and all the eastern 3 Ontario section. We went down to Cornwall and along the 4 valley -- along the -- the St. Lawrence there. We 5 encatched up the valley to Pembroke and to upper north. 6 That was our encatchment. A certain 7 number came from Quebec, but did not die in Quebec. 8 These are the patients that were hospitalized either in 9 Gatineau and then moved to CHEO because of their 10 conditions, and then they died at CHEO. So there was 11 entrapment of the -- that western Quebec. That was 12 basically our main section. 13 When Dr. Bechard became Regional Coroner, 14 he started to include some cases -- the suspic -- the 15 clinically suspicious case and some cases from the 16 Kingston area. They already had the University and their 17 staff there of pathologists who had been doing them for 18 years, but Dr. Bechard tried to introduce the concept of 19 sending them to Ottawa from that area. 20 MS. JENNIFER MCALEER: Do you remember 21 when Dr. Bechard started? 22 DR. BLAIR CARPENTER: No, but it was 23 probably in the '90s somewhere. 24 MS. JENNIFER MCALEER: And you said he 25 started to send the clinically suspicious cases. How --

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1 how would you define clinically suspicious, Dr. 2 Carpenter? 3 DR. BLAIR CARPENTER: Well -- 4 MS. JENNIFER MCALEER: What was your 5 views to what that term meant? 6 DR. BLAIR CARPENTER: -- well, but the 7 time they were sent to us from Belville or from Kingston, 8 somebody had to make that decision, usually it was the 9 policeman, often it was the coroner himself. And Dr. 10 Bechard, if I recall right, wanted to be involved in -- 11 very early on on all childrens that -- therefore in his 12 jurisdiction. 13 Therefore, he was usually involved very 14 early on, and, therefore, he was part of that decision 15 with the police to send them over to us. By then, they - 16 - we knew that they felt that they might be clinically 17 suspicious. So we did entrap some of those. 18 I'm sure we did not have all the pediatric 19 deaths and probably not all the suspicious pediatric 20 deaths from that area, especially the one close to 21 Kingston because they were still doing some that they had 22 already done. It was a transitional period. 23 During that -- the '90s, I received a memo 24 asking us -- or telling us -- I'm not too sure at this 25 point -- that the other jurisdiction -- there was a big

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1 jurisdiction that was going up north beside the eastern 2 Ontario jurisdiction by the -- so I -- I was now involved 3 with a second Regional Coroner who was sending us his 4 cases also, but we did not have that many. 5 It was a big area of entrapment. I can't 6 go further than that. I can't remember his name. If you 7 name -- give the name, I probably would. And it was the 8 jurisdiction beside the one from Ottawa, so we started 9 getting some case from them. 10 They were probably -- most of them were 11 either suspicious or not, but we did not receive that 12 many case from there, so did we get them all? I don't 13 know. Also during that period -- it's probably during 14 '90s, I would say -- we -- I got a phone call from the -- 15 the Head Coroner from the Territory of Nunavut, who asked 16 me if I could do their -- their medicolegal because 17 already they were sending their children to CHEO that 18 were sick, so might as well keep the continuity, which I 19 agreed to -- to do. 20 There weren't that many of those cases, 21 and none of them turned out to be criminally -- so 22 criminal case, so it never went to court or had any 23 involvement with criminal case from Nunavut. 24 COMMISSIONER STEPHEN GOUDGE: The number 25 you have used as an average per year for autopsies at

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1 CHEO, Dr. Carpenter, about a hundred and fifty (150)? 2 DR. BLAIR CARPENTER: About a hundred and 3 fifty (150). 4 COMMISSIONER STEPHEN GOUDGE: Of those, 5 how many would you say would have been criminally 6 suspicious? 7 DR. BLAIR CARPENTER: Oh, suspicious -- 8 that I don't have the data, but I wouldn't say very much. 9 If you look at -- 10 COMMISSIONER STEPHEN GOUDGE: We've been 11 using as a rough rule of -- how many of the hundred and 12 fifty (150) were done under warrant, under coroner's 13 warrant? 14 DR. BLAIR CARPENTER: I don't -- maybe 15 Joseph has that data for you. 16 COMMISSIONER STEPHEN GOUDGE: Are you 17 going to come to that? 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: We do have the 21 numbers for the -- 22 DR. BLAIR CARPENTER: I had them at one 23 (1) point, but I don't have them here. I know what -- I 24 can tell you that -- no, I can't tell you. I can tell 25 you no. It wasn't but --

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1 MS. JENNIFER MCALEER: Mr. Commissioner, 2 we have the numbers from 2005 forward. We don't have the 3 numbers from before 2005. 4 COMMISSIONER STEPHEN GOUDGE: Okay. 5 MS. JENNIFER MCALEER: But -- 6 DR. BLAIR CARPENTER: But I would say it 7 was roughly the same thing. I don't think it changed 8 significantly. That was about one third (1/3) -- 9 COMMISSIONER STEPHEN GOUDGE: So the 10 percentages -- 11 DR. BLAIR CARPENTER: One third (1/3). I 12 think we do have the data. 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: As I understood 16 it, Dr. Carpenter, there was approximately one (1) or two 17 (2) cases that were criminally suspicious in a given 18 year. 19 DR. BLAIR CARPENTER: Yeah. 20 MS. JENNIFER MCALEER: Is that correct? 21 DR. BLAIR CARPENTER: That's about it. 22 We're not talking large numbers. 23 COMMISSIONER STEPHEN GOUDGE: So one (1) 24 or two (2) cases of your one hundred and fifty (150). 25 DR. BLAIR CARPENTER: Yeah, that would --

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1 that was -- 2 COMMISSIONER STEPHEN GOUDGE: Wouldn't -- 3 DR. BLAIR CARPENTER: -- would -- would 4 require more in-depth police investigation and discussion 5 with us. Some year, add a few of that. Let's say five 6 (5) or less would probably be closer to it with some 7 variation. 8 COMMISSIONER STEPHEN GOUDGE: Okay, I -- 9 10 CONTINUED BY MS. JENNIFER MCALEER: 11 MS. JENNIFER MCALEER: Sorry, Dr. 12 Carpenter, I think I may have misled you a little bit. 13 It's one (1) or two (2) cases that would result in 14 criminal charges. 15 DR. BLAIR CARPENTER: Yes. 16 MS. JENNIFER MCALEER: But there would be 17 a slightly larger percentage that -- 18 DR. BLAIR CARPENTER: Oh, well, sure. 19 MS. JENNIFER MCALEER: -- would come in 20 and -- 21 DR. BLAIR CARPENTER: Sudden Expected 22 Death includes all the SIDS. Because when the SIDS comes 23 in, we did consider it to be a suspicious death until 24 everything is wrote up. If you include those, then the 25 number goes up quite significantly.

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1 COMMISSIONER STEPHEN GOUDGE: We can see 2 the numbers -- 3 DR. BLAIR CARPENTER: Yeah. 4 COMMISSIONER STEPHEN GOUDGE: -- that 5 you've got here. 6 DR. BLAIR CARPENTER: That goes up quite 7 significantly. 8 COMMISSIONER STEPHEN GOUDGE: Yeah. Then 9 I mean, if we came at it using another criteria and, Dr. 10 Carpenter, cases that would come to you with police 11 involvement already, that is, where there had, by the 12 time the child's body came to the hospital, then some 13 form of police involvement -- how many would that 14 constitute? What percentage of the cases that you got 15 each year? Would you have any sense of that? 16 DR. BLAIR CARPENTER: No, but more than a 17 few because all the SIDS come in with the police 18 investigation to start with, then we have a -- 19 COMMISSIONER STEPHEN GOUDGE: So that's 20 not a very good criteria in that -- 21 DR. BLAIR CARPENTER: Yeah. 22 COMMISSIONER STEPHEN GOUDGE: I see your 23 colleagues shaking their -- 24 DR. BLAIR CARPENTER: Dr. Bechard -- see, 25 Dr. Bechard.

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1 COMMISSIONER STEPHEN GOUDGE: -- heads in 2 agreement with me. 3 DR. BLAIR CARPENTER: Dr. Bechard always 4 wanted that the policemen be present at the autopsy on 5 all the case of -- 6 COMMISSIONER STEPHEN GOUDGE: Coroner's 7 warrant cases. 8 DR. BLAIR CARPENTER: Warrant cases 9 outside the hospital. 10 COMMISSIONER STEPHEN GOUDGE: Okay. 11 DR. BLAIR CARPENTER: And I don't have a 12 data on that. Maybe Joseph -- you may get more; I don't 13 have that data. 14 COMMISSIONER STEPHEN GOUDGE: Okay, well, 15 we'll probably come along with that, Ms. McAleer. I 16 don't want to go too far ahead. 17 18 CONTINUED BY MS. JENNIFER MCALEER: 19 MS. JENNIFER MCALEER: I also understand, 20 Dr. Carpenter, that in addition to Nunavut, you would 21 occasionally get Court cases from the Northwest 22 Territories. 23 DR. BLAIR CARPENTER: Yeah, that occurred 24 -- but that occurred, I'm not exactly sure in what 25 period. We didn't have many of those and that occurred a

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1 long time ago -- 2 MS. JENNIFER MCALEER: All right. 3 DR. BLAIR CARPENTER: -- before the 4 Nunavut; I would say in the '80's, and we did not get 5 many cases. 6 MS. JENNIFER MCALEER: All right. And 7 then I also understand, Dr. Carpen -- there -- Dr. 8 Carpenter, that internally, you had a conceptual 9 framework in which you categorized the medicolegal cases; 10 that you would put them in different levels. Can you 11 explain to the Commissioner your -- your -- 12 DR. BLAIR CARPENTER: Yes. 13 MS. JENNIFER MCALEER: -- thoughts with 14 respect to the triaging you did internally? 15 DR. BLAIR CARPENTER: Yes, well, this is 16 a way of thinking that I had and many other pathologists 17 have the same situation; we li -- we -- we divide them in 18 level 1, 2, 3. 19 How would that go; well, there's no 20 criteria, it's just purely subjective. What I use as a 21 view towards that was, example, a patient dies on the 22 operating table during cardiac surgery, repair of 23 congenital malformation of child; the coroner gets 24 involved, asks for a coroner's warrant for quality 25 control, and we call that a level 1.

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1 I mean we'll not go into Court unless we 2 get fifty (50) more of those and we realize that it's the 3 anaesthesia that's responsible, but at first sight, it's 4 -- it's quality control. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. BLAIR CARPENTER: A level 2 would be 7 a case where a SIDS -- the story is child was at home, 8 put to bed by the mother. The next morning when they 9 wake the child is found dead in the bed, The father's 10 there. There's other people in the house. It's cer -- 11 it's not suspicious, but we never know; that would be a 12 level 2. 13 A level 3 would be a case come in -- story 14 of a child comes in full of bruises and old recent and 15 the story is that it tumbled down the stairs. 16 Now this would be a level 3. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: And did the manner 21 in which you categorize, did that affect the autopsy? 22 Did you do the autopsies differently, or did they take 23 longer if it was a level 3 as opposed to a level 1? 24 DR. BLAIR CARPENTER: Not really, but in 25 practice, yes. Every autopsy is different -- at least in

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1 -- under my control, were always done the same way with 2 the same extent of finding the -- the cause of death, and 3 whatever we can do. Now if it is suspicious -- obviously 4 if there are bruise all over it's longer, because you 5 have to investigate and determine every one of these, and 6 take photo, take pictures, and document each of them. 7 If you got a person and a baby that comes 8 in with SID and is perfectly normal baby, you -- you move 9 ahead and it's going to be shorter, because that there's 10 no findings to be -- to be done, or documented. 11 So yes, there is a different approach, 12 there is a different thinking, but at the end of the day, 13 not -- one (1) is not done better then the other. 14 MS. JENNIFER MCALEER: All right. And as 15 I understand it, with respect to the medicolegal work you 16 were doing, there was no actual contract with the Office 17 of the Chief Coroner or the Solicitor General? It -- 18 you've never actually seen a physical contract that out - 19 - that -- 20 DR. BLAIR CARPENTER: No. 21 MS. JENNIFER MCALEER: -- described the 22 work you were doing, or any oversight mechanisms, or any 23 expectations? 24 DR. BLAIR CARPENTER: No. I always 25 suspected that there probably had been some negotiation

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1 with Dr. Norman, but again, as I said before, I was young 2 and innocent, and I was not being involved with those 3 things, and I have no clue of what was discussed or done. 4 MS. JENNIFER MCALEER: And you weren't 5 privy to any negotiations or you didn't see any contracts 6 between -- when you started in 1975 and when you left in 7 2004? 8 DR. BLAIR CARPENTER: No. 9 MS. JENNIFER MCALEER: And -- 10 DR. BLAIR CARPENTER: Well -- sorry, 11 there was that agreement or more discussion with the 12 Nunavut Territory. 13 MS. JENNIFER MCALEER: Right. A separate 14 side agreement with Nunavut -- 15 DR. BLAIR CARPENTER: Yeah, but from 16 Ontario, no. 17 MS. JENNIFER MCALEER: Okay. 18 COMMISSIONER STEPHEN GOUDGE: How many 19 level 3 cases would the unit get in a year? 20 DR. BLAIR CARPENTER: Oh, you exclude the 21 SIDS here? 22 COMMISSIONER STEPHEN GOUDGE: Yes. 23 DR. BLAIR CARPENTER: And the -- I will - 24 - I would say not more than -- I would say less than five 25 (5), and probably not as many as that. But again I --

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1 DR. JEAN MICHAUD: It was in his time. 2 COMMISSIONER STEPHEN GOUDGE: Yes. 3 DR. BLAIR CARPENTER: But again I think 4 that you -- you might have more information -- 5 COMMISSIONER STEPHEN GOUDGE: I just 6 wondered whether either of you -- 7 MS. JENNIFER MCALEER: Well, Dr. -- Dr. 8 de Nanassy started in 2004, so there -- there isn't very 9 much -- 10 COMMISSIONER STEPHEN GOUDGE: Yes, so he 11 was -- yeah -- 12 MS. JENNIFER MCALEER: -- overlap. 13 COMMISSIONER STEPHEN GOUDGE: -- so both 14 of you -- 15 MS. JENNIFER MCALEER: But -- 16 COMMISSIONER STEPHEN GOUDGE: -- escape 17 having to answer that question. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: Well Dr. Michaud 21 came in 1998, so Dr. Michaud and Dr. Carpenter did 22 overlap a little bit. 23 Dr. Michaud, you were doing the 24 neuropathology work, so did you have an appreciation or 25 understanding as to how many of the cases you were

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1 working on were of a criminally suspicious nature? 2 DR. JEAN MICHAUD: Of all those years? 3 MS. JENNIFER MCALEER: From -- 4 DR. JEAN MICHAUD: Between -- since 1998? 5 MS. JENNIFER MCALEER: Correct. 6 DR. JEAN MICHAUD: I think it varies from 7 years -- from year to year. There -- there has been some 8 years where we had more than five (5) cases. I would say 9 seven (7), eight (8) cases. There have been some year -- 10 COMMISSIONER STEPHEN GOUDGE: But it's 11 always single digits, Dr. Michaud? 12 DR. JEAN MICHAUD: It's always single 13 digits, yes. 14 COMMISSIONER STEPHEN GOUDGE: Okay. I 15 mean, that gives me some -- 16 DR. JEAN MICHAUD: Yeah. 17 COMMISSIONER STEPHEN GOUDGE: -- rough 18 order of -- 19 DR. JEAN MICHAUD: Yes. 20 COMMISSIONER STEPHEN GOUDGE: -- 21 magnitude. It's going to be a difficult matter to plot 22 every year. 23 DR. JEAN MICHAUD: Mm-hm. 24 COMMISSIONER STEPHEN GOUDGE: But the 25 level 3 designation is helpful.

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1 DR. JEAN MICHAUD: Yeah. 2 DR. BLAIR CARPENTER: Now there were a 3 few case which were not designate, because they didn't 4 end up being, but we also -- we also had to rule out 5 sometimes. They came in as suspicious and ended up as 6 not. 7 DR. JEAN MICHAUD: Mm-hm. 8 COMMISSIONER STEPHEN GOUDGE: Yes, 9 there'll be cases that are grey area cases that come in 10 as suspicious and turn out to be natural and vice versa. 11 DR. BLAIR CARPENTER: But we are dealing 12 with single digits. 13 COMMISSIONER STEPHEN GOUDGE: Okay, 14 that's helpful. Thank you. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: And there was no 18 contract, but I understand that the CHEO would receive a 19 facility fee per autopsy? 20 DR. BLAIR CARPENTER: There was one (1). 21 It was negotiated by Dr. Norman. It remained very low, 22 and I think, because -- I think -- I'll leave that to Dr. 23 Michaud who's our administrator here. 24 MS. JENNIFER MCALEER: Dr. Michaud, do 25 you know what the facility fee -- my understanding was

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1 it's approximately -- 2 DR. JEAN MICHAUD: Well the facility fee 3 remain at fifty dollars ($50) -- 4 MS. JENNIFER MCALEER: Fifty dollars 5 ($50). 6 DR. JEAN MICHAUD: -- until very recently 7 where it's now four -- four hundred dollar ($400) per 8 case. I've never seen in the ten (10) years I've been 9 there, and Joseph may correct me, I've never seen any 10 paperwork related to facility fees, you know, being dealt 11 with -- specifically with CHEO. 12 This was an announcement made throughout 13 the Province, and we got it that and our administrator's 14 proceeded accordingly. 15 MS. JENNIFER MCALEER: And I understand 16 it also, Dr. Michaud, that you're not aware of any kind 17 of internal accounting whereby the hospital has tried to 18 do an assessment as to how much it actually costs to do a 19 medicolegal autopsy, versus what the hospital's 20 receiving? 21 DR. JEAN MICHAUD: No. 22 MS. JENNIFER MCALEER: Okay. And the 23 pathologists who perform the medicolegal autopsies, be it 24 in your day, Dr. Carpenter or Dr. de Nanassy, you receive 25 a fee-for-service for the work that you do?

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1 DR. BLAIR CARPENTER: Yes. 2 MS. JENNIFER MCALEER: And does that -- 3 does that money go to you personally or does it go into a 4 pool at CHEO? 5 DR. BLAIR CARPENTER: Originally, the way 6 it was structured when Dr. Norman was there was that it 7 went into a -- a fund, a pathology fund, for -- for 8 buying equipment, for teaching, for going to meetings, 9 and so on. That was changed later on, and we -- we 10 decided among the three (3) of us then, that was Dr. 11 Nizalik, Dr. Jimenez, and myself, to -- to keep our own 12 stipend and not divide it anymore. And since we were 13 dividing the workload about equally, it came down to a 14 pretty equal division. 15 Now, I don't know at the moment how it's 16 being done. 17 MS. JENNIFER MCALEER: Dr. -- Dr. de 18 Nanassy, is that still the current situation. 19 DR. JOSEPH DE NANASSY: Yes, it is. 20 MS. JENNIFER MCALEER: Okay. And, Dr. 21 Michaud, you bill separately with respect to the 22 neuropathology work that you do on medicolegal cases? 23 DR. JEAN MICHAUD: I rarely bill. The 24 province of Ontario should thank me because I do not bill 25 for what Dr. Carpenter would call level 1 and level 2.

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1 MS. JENNIFER MCALEER: You only bill for 2 the criminally suspicious cases? 3 DR. JEAN MICHAUD: I bill only when I 4 know that we will have subsequent meetings about the 5 case. And that's when I do it. Otherwise, you know, for 6 me to do a brain of perinatal asphyxia is just regular 7 neuropathology, and I -- I don't charge for this. 8 MS. JENNIFER MCALEER: All right. So 9 turning to you then, Dr. de Nanassy, with respect to the 10 current situation at CHEO, you've been there since 2004. 11 Has the catchment area changed at all since -- as -- from 12 the way it was described by Dr. Carpenter? 13 DR. JOSEPH DE NANASSY: It's pretty well 14 about the same as described by Dr. Carpenter. Although, 15 I recall less cases coming from what he refers to as the 16 north. I don't think we had too many cases coming from 17 that area, but otherwise the catchment area is pretty 18 much the same. 19 MS. JENNIFER MCALEER: So your -- I'll 20 come to you in just a sec. Oh, go -- go ahead, Dr. 21 Michaud, what were you going to say? 22 DR. JEAN MICHAUD: Just to complete. 23 Along the St. Lawrence River, you know, Dr. Carpenter 24 mentioned Cornwall, I think now we have -- we are 25 receiving cases as south as Belleville.

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1 MS. JENNIFER MCALEER: I see. 2 DR. JEAN MICHAUD: Okay. So this is a 3 little bit more towards that area. But I agree with Dr. 4 de Nanassy, I don't -- I don't remember having seen a 5 single case from beyond the Deep River, which is the far 6 west of the Ottawa Valley. I don't think we've seen a 7 case from North Bay or -- they're probably all done in 8 Sudbury or Toronto, I don't know. 9 MS. JENNIFER MCALEER: So with the 10 exception of the Nunavut contract, you are dealing now 11 with one (1) regional supervising coroner? 12 DR. JOSEPH DE NANASSY: There is no 13 Nunavut contract. 14 MS. JENNIFER MCALEER: Pardon me? 15 DR. JOSEPH DE NANASSY: There is no 16 Nunavut contract. 17 MS. JENNIFER MCALEER: Well, the -- 18 sorry, the understanding with Nunavut that -- that there 19 is -- you're dealing in Ontario with one (1) regional 20 supervising coroner or -- or are you dealing with two 21 (2)? 22 DR. JOSEPH DE NANASSY: Usually with one 23 (1). Very rarely might a case come from somebody else. 24 MS. JENNIFER MCALEER: And, Dr. Michaud, 25 you seem to have someone in mind.

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1 DR. JEAN MICHAUD: Yeah, there is a 2 second one. 3 DR. JOSEPH DE NANASSY: Dr. Clark. 4 DR. JEAN MICHAUD: Dr. Clark. 5 MS. JENNIFER MCALEER: Dr. Clark. 6 DR. JEAN MICHAUD: Yes, and Dr. McCallum. 7 MS. JENNIFER MCALEER: All right. And 8 what's Dr. Clark's region, do you know? 9 DR. JEAN MICHAUD: The south Belleville 10 and so on. 11 MS. JENNIFER MCALEER: I -- 12 DR. JEAN MICHAUD: That's what I think, 13 I'm not sure, but -- 14 MS. JENNIFER MCALEER: All right. 15 DR. JEAN MICHAUD: -- we -- we don't 16 really -- 17 COMMISSIONER STEPHEN GOUDGE: Do you get 18 all the coroner's warrant cases that are children from 19 Belleville and Kingston? 20 DR. JEAN MICHAUD: No, we don't. 21 MS. JENNIFER MCALEER: There -- 22 COMMISSIONER STEPHEN GOUDGE: So there's 23 still some coroner's warrant cases that are done in 24 Kingston -- children? 25 DR. JEAN MICHAUD: We don't know.

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1 COMMISSIONER STEPHEN GOUDGE: You do not 2 know, but you know you do not get them all? 3 MS. JENNIFER MCALEER: There's -- 4 DR. JEAN MICHAUD: We don't think so. 5 MS. JENNIFER MCALEER: There's been a 6 recent -- there's been a recent change, Mr. Commissioner, 7 that I'm going to come to a little bit later. 8 COMMISSIONER STEPHEN GOUDGE: Okay. 9 Sorry, I jump -- 10 MS. JENNIFER MCALEER: But in -- in -- 11 COMMISSIONER STEPHEN GOUDGE: -- ahead. 12 I apologise. 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: Until recently, 16 it's been your understanding that you were getting all of 17 the pediatric medicolegal cases that fell within that 18 general catchment area that we've described. 19 Isn't that correct? 20 DR. JEAN MICHAUD: Yes, it's correct. 21 Until recently. 22 MS. JENNIFER MCALEER: Until recently. 23 And we'll come to that. If you could turn to Tab 31 of 24 your binder, please. 25

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1 (BRIEF PAUSE) 2 3 MS. JENNIFER MCALEER: And that's PFP301 4 -- oh, I've got an extra digit, that can't be right. 5 Just one (1) moment, Mr. Registrar. 6 7 (BRIEF PAUSE) 8 9 MS. JENNIFER MCALEER: It's PFP301636. 10 And you should have a series of statistics in front of 11 you for the CHEO autopsy statistics from 2005 to 2007, do 12 you all have that? 13 DR. JEAN MICHAUD: Yes, we do. 14 DR. JOSEPH DE NANASSY: Yes. 15 MS. JENNIFER MCALEER: Okay. Dr. de 16 Nanassy, I understand that you've prepared these 17 statistics. 18 DR. JOSEPH DE NANASSY: I do. 19 MS. JENNIFER MCALEER: All right. 20 Looking at the 2005 statistics, can you -- can you 21 explain to the Commissioner essentially what you 22 attempted to capture in this statistical information? 23 DR. JOSEPH DE NANASSY: What this 24 information is supposed to reflect is the one (1); the 25 total number of autopsies that have been carried out at

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1 the CHEO, and the breakdown there of how many of those 2 were medicolegal cases, called coroner's cases in the -- 3 in the chart, and how many of them were so-called family 4 consent cases; and then I also included the occasional 5 case that comes to Dr. Michaud where only the brain is 6 received for him as consultation. 7 MS. JENNIFER MCALEER: All right, so 8 looking at 2005 then, if we look under the column that's 9 called "total" and we go down to the bottom and we see "a 10 hundred and forty-one (141)", so that's a hundred and 11 forty-one (141) medicolegal autopsies for 2005? 12 DR. JOSEPH DE NANASSY: No. 13 MS. JENNIFER MCALEER: Sorry, total 14 autopsies -- 15 DR. JOSEPH DE NANASSY: That's the total 16 autopsies. 17 MS. JENNIFER MCALEER: -- for 2005. And 18 then of those, eighty-eight (88) of them are family 19 consent, or what we've been calling hospital autopsies, 20 is that correct? 21 DR. JOSEPH DE NANASSY: That's correct. 22 MS. JENNIFER MCALEER: And then the 23 coroners are the medicolegal and you have forty-six (46). 24 DR. JOSEPH DE NANASSY: Yes. 25 MS. JENNIFER MCALEER: And then brain

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1 only, so that would be a situation where Dr. Michaud has 2 been consulted simply with respect of doing the brain on 3 a case. 4 DR. JOSEPH DE NANASSY: It's an autopsy 5 brain; it's sent to him specifically and it is assigned 6 an autopsy number at CHEO, but the -- the rest of the 7 body is not there, so those are brain consultation for 8 Dr. Michaud. 9 MS. JENNIFER MCALEER: And those are all 10 children, Dr. Michaud? 11 DR. JEAN MICHAUD: No, they're mostly 12 adult. 13 MS. JENNIFER MCALEER: They're mostly 14 adult. 15 DR. JEAN MICHAUD: From across river, 16 from the Hull/Gatin -- 17 MS. JENNIFER MCALEER: I see, so the -- 18 the statistics are a little bit skewed then with respect 19 to some adult work with respect to brain only cases. All 20 right. And then -- 21 COMMISSIONER STEPHEN GOUDGE: Just as a 22 matter -- sorry, Ms. McAleer. 23 MS. JENNIFER MCALEER: No, go ahead. 24 COMMISSIONER STEPHEN GOUDGE: Just as a 25 matter of interest. How many of the hospital deaths at

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1 CHEO are cases for which there's family consent when an 2 autopsy is done? What percentage are you looking at? 3 DR. JOSEPH DE NANASSY: We don't know. 4 We are not privy to that information. I don't know how 5 many deaths there are. 6 COMMISSIONER STEPHEN GOUDGE: You don't 7 know whether that's 70 percent of the hospital deaths or 8 30 percent of the hospital deaths? 9 10 CONTINUED BY MS. JENNIFER MCALEER: 11 MS. JENNIFER MCALEER: Yes, Dr. Michaud? 12 DR. JEAN MICHAUD: We -- we used to have 13 statistics through the medical audit and tissue committee 14 and the rate, if I recall correctly -- and Dr. Carpenter 15 probably remember that, as well -- the rate of autopsies 16 on CHEO's death was around 60 percent. 17 COMMISSIONER STEPHEN GOUDGE: All right. 18 DR. JEAN MICHAUD: Okay. Now, however, 19 these eighty (80) -- let's say if we take the first page, 20 these eighty-eight (88) cases are not all CHEO cases. 21 There are cases coming from the Ottawa Hospital. They 22 could be coming from Queensway Carleton Hospital or other 23 hospitals in the area. 24 They are not coroner cases, but because of 25 the pediatric expertise, they are sent to us for autopsy.

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1 COMMISSIONER STEPHEN GOUDGE: Because of 2 the small amount of pediatric work that's done in the 3 other Ottawa hospitals. 4 DR. JEAN MICHAUD: Exactly. 5 COMMISSIONER STEPHEN GOUDGE: I see. 6 DR. JEAN MICHAUD: So this number, like 7 eighty-eight (88), does not represent eighty-eight (88) 8 CHEO cases. They represent eighty-eight (88) pediatric 9 autopsies done at CHEO. 10 COMMISSIONER STEPHEN GOUDGE: Fair 11 enough. 12 13 CONTINUED BY MS. JENNIFER MCALEER: 14 MS. JENNIFER MCALEER: Thank you for -- 15 DR. JEAN MICHAUD: But may be coming from 16 elsewhere. 17 MS. JENNIFER MCALEER: Thank you for 18 clarifying that, Dr. Michaud. 19 DR. BLAIR CARPENTER: If I may comment -- 20 MS. JENNIFER MCALEER: Yes, Dr. 21 Carpenter. 22 DR. BLAIR CARPENTER: At this point, yes, 23 the data that, as your asking, all exists. They don't 24 exist in my file or our file. They don't exist 25 necessarily in the Department of Pathology. They exist

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1 at the hospital. There is the medical audit and they did 2 calculate all the deaths and that the end of the year 3 they gathered data. 4 COMMISSIONER STEPHEN GOUDGE: It's not 5 critical for us, Dr. Carpenter. 6 DR. BLAIR CARPENTER: All right. 7 COMMISSIONER STEPHEN GOUDGE: We were 8 looking at statistics like this for the Hospital -- 9 DR. BLAIR CARPENTER: Okay. 10 COMMISSIONER STEPHEN GOUDGE: -- for Sick 11 Children, I was just curious. 12 DR. BLAIR CARPENTER: Okay. The other 13 thing, if I may add, is that all these datas of coroners 14 versus also exist because every year I used to give that 15 data for the medica -- for the -- the clinical review of 16 -- of our workload for the MAC at the hospital. So I 17 broke it down into medicolegals, so I do -- I didn't keep 18 this -- the data, but the data is in the archive or in 19 the files at CHEO, if it's required. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: Thank you, Dr. 23 Carpenter. 24 And I see from looking at the breakdown 25 that you've prepared, Dr. De Nanassy, that essentially

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1 you are currently sharing the medicolegal work equally 2 between the three of you, the other two (2) being Dr. 3 Jimenez and Dr. Nizalik. 4 DR. JOSEPH DE NANASSY: We take equal 5 turns being on autopsy services and, so purely on 6 statistical grounds the likelihood is that we had about 7 equal proportion of coroner's work. 8 MS. JENNIFER MCALEER: And you heard Dr. 9 Carpenter indicate that in his day they had an internal 10 kind of triaging system and that Dr. Carpenter tended to 11 do more of the criminally suspicious cases. 12 Currently is there any kind of internal 13 triaging going on? Is one or more of you doing more of 14 the criminally suspicious cases? 15 DR. JOSEPH DE NANASSY: No. 16 MS. JENNIFER MCALEER: And I -- I know 17 currently the hospital is not doing any criminally 18 suspicious cases, but before that change -- so between 19 2004, when you joined the hospital, up until the recent 20 change -- was one (1) person doing more of the criminally 21 suspicious work than anyone else? 22 DR. JOSEPH DE NANASSY: No. When I 23 joined CHEO I became aware of that informal internal 24 arrangement of the criminally suspicious cases being done 25 preferentially by Dr. Carpenter. And when I became head

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1 I instituted an approach among the three (3) of us that 2 each one of us will have equal access to cases coming, 3 irrespective of their nature. 4 MS. JENNIFER MCALEER: And to what degree 5 do you -- 6 COMMISSIONER STEPHEN GOUDGE: Could I 7 just ask what was your reason for doing that? 8 DR. JOSEPH DE NANASSY: I felt that we 9 should all be able to perform criminally suspicious cases 10 and so I wanted each of us to share equally in the 11 experience in that sense. 12 COMMISSIONER STEPHEN GOUDGE: And is 13 there any reluctance on the part of any of your 14 colleagues to do this sort of case? 15 DR. JOSEPH DE NANASSY: Dr. Jimenez tends 16 to -- 17 COMMISSIONER STEPHEN GOUDGE: Let's 18 differentiate it. They may all be reluctant. 19 DR. JOSEPH DE NANASSY: Yes. Dr. Jimenez 20 tends to be less eager, if you wish, and sometimes tries 21 asking me to perform one or the other medicolegal case 22 that might end up in court and I have never refused. Dr. 23 Nizalik has never asked me. 24 COMMISSIONER STEPHEN GOUDGE: Thank you. 25 MS. JENNIFER MCALEER: It's my

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1 understanding, too, Dr. De Nanassy, that with respect to 2 Dr. Jimenez, she doesn't particularly enjoy the court 3 part of the forensic work. 4 Is that correct? 5 DR. JOSEPH DE NANASSY: She didn't say as 6 much to me, but I infer that that's the case. 7 MS. JENNIFER MCALEER: And as far as you 8 know, is there anything about the nature of the work she 9 actually -- that's required for forensic autopsy that 10 she's uncomfortable with? 11 DR. JOSEPH DE NANASSY: Not to my 12 knowledge, no. 13 MS. JENNIFER MCALEER: She's never voiced 14 that to you? 15 DR. JOSEPH DE NANASSY: No. 16 MS. JENNIFER MCALEER: And what about 17 with -- with respect to Dr. Nizalik? 18 DR. JOSEPH DE NANASSY: Dr. Nizalik never 19 voiced an opinion one way or another. 20 MS. JENNIFER MCALEER: You're aware 21 though, Dr. De Nanassy, that Dr. Nizalik, in the past, 22 has indicated that she prefer not to do some cases that 23 are outwardly criminally suspicious and has in fact 24 deferred those cases to others? 25 DR. JOSEPH DE NANASSY: As you alluded to

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1 it, that was in the past, and as her experience and 2 confidence built over time she seems to be more 3 comfortable dealing with such types of cases. And she 4 never directly asked me to take over a criminally 5 suspicious case from her. 6 MS. JENNIFER MCALEER: Right, but as -- 7 as the -- as distinct from specifically asking you, is it 8 your understanding that she has on occasion asked perhaps 9 somebody else or sent a body elsewhere to have an autopsy 10 done because she wasn't comfortable doing a criminally 11 suspicious case? 12 DR. JOSEPH DE NANASSY: I know of one (1) 13 particular instance where referred a criminally 14 suspicious case out of CHEO for the autopsy to be done 15 elsewhere, but it was to the best of my understanding not 16 for reasons of professional knowledge. 17 MS. JENNIFER MCALEER: What was your 18 understanding as to why she did that? 19 DR. JOSEPH DE NANASSY: My understanding 20 was it was the circumstances in which the body was 21 discovered. In other words, the investigative work by 22 the police didn't quite end up to -- end up to what she 23 saw at the time of looking at the body. She contacted 24 the regional coroner and asked for the case to be 25 transferred out.

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1 MS. JENNIFER MCALEER: All right. So she 2 received a set of facts or information from the regional 3 coroner or from the police, it didn't match with what she 4 was seeing on the table, she decided she didn't want to 5 get involved, and sent the case elsewhere. 6 Is that correct? 7 DR. JOSEPH DE NANASSY: That's correct. 8 MS. JENNIFER MCALEER: Okay. And so Dr. 9 Michaud you -- you wanted to add something at one point, 10 or that's -- 11 DR. JEAN MICHAUD: Has been said. 12 MS. JENNIFER MCALEER: -- fine? Okay. 13 Now, with respect to the breakdown of work, Dr. De 14 Nanassy, is it true that the three (3) of you are still 15 doing -- approximately 70/80 percent of your work is 16 surgical pathology? 17 DR. JOSEPH DE NANASSY: Approximately, 18 yes. 19 MS. JENNIFER MCALEER: Okay. And within 20 the -- the number of coroner's cases that you would do in 21 a given year, how many of those cases would be SUDS or 22 SIDS cases? 23 DR. JOSEPH DE NANASSY: I don't have 24 exact numbers; I would say maybe ten (10) to fifteen (15) 25 cases.

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1 MS. JENNIFER MCALEER: So, if we look at 2 2005, for example, and the coroner's cases are forty-six 3 (46), a rough estimate would be that ten (10) to -- 4 sorry, did you say ten (10) to twenty (20)? 5 DR. JOSEPH DE NANASSY: Ten (10) to 6 fifteen (15). 7 MS. JENNIFER MCALEER: Sorry, ten (10) to 8 fifteen (15) would be SIDS or SUDS cases? 9 DR. JOSEPH DE NANASSY: That's my 10 estimate. 11 MS. JENNIFER MCALEER: Roughly. Dr. 12 Michaud, did you want to add -- 13 DR. JEAN MICHAUD: I would like to 14 mention that we would be able to retrieve that, because I 15 have a binder where I enter manually all the cases I'm 16 doing -- everything, surgicals, autopsy, and so on. 17 We would probably be able to retrieve 18 those number if we took the time, you know, manually to 19 go down the list and so on. My impression, you know, but 20 through the brain study is that the large category of S- 21 U-D is probably close to twenty (20), average; okay, 22 fifteen (15), twenty (20). But this is the same 23 ballpark, essentially. 24 MS. JENNIFER MCALEER: And the same 25 question that Mr. Commissioner had asked Mr. -- Dr.

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1 Carpenter, how many cases on average now are criminally 2 suspicious -- sorry, not now, but let's look at 2005, for 3 example, would be criminally suspicious cases? 4 DR. JOSEPH DE NANASSY: Ago -- again, 5 without having the actual figures in front of me, I would 6 still say single digit, five (5) to ten (10). 7 MS. JENNIFER MCALEER: Okay. And -- 8 COMMISSIONER STEPHEN GOUDGE: What we've 9 used as a rough order of magnitude, Dr. de Nanassy, in 10 the last couple of days, was 5 percent of the coroner's 11 cases were homicide, and maybe another 5 percent were 12 criminally suspicious at the front end of the autopsy 13 process. 14 That would give you, out of forty-six (46) 15 warrant cases in 2005, say, five (5) cases. 16 DR. JOSEPH DE NANASSY: About that. 17 COMMISSIONER STEPHEN GOUDGE: That sound 18 -- I mean without getting absolutely precise about it, 19 that strikes you as an order of magnitude that 20 corresponds with your general sense? 21 DR. JOSEPH DE NANASSY: Five (5) would be 22 a fair number, give or take. 23 COMMISSIONER STEPHEN GOUDGE: Yes, okay. 24 25 CONTINUED BY MS. JENNIFER MCALEER:

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1 MS. JENNIFER MCALEER: And since 2004, 2 Dr. de Nanassy, how often have you had to testify as a 3 result of medicolegal autopsy work that you've been doing 4 at CHEO? 5 DR. JOSEPH DE NANASSY: So far, once. 6 MS. JENNIFER MCALEER: Just once. And, 7 Dr. Michaud, since you came to CHEO in 1998, how often 8 have you had to testify with respect to medicolegal work 9 that you've been doing? 10 DR. JEAN MICHAUD: Three (3), four (4) 11 times, perhaps; I'm not absolutely certain about this, 12 but no more -- I don't think more than that. 13 MS. JENNIFER MCALEER: Within the 14 department, Dr. de Nanassy, is there any practice or 15 policy with respect to turnaround times on medicolegal 16 work? 17 DR. JOSEPH DE NANASSY: There are 18 guidelines for turnaround time of autopsies, not 19 specifically for medicolegal cases. And the guidelines 20 go from thirty (30) to ninety (90) days. 21 MS. JENNIFER MCALEER: Thirty (30) to 22 ninety (90) days for autopsies? Or does that include 23 some surgical work, as well? 24 DR. JOSEPH DE NANASSY: That's only 25 autopsies.

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1 MS. JENNIFER MCALEER: And is there some 2 criteria that distinguishes whether it's thirty (30) days 3 versus ninety (90) days? 4 DR. JOSEPH DE NANASSY: No, but there is 5 a range of difficulty among the cases. So the simpler 6 ones can be completed sooner, because they need less 7 investigative work. The more complex ones, by their very 8 nature, might require more time and would fall in the 9 outer ranges of -- of number of days. 10 MS. JENNIFER MCALEER: And how well are 11 you doing at meeting those benchmarks? 12 DR. JOSEPH DE NANASSY: That depends on 13 the pathologist. Some of us are more up-to-date. Others 14 are further behind. 15 I do generate a quarterly quality 16 assurance report, which I have to present to the Chair of 17 the Medical Tissue and Audit Committee every three (3) 18 months. And within the report there is a breakdown of 19 autopsy cases. 20 In that -- in those reports, those 21 autopsies that are ordered in six (6) months that have 22 not been completed for more that six (6) months get 23 flagged. 24 MS. JENNIFER MCALEER: And what means do 25 you use to ensure that the pathologists then sign out or

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1 complete those cases? 2 DR. JOSEPH DE NANASSY: Every one (1) of 3 the pathologists gets a copy of that quarterly assurance 4 report. So if they see their name showing up on that 5 list, there is a message there. 6 MS. JENNIFER MCALEER: So there's a bit 7 of a shaming aspect to the list? 8 DR. JOSEPH DE NANASSY: If you wish to 9 put it that way, yes. 10 MS. JENNIFER MCALEER: And is there any 11 other mechanism that's used to get people to complete 12 their medicolegal work? 13 DR. JOSEPH DE NANASSY: None that is 14 available to me, but the Office of the Regional Coroner 15 does send us reminders from time to time about cases that 16 he would like to see completed. 17 MS. JENNIFER MCALEER: So you'll get some 18 pressure from the regional coroner if the cases are 19 taking too long? 20 DR. JOSEPH DE NANASSY: Yes. 21 MS. JENNIFER MCALEER: And how often does 22 that happen? 23 DR. JOSEPH DE NANASSY: I don't know. I 24 don't get any myself. So some of them would be going to 25 my colleagues, and I don't know exactly how often. I am

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1 left guessing half a dozen (6) times a year. 2 MS. JENNIFER MCALEER: And is that a 3 communication that happens directly between the Regional 4 Coroner and the individual pathologist? 5 Or as -- you as head of the department 6 would you -- would you know if one (1) of your colleagues 7 was getting some pressure from the Regional Coroner to 8 have a report completed? 9 DR. JOSEPH DE NANASSY: There is direct 10 communication between the Coroner's Office and the 11 involved pathologist, either via phone call or by a fax. 12 MS. JENNIFER MCALEER: And sometimes does 13 the Regional Coroner call you and say, Listen, I can't 14 get Dr. Xs to complete their report. Can you please 15 intervene or can you help out? 16 DR. JOSEPH DE NANASSY: That hasn't 17 happened so far. 18 MS. JENNIFER MCALEER: All right. I'd 19 like to change -- yes, Dr. Michaud...? 20 DR. JEAN MICHAUD: I'm the one who gets 21 the phone call. 22 MS. JENNIFER MCALEER: You get the phone 23 call? 24 DR. JEAN MICHAUD: Yeah. 25 MS. JENNIFER MCALEER: And from whom --

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1 who calls you? 2 DR. JEAN MICHAUD: But I've never had a 3 phone for CHEO. 4 MS. JENNIFER MCALEER: I see. So you've 5 calls with respect to adult medicolegal work at other 6 hospitals? 7 DR. JEAN MICHAUD: I've had a few times, 8 but for CHEO I never get a call. Dr. de Nanassy is 9 correct. Usually faxes are sent, but they're not sent 10 all the time because we are late. At times they are sent 11 just because the family is a bit anxious. You know, you 12 deal with pediatric perinatal, sometimes stillbirth 13 death. 14 And -- and so sometimes the family's a bit 15 anxious. So as soon as we get a phone call, I gather, we 16 get a fax. And the faxes are received by our 17 receptionist and secretary. And she puts the faxes on 18 the desk of pathologist and the neuropathologist, if the 19 brain is not done yet. 20 MS. JENNIFER MCALEER: I see. And I 21 should clarify, Dr. de Nanassy, you are actually doing 22 all of the brain cases on all medicolegal autopsies as of 23 1998 -- sorry, Dr. Michaud? I'm sorry. 24 DR. JEAN MICHAUD: Yeah, I do all the 25 brains, period.

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1 MS. JENNIFER MCALEER: Right. So that -- 2 that is -- I don't -- do you know whether that's somewhat 3 unique, that you actually have a neuropathologist doing 4 the brain portion of every pediatric medicolegal autopsy? 5 Or is -- 6 DR. JEAN MICHAUD: I cannot answer the 7 question. I have never really asked my colleagues to 8 give me that type of precision. 9 MS. JENNIFER MCALEER: Yes, Dr. de 10 Nanassy? 11 DR. JOSEPH DE NANASSY: I could speak to 12 that a little bit. I am comparing with my practice in 13 Winnipeg. Initially, when I started there, Dr. Phillips 14 and I did the brains on all our autopsy cases. 15 And a year or two (2) after I had started 16 there, the neuropathologist offered to do all the autopsy 17 brains, which we had came to an agreement that they would 18 be doing. So it does exist in other -- to the best of 19 knowledge -- does exist in other jurisdictions, as well. 20 And going back even further, when I was a 21 clinical fellow at Sick Kids, the neuropathologists would 22 be looking at the brains of autopsy cases as well. So 23 it's -- it has been done and is being, as well. 24 MS. JENNIFER MCALEER: Yes, Dr. Michaud? 25 DR. JEAN MICHAUD: I could add that

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1 previous practice, Sainte-Justine in Montreal, I believe, 2 that the neuropathologist also does the same thing as I 3 was doing when I was there. 4 MS. JENNIFER MCALEER: So every single 5 case, it's not up to the pathologist who is the primary - 6 - primary care -- 7 DR. JEAN MICHAUD: Decision. 8 MS. JENNIFER MCALEER: I don't know if 9 care is the right word, but -- 10 DR. JEAN MICHAUD: Yeah, okay. 11 MS. JENNIFER MCALEER: -- the -- who has 12 primary carriage of the autopsy, it's not within his or 13 her discretion to involve the neuropathologist. 14 I understand the -- the practice at CHEO 15 is that every single medicolegal case you have to be 16 involved. Is that correct, Dr. Michaud? 17 DR. JEAN MICHAUD: Well, I -- I do not 18 impose that on my colleagues. 19 MS. JENNIFER MCALEER: No, I understand, 20 but that's the practice? 21 DR. JEAN MICHAUD: I propose that -- I 22 propose that -- you know, it's -- it's my personal view 23 as a pediatric pathologist -- as a neuropathologist and 24 also a pediatric or whatever experience I could put in my 25 background.

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1 But the pediatric population is a -- is a 2 peculiar population. As you know, out of one hundred 3 (100) births, there is about 2 to 4 percent where you'll 4 have malformation -- congenital malformation -- or some 5 disorders that may lead to genetic counselling. 6 Sometimes it does not involve the brain at all, but 7 regularly is does involve the brain. 8 And I've taken the position -- in 1981, 9 when I arrived at Sainte-Justine in Montreal -- that, you 10 know, we -- we have experts looking at liver; we have 11 experts looking at GI biopsy. Well, do we have experts 12 looking at brains? Yes. 13 And I think a pediatric -- a 14 neuropathologist is in a good position to be able to 15 evaluate not only the elements pertinent to a medicolegal 16 case, but also the element pertinent to any other 17 disorders that could occur in a baby, even if the death 18 is not related to that. 19 It could lead at times to genetic 20 counsellings, and I remember a few cases where the 21 medical tissue and audit committees; it was discussed 22 that because of the -- the process related to medicolegal 23 autopsies. There was a delay between the investigation 24 of a family, or even sometimes genetic counselling for 25 future pregnancies and so on; just because we had the

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1 knowledge of a -- an irritable disorder, but yet they 2 were not able to act on it immediately. 3 They had to wait -- the case to be final, 4 and so on. So it's just an anecdotal example, never -- 5 nevertheless, backing up the statement that we have to be 6 looking, not only, for the issues related to the -- to 7 the medicolegal aspect of a case, but there are times 8 where we find things that could have also an impact on -- 9 on the -- on the family. 10 COMMISSIONER STEPHEN GOUDGE: Can I just 11 ask, and this is sort of a simplistic question, Dr. 12 Michaud, but in a case that is a medicolegal case so the 13 report goes to the coroner, is the pathologist free to 14 discuss genetic issues with the family without the 15 coroner's consent, or does the coroner always have to 16 consent? 17 DR. JEAN MICHAUD: No, we're not. 18 COMMISSIONER STEPHEN GOUDGE: So the cor-- 19 DR. JEAN MICHAUD: We -- we never do 20 that. 21 COMMISSIONER STEPHEN GOUDGE: Yeah, so 22 the coroner would consent in -- in the kind of case 23 you're postulating, where there is something seen by the 24 neuropatholgist that would mean genetic counselling -- 25 DR. JEAN MICHAUD: Mm-hm.

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1 COMMISSIONER STEPHEN GOUDGE: -- might be 2 desirable. 3 DR. JEAN MICHAUD: Yeah. We have to have 4 interactions with the coroner -- 5 COMMISSIONER STEPHEN GOUDGE: You would 6 go to the coroner -- 7 DR. JEAN MICHAUD: -- and we have to have 8 his or her permission to have somebody, a geneticist, for 9 example. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. JEAN MICHAUD: We've had also cases 12 of peri-operative death after cardiac surgery, and so on; 13 after regular surgery -- other types of surgery. 14 And obviously, you know, there -- there is 15 a need at times for interactions between the physicians 16 and the family, but we always have to do this through -- 17 through the coroner. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. JEAN MICHAUD: That's our practice. 20 MS. JENNIFER MCALEER: And -- and 21 practically speaking, Dr. Michaud, how often are you 22 having those conversations with -- is it the Regional 23 Coroner with whom you speak? 24 DR. JEAN MICHAUD: Well, in a specific 25 case in the past, we -- we've dealt directly with the

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1 coroner in charge -- 2 MS. JENNIFER MCALEER: The local coroner? 3 DR. JEAN MICHAUD: -- but the Regional 4 Coroner was aware. But it -- it's very unusual, you 5 know. 6 But it -- it happens, and we need to have 7 a process to deal with this when it happens. 8 MS. JENNIFER MCALEER: I see. So it 9 happens occasionally -- 10 DR. JEAN MICHAUD: Mm-hm. 11 MS. JENNIFER MCALEER: -- and since 12 you've been there in 1998, how many times have you had to 13 approach the Investigating Coroner in order to ask for 14 that permission? 15 DR. JEAN MICHAUD: I cannot tell you the 16 answer, because I was involved, maybe, in two (2) -- 17 three (3) cases, not necessarily for genetic -- one (1) 18 or two (2) were for genetic counselling. 19 Others were for -- to deal with, you know, 20 interactions between treating physicians and the family 21 on -- you know, cause of per-op, or post-ops death, and 22 so on; not very often. 23 But maybe my colleagues have, or sometimes 24 it is done because our colleague's clinician know about 25 this because we had discussed this at a medical audit and

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1 tissue committee. And so there is a process known by 2 that committee, and clinicians have, I think, the 3 possibility to contact directly the coroner, and interact 4 with -- with the family. 5 So I cannot give you the answer. 6 MS. JENNIFER MCALEER: And on the few 7 occasions when you have made those inquiries, have they 8 generally been receptive? 9 Has the coroner been receptive to sharing 10 that information? 11 DR. JEAN MICHAUD: Very receptive. 12 MS. JENNIFER MCALEER: Okay. If we could 13 move on then to a -- a different topic completely. 14 Within Ottawa, there is the Eastern 15 Ontario Regional For -- Forensic Pathology Unit, the 16 EORFPU, which I would suggest, for ease of reference, we 17 just refer to as the Forensic Unit in Ottawa. 18 You are familiar with that Unit? 19 DR. JEAN MICHAUD: Yes, we are. 20 MS. JENNIFER MCALEER: Okay. Dr. 21 Carpenter, coming back to you. 22 As I understand it, that Unit was founded 23 in 1994. Were you aware of that fact that that Unit was 24 being set up? 25 DR. BLAIR CARPENTER: Yes.

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1 MS. JENNIFER MCALEER: And can you please 2 tell me where is that Unit howed -- housed? 3 DR. BLAIR CARPENTER: It's housed at the 4 Ottawa General Hospital. 5 MS. JENNIFER MCALEER: And what is the 6 geographic proximity of the Ottawa General Hospital to 7 Cheo Hospital? 8 DR. BLAIR CARPENTER: It's very close. 9 It can be walked to within about two (2) or three (3) 10 minutes. Mm, let's say five (5) minutes. And -- 11 MS. JENNIFER MCALEER: And as I 12 understand it, the -- the two (2) buildings are actually 13 connected by a -- 14 DR. BLAIR CARPENTER: Yes, you've got -- 15 MS. JENNIFER MCALEER: -- a corridor, an 16 underground walkway of such? 17 DR. BLAIR CARPENTER: There are -- there 18 are two (2) ways. 19 You can go directly from door to door by 20 outside, or you can take a corridor which is built 21 between CHEO and the University, and the University to 22 the Ottawa General Hospital. They're in -- continuit -- 23 there are two (2) paths around which are in continuity. 24 So that takes about maybe a little -- even 25 -- maybe if anything, it's a little longer to take the

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1 paths around than to go from door to door, but lets say 2 it's within five (5) minutes. 3 MS. JENNIFER MCALEER: And what was your 4 understanding, Dr. Carpenter, as to the purpose that that 5 Unit would serve when it was founded in 1994? 6 DR. BLAIR CARPENTER: I was not involved 7 in the negotiation or the structure of the Unit. I was 8 not involved in the running of that Unit or the direct 9 involvement, so I -- I don't have good knowledge. Dr. 10 Michaud would be the one that would know more about that, 11 even if he did come afterwards. 12 MS. JENNIFER MCALEER: And I'm going to 13 speak to Dr. Michaud later -- 14 DR. BLAIR CARPENTER: Okay. 15 MS. JENNIFER MCALEER: -- a little bit 16 later about the current situation with the Ottawa Unit, 17 but with respect to your experience, Dr. Carpenter, in 18 the time that the Ottawa Unit -- the Forensic Unit was up 19 and running from 1994 to when you left CHEO in 2004 -- so 20 that ten (10) year period -- what interaction, if any, 21 did you have with the Forensic Unit? 22 DR. BLAIR CARPENTER: Well, we knew one 23 another. We were part of the same department at the 24 University. We did go to some general rounds between all 25 pathologists in town. From a forensic pathology point of

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1 view, all the pediatric was being done at CHEO. None was 2 being done at the Ottawa General, the Forensic Unit. 3 Now that I have said that, there were a 4 certain number of cases where I -- I and my colleague in 5 that field -- all that comfortable doing -- and at that 6 point, we ask the permission of the forensic pathologist 7 if he wish to do the case for us. 8 There was good communication between the 9 two (2) groups. So I usually said yes. There were 10 occasional cases where either I was at -- we were too 11 busy or I was involved with other things, and asked them 12 to help out which was done. 13 There were also cases where -- how would I 14 say the -- their expertise was better than ours. And 15 that was involved there. We talking about minimal 16 numbers. We're really talking about below five (5). But 17 it did occur on occasion. 18 MS. JENNIFER MCALEER: All right. Can I 19 just ask you a series of follow-up questions with respect 20 to -- 21 DR. BLAIR CARPENTER: Mm-hm. 22 MS. JENNIFER MCALEER: -- that answer? 23 First of all, you referred to the fact 24 that you would participate with your colleagues from the 25 Forensic Unit in general rounds.

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1 How often would those rounds take place? 2 DR. BLAIR CARPENTER: At one (1) point, 3 they were quite frequent. At the beginning, they were 4 quite frequent. In fact, at those round, usually the 5 coroners were invited to come. 6 COMMISSIONER STEPHEN GOUDGE: Were these 7 forensic rounds? 8 DR. BLAIR CARPENTER: Yes. The coroners 9 were involved. The RCMP lab toxicology was involved. We 10 were all involved; resident were there, so it was quite 11 extensive round. 12 That last -- they were usually once a 13 month. Then it decrease progressively for some reason or 14 another. People could not come; less interest and being 15 busy. 16 17 CONTINUED BY MS. JENNIFER MCALEER: 18 MS. JENNIFER MCALEER: What -- what was 19 your understanding, Dr. Carpenter, as to the purpose of 20 those rounds? Was it an educational purpose? Was it a 21 quality assurance purpose? Was it consultative? 22 What was your understanding as to what was 23 going to be accomplished? 24 DR. BLAIR CARPENTER: I was not 25 responsible for the organization; that was being done by

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1 the Ottawa General Forensic Unit. So I'm not sure 2 exactly of their purpose. I can tell you what -- how I 3 looked at it. 4 MS. JENNIFER MCALEER: Well, how did you 5 see it? 6 DR. BLAIR CARPENTER: My feeling -- I 7 used to like to go there when I had the time to go 8 because they were for educational purpose. It brought me 9 some -- in contact with cases which I would not see 10 otherwise, 'cause they were from the adult side. 11 And it was always interesting to see 12 what's going on in the other areas. I don't think it had 13 quality assurance; at least, I'm was not aware of it. 14 Maybe there was a -- a component by the one in charge, 15 but it was not my feeling that I was involved in that 16 part of it. 17 MS. JENNIFER MCALEER: And you indicated 18 that -- that police officers would be present at these as 19 well? 20 DR. BLAIR CARPENTER: Originally, yes. 21 MS. JENNIFER MCALEER: All right. And 22 would the -- these actually take place at the Forensic 23 Unit? 24 DR. BLAIR CARPENTER: They were taking 25 place at the Ottawa General, wherever they could have a

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1 room to -- to do it. 2 MS. JENNIFER MCALEER: All right. 3 DR. BLAIR CARPENTER: Large enough. 4 MS. JENNIFER MCALEER: And from 5 participating in those rounds or observing those rounds, 6 did you develop a view that there was, perhaps, a -- a 7 forensic mind set or a forensic perspective that the 8 forensic pathologists were bringing to those cases as 9 distinct from the pediatric pathologists' approach? 10 DR. BLAIR CARPENTER: I don't know. I 11 don't know exactly what you mean. 12 MS. JENNIFER MCALEER: Well, let me 13 rephrase this. When you would go to these rounds, and 14 you would hear the forensic pathologists present their 15 cases -- I take it was -- it was their cases they were 16 presenting. You wouldn't go there and present your case. 17 Is that correct? 18 DR. BLAIR CARPENTER: On occasion -- 19 there weren't that many for the reason we just mentioned; 20 the sheer number was not there. 21 MS. JENNIFER MCALEER: All right, well 22 we'll -- we'll come back to when you present. But when - 23 - when your forensic pathologist colleagues were 24 presenting, did you have any appreciation or did you form 25 a view that they were coming at the case from, perhaps, a

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1 different perspective? Did you think, Well, that's 2 interesting. You know, I wouldn't have done it that way 3 or that seems to be a different approach. 4 DR. BLAIR CARPENTER: No, I did not have 5 that feeling because it was not my field of expertise. 6 And it was not up to me to -- to question an area that I 7 was not familiar with. 8 MS. JENNIFER MCALEER: Right, but -- 9 COMMISSIONER STEPHEN GOUDGE: That would 10 be the forensic pathology area. 11 DR. BLAIR CARPENTER: Yeah, the adult 12 type of forensic pathology. 13 COMMISSIONER STEPHEN GOUDGE: Adult or 14 forensic? 15 DR. BLAIR CARPENTER: Well, adult 16 forensic. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 DR. BLAIR CARPENTER: Where it -- 19 compared to pediatric forensic. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: But did you have 23 an appreciation that there was a field of expertise with 24 respect to forensic pathology. 'Cause you said you 25 weren't there to critique it.

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1 DR. BLAIR CARPENTER: Oh, and I -- 2 MS. JENNIFER MCALEER: I mean, that seems 3 to imply that there was something a little bit different 4 that was -- that was happening. Or was it simply that it 5 was adult pathology and, therefore, you weren't going to 6 critique it? 7 DR. BLAIR CARPENTER: I had no intention 8 of criticizing it. As I said, I was going there for my 9 own information. I thought they did a -- a good job. I 10 had no reason not to. There were also some discussion 11 with the toxicologist that came from the RCMP Lab. There 12 were also the policemen that gave their information. 13 There were also the coroner who brought their 14 information. 15 At the end of the day, I'm sure some of 16 the other people must have had some usefulness, aside 17 from just the academic approach. But for me, it was 18 mainly the academic approach. 19 COMMISSIONER STEPHEN GOUDGE: Sounds like 20 you were using it as an opportunity to learn about adult 21 pathology -- 22 DR. BLAIR CARPENTER: It was -- 23 COMMISSIONER STEPHEN GOUDGE: -- rather 24 than about forensic pathology. 25 DR. BLAIR CARPENTER: Well, adult

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1 forensic pathology. 2 COMMISSIONER STEPHEN GOUDGE: Okay. 3 DR. BLAIR CARPENTER: Now, you -- 4 pediatric case were not presented all frequently. First, 5 because we're talking single digits, so there weren't 6 that many case. And Dr. Bechard then, was not all that 7 up -- keen on having the pediatric suspicious or child 8 abuse by then, in work of investigation to be discussed 9 in public when -- 10 COMMISSIONER STEPHEN GOUDGE: At rounds. 11 DR. BLAIR CARPENTER: -- the 12 investigation was being going on. 13 COMMISSIONER STEPHEN GOUDGE: Dr. 14 Michaud, did you want to say something? 15 DR. JEAN MICHAUD: Yeah, I'd like to just 16 give a little point of view because if you go to Tab 26 17 of the binder, you have the list of individuals that are 18 invited at these rounds in 2000. 19 I -- I would say that the list has not -- 20 the names have changed, and I'm one (1) of the invitee 21 and I -- I will confess immediately that, in view of my 22 administrative duties, I'm -- I do not go very often. 23 I have been maybe to a few in the early 24 years I was in Ottawa. I do not go very -- I don't go 25 any more. I went only once last year because they asked

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1 me to present on Shaken Baby Syndrome. 2 This -- these rounds are -- this is -- 3 this is a CME activity, like several rounds that we could 4 have in an academic centre. This is CME activities; they 5 will choose cases that will illustrate unusual aspect or 6 unusual areas of forensic pathology. 7 They may, at times, use difficult cases; 8 cases where they had problems. But as you can see, you 9 know, there are people from the RCMP there, policemen and 10 so on, so the -- the number of people there is quite -- 11 it's a multi-disciplinary type -- type of rounds. 12 The frequency now has decreased in the 13 last two (2) or three (3) years. I would say it's 14 probably every other month, in general, but they're -- 15 they're still -- 16 COMMISSIONER STEPHEN GOUDGE: Am I 17 reading this right, Dr. Michaud? There is not a large 18 number of pathologists at this. 19 DR. JEAN MICHAUD: Well, the Unit has 20 only three (3) active forensic pathologists and in fact, 21 for a -- for at total of two (2) FTE in a way. 22 COMMISSIONER STEPHEN GOUDGE: And it 23 would only -- so that means each is doing about two- 24 thirds (2/3) of the time in the Unit? 25 DR. JEAN MICHAUD: Well, there is one (1)

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1 forensic pathologist who's a full-time forensic 2 pathologist. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. JEAN MICHAUD: He's the one having 5 the -- the largest load and -- 6 COMMISSIONER STEPHEN GOUDGE: And he 7 would work exclusively in the Unit? 8 DR. JEAN MICHAUD: Yes, exclusively in 9 the Unit. 10 COMMISSIONER STEPHEN GOUDGE: And the 11 other two (2)? 12 DR. JEAN MICHAUD: The other two (2) are 13 fifty/fifty (50/50) surgical pathologists and forensic 14 pathologists. 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 DR. JEAN MICHAUD: And then we have a 17 number of pathologists who help the on-call duty and do 18 some weekend cases -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. JEAN MICHAUD: -- that are more like 21 quote unquote "hospital or non-suspicious" cases. So 22 these would also -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. JEAN MICHAUD: -- contribute to the 25 load of the cases that are done in this Unit.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 3 CONTINUED BY MS. JENNIFER MCALEER: 4 MS. JENNIFER MCALEER: So between 1998 5 and -- and 2004, we'll just keep it in the same time 6 frame that was I was asking Dr. Carpenter about. How 7 often have you attended, Dr. Michaud, these forensic 8 pathology rounds? 9 DR. JEAN MICHAUD: Very honestly, as I 10 mentioned, two (2) or three (3) times; no more than that. 11 MS. JENNIFER MCALEER: And when you 12 attended the forensic pathology rounds did you have the 13 view that there was a -- that the forensic pathologists 14 had a particular skill set with respect to forensic 15 pathology that was perhaps a little distinct from your 16 own skill set or the skill set of your colleagues that 17 are doing pediatric pathology? 18 DR. JEAN MICHAUD: Without any 19 hesitation, yes. It's a definite yes. This is a 20 forensic pathology rounds and what's the angle there is a 21 true forensic pathology approach. And this is yes, there 22 is a difference between the type of approach and the 23 approach that we would have in a pediatric setting where 24 the -- the forensic elements are there but the pediatric 25 pathology aspect is very important. I -- I -- yes, I can

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1 say that. 2 MS. JENNIFER MCALEER: Can you articulate 3 some of those differences in approach? What is different 4 about the way a forensic pathologist approaches the cases 5 from your perspective? 6 DR. JEAN MICHAUD: I'm not sure if I 7 really can do it because I'm not a forensic pathologist. 8 Okay? I'm a neuropathologist doing some forensic work 9 but the -- the -- in pediatric pathology because quite 10 honestly between 1981 and 1988, I've done a good number 11 of SUD's and SIDS and so on. 12 Our approach is really to look into the 13 possibility of either suspicious or, you know, harmful 14 events but knowing also that, in a good number of cases, 15 we will either find nothing in true SIDS cases, or we 16 will find something that will explain why this kid died. 17 We're talking here about the large 18 category of Sudden Unexpected Death because obviously 19 when we have a coroner case on perinatal asphyxia the 20 whole environment and the whole picture defers, and 21 that's where the true pediatric pathologist will express 22 himself or herself. 23 When you have Sudden Expected Death, you 24 have a shift. You still remain a pediatric pathologist. 25 You still have the -- the desire to find something that

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1 will explain that death but yet you know that moving 2 towards the forensic side, you may also find something 3 that will either indicate that something harmful was 4 done. 5 So -- so, you know, that I would explain 6 on the pediatric pathology side. I think the forensic 7 side is much more -- you know, the -- the inception of 8 the -- of the work is more on the forensic nature of the 9 thing, although they do a large number of what we call in 10 our jargon "hospital cases" or "hospital-type cases." 11 They -- so -- do a lot of those cases, but yet I think 12 the approach is -- is more on the forensic side to -- to 13 that. It's -- it's -- 14 COMMISSIONER STEPHEN GOUDGE: Could you 15 say Dr. -- sorry, you finish, Dr. Michaud. 16 DR. JEAN MICHAUD: Well, in the Forensic 17 Institute in Toronto, that's where you will find the true 18 forensic behaviour. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. JEAN MICHAUD: While if you go to, I 21 don't know, St. Michael's Hospital, or TOH for example, 22 you have this mix of cases that require that the 23 pathologist has a couple of -- a dual-type of -- of 24 approach. 25 So there is a range there. I mean this is

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1 my own way of explaining things. And in pediatric 2 pathology, in view of the small number of suspicious -- 3 criminally suspicious cases, we have to have a 4 preponderant pediatric pathology approach; that's the way 5 I would express. 6 COMMISSIONER STEPHEN GOUDGE: And that 7 means being involved with the investigation of disease as 8 the cause of death where the forensic pathologist may be 9 more involved with the investigation of injury as the 10 cause of death, is that -- 11 DR. JEAN MICHAUD: Yeah, that -- that 12 would be the -- the output of this. 13 COMMISSIONER STEPHEN GOUDGE: Is that one 14 (1) way to articulate it? 15 DR. JEAN MICHAUD: That would be one (1) 16 way to articulate it. We have to have the knowledge of 17 diseases as much, if not more, as the knowledge of the 18 forensic elements. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: And I will come 23 back to this a little bit more later on, Mr. 24 Commissioner. If you'd like, I notice it's 11:15, would 25 this be a convenient time to break?

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1 COMMISSIONER STEPHEN GOUDGE: Sure. 2 We'll break then for fifteen (15) minutes. 3 4 --- Upon recessing at 11:16 a.m. 5 --- Upon resuming at 11:34 a.m. 6 7 THE REGISTRAR: All rise. Please be 8 seated. 9 COMMISSIONER STEPHEN GOUDGE: Ms. 10 McAleer...? 11 12 CONTINUED BY MS. JENNIFER MCALEER: 13 MS. JENNIFER MCALEER: Thank you. Dr. 14 Carpenter, you had been telling us a little bit about the 15 interaction with the Forensic Unit in Ottawa during the 16 time that you were at CHEO. 17 You indicated that you had good 18 communication with the unit and that, on occasion, you 19 had actually interacted with them with respect to some of 20 the cases that had originally come to you. 21 Can you provide us with a little bit more 22 detail with respect to those cases; would you ask for 23 consultation or would actually send the body over to the 24 Forensic Unit? 25 DR. BLAIR CARPENTER: In the case where

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1 the unit got involved, it's myself calling the head, Dr. 2 Johnson, and asking him if him or one (1) of his 3 assistants could help me out, and which he did each time 4 with -- with pleasure because there was good 5 communication. 6 MS. JENNIFER MCALEER: And the occasions 7 that you contacted him, was it as a result of recognition 8 of their particular expertise or was it a question of 9 resources, what -- what generated the request? 10 DR. BLAIR CARPENTER: In the later years 11 it was the manpower that prompted me to ask them to help 12 me out. 13 MS. JENNIFER MCALEER: You weren't 14 sufficiently staffed to deal with all of the cases that 15 were coming your way? 16 DR. BLAIR CARPENTER: Well, yes, were 17 staffed because we were three (3), but the last year that 18 I was working, one (1) of the pathologists was sick and 19 the other one (1) was on pregnancy leave because she had 20 adopted a child from China and had taken the -- the 21 leave, so I ended up being alone doing all of the work. 22 If we exclude the neuropathology, I was 23 doing all the surgical and all the autopsy on my own, 24 which was quite strenuous, including weekends and being 25 on call all the time.

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1 Therefore, at one (1) point I remember 2 that there was an awful week that I had and I was just 3 overwhelmed, and two (2) case came in on Friday 4 afternoon, medicolegal burn cases, and I -- I knew that 5 was it for the next twelve (12) hours. 6 So, I gave the phone call to the forensic, 7 can you help me out just for me to recuperate here, and 8 they had no problem since it was basically -- they were 9 children, but they was not specifically pediatric; it was 10 more whether it's a burn case, or whether it was adult, 11 or pediat -- or pediatric, the results were the same 12 category. 13 MS. JENNIFER MCALEER: So that was a 14 house fire death -- 15 DR. BLAIR CARPENTER: Yes. 16 MS. JENNIFER MCALEER: -- as I understand 17 it; three (3) children died -- 18 DR. BLAIR CARPENTER: Yes. 19 MS. JENNIFER MCALEER: -- and you decided 20 that you basic -- you just couldn't do it; you were too 21 busy. 22 DR. BLAIR CARPENTER: Just physically was 23 at that point it was -- I would have done it if there was 24 no other choice, but they -- they accepted to bail me out 25 and it was -- that's how we got in contact.

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1 MS. JENNIFER MCALEER: Do you recall any 2 other cases where you sent a case over there because of - 3 - because of resource issues, because you didn't have 4 enough staff or enough time to do the case yourself? 5 DR. BLAIR CARPENTER: Yes. Yes, that's - 6 - well, that's a long time ago. And that one (1) also 7 went to Court, but we didn't know that. And -- but that 8 -- at that point I was again alone, that's after Dr. 9 Norman had left, and at that point it was not the unit as 10 such -- not recognised as such, but it was still the same 11 person, Dr. Johnson, before the recognition of the unit, 12 and he accepted to bail me out that time also. 13 MS. JENNIFER MCALEER: All right, so that 14 was when Dr. Johnson was still at the Riverside Hospital? 15 DR. BLAIR CARPENTER: No, that was at the 16 -- or was it Dr. Johnson because I think it was done at 17 the General, so it may have been another pathologist then 18 who bailed me out. 19 MS. JENNIFER MCALEER: All right. And as 20 I understand it, that was a case involving the physical 21 and sexual abuse of a child. 22 DR. BLAIR CARPENTER: Yes. 23 MS. JENNIFER MCALEER: And you would have 24 done the case, but for the fact you didn't have 25 sufficient time?

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1 DR. BLAIR CARPENTER: I was -- I was not 2 there and the policeman -- I had to -- to move out, I had 3 another commitment, and the policeman wanted the -- the 4 autopsy to be done as fast as possible because they were 5 in the midst of an investi -- an important investigation. 6 And I -- I called and they accepted to 7 bail me out and to help the -- the police and so on. 8 MS. JENNIFER MCALEER: Do you remember 9 any other cases where you had to send the case either to 10 the forensic unit or somewhere else because of resource 11 problems? 12 DR. BLAIR CARPENTER: Elsewhere, no. 13 MS. JENNIFER MCALEER: Okay. 14 DR. BLAIR CARPENTER: On -- but on two 15 (2) occasions we were asked to send the case out. 16 MS. JENNIFER MCALEER: All right. Well, 17 -- 18 DR. BLAIR CARPENTER: One (1) case was 19 suspic -- suspected child abuse that occurred in the 20 province of Quebec was sent to CHEO where it died in our 21 intensive care unit. And the police force and the 22 coroner -- well, it was a coroner's case from Ontario 23 because it died in Ontario, but the case was basically -- 24 happened in Quebec. 25 And they ask if it could be done in

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1 Montreal because they were more familiar with the -- 2 MS. JENNIFER MCALEER: Potential 3 suspects? 4 DR. BLAIR CARPENTER: -- potential 5 suspect there. And I had no objection. If it suits 6 their purpose, I was willing to accommodate them. 7 Another case was from Ontario and I was 8 not all that clear, but it seemed there was potential 9 conflict of interest between the coroner in Ontario and 10 the family of the case that happened. 11 So they wan -- they asked me if they could 12 send the case to be done in another jurisdiction. 13 MS. JENNIFER MCALEER: I see. 14 DR. BLAIR CARPENTER: And, therefore, it 15 was decided to send the case to Toronto. 16 MS. JENNIFER MCALEER: All right. Now, 17 was there ever an occasion where you chose to send the 18 case to the forensic unit because you thought that it was 19 a case that would benefit by forensic expertise? 20 DR. BLAIR CARPENTER: I think so, but 21 it's nebulous. And I think it was a case of a gunshot 22 wound in Ottawa that I sent to the unit. That one was -- 23 they had to evaluate the various wounds and the entry 24 wound, path wound. And that I did not felt that I was 25 comfortable 'cause I did not have enough experience.

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1 I would have done it the best of my 2 knowledge, if I had to, but before I decided to start, I 3 asked if they would do it. And they accepted, and I was 4 quite happy that it was done by someone who was more 5 familiar than I was at doing that type of work. 6 MS. JENNIFER MCALEER: All right. And do 7 you recall any other occasion, Dr. Carpenter, when you 8 sent a case to the forensic unit as a result of 9 recognition that perhaps the case would benefit by an 10 increased level of forensic expertise? 11 DR. BLAIR CARPENTER: There probably were 12 some, but offhand it doesn't come to -- to mind. And 13 when we discussed it, it did not come to mind. And I 14 don't keep track of that. And there's thirty (30) years 15 of -- of work, so you don't remember everything. 16 So I have to say, no. Keeping in mind 17 that there probably were some or may have been some. 18 MS. JENNIFER MCALEER: Now, apart from 19 sending the body out, to what degree would you consult 20 with them? Would you ever pick up the phone and call Dr. 21 Johnson and seek some expertise or consultation on 22 forensic work? 23 DR. BLAIR CARPENTER: No. If I decided 24 to do that, as I said, I would have sent it over. It's 25 close by, it's easy to transfer. You're talking about

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1 minutes and it's over. That -- so if I had that, it 2 would have been that way. 3 Once the autopsy was started at CHEO, it 4 has not happened that I have called Dr. Johnson in. I 5 have called Dr. Michaud in for the brain when he was 6 close by, other member of our departments to come and 7 give a second opinion while I was working, either Dr. 8 Jimenez or Dr. Nizalik. 9 Obviously, radiology because we always did 10 the radiology first and never started the autopsy before 11 consulting the radiologist. And that's it. And the 12 eyes, all the eyes are sent to the -- well, what used to 13 be sent to the ophthalmology pathologist at the 14 University. So that was the extent of our consultation. 15 MS. JENNIFER MCALEER: Thank you, Dr. 16 Carpenter. 17 COMMISSIONER STEPHEN GOUDGE: Can I just 18 ask -- 19 MS. JENNIFER MCALEER: Yes. 20 COMMISSIONER STEPHEN GOUDGE: -- one (1) 21 question, Ms. McAleer? 22 On the level of the adjunct supports that 23 are available in doing an autopsy, I'm thinking of the 24 radiology, the toxicology, histology and so on. I take 25 it there's no difference, in your view, between your Unit

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1 and the Ottawa Forensic Unit because the Ottawa Forensic 2 Unit is in a hospital setting as is yours. 3 Is that fair? 4 DR. BLAIR CARPENTER: It is a fair 5 statement. In fact, I don't see any difference. We have 6 the same ancillary support, and if we're asking for 7 toxicology, we will be sending it to the Toronto Unit 8 anyhow, to -- to courier or the policeman bringing it 9 down. So they -- 10 COMMISSIONER STEPHEN GOUDGE: Does HSC do 11 all your toxicology? 12 DR. BLAIR CARPENTER: When I was there we 13 -- the -- originally, we used to have it done at the RCMP 14 lab, but they were overworked and it was not their work 15 to help the provincial system. 16 So, we were asked to send everything down 17 to Toronto to the forensic structure. So all our tox -- 18 COMMISSIONER STEPHEN GOUDGE: So you 19 don't do the toxicology -- 20 DR. BLAIR CARPENTER: Not when I was -- 21 COMMISSIONER STEPHEN GOUDGE: -- for your 22 autopsies? 23 DR. BLAIR CARPENTER: -- involved. 24 You'll -- last -- the last two (2) year maybe this has 25 been changed, but in my days, no, we all sent to Toronto.

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1 COMMISSIONER STEPHEN GOUDGE: Okay. 2 Thank you. 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: And Dr. de 6 Nanassy, was that the practice currently with toxicology? 7 DR. JOSEPH DE NANASSY: It is, yes. 8 MS. JENNIFER MCALEER: Okay. And, Dr. de 9 Nanassy, what has been your experience between 2004 and 10 lets say the end of 2006, 'cause we know there's been 11 some recent changes at the Forensic Unit, but between 12 2004 and 2006, did you have a greater or lesser contact 13 with the Unit then -- then Dr. Carpenter has explained? 14 DR. JOSEPH DE NANASSY: We -- 15 MS. JENNIFER MCALEER: What was the 16 nature of your contact with the Forensic Unit? 17 DR. JOSEPH DE NANASSY: None. 18 MS. JENNIFER MCALEER: None, okay. So 19 you've never sent a case over to them? You've never been 20 consulted by them on a case? 21 DR. JOSEPH DE NANASSY: No. 22 MS. JENNIFER MCALEER: Okay. And, Dr. 23 Michaud, I see from your resume that you actually for a 24 period of time were the Medical Director of -- of the 25 Unit.

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1 Apart from your administrative role, did 2 you have any interaction with the Forensic Unit? Have 3 you ever consulted with them on a case? Do they have a 4 neuropathologist on staff that you deal with? 5 DR. JEAN MICHAUD: Let me bring first the 6 corrections. There was a period of uncertainties when I 7 arrived in Ottawa, because I had some interaction with 8 Dr. Bechard, and I got the impression that I was the 9 Director of the Unit. 10 And in fact I had signed some contracts at 11 that time, but at some point in time I stopped signing 12 contracts, because the hospital administration wanted to 13 review them and sign them themselves. 14 And I learned, not long ago, that there 15 was an official letter appointing Dr. Johnson as the 16 Medical Director of the Unit. So I will -- I would have 17 to change the -- this little line in my -- my CV. 18 The interactions that I have with the 19 Forensic Units are just purely administrative at this 20 moment. I have never sent a brain there, although I've 21 had a couple of interactions with my colleague 22 neuropathologists who are at the Ottawa Hospital on 23 various specific elements or questions, but I never sent 24 them a case or slides or anything. I would just ask a 25 question, By the way, what do you think about this or

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1 that, and then that's it. 2 MS. JENNIFER MCALEER: All right. Thank 3 you for clarifying that point on your resume. 4 DR. JEAN MICHAUD: Yeah. 5 MS. JENNIFER MCALEER: And we will come 6 back to the current running of the Forensic Unit a little 7 bit later. 8 DR. JEAN MICHAUD: Mm-hm. 9 MS. JENNIFER MCALEER: Dr. Carpenter, if 10 you could turn to Tab 15, please, in the binder before 11 you. 12 Now, Dr. Carpenter, do you recall 13 receiving this memo from Dr. Bechard with respect to a 14 conference call procedure starting with respect to 15 certain investigations? 16 DR. BLAIR CARPENTER: I most likely got 17 the memo and put it in a binder. What I remember more is 18 discussing it with Dr. Bechard himself. 19 MS. JENNIFER MCALEER: Oh. 20 DR. BLAIR CARPENTER: He called me up and 21 we discussed the issue. So I'm -- I'm -- now that I read 22 it back here, yeah, that's what we were dis -- we 23 discussed. So I agree with the memo. 24 MS. JENNIFER MCALEER: All right. So in 25 or around June of 1997, you understood that there was a

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1 new procedure that was going to be in place, that there 2 would be conference calls with respect to certain 3 investigations, and one (1) of those categories pertained 4 to children's deaths? 5 DR. BLAIR CARPENTER: Yes. 6 MS. JENNIFER MCALEER: And how did those 7 conference calls work? 8 9 (BRIEF PAUSE) 10 11 DR. BLAIR CARPENTER: The way it 12 functioned, when -- when I -- my -- my report was 13 finished, I -- I had finalized all my thin -- the copy 14 that went to Dr. Bechard went to Dr. Bechard, and I 15 withheld the other copies. 16 Dr. Bechard would take that copy and send 17 it to Toronto. Then, when I -- I -- when the information 18 would get back to Dr. Bechard, he would call me and say, 19 Okay, you can let the -- the report go. And I would then 20 send a copy to the Crown Attorney, to the -- to the -- 21 the Coroner's Office, and to the local coroner, and Dr. 22 Bechard already had his own copy. 23 So that -- that -- so what that -- it went 24 very smoothly, and I -- we really did not have any 25 confrontation on that, except for one (1) case.

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1 MS. JENNIFER MCALEER: All right. I'm 2 going to stop you there, Dr. Carpenter, because I know 3 that you're talking about the review process by which you 4 would submit your post-mortem examination -- 5 DR. BLAIR CARPENTER: Yes. 6 MS. JENNIFER MCALEER: -- reports, so Dr. 7 Chiasson -- 8 DR. BLAIR CARPENTER: Isn't that what 9 we're talking about? 10 MS. JENNIFER MCALEER: I think this is 11 something different. I think this pertains to conference 12 calls with the regional coroner, with respect to certain 13 cases. 14 And I'll just give you a moment to look at 15 the memo perhaps a little more closely. 16 DR. BLAIR CARPENTER: Okay. I see your 17 point. Yes. I mislea -- okay, that's the other memo, 18 yes. 19 MS. JENNIFER MCALEER: Right. 20 DR. BLAIR CARPENTER: Okay. Okay. 21 Dr. Bechard wanted to have a firsthand -- 22 if that's what we're talking about -- on all the 23 pediatric case for Eastern Ontario. 24 Therefore, to my knowledge, the policemen 25 ordered local coroners -- that's the one (1) we're

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1 talking about -- were to call Dr. Bechard immediately. 2 If -- and him would call us, the 3 pathologists, as soon as he got the information and get 4 firsthand on the case, and we'd give some interaction. 5 If that had not been done, and we felt 6 that he had not called, we did it ourself, to call Dr. 7 Bechard and tell him we're going to proceed, are you 8 aware of? 9 Also we had an agreement -- well, 10 agreement, a verbal agreement with Dr. Bechard that if 11 there were some coroner's case, that the coroner was not 12 -- if they were hospital case that a coroner had not been 13 involved, that we felt that the coroner should have been 14 involved, we were to call Dr. Bechard and discuss and see 15 what his feeling was. And if yes or no, we would make 16 it. 17 So, yes, there was continuously a direct 18 cond -- communication with Dr. Bechard from -- from our 19 unit to him. 20 Once the autopsy was finished, we would 21 call him back and verbally discuss at least our 22 preliminary with him. So for the next step, where do we 23 go next, and how do we meet, or do we get a conference 24 among ourself or whatever. 25 So Dr. Bechard and myself and the other

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1 two (2) pathologists had a direct communication with Dr. 2 Bechard, and there was -- at that point there was no 3 problem with that, at least for us. We had felt it was 4 very useful for us. 5 MS. JENNIFER MCALEER: And what -- what 6 was your understanding as to the purpose of that, Dr. 7 Carpenter? 8 I mean, did this correspond with the time 9 period that you were talking about earlier, where more 10 cases started to get redirected to CHEO? 11 DR. BLAIR CARPENTER: Well, it all went 12 into that same period, because that's the period Dr. 13 Bechard was the regional coroner. So it all came to the 14 same thing. 15 I -- I thought that it was -- well, my -- 16 my impression was that Dr. Bechard had an interest in 17 pediatric, which it was an interest we had not seen as 18 extent -- as elaborate in the past. 19 And we -- I was very, very happy that it 20 happened, because that's what was the purpose of the 21 whole exercise to start with. So we were quite happy 22 with that. 23 MS. JENNIFER MCALEER: All right. If I 24 could then turn your attention to a different topic. 25 You have before you a separate binder,

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1 which is the coroner's investigation manual. You should 2 have it before you. 3 4 (BRIEF PAUSE) 5 6 MS. JENNIFER MCALEER: And this is 7 PFP057584. And if you could go to pages 349 please -- 8 page 349. 9 DR. BLAIR CARPENTER: PFP -- PFP -- yeah, 10 was PFP0 -- 11 MS. JENNIFER MCALEER: 057584 is the 12 first page of that document. But then go in to page 349. 13 COMMISSIONER STEPHEN GOUDGE: That whole 14 binder is all that number. So look at the number to the 15 right of the slash. 16 DR. BLAIR CARPENTER: Okay, sorry. 17 COMMISSIONER STEPHEN GOUDGE: Okay? 18 DR. BLAIR CARPENTER: Okay. And you want 19 me -- so the whole binder is that number. Well, you -- 20 you show me where it is. 21 COMMISSIONER STEPHEN GOUDGE: Yes. 22 23 (BRIEF PAUSE) 24 25 MS. JENNIFER MCALEER: It should also be

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1 on the screen before you. 2 3 (BRIEF PAUSE) 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: All right. Are 7 you familiar with this protocol, memo 631, Dr. Carpenter? 8 Have you previously seen this document? This is a 9 protocol for the investigation of sudden and unexpected 10 death of any child under two (2) years of age that came 11 out in April of 1995. 12 DR. BLAIR CARPENTER: I -- I don't 13 remember it, to tell you the truth, but I can read it and 14 see. 15 MS. JENNIFER MCALEER: Well, if you 16 flip -- 17 COMMISSIONER STEPHEN GOUDGE: Read the 18 "think dirty" part. 19 20 CONTINUED BY MS. JENNIFER MCALEER: 21 MS. JENNIFER MCALEER: If you flip the 22 page -- 23 DR. BLAIR CARPENTER: It's the dirty one. 24 COMMISSIONER STEPHEN GOUDGE: Yes. 25 DR. BLAIR CARPENTER: Oh yes, I'm

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1 familiar with that. 2 3 CONTINUED BY MS. JENNIFER MCALEER: 4 MS. JENNIFER MCALEER: All right. Now 5 that you've refreshed your memory, you -- you recall -- 6 you recall, then, the -- the concept of "think dirty," do 7 you, with respect to the approach to the investigation of 8 deaths in children under two (2) years of age? 9 DR. BLAIR CARPENTER: I do. 10 MS. JENNIFER MCALEER: And what is your 11 recollection as to that concept and how it was 12 communicated to you? 13 DR. BLAIR CARPENTER: Well -- well the 14 concept was that we, all pathologists, should think 15 dirty. I mainly heard about it at one (1) of the 16 coroners' meeting in Toronto, where that was expressed to 17 us as part of one (1) of the discussion group or -- or 18 session. And that's how I got involved -- well, I heard 19 about that. 20 MS. JENNIFER MCALEER: All right. And 21 what do you recall with respect to how that concept was 22 communicated to you? 23 DR. BLAIR CARPENTER: To me? 24 MS. JENNIFER MCALEER: Yes. 25 DR. BLAIR CARPENTER: How I reacted to

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1 it? 2 MS. JENNIFER MCALEER: Well, what was 3 your understanding as to what it meant? 4 DR. BLAIR CARPENTER: I -- I still don't 5 really know, but I think I -- I understand. But I don't 6 know why it was there. 7 Personally, I think that every autopsy has 8 to be throughout. It's not dirty. It's not clean. It's 9 -- it's an autopsy. Now, if there are dirty aspect in 10 the autopsy, like child abuse, well then you find it. 11 If there are none, then you don't find it. 12 But you don't think dirty. You -- you try -- your -- 13 your goal is to find the answer to what's there. You 14 don't try to prove that something is there or whatever. 15 So the term "dirty autopsy" to me made no 16 sense. But I knew they meant and what they wanted to try 17 and submit. 18 MS. JENNIFER MCALEER: Well, what did you 19 understand them to mean? 20 DR. BLAIR CARPENTER: I understood that 21 they -- that there had been some studies and some -- some 22 conclusions that there were a certain number of cases of 23 pediatric that had been called either SID or SUD that 24 were really part of the spectrum of child abuse. And 25 they wanted to make the pathologists aware that this

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1 concept exists and to make sure that they think about it. 2 And I looked at it more as something very 3 useful for pathologists who do maybe one (2) or two (2) 4 medicolegal pediatric autopsy in the year, to tell them 5 that, Yes, these things exist. Don't blind yourself. 6 It's there. It's out there, and it might be your case. 7 That's the way I looked at it. From my 8 perspective, I was fully aware of that, so the word -- so 9 that was not -- I did not need to be reinforced that 10 concept. It was part of my training. It was part of my 11 work. 12 It's the word "dirty" that I found funny. 13 I mean, it's -- whether it's dirty or not, I mean, it's a 14 question of perspective. But the term was in fact 15 shocking. The -- the word -- there was a point they 16 wanted to make, and they surely made that point. 17 If that's what you're going to, I think 18 that certainly didn't pass unnoticed, that's for sure. 19 If that was the goal of the whole expression, it did not 20 pass unnoticed. To me it was funny in a way. 21 MS. JENNIFER MCALEER: Did you discuss it 22 with your colleagues, Dr. Carpenter? Did you change your 23 approach to the autopsy -- 24 DR. BLAIR CARPENTER: No. 25 MS. JENNIFER MCALEER: -- as a result of

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1 that concept? 2 DR. BLAIR CARPENTER: No. 3 MS. JENNIFER MCALEER: Dr. Michaud, you 4 came to CHEO in 1998. Were you aware of the concept of - 5 - of "think dirty" as it may have been applied to the -- 6 the conduct of medicolegal autopsies? 7 DR. JEAN MICHAUD: No, I was not aware of 8 that. 9 MS. JENNIFER MCALEER: All right. 10 DR. JEAN MICHAUD: I would have reacted. 11 MS. JENNIFER MCALEER: Okay. And, Dr. de 12 Nanassy, you're familiar with the concept, are you? 13 DR. DE NANASSY: I am. 14 MS. JENNIFER MCALEER: And was a similar 15 concept used in Manitoba when you worked in Manitoba? 16 DR. DE NANASSY: Not as explicitly as I 17 have heard it expressed in Ontario. I think there is a 18 misunderstanding related to the word "dirty" itself. 19 I think the term meant rather to -- to 20 keep the pediatric pathologists aware of the fact that 21 there are forensic issues that need to be considered. 22 "Dirty" didn't necessarily imply that -- that there was 23 something suspicious that needed to be unearthed, but 24 rather to keep one's mind alert to the fact of covering 25 all investigative measures that needed to be taken care

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1 of. 2 MS. JENNIFER MCALEER: Okay. Dr. 3 Michaud, you indicated that you would have reacted. Why 4 is that that you would have reacted? 5 DR. JEAN MICHAUD: Because it's -- it's a 6 little bit -- you know, it's throwing a little -- a 7 negative image on the work we do. And I believe that the 8 word "dirty" wasn't used only for pediatric pathologists, 9 but also for police investigators and so on. But it -- 10 it gives a negative image. Certainly in pathology we are 11 trained to be aware that everything is possible. 12 On the medical side of our practice we're 13 dealing with clinicians who frequently are convinced that 14 their patient has such and such entity. They send us a 15 biopsy, and they are expecting us to confirm their -- 16 their opinion. We do frequently but are a good number of 17 times where even -- even if they have the best MRI in 18 town and so on, there are a good number of instances 19 where we tell them differently. 20 And so it's part of our practice. It's 21 part of our training. We train our student like this. 22 We have to be aware of all possibilities. We get into a 23 case. We have the information, but we have to proceed in 24 a way that may bring an element that would open a 25 different door.

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1 And so the terminology wanted perhaps to 2 really hit the targets and, you know, maybe it wanted to 3 illustrate the message in a way that would not be missed, 4 as Dr. Carpenter mentioned. But this is part of what 5 pathology is all about. 6 And so for us -- and when Dr. Carpenter 7 says that he hasn't changed his approach after this 8 concept was put out there, I think Dr. Carpenter reflect 9 the behaviour of all true pathologists. 10 MS. JENNIFER MCALEER: Using your -- your 11 example of the clinician, Dr. Michaud, in your experience 12 working with police officers or coroners have you 13 encountered situations where one comes to you expecting a 14 certain result? 15 And how do you handle those situations? 16 DR. BLAIR CARPENTER: Well, as -- since I 17 am in Ontario, I'm not the front line. My colleague 18 pediatric pathologists do the autopsies; I get the brain. 19 In my past I would mention to you, yes, 20 that at times there was a consensus where there was a 21 kind of a clear message coming in with the deceased. But 22 yet you approach the case and you have to challenge 23 sometimes this, but you have to find the elements. 24 You have to find -- you have to document 25 it nicely. So the process of doing an autopsy remains

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1 essentially the same. We document what we have. And at 2 the end we -- we drew -- we draw conclusions. And then 3 we -- we're in a position to challenge, perhaps, some of 4 the elements that were mentioned to us. 5 It's -- it's our role, and in fact that's 6 the whole purpose of doing autopsies, even in medical 7 settings. The -- the cause of death in hospitals is 8 frequently wrong, but you don't know it until you've done 9 the autopsy. 10 It's the same for medicolegal 11 investigation. You get into a case, but you don't have 12 the answer until you've done it. And then after that, 13 similarly to what we do in the medical setting, we put 14 our findings in context with the environment. That's 15 what we call in pathology "clinical pathological 16 correlation," CPCs. 17 In the medicolegal system -- 18 COMMISSIONER STEPHEN GOUDGE: I never 19 understood where that term came from. I never understood 20 where that came from but that's right, eh? 21 DR. JEAN MICHAUD: Yes, so in the 22 medical -- 23 COMMISSIONER STEPHEN GOUDGE: You will 24 get a clinical sending you a slide saying, I am sure that 25 my patient has cancer. And you will do the staining and

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1 find no. 2 DR. JEAN MICHAUD: Mm-hm. 3 COMMISSIONER STEPHEN GOUDGE: And then 4 you have the correlation of the pathology and the 5 clinical side. 6 DR. JEAN MICHAUD: Yeah, and these 7 correlations are frequently done discussing with the -- 8 the clinical team, or at times, more formally doing a 9 round, okay, clinical rounds. 10 So the medicolegal field, it's no 11 different; we're used to practice. We get into a case 12 with baggage, some information, we get out of it with 13 facts, and then we have to align that, and that's why a 14 process that includes several individuals is important. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: All right. Dr. de 18 Nanassy, what has been your experience with respect to 19 the expectations that may be presented to you with a case 20 or some of the background, circumstantial evidence, or 21 facts that may be presented with a case? How do you -- 22 how do you handle that information? 23 DR. JOSEPH DE NANASSY: I can echo some 24 of what Dr. Michaud had been saying, that every so often 25 police would come in with a certain idea of what might

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1 have happened; they communicate this to the pathologist, 2 but I think the pathologist is to maintain a completely 3 open mind, listen to what they have to say, but not at 4 all once have to be swayed by it. 5 After all, there is a -- there is a reason 6 we do an autopsy and we go into that autopsy we do a 7 total -- thorough work and we let the facts talk to us, 8 irrespective of what police or whoever else brought the 9 case to our attention might have communicated up to that 10 point because they might be wrong or they might have 11 findings that contradict what the scenario was coming in. 12 So, we should go into an autopsy with a 13 completely open mind, let the facts speak to us, and then 14 interpret it in light of the context. 15 MS. JENNIFER MCALEER: And to what 16 extent, if at all, Dr. de Nanassy, when you complete your 17 final post-mortem examination report, do you reflect the 18 information that you've received from either the police 19 officer or the coroner and the extent to which you've 20 relied upon it, how do you reflect that in your post- 21 mortem report? 22 DR. JOSEPH DE NANASSY: In my final post- 23 mortem report I would include a clinical summary. It's a 24 -- it's a paragraph or more called clinical summary, 25 where I would identify the source of the information.

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1 I would start the sentence by saying, this 2 information is obtained from, and then I refer to the 3 particular entity that the information came from, be it 4 police, or patient chart, or pictures that were shown to 5 me, or what have you, and that -- that puts the reader 6 into the context of what information was available to me 7 going into the autopsy. 8 MS. JENNIFER MCALEER: Yes, Dr. 9 Michaud...? 10 DR. JEAN MICHAUD: I -- I would just 11 would like to emphasis the fact that within a pathology 12 report we may be dealing with some information, but we 13 have to be aware that we don't have it all. 14 And it's my view that it's not within the 15 pathology report that this process should occur, it's 16 afterwards when -- with a mi -- a multi-disciplinary 17 team, you know, either through conference call and so on. 18 That's where -- because between the time 19 we -- we get the -- the body, we do the autopsy, and then 20 there is a delay -- variable -- varying, depending on the 21 individuals, and so on -- we have to wait for the brain 22 and so on. And between the time of the case and the time 23 of the autopsy report, the final report is done within 24 the institutions where the autopsy was done, other 25 information has accumulated and we're not aware of it.

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1 And so it's -- to me, my position has been 2 to be very careful when I try to correlate my findings 3 with what has been given to us at -- at the inception of 4 the case. My -- my recommendation is to have a process 5 where this thing is done after the report is issued with 6 people who are involved, who are knowledgeable, who have 7 the information; that's where you do the reconciliation. 8 To commit -- to come back to my example of 9 a biopsy with a technician, this correlation is not done 10 within the core of our report; frequently it's done 11 either during rounds, or a discussion with the medical 12 team, or sometimes there are specific meetings done to 13 discuss a pecular -- a particular case with, you know, 14 three (3), four (4), or five (5) specialists, and the 15 radiologist and some on. So I -- I believe that as 16 pathologists there is a limit to what we can do within a 17 report. 18 MS. JENNIFER MCALEER: All right. Then 19 if you have a case conference or a discussion, as -- as 20 you've articulated, and new information comes to light 21 that you think would alter your conclusions, how would 22 you handle that? 23 DR. JEAN MICHAUD: Well, if -- if this is 24 -- you know, if it's solid and so on, I would not have 25 any problem in modifying my report, even including

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1 comments, elements that would perhaps explain better the 2 finding with the information, I -- I would not have any 3 real problem. 4 Although, it could be done in a different 5 way or different setting, but certainly it has to be done 6 before the final report is issued to the judicial system, 7 you know, in my view. 8 MS. JENNIFER MCALEER So what you would 9 propose then, Dr. Michaud, is that you do an in-house 10 final post-mortem examination report that then gets 11 discussed in a forum that you've described. 12 You would get input, make any addendums 13 that you might need to make as a result, and then finally 14 sign-off on your post-mortem examination report? And 15 that would then be delivered to the justice system? 16 DR. JEAN MICHAUD: I know it's -- it's -- 17 it looks complicated and with everybody being busy and so 18 on and so on, I know this is maybe asking too much. But 19 in my view -- in my view, this would be the optimal way, 20 so that you would have an autopsy report that has a bit 21 more sense in trying to connect with available evidence, 22 but yet, as pathologists, we do not want to go beyond our 23 expertise and knowledge, obviously. 24 But at the end of the day -- at the end of 25 the day we should have only one (1) pathology report. I

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1 -- I think there is no need for side reports being issued 2 because it creates confusion. And so I -- I am in favour 3 of a process that would, over time, bring a final report 4 that is better linked with the other evidence. 5 That -- that's my view. 6 MS. JENNIFER MCALEER: In the -- in the 7 forum that you contemplate, though, would -- who would 8 participate? Would it be simply your peers, the Chief 9 Forensic Pathologist or would there also be police 10 officers, coroners -- 11 DR. JEAN MICHAUD: It depends of the 12 issue. You know, in some -- with some issues it would be 13 peers. During a -- a pathological review of the case, it 14 would be peer discussion. And -- and thi -- you know, 15 this is something that we do in our pathology life, if we 16 have difficult case we just, you know, knock on the door 17 of our colleague or -- or we -- we call a colleague in 18 the same speciality, like myself neuropathology. 19 We do that regularly. And we include in 20 our -- let's say a brain tumour report, sometimes I will 21 include, I've shown this case to Dr. so and so, and he 22 agrees with me or the result, my conclusion, takes into 23 account his and my views, okay. 24 So at the end of the day, you know, this 25 is one (1) set of -- of interactions that you may have in

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1 order to get to a safer and better report. Other time, 2 it could be consultations with other members of the -- of 3 the investigation team. 4 The limit in that circumstance is that it 5 does not necessarily help us to achieve a better report, 6 but it could help us to better link our findings with 7 their findings. And then it would be up to the 8 pathologist to decide, do I want to make a comment to 9 this or not or should it be the coroners in charge who 10 make the comments because I think he has a -- an 11 important role to play to putting all of that together, 12 eventually too. 13 So it -- you know, it has to be discussed. 14 We -- we never had a chance to really discuss that type 15 of -- of thing. But it has to be -- you know, we have to 16 agree upon a process which makes sense and contributes to 17 a better output. 18 MS. JENNIFER MCALEER: Would -- would you 19 agree, Dr. Michaud, that if you were essentially going to 20 a -- a meeting or a case conference, as you've suggested, 21 with essentially a draft report and there was input from 22 the coroners and the police officers that that input 23 should, in some respect, be captured somewhere, and that 24 that should all be disclosable to the defence, for 25 example, if there was going to be a criminal prosecution?

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1 DR. JEAN MICHAUD: Well, I -- you know, 2 let me just give an example. I don't think the pathology 3 report should go into the details that say of what was 4 found at the scene. That -- there are documents 5 elsewhere that will document that. 6 But, you know, there are other elements 7 that could perhaps be mentioned in comments that would be 8 part of -- of the report. If, for example -- overlaying, 9 for example, you know, this is the type of situation 10 where knowledge of this have been -- this may have 11 occurred. I'm sure my colleagues are happy to say that 12 the findings would be consistent with this knowing that 13 the -- this part of the investigation may be completed 14 later, after investigations and so on. 15 We have to be aware also that in this 16 process we may expose grey zones of pathology, and we may 17 have discussions, and we may have disagreements, so, in 18 those circumstances, which is part of pathology all the 19 time, by the way, we are used to doing that in the 20 medical settings and so on. There are grey zones; there 21 are sometimes disagreement in difficult cases, complex 22 cases, between decisions. Then you have a process; you 23 show it to a third party or you -- you know, you -- we 24 have to have a process to deal with that as well. 25 So that at the end of the process, there

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1 is a very good understanding that the final result is 2 credible and takes care of all the elements including the 3 science uncertainties. 4 MS. JENNIFER MCALEER: Dr. De Nanassy, 5 what consultation would you ideally like to see with 6 either members of the police or the coroners before you 7 actually finalize your report? 8 DR. JOSEPH DE NANASSY: Well, there is a 9 time line there, as Dr. Michaud alluded to. There is 10 information that is available prior to the autopsy or at 11 the initial stages of the investigation into the death, 12 which I think should be communicated to the pathologists. 13 I mean, those are not secrets; we are not 14 practising in a vacuum. We should be informed and then 15 we -- we are able to judge the relevance of the 16 information to the case. We have to perform a -- a -- a 17 thorough post-mortem examination irrespective of the 18 information given to us, so why withhold it? 19 If there is later on down the road weeks 20 or months later information that comes up that could 21 materially affect the -- the final outcome of the autopsy 22 report, then that should also be communicated by police 23 to the -- to the pathologist. 24 After all, we should be able to judge what 25 is important and what isn't and what deserves attention

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1 in terms of formulating the final toxicity report and 2 what doesn't. 3 MS. JENNIFER MCALEER: All right. Yes, 4 Dr. Michaud? 5 DR. JEAN MICHAUD: There are two benefits 6 to a more collegial ways -- way of doing things. The 7 first one is CME type of benefits. You contribute to 8 increased expertise of more individuals than just a few; 9 that's -- that's one of them. 10 The -- the second one is that you have a 11 better widespread expertise. You contribute to the 12 expertise. I mean, knowledge, personal knowledge, but 13 also expertise for the system. You increase the 14 expertise of more individuals that way by discussing more 15 cases than just the ones that you may have in any given 16 situation. 17 To me these are -- are benefits that are 18 not as obvious, as palpable when we deal with one case -- 19 on a case-per-case basis, but at the end of the day these 20 are elements that could help the system. 21 MS. JENNIFER MCALEER: All right. And 22 Dr. Michaud, you're referring now to -- more along the 23 lines of contact with the chief forensic pathologist and 24 the review process that happens within -- 25 DR. JEAN MICHAUD: No, there are review

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1 committees also. 2 MS. JENNIFER MCALEER: Right. 3 DR. JEAN MICHAUD: I'm talking about 4 review committees and yeah. 5 MS. JENNIFER MCALEER: All right. And 6 we'll discuss that a -- a -- in a little bit greater 7 detail later. If I could just change the topic again to 8 internal oversight, because we've been talking a little 9 bit about external consultation, but internal oversight. 10 Dr. Carpenter, when you were running the 11 unit, what internal oversight mechanisms did you have in 12 place? 13 DR. BLAIR CARPENTER: Concerning 14 autopsies? 15 MS. JENNIFER MCALEER: Yes, medical/legal 16 autopsies. 17 DR. BLAIR CARPENTER: We were -- we -- we 18 -- we -- we were relatively, in fact, very close then, 19 the three pathologists that were working on -- on those 20 days. And I -- I was the division head and I must say 21 that each time either the police were there and I had 22 the first hand at taking a look at it, so, I was on -- on 23 top of the case right at the beginning on all 24 medical/legal, whether I was going to do it or not do it. 25 MS. JENNIFER MCALEER: All right. So

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1 even if the case wasn't assigned out by you -- 2 DR. BLAIR CARPENTER: So I -- I had an 3 idea when the case came in; the chart was available. 4 There may or may not be the police; I had an idea. 5 MS. JENNIFER MCALEER: All right. So 6 that was your practice, was to look at every -- 7 DR. BLAIR CARPENTER: That was my 8 practice as the -- the head. Once that was done, we -- 9 if the person that was on autopsy wanted to do the 10 autopsy, then that person did it. If it was me, well, 11 then I would do it. Or if that person wanted me to do 12 it, it was decided then and I would usually say yes. 13 Now that that was done, the autopsy would 14 start. At that point, not all the time but often during 15 the autopsy, I -- the -- I would walk in, take a look, 16 just to make sure that our -- that the person, if it was 17 not me, was aware that if there are question, this is the 18 time to ask them to me. 19 If he wants or she wants -- when there 20 were two (2) she's -- if they -- they wanted 21 consultation, that was the time, or that I was available. 22 I didn't ask them to tell me nothing; just made myself 23 available. 24 MS. JENNIFER MCALEER: And as I 25 understand it, Dr. Carpenter, you wouldn't have formal

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1 rounds within your department -- 2 DR. BLAIR CARPENTER: Well -- 3 MS. JENNIFER MCALEER: -- because it was 4 just the three (3) of you? 5 DR. BLAIR CARPENTER: -- no, well we 6 would not have the formal round on medicolegal. We would 7 -- now that that was done, they would finish. If they're 8 satisfied, we would say -- well, I would say, Well, is it 9 okay? You feel good? Okay, rr-rr-rrhral, talk for 10 nothing. 11 And then was that the case was a valut 12 (phonetic) they -- I was already aware somehow -- not of 13 all the details, but I had a rough idea. And if they 14 wanted to bring it back they would. So there was some 15 communication that was being held there. 16 If there was no problem, I would let them 17 go. I would not go in and check the report to make sure 18 it was right. I had confidence in them. If they knew I 19 was there and we would discuss it. 20 Formal round on them, no, we did not have 21 a formal round on them. And sometime, if the police was 22 involved and the coroner was involved, sometime they ask 23 me to sit in with the other one. 24 At that -- 25 MS. JENNIFER MCALEER: Sorry --

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1 DR. BLAIR CARPENTER: -- with the other 2 pathologists at the discussion. Just to -- so I can add 3 my little piece -- 4 MS. JENNIFER MCALEER: Oh, just -- 5 DR. BLAIR CARPENTER: -- of -- of 6 whatever you want to call it. 7 MS. JENNIFER MCALEER: So to sit in on 8 case conferences? 9 DR. BLAIR CARPENTER: Well -- well, that 10 it went to the other stage where they wanted to have a 11 discussion with the police under the finding and so on. 12 That usually happened if you -- in the next days or a few 13 weeks after. 14 Sometime I would set -- sit in, if I did 15 not do the case. 16 MS. JENNIFER MCALEER: I see. 17 DR. BLAIR CARPENTER: Just to listen and 18 to be an advisor, if you wish; not for quality control, 19 but as an advisor, just for my experience. 20 MS. JENNIFER MCALEER: And would you -- 21 would you review the post-mortem examination -- 22 DR. BLAIR CARPENTER: No. 23 MS. JENNIFER MCALEER: -- reports? I 24 think I understood you to say that only if -- 25 DR. BLAIR CARPENTER: No.

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1 MS. JENNIFER MCALEER: -- pathologist 2 approached you -- 3 DR. BLAIR CARPENTER: Yeah. 4 MS. JENNIFER MCALEER: -- that they had a 5 concern with it? 6 DR. BLAIR CARPENTER: No, I would not. I 7 would not. But I was available for it. 8 MS. JENNIFER MCALEER: All right. And -- 9 COMMISSIONER STEPHEN GOUDGE: So the 10 pathologist would simply, on concluding the post-mortem 11 report, would send it to the coroner? 12 DR. BLAIR CARPENTER: Yes. If he felt 13 that there was no problem and -- then the coroner could 14 always come back to me if he did not like what he got or 15 was -- and wanted some form of information; not another 16 report, just some explanation and see what my feeling was 17 about the -- the case. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: And, Dr. de 21 Nanassy, is that still the current practice within the 22 department? 23 DR. JOSEPH DE NANASSY: There is no 24 formal internal review mechanism in place. In an ideal 25 world, yes, it would be nice to have regular meetings;

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1 sit down and discuss each other's cases. 2 But the reality is that we are busy enough 3 and don't have such an internal mechanism in place. 4 MS. JENNIFER MCALEER: And you don't 5 review all of the post-mortem examination reports in 6 medicolegal cases before they're sent out of the Unit 7 either? 8 DR. JOSEPH DE NANASSY: No, I don't. 9 When I took over from Dr. Carpenter as Division Chief, my 10 understanding was that I was also the designated 11 Coroner's Pathologist. And in fact, I have been asked 12 once to review an autopsy of one (1) of my colleagues in 13 that role of being the Coroner's Pathologist which I did. 14 I met with my colleague. We discussed 15 what my findings were; what needed to be done about it, 16 and that was the end of it. 17 MS. JENNIFER MCALEER: All right. And, 18 Dr. Carpenter, Dr. de Nanassy has -- has raised this 19 issue of the Coroner's Pathologist. As I understand it, 20 you were designated a Coroner's Pathologist in the 21 1990's, although you didn't actually apply for that 22 designation, is that correct? 23 DR. BLAIR CARPENTER: That's my feeling 24 here. 25 MS. JENNIFER MCALEER: Okay. That's what

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1 you recall? 2 DR. BLAIR CARPENTER: Yeah. 3 MS. JENNIFER MCALEER: All right. And 4 what was your understanding as to what was the role of a 5 Regional -- or sorry, the coroner's patholo -- Regional 6 Coroner's Pathologist? 7 DR. BLAIR CARPENTER: Well, it was the 8 extension of what I was already doing. That's why it was 9 not a big change. In fact, it was a continuity of what I 10 was already doing with Dr. Bechard. 11 We -- I was the -- the one that was 12 handling the cases that the other two (2) did not want to 13 do. 14 MS. JENNIFER MCALEER: The more 15 criminally suspicious cases? 16 DR. BLAIR CARPENTER: The more suspicious 17 case. And already say -- I was already doing that. So 18 it was not a -- a major change. 19 MS. JENNIFER MCALEER: All right. And 20 Dr. de Nanassy, you've all ready indicated that -- 21 essentially the criminally suspicious cases are equally 22 divided among the three (3) of you -- were equally 23 divided among the three (3) of you, despite the fact that 24 you are the one (1) who has the Regional Coroner's 25 pathologist designation.

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1 Is that correct? 2 DR. JOSEPH DE NANASSY: That's correct, 3 but on the part of my colleagues knowing that I am the 4 designated person, always gave them the option to come to 5 me with cases that I might have had issues with, and I 6 would take it from there. 7 MS. JENNIFER MCALEER: All right. Is 8 there any other internal oversight mechanism at present, 9 Dr. de Nanassy, that we haven't mentioned? 10 DR. JOSEPH DE NANASSY: No. 11 MS. JENNIFER MCALEER: Okay. And you -- 12 that's fine. 13 Changing now to external oversight. Dr. 14 Carpenter, what, if any, interaction did you have with 15 the Chief Forensic Pathologist Dr. Hillsdon Smith during 16 the time period in which he was the Chief Forensic 17 Pathologist and you were head of the Unit? 18 DR. BLAIR CARPENTER: Really none. 19 MS. JENNIFER MCALEER: Okay. 20 Did you ever meet him? 21 DR. BLAIR CARPENTER: No. Well, I saw 22 him at meetings, I think. I think but, again, I was 23 young and innocent, and Dr. Norman was the one handling 24 most of the thing, and I don't remember him coming to 25 Ottawa, or he -- or talking -- he never talked to me.

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1 MS. JENNIFER MCALEER: All right. 2 DR. BLAIR CARPENTER: I never talked to 3 him. 4 MS. JENNIFER MCALEER: And did you ever 5 have occasion to pick up the phone and call him to seek 6 advice or consultation on any of your cases? 7 DR. BLAIR CARPENTER: No. No, no. 8 MS. JENNIFER MCALEER: Okay. That -- 9 that's fine. 10 Then in 1994, you understand that Dr. 11 David Chiasson became the Chief Forensic Pathologist? 12 DR. BLAIR CARPENTER: Yes -- yes. 13 MS. JENNIFER MCALEER: And what contact, 14 if any, did you have with Dr. Chiasson? 15 DR. BLAIR CARPENTER: Very little. Very 16 little. I -- I met him at meetings, then we had those 17 coroners meeting, and he was there. I knew who he was. 18 He knew who I was. And we did speak at those meeting. 19 I also met Dr. Chiasson on occasion at the 20 pediatric society meetings in the -- in the US, where he 21 -- he is also a member, as I was. And we would -- we 22 were fraternists, talk together. 23 MS. JENNIFER MCALEER: All right. 24 DR. BLAIR CARPENTER: And nothing much 25 more than that. On -- on a professional basis, I

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1 respected him. I suspect he did the same thing. And 2 there was no real communication if there was no need for 3 it. 4 MS. JENNIFER MCALEER: All right. 5 DR. BLAIR CARPENTER: At least from my 6 perspective. 7 MS. JENNIFER MCALEER: If you could turn 8 to Tab 6 of your binder for a moment. 9 DR. BLAIR CARPENTER: Six (6). 10 MS. JENNIFER MCALEER: See a document 11 called Forensic Pathology Coroner. It's PFP129356. 12 DR. BLAIR CARPENTER: Yes. 13 MS. JENNIFER MCALEER: Now, do you recall 14 -- there's a series of these in this binder, Dr. 15 Carpenter, and I've reviewed them with you. 16 Do you recall receiving these forensic 17 pathology coroner newsletters? 18 DR. BLAIR CARPENTER: Yes. 19 MS. JENNIFER MCALEER: So you did receive 20 some written communication from Dr. Chiasson? 21 DR. BLAIR CARPENTER: Yes, through the -- 22 the coroner -- what was it? That's called the coroner 23 pathologist, or whatever, in that -- those -- 24 MS. JENNIFER MCALEER: The Regional 25 Coroner's Pathologist?

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1 DR. BLAIR CARPENTER: Yeah -- no, those 2 little communicate we received from the coroner's office, 3 there was always a portion by Dr. Chiasson in that, among 4 other things. 5 Yeah. They -- they are always -- were 6 very good. I -- I enjoyed reading them. 7 MS. JENNIFER MCALEER: All right. 8 COMMISSIONER STEPHEN GOUDGE: There's one 9 (1) at the next tab. Is that what you're talking about? 10 Look at the next tab. Forensic Pathology Coroner. 11 DR. BLAIR CARPENTER: Yes. 12 MS. JENNIFER MCALEER: I think they're 13 all called Forensic Pathology Coroner. 14 COMMISSIONER STEPHEN GOUDGE: They're 15 all -- 16 DR. BLAIR CARPENTER: Whatever they were, 17 I don't -- I knew I received them. I read them. I 18 enjoyed them. In fact, I put them aside. 19 20 CONTINUED BY MS. JENNIFER MCALEER: 21 MS. JENNIFER MCALEER: Oh, Ms. Ritacca 22 just pointed out to me there was a publication called the 23 Mortem Post. 24 Do you remember receiving the Mortem Post? 25 DR. BLAIR CARPENTER: That's what I'm

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1 referring to, and there was often some articles by Dr. 2 Chiasson in that -- 3 MS. JENNIFER MCALEER: In the Mortem 4 Post. 5 DR. BLAIR CARPENTER: -- most -- Mortem 6 Post. 7 MS. JENNIFER MCALEER: All right. And 8 then if we could turn to Tab 39, please. 9 DR. BLAIR CARPENTER: Thirty-nine (39). 10 Yep. 11 MS. JENNIFER MCALEER: You have that 12 document -- the document is September 1st, 1995, to all 13 pathologists and coroners regarding the review of the 14 autopsy reports on homicide cases. 15 DR. BLAIR CARPENTER: Yes. 16 MS. JENNIFER MCALEER: All right. And as 17 I understand it, in -- in or around this time, Dr. 18 Chiasson instituted a procedure by which he requested 19 that criminally suspicious post-mortem examination 20 reports be submitted to the Office of the Chief Coroner 21 so that he could review them? 22 DR. BLAIR CARPENTER: Yes. 23 MS. JENNIFER MCALEER: You understood 24 that that was a process that was in place in or around 25 that time?

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1 DR. BLAIR CARPENTER: Yes. That's what I 2 was referring, and I mixed up when I was -- started to 3 answer your other question. 4 MS. JENNIFER MCALEER: Right. 5 DR. BLAIR CARPENTER: I thought that's 6 what you were referring to. 7 MS. JENNIFER MCALEER: And did you in 8 fact submit post-mortem examination reports to the Chief 9 Forensic Pathologist? 10 DR. BLAIR CARPENTER: Yes. Yes, I -- as 11 I said, I had very good communication with Dr. Bechard. 12 He asked me to do that. He said this is a new procedure. 13 I didn't see no objection to doing that, so I -- I did 14 that. 15 MS. JENNIFER MCALEER: And what feedback, 16 if any, did you receive as a result of forwarding those 17 reports? 18 DR. BLAIR CARPENTER: In fact very 19 little, except that when Dr. Bechard was telling me, 20 Okay, now you can proceed in sending. So all case were 21 all done that way, except for one (1) case, where there 22 was some disagreement in the wording of my final comments 23 on my final autopsy. 24 And Dr. Bechard instituted a telephone 25 conference. Dr. Michaud was involved in that because he

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1 had done the neuropathology. I was involved with that 2 because I was the primary pathologist. Dr. Chiasson was 3 involved in Toronto and Dr. Bechard in Kingston, and we 4 had a discussion over the -- the case. 5 MS. JENNIFER MCALEER: Do you remember 6 what the issue was, Dr. Carpenter? Do you recall, Dr. 7 Michaud? 8 DR. JEAN MICHAUD: I -- I don't. I 9 don't. 10 DR. BLAIR CARPENTER: There was some 11 diluting of my conclusion. He thought I was maybe a 12 little forceful in my final comment and to some degree 13 disagreed with it. 14 MS. JENNIFER MCALEER: All right. And do 15 you recall what your cause of death was or...? 16 DR. BLAIR CARPENTER: I thought it was a 17 child abuse. 18 MS. JENNIFER MCALEER: And he felt -- 19 DR. BLAIR CARPENTER: And he thought that 20 there might be an element of -- that he might have been 21 strangulated. 22 MS. JENNIFER MCALEER: All right. 23 DR. BLAIR CARPENTER: It's far apart. 24 It's far apart. Don't ask me why. 25 MS. JENNIFER MCALEER: Why do you call

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1 that a "dilution," Dr. Carpenter? 2 DR. BLAIR CARPENTER: Because then he 3 wanted me to include those things. And I -- my -- well, 4 it was not -- I finally said in my wording that -- no, at 5 the end we -- we agreed to -- to stick that the -- to 6 with the -- the child abuse but to put some wording 7 saying that -- that it was -- to dilute the -- that it 8 was not as sure as it should be. 9 MS. JENNIFER MCALEER: That you were not 10 as certain as you should be? 11 DR. BLAIR CARPENTER: Oh, me? I was 12 quite certain. I was -- I was being nice by diluting 13 just to show my goodwill. 14 MS. JENNIFER MCALEER: All right. Dr. 15 Michaud, do you remember anything about this case? 16 DR. JEAN MICHAUD: I vaguely remember 17 that the conclusion, it was, I think, only one (1) word 18 that was being -- 19 DR. BLAIR CARPENTER: Being challenged. 20 DR. JEAN MICHAUD: -- challenged. And I 21 remember Blair and I talking about it. And I -- I think 22 we were sticking to our guns. But I think Dr. Carpenter 23 at the end made a comment, as he just mentioned. 24 DR. BLAIR CARPENTER: I will add to that. 25 I did agree to something very important here. Okay? I

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1 did not change that much of my final diagnosis except for 2 one (1) word. 3 But I agreed -- and I -- I assured Dr. 4 Chiasson -- that when the -- the Crown Attorney would 5 come up, that I made clear to the Crown Attorney that we 6 had that discussion, that there was some dissension and 7 what the level of the dissension was. 8 I made -- so I -- I agreed to that, in 9 fact several -- then the reports went out. 10 MS. JENNIFER MCALEER: So you said "the 11 reports." Was there more than one (1)? 12 DR. BLAIR CARPENTER: Sorry? 13 MS. JENNIFER MCALEER: You said, "the 14 reports." 15 DR. BLAIR CARPENTER: The reports were 16 sent. 17 MS. JENNIFER MCALEER: More than one (1) 18 report? Was there -- 19 DR. BLAIR CARPENTER: Well, the one (1) 20 to the other people other than the Crown; the -- the one 21 (1) to the Crown; the one (1)-- 22 COMMISSIONER STEPHEN GOUDGE: The copies 23 of your -- 24 DR. BLAIR CARPENTER: And then other 25 copies were sent out.

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1 MS. JENNIFER MCALEER: Oh, I see. 2 3 CONTINUED BY MS. JENNIFER MCALEER: 4 MS. JENNIFER MCALEER: Dr. Chiasson 5 didn't -- 6 DR. BLAIR CARPENTER: Then -- then I met 7 -- then -- then obviously the -- the Crown Attorney, when 8 he got the report, realized that -- and the police and -- 9 he was already aware, so he had the choice to prosecute 10 or not. That was then his decision. 11 Then I made clear -- he phoned me up. We 12 discussed the issue together. And I made clear to him 13 that I told him that Dr. Chiasson -- and I told him to -- 14 as I agreed with Dr. Chiasson, I told him to call him if 15 he wished, that there was a disagreement here. If he 16 wanted to know more about it, that Dr. Chiasson would 17 speak with him. And then he would have to make up his 18 mind, because there was two (2) version. 19 MS. JENNIFER MCALEER: All right. 20 DR. BLAIR CARPENTER: That was -- and I 21 couldn't do much more about that, but he could do 22 something about it. He was the Crown attorney. He had 23 his choice then to -- to look at the all the evidence and 24 push forward. He did push forward on -- on our 25 recommendation.

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1 I don't know what the outcome turned out 2 to be because there was a preliminary report and the 3 police was -- I -- after the preliminary trial -- 4 MS. JENNIFER MCALEER: The preliminary 5 hearing? 6 DR. BLAIR CARPENTER: -- was done -- the 7 -- the preliminary hearing. The -- the judge pushed on 8 that; he recommended there should be a trial. And -- my 9 understanding, by talking to the police when I called 10 them back, there was a plea guilt going on. 11 And I would -- should know by Christmas. 12 He'll come back to me -- that was in November or 13 something, October/November. By then, the police was 14 supposed to come back to me by -- by January, in the 15 most, if they were going to trial; if the plea bargain 16 was not accepted. 17 They never came back to us, so I suspect 18 the plea bargain was accepted and the -- and the -- the 19 person pleaded guilty to -- to our way of seeing things. 20 That was my conclusion. So that's the only time when 21 there was some dissension in my experience. 22 MS. JENNIFER MCALEER: Thank you, Dr. 23 Carpenter. Dr. de Nanassy and Dr. Michaud, what has been 24 your experience currently, with respect to interaction, 25 with the Office of the Chief Forensic Pathologist.

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1 Are you -- are you still sending in 2 reports in criminally suspicious or homicide cases? 3 DR. JOSEPH DE NANASSY: We personally are 4 not. I think this is happening by way of the Regional 5 Coroner. 6 MS. JENNIFER MCALEER: I see. And have 7 you ever received any feedback from the Chief Forensic 8 Pathologist with respect to any reports that you 9 understand have been forwarded to him by the Regional 10 Coroner? 11 DR. JOSEPH DE NANASSY: Very little. In 12 the past year or so and more in the past three (3) to six 13 (6) months, there has been one (1) verbal and one (1) 14 written communication from Dr. Pollanen, and one (1) 15 written communication from Dr. Chiasson. 16 Those are the ones I can recall. 17 MS. JENNIFER MCALEER: Yes, Dr. Michaud? 18 DR. JEAN MICHAUD: There has been one (1) 19 case where we had a phone conference. 20 DR. JOSEPH DE NANASSY: That's the verbal 21 I am referring to. 22 DR. JEAN MICHAUD: There was disagreement 23 as to our conclusions. 24 MS. JENNIFER MCALEER: What was the 25 nature --

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1 DR. JEAN MICHAUD: We learned -- we 2 learned afterwards that there has been -- I think there 3 was -- yeah. The -- the conference, in fact, was 4 triggered by the fact that we learned that there had been 5 an -- what I call an, unsolicited independent report done 6 on our case. 7 And we never had any news of this. We 8 never saw a copy of that report. And we were never 9 involved in any discussion whatsoever. I learned it 10 through talking to the cor -- the Crown attorney or one 11 (1) of his assistants -- that we -- we would likely go to 12 trial on this case or maybe it was a preliminary, I'm not 13 sure. 14 And that -- he informed me that there was 15 a -- another report on the table and -- 16 COMMISSIONER STEPHEN GOUDGE: Another 17 pathology report? 18 DR. JEAN MICHAUD: An unsolicited 19 independent report by Dr. Pollanen, and I reacted to 20 this. And I -- in fact, we had the conference call at 21 some point in time, and we had some discussion about the 22 pathological -- it was a neuropathological elements. 23 And we never really came to any firm 24 conclusion except that the case never went to -- to 25 trial. I think everything was solved by plea of guilt,

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1 but I -- I don't know. We don't get the information. 2 Let me open one (1) parenthesis here: 3 "It would be, sometime, very 4 interesting for us and contribute 5 knowledge and better expertise if we 6 had some feedback, sometimes, of what 7 happens. The case that Dr. Carpenter 8 alluded to; I talked to the police, the 9 investigator, and I said, Once 10 everything is finished it would be nice 11 to know exactly what kind of plea of 12 guilt was at the table because it would 13 have helped us to better understand 14 what we found, and it would probably 15 have comforted us in the belief we had 16 in our findings or differently, maybe 17 we would have said, Gee, that's 18 interesting." 19 So coming back to that case -- so we had 20 this thing and then find out we never went. And 21 recently, we learned that another case of ours was -- 22 there was a -- an unsolicited independent report issued 23 without even our knowledge. 24 And in fact, we got copy of this following 25 a specific request by Dr. de Nanassy. My comments on

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1 this are that this is not optimal. In the world of 2 pathology -- I'm talking about in general -- this -- this 3 could create confusions. It creates also question marks 4 on -- on the -- on the work of our colleagues and so on. 5 Let me give you an example in the medical 6 field. If, for example, there is a retroperitoneal 7 tumour that's seen by Dr. De Nanassy, he makes a 8 diagnosis of ganglioneuroblastoma. Well this is in the 9 area of neuropathology. Let's take the example where I 10 would send them my rep -- my own report to the 11 clinicians. 12 The clinician would have two (2) reports. 13 What kind of message am I sending to my colleagues? What 14 kind of confusion is arisen in the -- in the mind of the 15 clinicians who have to treat this patient? 16 So you know, this is the type of thing 17 that we -- we -- personally, it's not optimal. And I -- 18 I have to voice it, because this is not what happens in 19 the general world of pathology. 20 In general world of pathology, there is 21 one (1) primary pathologist. He is in charge of the case 22 from beginning to end. There are consultations done at 23 times, consultation reports come back. These are 24 included with the report and so on. I'm talking about in 25 general field of pathology.

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1 So in my view the -- the system has had, 2 you know, this is one (1) irritant that we've lived in 3 the last two (2) or three (3) years. However I've had 4 outstanding communication with Dr. Pollanen on other 5 matters. And I'm not, you know, I don't want to put any 6 negative tone to -- to this matter. 7 But this is one (1) element that we -- we 8 have to discuss, because personally, I'm -- I'm not 9 willing to accept that way of proceeding. 10 MS. JENNIFER MCALEER: All right. So 11 just to back up a little bit, Dr. Michaud. 12 DR. JEAN MICHAUD: Yes. 13 MS. JENNIFER MCALEER: So your 14 understanding is that there is a report that you -- with 15 respect to the first one (1), that there's a report that 16 you and Dr. de Nanassy had -- 17 DR. JEAN MICHAUD: Yes, I think -- 18 MS. JENNIFER MCALEER: No, sorry, you 19 mentioned two (2) recently that resulted in unsolicited 20 report -- 21 DR. JEAN MICHAUD: Well one (1) was maybe 22 two (2) or three (3) years ago, but, yeah. 23 MS. JENNIFER MCALEER: All right. Well 24 let's -- let's deal with the most recent one (1) then. 25 So you and Dr. de Nanassy had prepared a

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1 report together. Is that correct? 2 DR. JEAN MICHAUD: Yes. 3 MS. JENNIFER MCALEER: And you had given 4 it to the Regional Supervising Coroner? 5 DR. JEAN MICHAUD: Yes. 6 MS. JENNIFER MCALEER: You now understand 7 that it had then been forwarded on to the Chief Forensic 8 Pathologist. 9 Did you understand at the time that it was 10 going to be sent on to the Chief Forensic Pathologist? 11 DR. JEAN MICHAUD: We -- we don't know -- 12 we -- we are not aware of the exact process. Although 13 reading some of that document here, I think we have a 14 better knowledge. 15 The only thing we know is that these 16 reports are sent to the original coroner, and then he has 17 a decision to make as to that's it, that's fine, or he 18 can send it to the -- to a review committee. 19 Certainly all kids under five (5), we 20 believe, we think, are reviewed. We don't know the 21 membership of the committee. In fact I learned the 22 membership of the committee last night. 23 MS. JENNIFER MCALEER: Right. I don't 24 want to get into that just yet -- 25 DR. JEAN MICHAUD: But --

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1 MS. JENNIFER MCALEER: -- Dr. Michaud, so 2 just -- 3 DR. JEAN MICHAUD: Okay. 4 MS. JENNIFER MCALEER: -- let me narrow 5 my question down. 6 DR. JEAN MICHAUD: Please. 7 MS. JENNIFER MCALEER: So with respect to 8 this particular case -- 9 DR. JEAN MICHAUD: Yes. 10 MS. JENNIFER MCALEER: -- when you 11 submitted that report to the Regional Supervising 12 Coroner, you didn't know where it would go from there. 13 Is that correct? 14 DR. JEAN MICHAUD: Well we suspected it 15 goes to review committee, or perhaps -- 16 MS. JENNIFER MCALEER: You thought it -- 17 DR. JEAN MICHAUD: -- the Chief 18 Pathologist, but we -- we don't know for sure. 19 MS. JENNIFER MCALEER: You don't know for 20 sure? 21 DR. JEAN MICHAUD: No. 22 MS. JENNIFER MCALEER: And we'll come 23 back to that. 24 And then what happened is that you were 25 told by the Crown Attorney that in fact the Chief

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1 Forensic Pathologist had authored -- no, sorry. 2 What happened, Dr. de Nanassy? 3 DR. JOSEPH DE NANASSY: The way it 4 happened, I got a written communication from Dr. Pollanen 5 saying, I have issued an independent report on this case 6 of yours. 7 MS. JENNIFER MCALEER: I see. 8 DR. JOSEPH DE NANASSY: Should you wish 9 to have a copy, let me know. 10 MS. JENNIFER MCALEER: I see. 11 DR. JOSEPH DE NANASSY: So I wrote back 12 to him. I said, Yes, if there is no objection on the 13 part of counsel, we would like to get a copy. And next 14 thing we have is in the mail comes a copy of his 15 independent report. 16 MS. JENNIFER MCALEER: I see. And that 17 gets us to where Dr. Michaud was explaining? 18 DR. JOSEPH DE NANASSY: Yes. 19 MS. JENNIFER MCALEER: Now would you 20 agree though that there is a role for the Chief Forensic 21 Pathologist with respect to providing oversight on the 22 work of pathologists practising in areas that give rise 23 to forensic reports or in -- in the area of forensic 24 pathology? 25 DR. JEAN MICHAUD: Oh there is no doubt

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1 that he has an important role in there. He doesn't have 2 to do everything. He has to set up a system where things 3 are done. I would not recommend that he takes on his 4 shoulder everything that has to be done. 5 That's why, you know, the notion of 6 committees exist, notions of delegations through roles 7 that are better -- well defined and so on. There is no 8 doubt, absolutely no doubt. 9 MS. JENNIFER MCALEER: Dr. de Nanassy -- 10 DR. JEAN MICHAUD: I said that it's -- 11 MS. JENNIFER MCALEER: -- do you agree? 12 DR. JOSEPH DE NANASSY: I agree. 13 MS. JENNIFER MCALEER: Okay. And you've 14 made reference to the fact that there are a few 15 committees. 16 What is your understanding as to what are 17 the committees that exist, Dr. de Nanassy? 18 DR. JOSEPH DE NANASSY: There is the 19 Death Under Five Committee that we know of, and the 20 Pediatric Deaths Review Committee. 21 MS. JENNIFER MCALEER: And what is your 22 understanding as to the role of the Death Under Five 23 Committee? 24 DR. JOSEPH DE NANASSY: We were never 25 informed formally as to what the role of that Committee

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1 might be, but we are not dummies. 2 Our understanding is that they probably 3 would be reviewing all autopsies that have been done on 4 the record as warrant in children under five (5). 5 MS. JENNIFER MCALEER: Do you -- do you 6 know who's on the Committee? 7 DR. JOSEPH DE NANASSY: I have no idea. 8 MS. JENNIFER MCALEER: Do you know what 9 the Committee's mandate is? 10 DR. JOSEPH DE NANASSY: No, I don't. 11 MS. JENNIFER MCALEER: Have you ever had 12 any interaction with the Coroner's Office about the Death 13 Under Five Committee? 14 Have you ever spoken to the Chief Coroner, 15 or the Chief Forensic Pathologist about the Death Under 16 Five Committee? 17 DR. JOSEPH DE NANASSY: Never. 18 MS. JENNIFER MCALEER: Dr. Michaud, have 19 you? 20 DR. JEAN MICHAUD: The same. In fact, 21 today I know more than I knew yesterday, because of the 22 documentation that was put as -- in this binder last 23 night, and so on. 24 This is the first time I had access to the 25 terms of reference of -- of those committees; the

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1 membership of those committees; the kind of work that 2 they do. 3 I think I gather the notion that they 4 don't review all cases now. I think the original coroner 5 has some -- a word to say about the -- about the type of 6 cases that could be reviewed, but you know -- no. This 7 is something that we were -- we were really in the dark. 8 You could accuse us of not having asked. 9 MS. JENNIFER MCALEER: That was -- that 10 was going to be my next question is that you -- you've 11 obviously been aware that this committee exists for some 12 time, correct? 13 DR. JEAN MICHAUD: Yeah. We never -- 14 MS. JENNIFER MCALEER: And -- and you've 15 not -- 16 DR. JEAN MICHAUD: -- we've never -- I'm 17 sorry. I interrupted, I'm sorry. 18 MS. JENNIFER MCALEER: You've not made 19 inquiries of the Office of the Chief Coroner to try and 20 learn more about the committee, or the role it serves? 21 DR. JEAN MICHAUD: You -- you never get 22 feedback. So you know, life -- human nature is human 23 nature. 24 We're all busy. We all have things to do 25 every day -- every hour of the day.

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1 If you never get any feedback, you don't 2 get a trigger. 3 So not having any trigger, we never asked. 4 MS. JENNIFER MCALEER: And -- and do you 5 know which cases go to the Death Under Five Committee, or 6 is it your understanding that they all go? All death 7 under five (5) is -- the Regional Coroner is sending them 8 to this committee? 9 DR. JEAN MICHAUD: We don't know for 10 sure. 11 MS. JENNIFER MCALEER: Okay. And -- for 12 just briefly, with respect to the other committee you 13 mentioned, the -- the Pediatric Death Review Committee. 14 Do you have any greater knowledge with 15 respect to who's on that committee, or what the mandate 16 is, or which cases may be going to that committee? 17 DR. JEAN MICHAUD: Today a little bit 18 better, yeah. 19 MS. JENNIFER MCALEER: Just from 20 reviewing the materials that were provided to you last 21 night? 22 DR. JEAN MICHAUD: Exactly, yeah. 23 MS. JENNIFER MCALEER: And same question, 24 you hadn't made previous inquiries of the Office of the 25 Chief Coroner with respect to that committee, or it's

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1 mandate. Is that correct? 2 DR. JEAN MICHAUD: Never any 3 interactions. No interactions whatsoever. 4 MS. JENNIFER MCALEER: All right. This 5 might be a good time to break for lunch. 6 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 7 McAleer. 8 We'll come back then at 2:00. 9 10 --- Upon recessing at 12:46 p.m. 11 --- Upon resuming at 2:03 p.m. 12 13 THE REGISTRAR: All Rise. Please be 14 seated. 15 COMMISSIONER STEPHEN GOUDGE: Ms. 16 McAleer...? 17 18 CONTINUED BY MS. JENNIFER MCALEER: 19 MS. JENNIFER MCALEER: Thank you, Mr. 20 Commissioner. Dr. de Nanassy, before the break there was 21 a -- a reference to the fact that in Ottawa at CHEO, you 22 are no longer doing any of the criminally suspicious 23 cases. 24 Can you please indicate when it was that 25 you first became aware of the fact there had been a

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1 decision that these cases would no longer be sent to 2 CHEO? 3 DR. JOSEPH DE NANASSY: I don't know 4 about any decision having been taken. The way we found 5 out was in kind of a serendipitous way, in that one (1) 6 day there were police officers sitting in the hallway in 7 front of the morgue. 8 And there was a body in there, which was 9 going to have a medicolegal autopsy done, except the 10 police officers were there to accompany the body to 11 Toronto. 12 MS. JENNIFER MCALEER: And when was this, 13 Dr. de Nanassy? 14 DR. JOSEPH DE NANASSY: Two (2) or three 15 (3) months ago, ballparkin' it. 16 MS. JENNIFER MCALEER: And did you make 17 inquiries as a result of that event? 18 DR. JOSEPH DE NANASSY: I mentioned the 19 occurrence to Dr. Michaud, and he wasn't aware of any 20 decision having been taken either. And he asked me to 21 inquire from the Regional Coroner as to why that would be 22 happening. 23 And so I contacted the Regional Coroner, 24 who happened to be away on an inquest. And I spoke to 25 his replacement who was surprised that I would not know.

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1 MS. JENNIFER MCALEER: And I understood 2 that the -- the replacement was actually Dr. Bechard, who 3 had -- 4 DR. JOSEPH DE NANASSY: I spoke to Dr. 5 Bechard. 6 MS. JENNIFER MCALEER: -- previously 7 retired but was filling in for Dr. McCallum as a result 8 of his work on the inquest. Is that correct? 9 DR. JOSEPH DE NANASSY: That's correct. 10 MS. JENNIFER MCALEER: All right. 11 COMMISSIONER STEPHEN GOUDGE: It's Dr. 12 McCallum who is now...? 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: Yes, Dr. McCallum 16 is now the Regional Supervising Coroner. And what did 17 you learn from your conversation with Dr. Bechard? 18 DR. JOSEPH DE NANASSY: Well he was 19 surprised that we wouldn't know. And he thought -- he 20 was under the assumption that we were aware of that 21 change. 22 MS. JENNIFER MCALEER: Sorry, and what 23 was the change? 24 DR. JOSEPH DE NANASSY: That -- that 25 criminally suspicious cases would not be autopsied at

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1 CHEO. 2 COMMISSIONER STEPHEN GOUDGE: But would 3 go to Toronto? 4 DR. JOSEPH DE NANASSY: But would go to 5 Toronto. 6 COMMISSIONER STEPHEN GOUDGE: Where in 7 Toronto? 8 DR. JOSEPH DE NANASSY: I don't know 9 exactly; I suppose the Hospital for Sick Children. 10 11 CONTINUED BY MS. JENNIFER MCALEER: 12 MS. JENNIFER MCALEER: And did Dr. 13 Bechard explain to you his understanding as to why that 14 decision had been made or who had made that decision? 15 DR. JOSEPH DE NANASSY: No. But what he 16 offered was that he was going to have a meeting in 17 Toronto with all the other regional coroners and the 18 Chief Forensic Pathologist, and he was going to raise the 19 issue at that meeting and feedback to me. 20 MS. JENNIFER MCALEER: And what was the 21 next you heard on the subject, Dr. de Nanassy? 22 DR. JOSEPH DE NANASSY: Well he called me 23 back several days, if not a week, later. And so we were 24 on the phone. And he -- he said this is a temporary 25 measure. The criminally suspicious cases would be

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1 bypassing CHEO until such time that this Commission 2 issues its report, at which time the -- the situation 3 will be reviewed. 4 MS. JENNIFER MCALEER: And did he provide 5 you with any other explanations to why CHEO was being 6 bypassed? 7 DR. JOSEPH DE NANASSY: All he said is 8 that it's not a matter of competence -- professional 9 competence -- on our part. It's more a precautionary 10 measure. 11 MS. JENNIFER MCALEER: And since that 12 conversation, that second conversation with Dr. Bechard, 13 have you had any other conversations with Dr. McCallum, 14 for example, with respect to this issue? 15 DR. JOSEPH DE NANASSY: Yes, when Dr. 16 McCallum resumed his functions as regional coroner, he 17 called me one day on an unrelated issue. And since he 18 was on the line anyway, I took the issue up with him. 19 And he said, I thought we had discussed 20 this in the summer? And in fact we hadn't, at least I 21 don't have a recollection of us having discussed that. 22 And so I asked him to provide us with something in 23 writing as to why those criminally suspicious cases would 24 be bypassing CHEO, to which he agreed. 25 He said he might sent an email clarifying

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1 it, and so we would have something in writing. I'm still 2 waiting. 3 MS. JENNIFER MCALEER: All right. And 4 since that conversation with Dr. McCallum, have you 5 learned anything more on the subject? 6 DR. JOSEPH DE NANASSY: No, I have not. 7 MS. JENNIFER MCALEER: And what are your 8 views, Dr. de Nanassy, as to whether or not CHEO should 9 be bypassed at present with respect to criminally 10 suspicious cases? 11 DR. JOSEPH DE NANASSY: I don't think we 12 should. We have not been bypassed prior -- in prior 13 times. So I don't quite -- I'm not quite 100 percent 14 sure why, out of the blue. 15 We were not involved in the process. We 16 were not involved in the decision. The decision was not 17 communicated to us. We kind of found out as a surprise. 18 MS. JENNIFER MCALEER: All right. Dr. 19 Michaud, had you had any discussions with Dr. Bechard or 20 Dr. McCallum, or anybody from the Office of the Chief 21 Coroner with respect to this decision to not send 22 criminally suspicious cases to CHEO, at least for the 23 time being? 24 DR. JEAN MICHAUD: No, I had not -- I 25 have not had any discussion with either Dr. Bechard or

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1 Dr. McCallum. 2 MS. JENNIFER MCALEER: And what are your 3 views on the subject? 4 DR. JEAN MICHAUD: My views are -- I -- I 5 would like to endorse with it, other than, as he just 6 mentioned -- you know, there -- there is no major 7 objections to make such a decision. What I'm objecting 8 very strongly is the process. 9 MS. JENNIFER MCALEER: I see. 10 DR. JEAN MICHAUD: Again, it's a -- it's 11 a lack of transparency, a lack of collegiality, and the 12 way the process evolved and the decision was made. I -- 13 so I -- I think the process was not optimal and wasn't 14 adequate in this case. 15 MS. JENNIFER MCALEER: What would you 16 have preferred, Dr. Michaud? 17 DR. JEAN MICHAUD: It would have been 18 very nice for the authorities, whoever, to sit -- sit 19 down with us and explain the rationale for this decision. 20 We would have had the possibility to discuss, argue 21 perhaps, and so on. But at least we would have a word to 22 say. 23 And then a written notice would have been 24 nice just to confirm the -- the whole thing. But, you 25 know --

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1 COMMISSIONER STEPHEN GOUDGE: Who do you 2 think made the decision, Dr. Michaud, the chi -- 3 DR. JEAN MICHAUD: We don't know. 4 COMMISSIONER STEPHEN GOUDGE: Who -- 5 DR. JEAN MICHAUD: We don't know. 6 COMMISSIONER STEPHEN GOUDGE: -- who do 7 you suspect: the Chief Coroner, the Chief Forensic 8 Pathologist, combination? 9 DR. JEAN MICHAUD: Well, if -- if the 10 administrative system works well, I believe that this is 11 probably a several-person decision. I don't know. But 12 we don't know. 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: And as I 16 understand it, then, Dr. Michaud, you don't have any 17 concern with the fact that the decision was made. 18 Simply your concern is with the manner in 19 which is was communicated or not communicated to you. Is 20 that correct? 21 DR. JEAN MICHAUD: You know, ady -- any 22 administrative decision has pluses and minuses. It's 23 possible that we would have accepted the rationale behind 24 that decision. 25 But we were not, I believe, treated in a

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1 collegial fasson -- fashion. I do not believe that we 2 were treated in a profession fashion for that specific 3 aspect of -- of the -- of the process. We never had a 4 chance to have a word about this, and we never had a 5 chance to even get the information. 6 We -- we learned indirectly, in fact -- 7 Dr. de Nanassy mentioned the police in the corridor. The 8 day before, I had -- I had read the Citizen article about 9 this -- this case, and I was surprised not to see the -- 10 the case in the autopsy logbook. And when I talked to 11 him about it, well, he -- he told me the story about the 12 policeman in the corridor and the case in Toronto. 13 So -- so that's -- you know, that's not 14 fair, and that's not the way we should proceed with 15 professional colleagues. 16 MS. JENNIFER MCALEER: All right. 17 COMMISSIONER STEPHEN GOUDGE: Did either 18 of you form any understanding about what was meant, that 19 this is a precautionary measure? 20 What does that mean to both of you? 21 22 (BRIEF PAUSE) 23 24 DR. JEAN MICHAUD: It means that they are 25 pushing the precaution to the limit. It infers that we

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1 may not have the capacity to be able to work at the limit 2 of the capacity of the system. 3 I -- I think it has -- there is an 4 insidious message about our capacity to do these cases. 5 COMMISSIONER STEPHEN GOUDGE: About your 6 qualifications? 7 DR. JEAN MICHAUD: Ask them; I don't 8 know. 9 COMMISSIONER STEPHEN GOUDGE: No, but 10 when you say "capacity," Dr. Michaud, you mean your -- 11 DR. JEAN MICHAUD: Yeah, about the 12 professional capacity -- 13 COMMISSIONER STEPHEN GOUDGE: Competence. 14 DR. JEAN MICHAUD: -- and competence. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. JEAN MICHAUD: That -- that's what it 17 infer. That's the kind of message that you are tempted 18 to -- 19 COMMISSIONER STEPHEN GOUDGE: -- to read 20 into it? 21 DR. JEAN MICHAUD: Exactly. Do I read 22 that message? No, I don't have any, any, any evidence 23 whatsoever that there is a lack of competence in -- in 24 our group. And I have, in fact, indications that when my 25 colleagues feel that they have reached their limit, they

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1 act accordingly. And I think examples were given earlier 2 today that some cases are sometimes are sent out and so 3 on. 4 But -- so again, the process, in our view, 5 was not very optimal of whatever -- 6 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 7 McAleer. 8 9 CONTINUED BY MS. JENNIFER MCALEER: 10 MS. JENNIFER MCALEER: And, Dr. de 11 Nanassy, what is your view with respect to whether or not 12 CHEO should be doing cases that are criminally suspicious 13 or where a homicide is suspected? 14 DR. JOSEPH DE NANASSY: Let me state 15 unequivocally, I think criminally suspicious cases in 16 pediatric-age patients should be done by a pediatric 17 pathologist in a pediatric hospital setting with the 18 option of calling in a forensic expert as needed, 19 depending on the case. 20 MS. JENNIFER MCALEER: And -- and is why 21 is that, Dr. de Nanassy? 22 DR. JOSEPH DE NANASSY: Because there is 23 a reason there is a subspecialty called pediatric 24 pathology. There are aspects of pediatric pathology 25 which a forensic pathologist might not be fully cognizant

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1 with, hence we as pediatric pathologists are the 2 gatekeepers of those conditions that affect the pediatric 3 population more so -- or almost exclusively in certain 4 instances -- that would not occur in a -- in a -- an 5 adult-type forensic setting. 6 And so we should be the ones to be the 7 judges of when to call in forensic experience. 8 MS. JENNIFER MCALEER: So you would not 9 be willing to agree to a system, then, in which the 5 10 percent of cases that are criminally suspicious or look 11 like homicide from the outset, that those cases be sent 12 to a forensic pathologist and that the forensic 13 pathologist in his or her discretion contact the 14 pediatric pathologist if in their view they feel they 15 need added expertise? 16 DR. JOSEPH DE NANASSY: I would -- I 17 would favour my previous approach, in that we should be 18 the first ones to have a first look at a given case. And 19 we know where our limits lie; we would call in help. 20 MS. JENNIFER MCALEER: And -- but -- but 21 why is that, Dr. de Nanassy? 22 I mean, with -- with the cases that are 23 obvious, criminally suspicious or potential homicides, 24 why shouldn't those goes to somebody who has that 25 skillset, that forensic skillset that's probably going to

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1 be rather important in evaluating that case? 2 DR. JOSEPH DE NANASSY: Because there 3 might be conditions in a given patient which might be 4 unknown or had -- had gone undetected up to that point in 5 time, which a pediatric pathologist would be in a better 6 position to -- to identify or at least raise suspicion 7 about. 8 I'm thinking congenital abnormalities, 9 metabolic disorders, genetic abnormalities, that kind of 10 things, which a forensic pathologist may or may not -- 11 depending on -- on experience -- be even aware of. 12 MS. JENNIFER MCALEER: Dr. Michaud, what 13 are views on this topic? 14 DR. JEAN MICHAUD: Well, my views are -- 15 are -- my -- my views are not very firmly anchored one 16 way or the other. Let me preface my answer to the 17 following. 18 Again, this is the kind of circumstances 19 where we should have the possibility to sit down, review 20 the pros and cons, discuss collegially with people, and 21 come up with a process that would be fair and equitable, 22 but will, most importantly, contribute to the better of 23 the individual's knowledge, but also contribute to the 24 better of the system. 25 Now, in true forensic pediatric pathology,

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1 there are elements that are indeed truly forensics. But 2 there are issues that are purely pediatrics. 3 Unless you take care of one (1) or two (2) 4 cases in the literature of Adult Shaken Syndrome -- The 5 Shaken Syndrome, or Shaken Impact Syndrome, Shaken Baby 6 Syndrome, and so on -- this is a pediatric forensic issue 7 that -- with -- with grey zones, with elements of 8 discussions and so on, that are better known by pediatric 9 pathologists than adult pathologists. In fact, they 10 don't know much about it compared to pediatric 11 pathologists. 12 This body of knowledge also lies on 13 elements that pertain to the pediatric knowledge. The -- 14 for example, as a neuropathologist I can tell you that 15 the brain of premature baby, the brain of a newborn, and 16 the brain of a three (3) month old is not the same as an 17 adult brain. 18 The musculature of babies and so on -- you 19 know, there're a set of elements that form the base in 20 better understanding the physiopathology of various 21 elements that are part of that syndrome. 22 And -- and I'm using that example because 23 I think it's a -- it's a nice example. But at the same 24 time I acknowledge that this is an example where there 25 are grey zones, and then you would probably benefit from

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1 some discussions with others and so on. 2 But this is one (1) area where I'm not 3 sure if an adult forensic pathologists would even care to 4 be part of. In other circumstances, yes, perhaps a 5 forensic pathologist would be of great help. And at some 6 times, you know, I -- I wouldn't even mind perhaps that 7 he -- he takes lead in the case, providing the second 8 doctoring -- the second doctor would be a pediatric 9 pathologist. 10 We're talking here things that we see more 11 in adults. We're talking then of older children, okay. 12 MS. JENNIFER MCALEER: So what kinds of 13 cases would those be, Dr. Michaud? Are we talking about 14 stabbing cases or -- 15 DR. JEAN MICHAUD: Yeah, we could talk 16 about that type of things, toxicology, you know, drug 17 abuse in teenagers, even suspicious fire with death, and 18 so on. 19 You know, we're talking about this range 20 of case where I believe that I would not have any problem 21 to have either a forensic pathologist be the second 22 doctor in the room or even be the primary doctor. I 23 think we would probably all agree with this. 24 But there -- there is -- there is this 25 other side of pediatric forensic pathologist, which is

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1 very indirectly integrated in -- in the body of knowledge 2 in our training, in our CME activities, and so on, where 3 I believe the pediatric pathologist should have -- should 4 have the lead. 5 You want to put a -- a forensic 6 pathologist in the room, no problem. But I -- I would -- 7 I would argue that in those circumstances pediatric 8 pathologist remains the primary pathologist, the one who 9 eventually, after proper consultation, discussions, and 10 so on, issue the report. 11 So that -- that's -- that's the way I see 12 this thing. But again, it's open for discussion. And we 13 hope that at some point in time we'll be asked to be part 14 of the discussion, unless, you know, the -- the system is 15 such that it's very regulatory and so on. But this is 16 something that has to be discussed collegially. 17 MS. JENNIFER MCALEER: So in -- in your 18 view, Dr. Michaud, who should be making that decision? 19 Is that a decision that should be made the Coroner's 20 Office or the -- the regional coroner, as to who should 21 take the lead on a particular case? Or is that something 22 where you'd like to see a set of criteria developed and - 23 - and by whom? 24 How should we set about putting in -- into 25 place a system that would triage these cases?

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1 DR. JEAN MICHAUD: Well, as in any 2 institution, the senior management is the one doing the - 3 - the -- doing -- take the -- making the -- the decision, 4 okay. So it's the Office of the -- the Chief Coroner. 5 What -- what I'm saying here is that this 6 is a type of decision that requires input from those who 7 work within the system. Let me just give you an analogy. 8 We've received -- and at time we have not 9 received -- guidelines. You know, there are some stuff 10 here in this book pertaining to pediatric forensic 11 pathology that were issued no later than this year that 12 we have never received. 13 MS. JENNIFER MCALEER: Now, are you 14 talking, Dr. Michaud, about the guidelines that have been 15 prepared recently, in October of 2007, with respect to 16 criminally suspicious cases? 17 DR. JEAN MICHAUD: Yeah, the ones in 18 October -- the ones in October. 19 And also let me give you a couple of other 20 examples. Tab 42, "Report of the Pediatric Death Review 21 Committee," we had not received, issued in June 2007. 22 MS. JENNIFER MCALEER: All right. Just 23 slow down for a second. So that's PFP0571. 24 That's the June 2007 report from the 25 Pediatric Death Review Committee?

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1 DR. JEAN MICHAUD: Yeah. And another 2 interesting document, it's not because it -- it adds a 3 lot to our knowledge, but it -- it's very interesting 4 information and so on. 5 And this is the appendix R, or Tab 43, 6 which is entitled "Protocol for the Investigation of 7 Sudden and Unexpected Death in Children Under Five (5) 8 Years of Age." We have it now, but, you know, I -- I -- 9 personally, I have not seen that before. And -- 10 MS. JENNIFER MCALEER: Dr. de Nanassy, 11 you're nodding. Had you seen that document before? 12 DR. JOSEPH DE NANASSY: Yes, we have it 13 on file. 14 DR. JEAN MICHAUD: You have -- well, I 15 did not -- I'm sorry. But, you know, the guidelines for 16 the performance of pediatric autopsy in the forensic 17 world, I do not believe that people -- my colleagues -- 18 that we were ever consulted about this. You know, so we 19 received these guidelines, and we don't -- we don't have 20 a real chance to give input. 21 So, you know, this -- these are the issues 22 that are irrita -- irritating a little bit, is that we 23 receive these things. But we're -- we're part of the 24 practising body, and -- and yet we don't have a -- you 25 know, we don't have a chance to say a word or giving some

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1 feedbacks and so on. 2 In my other administrative roles, policies 3 are developed all the time. They are reviewed by 4 people. People have the chance to give a feedback. 5 And, you know, various policies on medical 6 directives in hospitals at large, this is reviewed by the 7 Medical Advisory Committee. This is reviewed by the 8 nursing body. This is reviewed sometimes by even those 9 in -- in charge of the sedation and so on. And at the 10 end of the day there is a final report. It's approved by 11 senior management and so on, and here it is. 12 But at least people have had a chance to 13 comment and bring sometimes very positive and 14 constructive suggestions for improvement. 15 But, you know, this is another area that 16 pertains in -- in a way to the same that we were 17 discussing. It's nice to have those practising, it's 18 nice to have their opinion. 19 MS. JENNIFER MCALEER: Dr. de Nanassy, 20 with respect to the documents that Dr. Michaud has 21 pointed out, in particular the -- the guidelines on 22 autopsy practice for forensic pathologists, which is at 23 Tab 38, PFP139350, from October of 2007. 24 Do I understand that you had not 25 previously seen this document, Dr. de Nanassy?

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1 DR. JOSEPH DE NANASSY: I have not seen 2 it prior to being involved with this -- the -- the work 3 of this Commission. 4 MS. JENNIFER MCALEER: And is this a 5 document that, like Dr. Michaud, you would like to have 6 had some input or a consultation -- 7 DR. JOSEPH DE NANASSY: Yes. 8 MS. JENNIFER MCALEER: -- in with the 9 Coroner's Office with respect to drafting that? 10 DR. JOSEPH DE NANASSY: Yes. 11 MS. JENNIFER MCALEER: And having had the 12 chance to review the document, although briefly, Dr. de 13 Nanassy, is there anything in that document that troubles 14 you or that you disagree with? 15 DR. JOSEPH DE NANASSY: Let me state in 16 very general terms, I think this is a very good document. 17 It's -- it's the right -- it's -- it's a step in the 18 right direction. As I was going over it there were a 19 couple of little things that attracted my attention, 20 specifically on page 6 of the document point -- 2.4, the 21 second sentence in that paragraph: 22 "Only a forensic pathologist with 23 pediatric forensic experience or a 24 pediatric pathologist with significant 25 forensic experience will perform the

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1 autopsy in the homicidal and criminally 2 suspicious deaths of an infant or 3 child." 4 MS. JENNIFER MCALEER: And what is it 5 that troubles you with respect to that sentence? 6 DR. JOSEPH DE NANASSY: The -- the 7 reference to a pediatric pathologist with significant 8 forensic experience. If those cases are bypassing me, 9 how am I going to acquire that significant forensic 10 experience? 11 MS. JENNIFER MCALEER: Perhaps through 12 CME activities, or courses by the Coroner's Office, or 13 mentoring with doctors from the Forensic Unit, double 14 doctoring. 15 Are those viable possibilities that could 16 provide one with the level of experience one would 17 require? 18 DR. JOSEPH DE NANASSY: I agree with you, 19 they would be, except that attending at courses and CME 20 activity is theoretical. You also learn by doing. So if 21 those cases are bypassing me, when will I get a chance to 22 actually doing them? 23 MS. JENNIFER MCALEER: I see. And Dr. de 24 Nanassy, has anybody suggested to you any possibility 25 with respect to how you might gain that experience?

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1 Have you ever been invited to come to the 2 Office of the Chief Coroner, for example, to do a 3 internship or -- that's probably not the right word -- 4 but at least a placement with them for a couple of 5 months, for example, to get that added experience? 6 DR. JOSEPH DE NANASSY: In the lead up to 7 the work of this Commission it has been suggested to me 8 by the regional Chief Coroner that if I wanted to, I 9 would be able to come to the Chief Forensic Pathologist's 10 office and upgrade my skills in that area. Prior to that 11 I was not offered that option. 12 I should also add that I have received 13 communication from Dr. Pollanen's office in the last few 14 months referring to a -- to a conference on forensic 15 pathology that was to be offered in November, the 16 beginning of November of this year, to which pathologists 17 and others working in the -- in the forensic field were 18 invited to. 19 And had I been available, I would have 20 gladly come. But I had a prior commitment. I was out of 21 town elsewhere in Canada and couldn't physically be in 22 two (2) locations. But I would avail myself of the 23 opportunity in the future, any time. 24 MS. JENNIFER MCALEER: Well, what -- what 25 about the invitation to come to the Office of the Chief

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1 Coroner? 2 Is that something that you think you might 3 be able to avail yourself of? 4 DR. JOSEPH DE NANASSY: Yes, I would -- I 5 would be interested. I would like to -- I would make 6 myself available. 7 MS. JENNIFER MCALEER: All right. Dr. 8 Michaud, you had an added comment? 9 DR. JEAN MICHAUD: The comment I'd like 10 to add is that there are two (2) angles to that document 11 in October and realistically we haven't had the time to 12 scrutinize it or read in its entirety or very carefully, 13 whatever. 14 There is one (1) element that pertains to 15 the science of forensic pathology, some of it adult, some 16 of it pediatrics. 17 There is another element that deals with 18 processes. And if I look, for example, at the -- I'm 19 looking at the table of contents, page 3: 20 "Policy of quo -- for quality assurance 21 and peer review of autopsy reports in 22 homicides and criminally suspicious 23 cases." 24 This is one (1) other area where you need 25 input from the stakeholders. In -- in our regular

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1 department of pathology there is a lot -- and in fact, in 2 departments of lab medicine in general -- there's a lot 3 of quali -- quality assurance activities, quality 4 management activities that occur. 5 This is an area where you have to give 6 information to everybody. You have -- you have to have 7 the process, well, you know, the proc -- the policies, 8 the processes, and the procedures spelled out. You have 9 to get some feedback. You have to have input of -- of 10 also those who are peripheral to the system and so on. 11 And then once accepted, this has to be shared with 12 everybody. 13 This is -- this has to be a transparent 14 process. And it has to be a process that aims at 15 improving the things and also respect the individuals who 16 are part of this system. 17 So this is another angle which I -- I feel 18 is as important as the science, because the science we 19 can always discuss and improve. But once a process is -- 20 is in place, it's a bit more difficult to change. And 21 better -- better to do it as best as possible right from 22 the beginning. 23 So that's another comment I'd like to make 24 on this document. 25 MS. JENNIFER MCALEER: But if I

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1 understand you, what you're saying, Dr. Michaud, is that 2 you acknowledge the importance of quality assurance as 3 recognized in the document? 4 DR. JEAN MICHAUD: This is essential. 5 MS. JENNIFER MCALEER: Right. But not 6 that you disagree with anything that's in this document 7 with respect to quality assurance. Is that correct? 8 DR. JEAN MICHAUD: There -- there are 9 elements I would like to have the opportunity to discuss, 10 yes. But I am totally, totally in favour of a quality 11 assurance process. 12 And I'm also in favour of performance 13 review process. Performance review is even more 14 important, even more important to have a buy in of 15 everybody who's in the system and who may likely -- who 16 is likely to be reviewed at some point in time. 17 MS. JENNIFER MCALEER: So you would like 18 to have some input into the development of the policy due 19 to the fact that you see it as being very important and 20 you have to have buy in from the institution? 21 DR. JEAN MICHAUD: This is an example 22 that I am using for a need for interactions between 23 people practising in this field. Yes, input should be 24 requested. The documents are excellent. I'm not -- 25 don't take me wrong here. But there are elements, I

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1 believe, that have to be discussed, some that may be 2 improved, some where we should get a better of the 3 understanding on how it's -- it came to be there or why 4 it's there. 5 You know, at this moment it's tabled. We 6 receive it, we read. But we -- sometimes we don't have 7 the -- the background information that may have lead the 8 inclusion of such -- or such element in this document. 9 All of this contributes to collegiality 10 and, in -- in my book, contributes to a better output. 11 MS. JENNIFER MCALEER: Yes, Dr. de 12 Nanassy? 13 DR. JOSEPH DE NANASSY: A moment ago you 14 had asked me about CME. And I just wanted to add to that 15 I have been reading about Dr. Pollanen's offer to 16 organize such CME activity under the aegis of his office. 17 I just wanted to say that I'm very 18 supportive of Dr. Pollanen's initiative in -- in that 19 field. There isn't very much in terms forensic 20 continuing education being offered, and so I -- I would 21 applaud Dr. Pollanen's initiative along those lines. 22 MS. JENNIFER MCALEER: Dr. Carpenter, 23 just to bring you back into the discussion, given your 24 twenty-five (25) odd years of experience doing pediatric 25 forensic work, are -- what are your views?

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1 Do you think there are certain cases that 2 might be better done by a forensic pathologist than a 3 pediatric pathologist or where the forensic pathologist 4 takes primary carriage of the autopsy? 5 DR. BLAIR CARPENTER: Personally, I think 6 that the first -- that the first choice would be a 7 pediatric pathologist with experience in forensic 8 pathology. There aren't that many of those people 9 around, and certainly is not easy to -- to do. 10 I think there should be some in the major 11 centre, if there are two (2): one (1) in Ottawa, one (1) 12 in -- at least some in Toronto, some in Ottawa. If we 13 put other centres in the province that will do for our 14 pediatric, then we should have some of those in those 15 centres too. 16 If that implies that you have some fellow, 17 some resident who can be -- may be stimulated or to -- to 18 do such a fellowship and some training, then the problem 19 would be solved in the Province of Ontario if we could 20 have three (3) or four (4) -- maybe two (2) in Toronto 21 area and one (1) in the other areas -- of -- experienced 22 as pediatric pathologists doing forensic pathology. 23 That is the answer. This is the number 1 24 and it precedes, as far as I'm concerned, everything 25 else.

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1 MS. JENNIFER MCALEER: A matter of 2 training -- 3 DR. BLAIR CARPENTER: Yes. Now -- now, 4 this is a view that may or may not be possible in the 5 near future or even in the longer future. Therefore, the 6 second choice would be to have some adult forensic 7 pathologists with some training in pediatric pathology 8 with a will and an interest in those and realizing that 9 would be the Number 2. 10 Number 3, now, you're going down the 11 ladder, and that would be having a pediatric pathologist 12 with little forensic training, if you have no other 13 choice. 14 And the forth down the line would be an 15 adult pathologist without pediatric experience in forens 16 -- and significant major pediatric forensic training. 17 So you're back to stimulating, training, 18 organizing over the next five (5), ten (10) years a 19 cohort of pediatric pathologists with forensic training 20 or adult pathologists with good, strong pediatric 21 training. 22 COMMISSIONER STEPHEN GOUDGE: When you 23 say adult, you mean forensic? 24 DR. BLAIR CARPENTER: Foren -- I mean 25 adult forensic pathologist. That is, to me, the answer

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1 to the problem if we're going to face the challenge of 2 the future, if we want to eliminate the empiric training, 3 like I had and some other and some other had, and to work 4 on a chance basis. This is up to the department heads 5 of the various university in this province who are 6 training pathologists, as part of their mandate, to 7 assure to or at least try and encourage some young people 8 to do that. And that would be the answer to your 9 question. 10 The last comment I have on that is that 11 it's expensive. There's no doubt it's going to be 12 expensive, they'll have to pay these people. You'll have 13 to find these people, and it'll have to be budgeted into 14 the budget of -- of these hospitals. Example, CHEO, who 15 has a limi -- needs a cohort of pathology doing the 16 regular work. 17 If they don't have the inclination or the 18 -- the time or the will to do what I just said, then what 19 do you do? Then you have to hire someone with that 20 skill -- 21 MS. JENNIFER MCALEER: So you're 22 suggesting, Dr. Carpenter, there had to be more of a 23 partnership between the hospitals, the institutions, and 24 -- and the universities to make sure you get -- 25 DR. BLAIR CARPENTER: Yes, and the

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1 government. 2 MS. JENNIFER MCALEER: -- people properly 3 trained? 4 DR. BLAIR CARPENTER: That's it. And the 5 government, who will, at the end, pay the bill. And, 6 yes, it's a -- it's -- it's not a solution that will be 7 done at the end of this Commission. It's a thing that 8 will take maybe fift -- ten (10), five (5), ten (10),(15) 9 years, because it takes five (5) years, four (4) years, 10 five (5) years to train people 11 MS. JENNIFER MCALEER: Dr. de Nanassy, 12 you wanted to add a comment to that? 13 DR. JOSEPH DE NANASSY: Yes. I just -- I 14 just wanted to expand a little bit on what Dr. Carpenter 15 said, specifically as to why a pediatric pathologist 16 should be at least given the option to be the first one 17 to be involved. 18 There are causes of death that are not age 19 dependent, and then there are other causes of death that 20 are age dependent. 21 Whether it's an adult or a child that dies 22 in a motor vehicle accident, or as a -- as a result of a 23 stab wound, or in a house fire, the age doesn't make a 24 difference. 25 But if a pediatric-age patient dies of --

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1 let me give an example, MCAD -- MC-A-D, all capital 2 letters -- condition, medium-chain RC -- TetD RC 3 (phonetic), the oxidation defect -- a condition only a 4 pediatric pathologist might know about the existence 5 thereof. So if an adult were to do an autopsy on such a 6 child, he might say, No cause of dea -- no anatomical 7 cause of death. 8 MS. JENNIFER MCALEER: All right. Dr. 9 Michaud, that might be a good segue to talk about a study 10 that I understand that you did in Quebec, which is at Tab 11 22 of the binder. 12 I understand that you were part of a -- a 13 team that had looked at cases of sune -- Sudden 14 Unexpected Death throughout the Province of Quebec over - 15 - I'm looking for the timeframe again. 16 Dr. Michaud, what was the time period? 17 DR. JEAN MICHAUD: I don't -- I don't 18 even remember myself, so... 19 MS. JENNIFER MCALEER: All right. 20 Well, -- 21 DR. JEAN MICHAUD: It's already several 22 years back. Yeah, over several years -- let me -- 23 '87/'96. 24 MS. JENNIFER MCALEER: Right. It's in 25 the -- on the second page, the third full paragraph.

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1 And what -- what was the purpose of that 2 study, Dr. Michaud, and -- and what did you discover? 3 DR. JEAN MICHAUD: Well, Dr. Aurore Cote 4 was heading -- is still heading the Jeremy Rill Centre, 5 which is a centre dedicated to the study and better 6 understanding of Sudden Infant Death Syndrome. It's 7 based at the Montreal Children's Hospital in Montreal. 8 But Sainte-Justine was doing a very large 9 portion of Sudden Unexpected Death of babies in the late 10 '80s. And I was also involved with her in -- in a 11 different project. We were looking at neurohormonal 12 changes in the hippocampus, presence of apoptosis and so 13 on. So that's -- so I got to interact with Dr. Cote. 14 And Dr. Russo (phonetic) was -- joined our 15 department in 1988, and he became the head eventually in 16 1995, when I stepped down of the headship of the 17 department. So he was also involved in managing and 18 controlling the work of our, you know, the forensic 19 pathology side of our work. 20 But Dr. Cote was a bit -- all -- always a 21 bit surprised about how often we would come with a 22 diagnosis in these cases. And the experience she had 23 with other her centres had not given her the impression 24 that we were able to make a specific diagnosis as often 25 as we were able to.

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1 So, at some point -- 2 MS. JENNIFER MCALEER: Sorry, let me just 3 stop you there -- 4 DR. JEAN MICHAUD: Yeah. 5 MS. JENNIFER MCALEER: -- because you're 6 talking about a couple of different centres. 7 DR. JEAN MICHAUD: Yeah. 8 MS. JENNIFER MCALEER: Is -- is the idea, 9 as I understand it from reading your article, that when 10 autopsies were done in pediatric facilities, there was a 11 higher rate of actually determining a cause of death 12 other than SIDS -- 13 DR. JEAN MICHAUD: Exactly. 14 MS. JENNIFER MCALEER: -- than if the 15 autopsy had been done in non-pediatric facility? 16 DR. JEAN MICHAUD: Or even at the 17 forensic unit in -- in Montreal. And in fact, the table 18 that you see in the -- in -- you know, tables that you 19 see in this article, I think, demonstrate that with -- 20 with data are quite precise. 21 In fact, the Table 2 in page 440 of the 22 article puts three (3) column there: the medicolegal 23 institute, general hospital, and pediatric hospital. And 24 you can see the difference in the percent of non-SIDS 25 cases that were determined at time of autopsy.

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1 So, Dr. Cote's -- 2 MS. JENNIFER MCALEER: And, sorry, Dr. 3 Michaud -- 4 DR. JEAN MICHAUD: Yeah. 5 MS. JENNIFER MCALEER: -- let me stop you 6 there. And that's in particular with respect to the 7 histologic examination, correct? 8 DR. JEAN MICHAUD: Well -- 9 MS. JENNIFER MCALEER: Is it -- because 10 if you go back a page, you can see you -- you've outlined 11 where -- at what stages people were able to determine the 12 cause of death. 13 DR. JEAN MICHAUD: Yeah. 14 MS. JENNIFER MCALEER: The review of the 15 circumstances in some cases was sufficient to determine 16 the cause of death. In other cases it was once one had 17 done the external or macroscopic examination that the 18 cause was determined. 19 And then in a large number of cases -- 20 seventy-two (72) of them -- it was only upon the 21 histologic examination that one determined the cause of 22 death. 23 DR. JEAN MICHAUD: Yeah. 24 MS. JENNIFER MCALEER: And it was within 25 that subgroup that you saw the largest difference, I

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1 should say, between the pediatric pathologist autopsy and 2 the autopsies done in the medicolegal setting. 3 Is that correct? 4 DR. JEAN MICHAUD: That's correct. In 5 fact, this is one (1) of the cytoanalysis that we made 6 following the data that we had accumulated in Table 2. 7 In -- in fact, one (1) of the conclusion 8 is that the histology portion of pediatric cases is more 9 often important in achieving a more precise diagnosis and 10 achieving more often the exclusion of some cases out of 11 the SIDS category or undetermined category, yes. 12 MS. JENNIFER MCALEER: I see. 13 DR. JEAN MICHAUD: And very honestly, 14 this -- these data were known -- although the paper was 15 published in 1999, we had already a pretty good idea of 16 death in the early '90s. 17 And as the article mentions, there was a 18 decision made -- I believe in 1992 -- that pediatric 19 autopsies in the entire Province of Quebec should be done 20 in a pediatric centre. 21 MS. JENNIFER MCALEER: Yes, you made 22 reference to that earlier. 23 DR. JEAN MICHAUD: Yes. 24 MS. JENNIFER MCALEER: This -- this study 25 was done in 1999, is that correct? So is it --

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1 DR. JEAN MICHAUD: The article was issued 2 in 1999, yes. 3 MS. JENNIFER MCALEER: All right. And 4 again, just with respect to some of the data, you have 5 looked at cases between, as you indicated, January of 6 1987 and December of 1996 -- 7 DR. JEAN MICHAUD: Yes. 8 MS. JENNIFER MCALEER: And you looked at 9 cases where there was no obvious explanation for the 10 death and -- and no past medical history. 11 Is that the idea? 12 DR. JEAN MICHAUD: Mm-hm, yes. 13 MS. JENNIFER MCALEER: And you narrowed 14 that field down to six hundred and twenty-three (623) 15 cases. 16 DR. JEAN MICHAUD: Yes. 17 MS. JENNIFER MCALEER: And as a result of 18 the assessment you did or the study you did, you 19 recommended -- as pointed out in the box on page 1 under 20 the conclusion section -- that in addition to a thorough 21 investigation of each sudden unexpected death, autopsies 22 be performed in centres with expertise in pediatric 23 pathology. That was the conclusion of the report. 24 DR. JEAN MICHAUD: That was the 25 conclusion. I must stress that a good deal of that work

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1 at the end was done Dr. Cote herself. 2 MS. JENNIFER MCALEER: Okay. 3 COMMISSIONER STEPHEN GOUDGE: Can I take 4 you to the table on page 440, Dr. Michaud. I confess I 5 haven't had the benefit of reading the paper, but just 6 looking at the chart -- 7 DR. JEAN MICHAUD: Mm-hm. 8 COMMISSIONER STEPHEN GOUDGE: -- the 9 figures are interesting. I take it one might make the 10 case from comparing the causes of death determined by the 11 pediatric pathologists; which are those in the column on 12 the right, is that right? 13 DR. JEAN MICHAUD: Yes. 14 COMMISSIONER STEPHEN GOUDGE: To the 15 causes of the death determined by the forensic 16 pathologists; who are the column on the left? 17 DR. JEAN MICHAUD: Yes. 18 COMMISSIONER STEPHEN GOUDGE: One might 19 say the pediatric pathologist would say a forensic 20 pathologist underdiagnosed natural causes of death? 21 DR. JEAN MICHAUD: You would say that, 22 yes. 23 COMMISSIONER STEPHEN GOUDGE: If you go 24 to the line opposite "child abuse," okay? 25 DR. JEAN MICHAUD: Yes.

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1 COMMISSIONER STEPHEN GOUDGE: Could the 2 forensic pathologists say the pediatric pathologist 3 overdiagnoses causes of death based on child abuse? 4 DR. JEAN MICHAUD: I don't' think we 5 could say that. 6 COMMISSIONER STEPHEN GOUDGE: Why not? 7 MS. JENNIFER MCALEER: And -- and -- 8 DR. JEAN MICHAUD: Because the -- the 9 only thing this table says is that in the -- in the frame 10 of the study -- in the frame of the study out of the 11 selected cases where there was no history before and so 12 on -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. JEAN MICHAUD: -- we were able to 15 track down -- you know, look -- look at the inclusion 16 criteria of the cases. Okay? 17 We have those cases. We eliminated this, 18 this, and that, and we were left with cases where there - 19 - it a true unexpected death without any history at all. 20 So the only thing I can say with this 21 table is that although these cases were done in a 22 pediatric centre, we were nevertheless able to track down 23 three (3) cases where there was child abuse. 24 COMMISSIONER STEPHEN GOUDGE: Okay. 25

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1 CONTINUED BY MS. JENNIFER MCALEER: 2 MS. JENNIFER MCALEER: And -- and as I 3 understand it, too, Dr. Michaud, just to clarify, the -- 4 the chart that's Table 2 is -- is simply a breakdown of 5 the seventy-two (72) cases where from the previous chart 6 you could only reach the cause of death once you've got 7 to the histologic examination. 8 DR. JEAN MICHAUD: Yes. 9 MS. JENNIFER MCALEER: So there were 10 other cases were one had determined that a cause of death 11 was child abuse for example -- 12 DR. JEAN MICHAUD: Yes. 13 MS. JENNIFER MCALEER: -- by simply the 14 external? 15 DR. JEAN MICHAUD: Yes. 16 MS. JENNIFER MCALEER: But we didn't 17 break that down by -- by institution, is that correct? 18 DR. JEAN MICHAUD: That's correct. 19 MS. JENNIFER MCALEER: It's only broken 20 down by institution with respect to the histologic 21 findings that led to the cause of death? 22 DR. JEAN MICHAUD: Exactly. 23 MS. JENNIFER MCALEER: Okay. All right. 24 Dr. -- Dr. Michaud, Dr. Carpenter, and Dr. De Nanassy had 25 spoken -- or Dr. Carpenter, in particular, had spoken

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1 about training and recruiting. 2 What has been your experience with respect 3 to some of the challenges that -- that you faced, 4 recruiting either pediatric pathologists or 5 neuropathologists? Do you have any views on what some of 6 the challenges are, with respect to getting more people 7 into the profession? 8 DR. JEAN MICHAUD: Well, I would -- I 9 would first preface my answer by saying that recruitment 10 in the medical field in general is more difficult than it 11 used to be, and it's not only for pathology, it's also 12 for other areas of lab medicine and also other 13 specialties. And the reasons for that I'm not going to 14 go into much details because I don't think there is a 15 purpose here. 16 Let me mention that I have recruitment 17 experience in pediatric pathology in the '80s and the 18 '90s and the 2000s and the '80s was relatively easy. It 19 got -- it got much worse. 20 My experience in recruitment of forensic 21 pathologists is -- is limited to my stay in Ottawa, and 22 in fact limited to the last two (2) or three (3) years 23 because we -- 24 MS. JENNIFER MCALEER: And just on that 25 topic I understand you've been part of the team that's

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1 been trying to recruit forensic pathologists for the 2 Forensic Unit in Ottawa? 3 DR. JEAN MICHAUD: Yes, because I have 4 administrative -- I'm the head of the department at the 5 Ottawa hospital and at CHEO, so I have experience in 6 recruitment in these two (2) centres since I'm in Ottawa. 7 And I'm not mentioning the -- the basic scientists at the 8 university. 9 They -- yeah, the recruitment of forensic 10 pathologists is difficult because there is a very small 11 pool of forensic pathologists in the country. The 12 recruitment of pediatric pathologists is also very 13 difficult because there is a very small pool of pediatric 14 pathologists in the country, and they're relatively 15 stable and so that makes it somewhat difficult. 16 Pathology -- pathologists in general, it's 17 not easy either. We have more and more to go outside the 18 country; go to US. We're able to attract -- in Ottawa, 19 because of, I guess, the bilingual nature of the city, 20 we've been successful in recruiting pathologists from 21 Quebec as well, but more and more, we have to go outside 22 the country and recruit what we call "international 23 medical graduates" with background that is somewhat 24 different. 25 But let me tell you that they're --

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1 they're competent, and when we can attract them we're 2 very pleased. Difficulties will resolve -- be resolved 3 only, I would say, in about ten (10), twelve (12), 4 fifteen (15) years. The cohort in medical school has 5 been increased in the last four (4) or five (5) years. 6 The -- 7 MS. JENNIFER MCALEER: Sir, what -- what 8 do you mean, the cohort? You mean the -- 9 DR. JEAN MICHAUD: Medical students. 10 MS. JENNIFER MCALEER: The number -- the 11 number of people entering medical school? 12 DR. JEAN MICHAUD: Yeah, number of people 13 entering medical schools in the country -- let's talk 14 about Ontario -- has increased and now these cohorts are 15 reaching the residency level. And then, we may -- we 16 will see -- in fact, we're beginning to see an increase 17 in the number of residency positions in various -- I'm 18 sorry -- in various specialities. 19 Obviously, government has priorities -- 20 internal medicine, general surgery, pediatrics, 21 psychiatry -- you know, those -- those specialities that 22 could help resolve difficulties in distant areas like 23 Northern Ontario and so on. But let me tell you that 24 even in larger centres, we have some difficulties at 25 times.

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1 MS. JENNIFER MCALEER: Sir -- 2 DR. JEAN MICHAUD: So the pathology -- 3 MS. JENNIFER MCALEER: Can I stop you 4 there, 'cause -- 5 DR. JEAN MICHAUD: Yes. 6 MS. JENNIFER MCALEER: -- I -- I don't 7 know -- quite understand you. You're saying that there's 8 more government funding of residency positions in the 9 fields you've just listed because of the need to service 10 remote communities? 11 DR. JEAN MICHAUD: Not quite. The 12 cohorts are reaching residency levels, so there will be 13 more residency positions supported by the government. 14 It's coming; it's beginning to be implemented. But the 15 government favours some specialties because of the needs 16 of the population. 17 So they will direct, at times, the number 18 of positions -- let's say, University of Ottawa gets 19 twenty-five (25) more positions. They may say, Well, a 20 number has to be dedicated to general surgery; a number 21 has to be dedicated to internal medicine and so on. 22 Pathology -- there was a report I would 23 say now, seven (7), six (6), seven (7), eight (8) years 24 ago, Dr. McKendry from Ottawa was the lead. He had 25 identified pathology as a specialty in need.

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1 At this moment, I would -- my personal 2 view -- I do not believe that pathology and lab medicine 3 has seen a real change in the determination to improve 4 the numbers of trainees in pathology in general. 5 MS. JENNIFER MCALEER: So you're saying 6 there's a recognition of a need, but the funding isn't 7 there yet? 8 DR. JEAN MICHAUD: Well, the number of 9 positions in medical school is determined by a committee; 10 it's a medical school committee. And for example, at 11 University of Ottawa, when I got there, we had four (4) 12 lab medicine programs. We had only one (1) residency 13 position. 14 I can tell you now that we have six (6) 15 university -- six (6) residency positions -- three (3) 16 out of -- of the Canadian match -- matching system; and 17 three (3) out of the internal -- international medical 18 graduate system. 19 So we have improved our situation -- 20 MS. JENNIFER MCALEER: Those are two (2) 21 different funding bodies? 22 DR. JEAN MICHAUD: No, at the end of the 23 day, it's the same funding -- 24 MS. JENNIFER MCALEER: Okay. 25 DR. JEAN MICHAUD: -- body, but we have

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1 been able to improve our capacity to train residents. 2 But all the other disciplines have seen, you know, 3 similar increases. And my colleagues in Ontario, you 4 know -- the chair in Toronto -- certainly can say that he 5 has been able to increase the number of residency 6 positions. 7 But compare -- you know, the number of 8 trainees that we can generate in Ontario compared to the 9 numbers who will be retiring in the next five (5), ten 10 (10) years, I mean there is still -- it's still 11 disproportionate. You know, it's -- we cannot match, at 12 this moment, the expected retirements with the number of 13 trainees that we have. 14 Acknowledging also the fact that some of 15 them go elsewhere. You know, there is competition of the 16 market; we've seen a lot of people going west, and so on 17 and so -- it's a very -- it's very difficult. 18 And I'm talking about pathology in 19 general. So if you go into subspecialties like pediatric 20 pathology, forensic pathology, these are real challenges. 21 Also let me just -- it's maybe anecdotal but I have been 22 interviewing, since 1998, all the candidates for our 23 programs -- you know, the medical students that come and 24 explore specialties -- and several are interested in 25 forensic pathology. But once they get into the training,

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1 they -- they go elsewhere. 2 COMMISSIONER STEPHEN GOUDGE: Why? 3 DR. JEAN MICHAUD: So at the end of the 4 day -- 5 COMMISSIONER STEPHEN GOUDGE: Why? 6 DR. JEAN MICHAUD: Well, I don't have all 7 the answers, but the image of forensic pathology has 8 portrayed in televisions and so on, is -- is one that is 9 not really the true reality. That's one (1) -- one (1) 10 thing -- 11 COMMISSIONER STEPHEN GOUDGE: So it is 12 not all like CSI? 13 DR. JEAN MICHAUD: It's not at all, okay. 14 And second, they discover other areas of pathology, and 15 they -- they are attracted by other areas of pathology. 16 And third, very honestly, I do not think that forensic 17 pathology, and I would even say pathology in general, has 18 been well portrayed in media for various reasons. 19 So all these elements, in my view, puts 20 forensic pathology in -- in a special place. And 21 although we may all love do some forensic pathology, it's 22 not obvious that residents will just come as a crowd to 23 do forensic pathology. 24 COMMISSIONER STEPHEN GOUDGE: Let me just 25 ask you a couple questions, generally, Dr. Michaud.

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1 First of all, if one plotted the increase in residency 2 positions -- take your university over the last five (5) 3 years, say -- how would pathology, as a specialty, stack 4 up against other specialties; oncology, internal 5 medicine, and so on. 6 Are they getting increases at the same 7 rate or slower rates? 8 DR. JEAN MICHAUD: I would talk only 9 about my University of Ottawa experience as a Chair of a 10 Department at the University and looking at numbers -- 11 I'm not a member of the postgrad -- postgraduation study 12 committee and so on -- there has been, I think, a good 13 incr -- a proportional increase with various specialties 14 except for some specialities where the government had 15 mandated a larger increase like -- 16 COMMISSIONER STEPHEN GOUDGE: On -- 17 DR. JEAN MICHAUD: -- internal medicine-- 18 COMMISSIONER STEPHEN GOUDGE: -- 19 oncology? 20 DR. JEAN MICHAUD: Not really oncology, 21 but internal medicine, general surgery, -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. JEAN MICHAUD: -- you know, and -- 24 and some of those specialties that are useful in mid-size 25 or regional hospitals, you know, far away at a distance

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1 and so on. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. JEAN MICHAUD: These have increased a 4 bit more. Family medicine is -- is doing pretty well, 5 certainly at the University of Ottawa in terms of numbers 6 and so on. So we've -- we've had an increase that I 7 would say is proportional to other specialties. 8 Like, I would say, orthopedic surgery, 9 cardiology, and so on, but -- 10 COMMISSIONER STEPHEN GOUDGE: Less than 11 some others? 12 DR. JEAN MICHAUD: Les than some others, 13 yes. 14 COMMISSIONER STEPHEN GOUDGE: Okay. Now, 15 can I -- sorry, Dr. Carpenter, let me just ask one (1) 16 more question. Is the decision about the relative 17 increase in numbers of residencies entirely in the 18 government's hands or is that something that is done in - 19 - in some kind of communal way amongst medical schools? 20 DR. JEAN MICHAUD: Okay, the number of 21 residency positions allocated to medical school comes 22 from above; comes from government. Within the medical 23 school, there is a committee that is mandated to 24 attribute the number of positions to each program. 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. JEAN MICHAUD: That's where it 2 happens at the medical school level. They may be -- as I 3 mentioned earlier -- they may be directed by the 4 government for some specialties, and I -- if I recall 5 correctly -- I remember a year, I think two (2) or three 6 (3) years ago, there were a -- a small num -- there was a 7 small number attributed to the University of Ottawa, and 8 that number had to go to only five (5) specialities. 9 I don't remember all of them. So we were 10 not even in -- in the ballpark there. I mean, there were 11 very -- 12 COMMISSIONER STEPHEN GOUDGE: That was a 13 government decision? 14 DR. JEAN MICHAUD: That was a very 15 directed decision by -- by government. But otherwise, 16 yes, we have a role to play within each medical school. 17 And every year, our Residency Program Directors have to 18 sit down and justify new requests; why we would like to 19 have more. 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. JEAN MICHAUD: And what are the 22 reasons -- and we have to include market data on this. 23 There is a shortage and whatever. So we have to justify 24 this. But when comes the time to discuss shortage in 25 medical fields, we're not alone. There are several

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1 disciplines where there is a shortage, even in family 2 medicine. 3 COMMISSIONER STEPHEN GOUDGE: Yes, but -- 4 DR. JEAN MICHAUD: So we're competors -- 5 competitors, all of us are competitors. 6 COMMISSIONER STEPHEN GOUDGE: But if I 7 said to you, and I know you -- it would be amazing if you 8 had statistics on this, but on the shortage side of it, 9 okay, how would pathology rate against other specialties? 10 Take family medicine. If I said to you, in which is 11 there a greater shortage right now, proportionally? 12 DR. JEAN MICHAUD: As I mentioned, with 13 the McKendry Report done a few years back, the -- 14 COMMISSIONER STEPHEN GOUDGE: What's the 15 name of that report? 16 DR. JEAN MICHAUD: McKendry. 17 COMMISSIONER STEPHEN GOUDGE: McKendry? 18 DR. JEAN MICHAUD: Yeah. I forgot his 19 first name. He's -- he's a physician at the Ottawa 20 Hospital. 21 COMMISSIONER STEPHEN GOUDGE: And was 22 that -- 23 DR. JEAN MICHAUD: And I apologize if 24 he's listening to me, I don't remember his first name. 25 But that was the provincial report made at that time,

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1 looking at human resources in medical -- in medicine in 2 Ontario. 3 And he had identified a number of 4 disciplines that were in jeopardy as far as delivery is 5 concerned. And -- and pathology was one (1) of them. I 6 don't remember what the other is, but, you know, 7 pathology was one (1) of them. 8 COMMISSIONER STEPHEN GOUDGE: And is 9 that -- 10 DR. JEAN MICHAUD: It's several years 11 back. 12 COMMISSIONER STEPHEN GOUDGE: -- And is 13 that still the case from your perspective, albeit I'm 14 sure, anecdotal? 15 DR. JEAN MICHAUD: It is. It is still 16 the case, and I would say that the Canadian Association 17 of Pathologists does a good deal of work to document 18 that, and every year, you know, we have that and so on. 19 So it's still the case. Pathology suffers in terms of -- 20 COMMISSIONER STEPHEN GOUDGE: If the 21 residencies were there, would students choose to come? 22 DR. JEAN MICHAUD: I must say that, in 23 the -- in the last few years, there has been an increase 24 in applicants for laboratory medicine, in general, and 25 pathology, in particular.

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1 We have to -- and I don't want to prolong 2 the discussions too much, but the '90's were very 3 difficult for laboratory medicine -- the 90 -- the years 4 of the '90's. You may recall, that in Alberta, there was 5 a governmental directions regionalizing all the labs. 6 There were significant cuts there. And 7 also there were -- there were some messages passing about 8 the control of salaries, the controls of positions in lab 9 medicine. We can make a lot of money in medicine; we can 10 privatize laboratory medicine, and so on. 11 So the number of applicants in laboratory 12 medicine, as of that time, went down. And all the 13 programs in -- as they're committed by Royal College of 14 Canada for example, went down; number of AP, number of 15 general pathologists and so on -- to the point, where we 16 lost some positions because a medical school will not 17 give to lab medicine six (6) position if you fill in only 18 three (3). 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. JEAN MICHAUD: Okay? So the -- the 21 market then was -- had this notion that lab medicine was 22 not, perhaps, a very interesting place to go as far as 23 professional career was concerned. 24 But in the last three (3) or four (4) 25 years, very honestly, the number of applicants is -- is

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1 coming back. And if we had more positions, I'm -- I'm 2 certain that we would be able to -- to fill them in. 3 COMMISSIONER STEPHEN GOUDGE: And apart 4 from CSI, do you have an explanation of the increase in 5 applicants? Why is it -- 6 DR. JEAN MICHAUD: Oh, you mean the 7 interest for -- 8 COMMISSIONER STEPHEN GOUDGE: Yes. 9 DR. JEAN MICHAUD: -- forensic -- at the 10 beginning of the -- 11 COMMISSIONER STEPHEN GOUDGE: Yes. 12 DR. JEAN MICHAUD: -- at time of 13 interviews? 14 COMMISSIONER STEPHEN GOUDGE: Yes, I 15 mean, why is there more interest now? 16 DR. JEAN MICHAUD: There is an interest 17 before they get into pathology. After that, they lose 18 it. 19 COMMISSIONER STEPHEN GOUDGE: Yes, I 20 know, but -- 21 DR. JEAN MICHAUD: That's what I wanted 22 to say. 23 COMMISSIONER STEPHEN GOUDGE: Yeah, and 24 you -- 25 DR. JEAN MICHAUD: I mean, this is very

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1 important. 2 COMMISSIONER STEPHEN GOUDGE: -- you've 3 said that, but at -- 4 DR. JEAN MICHAUD: Oh, at least -- 5 COMMISSIONER STEPHEN GOUDGE: -- at least 6 it's a positive that they are interested at the 7 beginning? 8 DR. JEAN MICHAUD: Yes. I -- I think -- 9 I think the -- the lack of formal training was, perhaps - 10 - is perhaps, a deterrent. Once they get into pathology, 11 the lack of formal training in forensic pathology may be 12 a deterrent. The bad press that we've got -- we've had 13 in the last ten/fifteen (10/15) years may be an element; 14 the -- the excitement that they may find in other areas 15 of pathology. 16 I think it's multi-factorial. You know, I 17 even remember a lady coming -- a medical student coming 18 and I -- saying, I want to be a forensic anthropologist, 19 because she had read the, you know, Cathy Wright's book 20 and so on, and she wanted to be that. 21 I don't know what happened to her -- she 22 was in another program -- but, you know, there -- there 23 is this notion, but then once -- once you get on the -- 24 on the floor -- your two (2) feet on the floor -- well, 25 things are different.

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1 And -- but -- 2 COMMISSIONER STEPHEN GOUDGE: It's like 3 watching a TV show about lawyers. 4 DR. JEAN MICHAUD: Well, we could have 5 feedback here. 6 MS. JENNIFER MCALEER: We're all living 7 the dream. Dr. Carpenter -- 8 COMMISSIONER STEPHEN GOUDGE: Sorry, Dr. 9 Carpenter. 10 DR. BLAIR CARPENTER: No, no, I'm 11 listening, it's interesting. But I do have two (2) 12 comments. And one (1) of the answers to your question in 13 perspective could be helpful. When I started on the 14 University some twenty-five (25) years ago, I was on the 15 residence program representing CHEO. 16 We had twenty-three (23) position that 17 were filled up for pathology and laboratory medicine. 18 That's a whole lot of people would finish four (4) years 19 later as pathologists. Twenty-three (23) position. 20 Every years the government has skimmed couple of post -- 21 couple of position. 22 And now you were telling me -- that's why 23 I was asking you yesterday -- and you're down to six (6) 24 or seven (7) positions? 25 DR. JEAN MICHAUD: At this moment they --

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1 four (4) programs -- 2 DR. BLAIR CARPENTER: Four (4), that's 3 still -- 4 DR. JEAN MICHAUD: -- an ethical 5 pathology, general pathology, hematopathology, and 6 microbiology. 7 DR. BLAIR CARPENTER: So this -- this 8 explains to some degree, and they were all filled up 9 then, the positions. Something is missing somewhere, and 10 we're not producing on the market. Whatever the reason 11 that the Government or the people behind those decisions 12 was, I don't know. I was not involved in that, but they 13 certainly had some reason to cut. 14 Maybe there was a surplus. I don't know, 15 but at the moment, there's no doubt we're sitting here 16 and we're all realizing that, at least, in the forensic 17 and in the pediatric and the combination, there -- there 18 is a lack of -- well, where did we go from twenty-three 19 (23) to -- to six (6) positions? 20 COMMISSIONER STEPHEN GOUDGE: Let me ask 21 all three (3) of you this question. Is a part of this 22 played at all by the incomes to be earned practising this 23 specialty of medicine once one finishes ones 24 qualifications? 25 DR. BLAIR CARPENTER: Yes, it does --

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1 COMMISSIONER STEPHEN GOUDGE: That is, is 2 this somehow seen as less remunerative than other areas 3 of medicine and therefore, less desirable? Is that at 4 all a consideration, Dr. Michaud? 5 DR. JEAN MICHAUD: Are you talking about 6 forensic pathology only or pathology in general? 7 COMMISSIONER STEPHEN GOUDGE: Pathology, 8 in general, but if you can break it down for pediatric 9 pathology and forensic pathology? 10 DR. JEAN MICHAUD: Well, in -- in 2007, 11 in the Province of Ontario, laboratory medicine is very 12 well supported by our governments. You know, there was a 13 laboratory medicine funding framework agreement that came 14 in. There -- there are some negative sides to this but, 15 at least, there is one (1) side -- a good side to it is 16 that they bring the floor salary of all laboratory 17 medicine physicians, in this province, at a level that is 18 competitive with other provinces, because I would not 19 say, only in pathology, but in other -- in all fields of 20 lab medicine, we've lost people in the last few years to 21 western provinces where the working conditions were much 22 better. 23 I think now we're at a level where we can 24 retain our pathologists and laboratory physicians. So at 25 this moment, I would not say that this is true anymore.

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1 It used to be but today in 2007, for the last three (3) 2 or four (4) years, I think, the -- this angle of our 3 working condition is inadequate. 4 COMMISSIONER STEPHEN GOUDGE: Including 5 compensation? 6 DR. JEAN MICHAUD: I'm talking about 7 compensations, benefits, and so on. The angle that 8 would, perhaps, need to be improved is the workload 9 because professional comfort, you know, and I've learned 10 that over the last several years, our professors are not 11 necessarily happy because they make a good salary. They 12 may be happier if the workload is adequate to what they 13 can take and so on. There is a comfort with the workload 14 as well. In an academic centre, part of the workload has 15 to include academia. 16 And very often, we have significant 17 discussions with our senior management when it comes the 18 time to request new positions because the angle is more 19 on the clinical side while sometimes the academic side 20 needs to be nurtured and better supported and so on. 21 So all this enters in -- in the mind of 22 individuals when you talk about professional comfort. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 That's helpful. Do you want to add something? 25 DR. JOSEPH DE NANASSY: Yes, I just

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1 wanted to add one doesn't enter a particular specialty or 2 medicine, in general, for the income potential that there 3 might be. You also have to be interested in the area 4 that you are going to practice in. After all, you will 5 be doing it for the next few decades of your life. 6 So just throwing money at the issue might 7 not automatically improve recruitment. You have to have 8 people with interest in -- in that particular field. So 9 you could offer a salary of a million a year to someone 10 who is not interested. He will not take it. So there 11 has to be job satisfaction as well, and I can echo the 12 workload concerns that Dr. Michaud expressed. 13 DR. JEAN MICHAUD: There is one (1) 14 element, very briefly, also that may have affected the 15 number of medical students interested in -- in pathology 16 and medicine is that there -- there has been, in medical 17 schools across the country, a lot of changes in the 18 medical undergraduate curriculum and sometimes the 19 exposure of these students to pathology, in that 20 medicine, is not what I would consider optimal. 21 And so that's another -- so -- so we have 22 -- certainly at the University of Ottawa, we have a few 23 outstanding professors who have been able over the years 24 to really tease the students for pathology and so on and 25 attract some students, and we need those in all

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1 universities and but it's -- it has -- it requires an 2 effort. It requires work and it requires a -- 3 COMMISSIONER STEPHEN GOUDGE: It requires 4 a focus -- 5 DR. JEAN MICHAUD: -- dedication. 6 COMMISSIONER STEPHEN GOUDGE: -- a 7 focussed effort. 8 DR. JEAN MICHAUD: Exactly. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 Thanks, Ms. McAleer. 11 12 CONTINUED BY MS. JENNIFER MCALEER: 13 MS. JENNIFER MCALEER: Just one (1) 14 follow-up on that topic, Dr. Michaud. I understand that 15 you have been involved with the Royal College of 16 Physicians and Surgeons with respect to the fact that we 17 are now going to have a sub-specialty recognition in 18 forensic pathology. 19 Could you, briefly, outline whether or not 20 you think that's going to have any impact on how one 21 recruits into this field? Will we see more forensic 22 pathologists as a result of the sub-specialty program? 23 DR. JEAN MICHAUD: In the mid '90's, the 24 Royal College of Canada put a freeze on the development 25 of any new specialties and fellowships. At that time,

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1 Dr. Nadia Michael (phonetic) was working for the 2 recognition of forensic pathology as a sub-specialty of 3 anatomical pathology and general pathology, but this 4 freeze came and we had to wait several years. 5 I -- I'm the one who succeeded to Dr. 6 Michael and at some point in time, she mentioned to me 7 that, perhaps, it would be time to re -- re-look at this, 8 as the freeze was supposed to go away at some point in 9 time. 10 At that time, she was working at the -- at 11 the Royal College of Canada. 12 MS. JENNIFER MCALEER: And you actually 13 were the Chair of the Committee, were you not, from 14 2000 -- 15 DR. JEAN MICHAUD: That's before that 16 because -- 17 MS. JENNIFER MCALEER: Right, but -- but 18 from 2004 to 2007, you were actually the Chair of the 19 subcommittee. 20 DR. JEAN MICHAUD: Yeah, but before that, 21 we had to do some work to have the sub-specialty 22 recognized, so we worked, I think, from 2001 to about 23 2003. 24 We prepared a couple of documents 25 justifying the justif -- you know, the -- justifying the

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1 -- the need for a Fellowship in forensic pathology. 2 That, I think -- I think, the news of that came late 2003 3 or early 2004. 4 And then there was this committee that was 5 formed with the Royal College guidelines, that is one 6 representative per region in the country, and a Chair. 7 And so we began to work on this in 2004 and, very 8 honestly, that took some time. 9 First, because it's a very meticulous 10 process. This -- the -- the work we were doing is 11 reviewed by a couple individuals -- feedback, and so on - 12 - and second, people -- we're a member of the committee, 13 we're all busy, and there were long gaps where we didn't 14 do much of anything, but yet after that, we would sit and 15 work on this. 16 Most of the work wa -- was done, I think, 17 by the early 2006, and then there was a gap at the Royal 18 College level, and then we finalized the whole thing in 19 the late -- in the early 2007. 20 Now I stepped down because I -- I wanted 21 somebody -- a true forensic pathology. So, since July 22 2007 -- this is Dr. Michael Shkrum who is in charge of 23 this committee -- and the next step are an invitatio -- 24 is an invitation to the medical school to apply for a 25 Residency Program in forensic pathology.

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1 MS. JENNIFER MCALEER: Yes, I understand 2 that's the status. And do you think that that will 3 assist in -- in recruiting people into the field of 4 forensic pathology? Do you think the numbers will 5 increase as a result of this sub-specialty program? 6 DR. JEAN MICHAUD: It is. I hope -- I 7 hope it will help. In the reality, we have to be 8 cautious for a few reasons. 9 First of all, there are not many residents 10 in pathology, not enough. Along the way, they are 11 attracted by other fields, but I believe that this -- I - 12 - I think it will help. I think it will help. 13 I think it will give better recognition of 14 the field in the working arena, particularly, when you go 15 to court and so on. 16 I think it will give better support for 17 these individuals. And in fact, we have discussed also a 18 process by which those who have experience and are 19 currently practising could eventually go to -- to the 20 exam and be recognized. 21 The Royal College initially said "no" to 22 that, but -- and I apologize, I'm unable to give you too 23 much details because I forgot the details of the -- of 24 the document -- but now it looks like there is a -- an 25 opening for practising forensic pathologists to

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1 eventually sit at the exam -- at the examination, 2 provided there has been, at least, one (1) exam offered 3 for new trainees before, I think. 4 That's one (1) of the rule, but I -- I 5 cannot be more affirmative on this. I would have to 6 refresh my memory on this. 7 MS. JENNIFER MCALEER: Okay, thank you. 8 Mr. Commissioner, I'm about to move into a completely 9 different topic. I note that it's almost thirteen (13) 10 minutes after 3:00. 11 COMMISSIONER STEPHEN GOUDGE: Sure. 12 MS. JENNIFER MCALEER: This might be a 13 convenient time to break. 14 COMMISSIONER STEPHEN GOUDGE: Absolutely. 15 MS. JENNIFER MCALEER: I anticipate that 16 we will be finishing early -- early today, but -- 17 COMMISSIONER STEPHEN GOUDGE: That's 18 fine. We'll be back then at 3:30. 19 20 --- Upon recessing at 3:12 p.m. 21 --- Upon resuming at 3:33 p.m. 22 23 THE REGISTRAR: All rise. Please be 24 seated. 25 COMMISSIONER STEPHEN GOUDGE: Ms.

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1 McAleer...? 2 3 CONTINUED BY MS. JENNIFER MCALEER: 4 MS. JENNIFER MCALEER: Thank you, Mr. 5 Commissioner. Dr. Carpenter, my last line of questioning 6 will be directed to you, and it pertains to the work that 7 you did at the request of the Office of the Chief Coroner 8 in 2001 related to Dr. Smith's cases. 9 Could you please turn to Tab 27 of the 10 binder that's before you? Do you have that, Dr. 11 Carpenter? 12 DR. BLAIR CARPENTER: Yes. 13 MS. JENNIFER MCALEER: And that's 14 PFP029441. And that is a letter from Dr. Chiasson to you 15 dated June 1st. The first paragraph refers to a 16 telephone conversation that had happened the previous 17 week, and then encloses some reports of post-mortem 18 examination; histological, and photographic slides 19 related to six (6) cases. 20 Now, Dr. Carpenter, can you tell us, how 21 did you come to be retained to do this work? 22 DR. BLAIR CARPENTER: It was a phone call 23 by Dr. Chiasson. At that point, there was some concern 24 about Dr. Smith. Not much that I knew about, but I did 25 know that Dr. Smith had stopped, for a period of time,

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1 doing some work, some autopsies and forensic autopsy. 2 And through the media, I had heard that 3 there was some problem. So there -- 4 MS. JENNIFER MCALEER: And what was your 5 -- what was your prior knowledge of Dr. Smith? Had you 6 ever worked with him? Had you met him at conferences? 7 DR. BLAIR CARPENTER: No, I never -- I 8 met Dr. Smith the first time when I offered him a 9 position at CHEO which he decided to go to -- to Sick 10 Kids. That was many years ago. 11 MS. JENNIFER MCALEER: I understand that 12 was -- that was when he finished his residency, correct? 13 DR. BLAIR CARPENTER: Yes. Well, I think 14 so. It's -- it's a long time ago. 15 MS. JENNIFER MCALEER: All right. 16 DR. BLAIR CARPENTER: Then I met Dr. 17 Smith, more on a social point, at various meetings when I 18 did go down to Toronto, and sometimes, I met with some of 19 the pathologists, and he was among them. I met him, on 20 occasion, at -- at trials. 21 I remember, at least, one (1) coroner's 22 inquest in the north of Ontario. I think it was 23 Pembroke, but don't quote me, over well a year. I did 24 meet him also -- he came as an expert witness on a case 25 of child abuse that Dr. Jimenez was the primary

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1 pathologist on, but I was also called in. 2 And I did participate, as you can see, on 3 a few occasions with Dr. Smith. But most of my 4 encounters with Dr. Smith were more on a social level at 5 meetings and at conference; well, yes, all the conference 6 of the Coroner's Office. 7 So I did not have much, let's say, 8 communication with Dr. Smith on a professional basis -- 9 mainly on a social basis. 10 MS. JENNIFER MCALEER: And with putting 11 aside then the media reports and your limited 12 understanding as to the circumstances -- 13 DR. BLAIR CARPENTER: Yeah. 14 MS. JENNIFER MCALEER: -- that may have 15 given risen to the request for this particular review, 16 what was your general impression, with respect, to Dr. 17 Smith's reputation? 18 DR. BLAIR CARPENTER: Well, I knew he was 19 in trouble. 20 MS. JENNIFER MCALEER: No, I mean -- I 21 mean with the -- putting aside the media reports. 22 DR. BLAIR CARPENTER: Oh, I see. 23 MS. JENNIFER MCALEER: So before the 24 media reports, before you were contacted by the of Office 25 of the Chief Coroner to do this review, based on the

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1 experience that you've just detailed to the Commissioner; 2 the fact that you had offered him a position at one 3 point, the limited experience you had with him on cases, 4 meeting him at conferences, what had been your assessment 5 or your view with respect to his reputation? 6 DR. BLAIR CARPENTER: Well, personally, I 7 had very little opinion because I -- I was not in contact 8 with him, so I don't know. One (1) comment I heard at 9 one (1) meeting by someone, but that again was 10 secondhand, was that he may -- might not have to been up 11 to par compared to the other pathologists in a tertiary 12 care like Sick Kids. But then again, that was -- that 13 was from -- you're seeing -- say -- saying, and I -- I 14 just can't comment further that -- 15 MS. JENNIFER MCALEER: You don't remember 16 the context of that comment -- 17 DR. BLAIR CARPENTER: No. 18 MS. JENNIFER MCALEER: -- or who made it 19 or -- 20 DR. BLAIR CARPENTER: No, this was social 21 that -- 22 MS. JENNIFER MCALEER: -- when? 23 DR. BLAIR CARPENTER: -- was during 24 social meeting just talking between sessions and -- and 25 it just went in one (1) ear and get out of the other ear

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1 because I had no reason to put anymore attention -- until 2 when we came up with the issues here. 3 MS. JENNIFER MCALEER: All right. So 4 you're contacted by Dr. Chiasson, and what is your 5 understanding, or what does Dr. Chiasson communicate to 6 you as to why he wants you to do this review? 7 DR. BLAIR CARPENTER: Yes, my impression 8 was that Dr. Smith had stopped doing some, that they were 9 planning to reinstate -- 10 MS. JENNIFER MCALEER: Had stopped doing 11 some what? 12 DR. BLAIR CARPENTER: Doing forensic 13 pathology autopsies. And that there was some possibility 14 of reinstalling him in doing so. What they wanted to 15 know if it was adequate to do it. Now -- 16 MS. JENNIFER MCALEER: Sorry, if -- if 17 what was adequate? 18 DR. BLAIR CARPENTER: Well, if he was 19 adequate -- capable of doing that. 20 MS. JENNIFER MCALEER: All right. 21 DR. BLAIR CARPENTER: At that point, 22 there was no understanding or discussion about revising 23 any case that were cri -- suspiciously criminal or 24 whatever that wen -- either went to court or were 25 planning to go to court.

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1 MS. JENNIFER MCALEER: Of -- of 2 reviewing? You -- 3 DR. BLAIR CARPENTER: Yes. 4 MS. JENNIFER MCALEER: -- Your 5 understanding was that you were not -- 6 DR. BLAIR CARPENTER: No, I was not -- 7 MS. JENNIFER MCALEER: -- you were not 8 going to be given cases that were of a criminally 9 suspicious nature? 10 DR. BLAIR CARPENTER: No, that was not to 11 be done. 'Cause that was not the goal of the -- of the 12 exercise. 13 MS. JENNIFER MCALEER: So the goal of the 14 exercise was to determine whether or not he could be -- 15 DR. BLAIR CARPENTER: He was -- 16 MS. JENNIFER MCALEER: -- reinstated to 17 do medicolegal autopsies that were not of a criminally 18 suspicious nature, is that what -- 19 DR. BLAIR CARPENTER: No, if he was -- if 20 he was -- well, academically or professionally adequate 21 to restart and to do them. 22 MS. JENNIFER MCALEER: To do what though? 23 DR. BLAIR CARPENTER: The -- the 24 autopsies. 25 MS. JENNIFER MCALEER: What kinds of

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1 autopsies? 2 DR. BLAIR CARPENTER: Forensic autopsies. 3 MS. JENNIFER MCALEER: All forensic 4 autopsies? 5 DR. BLAIR CARPENTER: Well, not all 6 forensic autopsies -- well, probably that -- that depends 7 on what the Coroner's Office or Dr. Chiasson wanted to 8 do. From my point of view was if he was qualified to do 9 it. 10 MS. JENNIFER MCALEER: All right. 11 DR. BLAIR CARPENTER: More than revising 12 what he had done before. 13 MS. JENNIFER MCALEER: So you say 14 revising, do you mean reviewing? 15 DR. BLAIR CARPENTER: Reviewing. 16 MS. JENNIFER MCALEER: Reviewing the 17 cases he'd done before? 18 DR. BLAIR CARPENTER: Yeah. So I -- I 19 suggested, and we agreed upon, 'cause we had to take it 20 in a certain number, we reviewed upon choosing six (6) 21 cases which -- 22 MS. JENNIFER MCALEER: And did you have - 23 - did you participate in choosing which six (6) -- 24 DR. BLAIR CARPENTER: No. 25 MS. JENNIFER MCALEER: -- cases?

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1 DR. BLAIR CARPENTER: No. 2 MS. JENNIFER MCALEER: And -- 3 DR. BLAIR CARPENTER: That was again, the 4 aim of the exercise was to -- so I'd be blinded at that 5 point. 6 MS. JENNIFER MCALEER: All right, so -- 7 DR. BLAIR CARPENTER: But it was not 8 completely blinded, because we knew that it would not 9 include cases that had gone to court before. 10 MS. JENNIFER MCALEER: All right. So who 11 chose the cases as far as you understood? 12 DR. BLAIR CARPENTER: Dr. Chias -- well I 13 think it's Dr. Chiasson. 14 MS. JENNIFER MCALEER: All right. And 15 then looking from the first paragraph of the letter, you 16 were provided with the reports of post-mortem? 17 DR. BLAIR CARPENTER: Yes. 18 MS. JENNIFER MCALEER: Histological and 19 photographic slides relating to the cases? 20 DR. BLAIR CARPENTER: Yes. 21 MS. JENNIFER MCALEER: Were you provided 22 with any other information? 23 DR. BLAIR CARPENTER: Yeah, I was in -- 24 well, I had the full report. I had all the -- the result 25 of the ancillary tests that were done. I was forwarded,

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1 whenever available, some gross photograph, the slides for 2 the microscopy, and obviously, the report. 3 MS. JENNIFER MCALEER: All right. If we 4 turn to Tab 28 which is PFP104140. 5 DR. BLAIR CARPENTER: Yes. 6 MS. JENNIFER MCALEER: And this is a 7 series of documents related -- or sorry, a series of 8 pages related to those individual cases that list 9 information. Were -- were you provided, for example, 10 with respect to the first case, -- were you provided will 11 all of the information that's listed there? 12 DR. BLAIR CARPENTER: Well, what's listed 13 there I had. 14 MS. JENNIFER MCALEER: All right. So all 15 of that information -- 16 DR. BLAIR CARPENTER: All that was there, 17 that was all available. 18 MS. JENNIFER MCALEER: All right. For 19 each one (1) of the cases? 20 DR. BLAIR CARPENTER: Yes. 21 MS. JENNIFER MCALEER: And with each one 22 (1) of those cases, did you actually review all of that 23 information? 24 DR. BLAIR CARPENTER: Yes. 25 MS. JENNIFER MCALEER: Okay. And what --

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1 what methodology did you use, Dr. Carpenter? 2 DR. BLAIR CARPENTER: Well, as -- well, 3 on each case I had the gross description, micro -- the 4 photograph, microscopy, ancillary tests, diagnosis and 5 conclusions. 6 MS. JENNIFER MCALEER: All right. So if 7 we -- 8 DR. BLAIR CARPENTER: On each of these 9 item I looked at, I examined and I commented on. 10 MS. JENNIFER MCALEER: All right. So 11 staying with Tab 27, which is PFP029441. If we actually 12 turn the page, photocopied on the back of the letter 13 retaining you is -- is your response of June 13th, 2001? 14 DR. BLAIR CARPENTER: Yep, okay. 15 MS. JENNIFER MCALEER: And you -- if we 16 look at the next page, there's -- for case number 1 there 17 a series of six (6) headings, and those are the six (6) 18 headings you've just described -- 19 DR. BLAIR CARPENTER: Yes. 20 MS. JENNIFER MCALEER: -- that's the 21 methodology you used? 22 DR. BLAIR CARPENTER: Yes. Yes. 23 MS. JENNIFER MCALEER: Okay. Do you have 24 that, Mr. Commissioner? 25 COMMISSIONER STEPHEN GOUDGE: Mm-hm.

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1 Thanks. 2 3 CONTINUED BY MS. JENNIFER MCALEER: 4 MS. JENNIFER MCALEER: All right. So 5 then you were retained on June 1st. You provided your 6 review on June 13th. That's not a lot of time, Dr. 7 Carpenter. 8 I mean, did you have sufficient time to 9 review all of the documentation? 10 DR. BLAIR CARPENTER: Yes. 11 MS. JENNIFER MCALEER: All right. And 12 looking at your letter, your response of June 13th, 2001: 13 "I have reviewed six (6) post-mortem 14 cases from Dr. Smith -- from Dr. 15 Charles Smith, pathologist at the 16 Hospital for Sick Children in Toronto 17 for purposes of quality control." 18 And I think you've explained to us what 19 your understanding of that was. 20 "I have evaluated each from a 21 perspective of gross description, gross 22 photographs, microscopical 23 descriptions, use of ancillary tests, 24 summary of diagnosis, comments, and 25 causes of deaths. A summary of my

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1 comments for each cage -- case is 2 attached to this letter. 3 In all cases, the quality of the gross 4 description, gross photographs, gross 5 sampling of microscrop -- 6 microscopy..." 7 Can you help me with the pronunciation 8 there, Dr. Carpenter? 9 DR. BLAIR CARPENTER: Sorry? 10 MS. JENNIFER MCALEER: It's all right. 11 "...microscopy and miscropial 12 (phonetic) descriptions were of the 13 highest quality, above the average for 14 what is expected from the average 15 pathology service, highly accurate, and 16 without obvious omissions." 17 Now, does that accord with your -- your 18 findings? 19 DR. BLAIR CARPENTER: Yes, they were all 20 there. It was -- it looked adequate. 21 MS. JENNIFER MCALEER: Well, you -- it 22 seems like you're saying a little bit more than it looks 23 adequate. You're saying it's -- it's the highest 24 quality? 25 DR. BLAIR CARPENTER: Yeah.

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1 MS. JENNIFER MCALEER: All right. And 2 can you -- going beyond the four (4) corners of your 3 letter, Dr. Carpenter, what -- what was your assessment? 4 How would you describe Dr. Smith's work 5 that you reviewed? 6 DR. BLAIR CARPENTER: It was excellent. 7 What I saw there was excellent. I had nothing to 8 complain about. The -- these -- all these things were 9 available, they were they, and they were well done. 10 On the case that I had, I must say that I 11 would not have -- I would have gave them a good bill of 12 health. 13 MS. JENNIFER MCALEER: All right. And 14 then -- 15 DR. BLAIR CARPENTER: If he -- sorry? 16 MS. JENNIFER MCALEER: Sorry, I'll -- 17 I'll let you finish your sentence. 18 DR. BLAIR CARPENTER: If he was the 19 resident -- or I looked at it as if he was restarting. 20 What would -- would I do if I had -- if I -- would I say 21 that -- that resident or that fellow is adequate to work 22 on what I had there? My answer is yes. 23 MS. JENNIFER MCALEER: Or -- or as a 24 colleague, if you were going retain him as a colleague? 25 DR. BLAIR CARPENTER: As a colleague, if

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1 I was going to hire him, and I had only this, this was 2 ade -- more than adequate. 3 MS. JENNIFER MCALEER: Okay. And then 4 looking at the last paragraph: 5 "In conclusion, if these cases are the 6 reflection of Dr. Smith's overall work, 7 I personally think that there is no 8 ground for concern at the moment for 9 the quality, completeness, and accuracy 10 of the pediatric medicolegal post- 11 mortems performed by Dr. Smith at the 12 Hospital for Sick Children in Toronto. 13 I hope this will be useful." 14 And that basically sums up your 15 conclusions, Dr. Carpenter? 16 DR. BLAIR CARPENTER: Yes. That was my 17 impression then. And I know at this point it looks funny 18 to have written that, but I -- I did look at those six 19 (6) case, and they were adequate. 20 MS. JENNIFER MCALEER: Right. And you 21 say at this point it looks funny to -- 22 DR. BLAIR CARPENTER: Well, we're in -- 23 we're -- we're sitting here discussing this. And at the 24 time I wrote that, it was excellent. 25 MS. JENNIFER MCALEER: But this is an

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1 accurate reflection of your views upon reviewing -- 2 DR. BLAIR CARPENTER: At that point, yes. 3 MS. JENNIFER MCALEER: -- Dr. Smith's 4 work? 5 DR. BLAIR CARPENTER: Yes. 6 COMMISSIONER STEPHEN GOUDGE: You have 7 not changed your mind about these cases? 8 DR. BLAIR CARPENTER: No, no, no, no, no, 9 no. 10 COMMISSIONER STEPHEN GOUDGE: I mean, he 11 was doing excellent work in those cases? 12 DR. BLAIR CARPENTER: Well, I mean, you - 13 - you got a choice. You had a case of -- of 14 intracerebral hemorrhage, a case of drowning, a SUD, a 15 necrotizing fasciitis, hydrocephalus, and a SUD. And I 16 think it's -- it's a fair cross -- I agree, there's no 17 child abuse or nothing of that kind, but that was not -- 18 COMMISSIONER STEPHEN GOUDGE: That was 19 not the pool from which these cases were taken? 20 DR. BLAIR CARPENTER: -- that was not -- 21 cases were chosen, were taken. So we knew we were not 22 going to have them. 23 24 CONTINUED BY MS. JENNIFER MCALEER: 25 MS. JENNIFER MCALEER: All right. So

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1 based on the cases you reviewed, the conclusions that you 2 reach are reflected in your June 13th letter -- 3 DR. BLAIR CARPENTER: Yeah. 4 MS. JENNIFER MCALEER: -- and you haven't 5 changed your mind -- 6 DR. BLAIR CARPENTER: I did not change -- 7 MS. JENNIFER MCALEER: -- with respect to 8 any of that? 9 DR. BLAIR CARPENTER: -- my mind on any 10 these cases. 11 MS. JENNIFER MCALEER: All right. And 12 following your submission of this letter to Dr. Chiasson, 13 have you had any followup with the Office of the Chief 14 Coroner with respect to -- 15 DR. BLAIR CARPENTER: No. 16 MS. JENNIFER MCALEER: -- your review? 17 DR. BLAIR CARPENTER: No. At one point I 18 did receive a phone call from a -- a firm of defence 19 lawyer asking me if I had anything more than that. They 20 -- they had that report. At that point, I did not real - 21 - I was -- I wasn't too sure what my response should be, 22 because it came from -- from nowhere. 23 And so I -- I said -- I stopped there, and 24 I said, Okay, good, good. And I -- I was very -- very 25 secure or negative or certainly very --

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1 COMMISSIONER STEPHEN GOUDGE: Cautious? 2 DR. BLAIR CARPENTER: -- cautious. So I 3 -- I -- once it was done, I phoned back Dr. Bechard, and 4 I said, Am I allowed to discuss those things with those 5 people? 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. BLAIR CARPENTER: Before I got into 8 trouble. He said by no means did they have a right, they 9 want to talk to you, they can subpoena you if you -- if 10 you don't want to cooperate. 11 MS. JENNIFER MCALEER: So I think you 12 mean by any means? That you -- you should -- 13 DR. BLAIR CARPENTER: No, no. Well, he 14 saw no objection -- 15 MS. JENNIFER MCALEER: Right. You should 16 feel free to speak to them? 17 DR. BLAIR CARPENTER: -- for me, and in 18 fact he told me if they want to they can subpoena you, 19 because they want some answers. 20 So when I saw that, I -- I had their -- 21 their phone number, and I had the -- so I phoned back. I 22 told them that I was willing to discuss the thing further 23 with them if they -- they wanted to, but that I had 24 nothing more to say or less than what I'm saying now, and 25 I said to them then of my -- my study, and I never heard

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1 back from them. 2 So that -- stayed at that point and never 3 had any further involvement with the... 4 MS. JENNIFER MCALEER: With the review? 5 DR. BLAIR CARPENTER: Yeah. 6 MS. JENNIFER MCALEER: Or with -- with 7 any review of Dr. Smith's work? 8 DR. BLAIR CARPENTER: No. 9 MS. JENNIFER MCALEER: Thank you, Dr. 10 Carpenter. Mr. Commissioner, those are all of my 11 questions for this panel. 12 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 13 McAleer. We're going to break now and reconvene at 9:30 14 tomorrow morning. Ms. McAleer will canvas to see what 15 cross-examination times are likely to be in play, but I'm 16 confident, gentlemen, we'll be able to get you out of 17 here by the middle of the day tomorrow. 18 DR. BLAIR CARPENTER: Thank you. 19 20 (WITNESSES RETIRE) 21 22 COMMISSIONER STEPHEN GOUDGE: So I'll 23 look forward to seeing you all tomorrow at 9:30. 24 MS. JENNIFER MCALEER: Thank you, Mr. 25 Commissioner.

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1 --- Upon adjourning at 3:49 p.m. 2 3 4 5 Certified correct, 6 7 8 _____________________ 9 Rolanda Lokey, Ms. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25