11 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 February 11th, 2008 25
21 Appearances 2 Linda Rothstein ) Commission Counsel 3 Mark Sandler ) 4 Robert Centa ) 5 Jennifer McAleer (np) ) 6 Johnathan Shime (np) ) 7 Ava Arbuck (np) ) 8 Tina Lie (np) ) 9 Maryth Yachnin (np) ) 10 Robyn Trask (np) ) 11 Sara Westreich ) 12 13 Brian Gover ) Office of the Chief Coroner 14 Luisa Ritacca (np) ) for Ontario 15 Teja Rachamalla (np) ) 16 17 Jane Langford (np) ) Dr. Charles Smith 18 Niels Ortved ) 19 Erica Baron (np) ) 20 Grant Hoole (np) ) 21 22 William Carter ) Hospital for Sick Children 23 Barbara Walker-Renshaw (np)) 24 Kate Crawford ) 25
31 APPEARANCES (CONT'D) 2 3 Paul Cavalluzzo (np) ) Ontario Crown Attorneys' 4 Association 5 6 Mara Greene (np) ) Criminal Lawyers' 7 Breese Davies (np) ) Association 8 Joseph Di Luca (np) ) 9 Jeffery Manishen (np) ) 10 11 James Lockyer (np) ) William Mullins-Johnson, 12 Alison Craig ) Sherry Sherret-Robinson and 13 Phillip Campbell (np) ) seven unnamed persons 14 15 Peter Wardle (np) ) Affected Families Group 16 Julie Kirkpatrick (np) ) 17 Daniel Bernstein (np) ) 18 19 Louis Sokolov (np) ) Association in Defence of 20 Vanora Simpson (np) ) the Wrongly Convicted 21 Elizabeth Widner (np) ) 22 Paul Copeland (np) ) 23 24 25
41 APPEARANCES (cont'd) 2 Jackie Esmonde ) Aboriginal Legal Services 3 Kimberly Murray (np) ) of Toronto and Nishnawbe 4 Sheila Cuthbertson (np) ) Aski-Nation 5 Julian Falconer (np) ) 6 7 Suzan Fraser (np) ) Defence for Children 8 ) International - Canada 9 10 William Manuel (np) ) Ministry of the Attorney 11 Heather Mackay (np) ) General for Ontario 12 Erin Rizok (np) ) 13 Kim Twohig (np) ) 14 Chantelle Blom (np) ) 15 16 Natasha Egan (np) ) College of Physicians and 17 Carolyn Silver (np) ) Surgeons 18 19 Michael Lomer (np) ) For Marco Trotta 20 Jaki Freeman (np) ) 21 22 Emily R. McKernan (np) ) Glenn Paul Taylor 23 24 25
51 TABLE OF CONTENTS Page No. 2 CREDENTIALING AND GROWING THE PEDIATRIC FORENSIC PATHOLOGY 3 SERVICE IN ONTARIO PANEL: 4 5 RANDY HANZLICK 6 STEPHEN CORDNER 7 MICHAEL POLLANEN 8 MICHAEL SHKRUM 9 CHRISTOPHER MILROY 10 AVRUM GOTLIEB 11 12 Questioned by Ms. Linda Rothstein 6 13 Questioned by Mr. Brian Gover 115 14 Questioned by Mr. William Carter 120 15 Questioned by Mr. Niels Ortved 131 16 17 ORGANIZING PEDIATRIC FORENSIC PATHOLOGY IN ONTARIO PANEL: 18 MICHAEL POLLANEN 19 RANDY HANZLICK 20 GLENN TAYLOR 21 DAVID RANSON 22 DAVID CHIASSON 23 Questioned by Mr. Mark Sandler 136 24 25 Certificate of transcript 242
61 --- Upon commencing at 9:32 a.m. 2 3 THE REGISTRAR: All Rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Good 6 morning. Good morning, gentlemen, I'm afraid I'm behind 7 you, but we'll figure out a way to do this. 8 Ms. Rothstein...? 9 10 CREDENTIALING AND GROWING THE PEDIATRIC FORENSIC 11 PATHOLOGY SERVICE IN ONTARIO PANEL: 12 13 RANDY HANZLICK 14 STEPHEN CORDNER 15 MICHAEL POLLANEN 16 MICHAEL SHKRUM 17 CHRISTOPHER MILROY 18 AVRUM GOTLIEB 19 20 QUESTIONED BY MS. LINDA ROTHSTEIN: 21 MS. LINDA ROTHSTEIN: Well good morning, 22 Commissioner. As you can see, we have an embarrassment 23 of riches this morning. We have gathered some of the 24 world's leading forensic pathologists, it must be fairly 25 said, and I'm going to briefly welcome them by
71 introducing them in a way that doesn't, of course, begin 2 to delve into their multi-page CVs. 3 Closest to you and on my far right, Dr. 4 Randy Hanzlick is the Chief Medical Examiner for Fulton 5 County, Georgia. He is a professor of forensic pathology 6 at Emory University School of Medicine, and the Director 7 of Forensic Pathology Training at Emory. He is a past 8 president of the National Association of Medical 9 Examiners, and is currently a member of the Subcommittee 10 on Forensic Pathology Training for N-A-M-E, the National 11 Association for Medical Examiners. 12 Welcome, Dr. Hanzlick. 13 DR. RANDY HANZLICK: Thank you. 14 MS. LINDA ROTHSTEIN: Seated beside him 15 is Dr. Christopher Milroy who most in the room will 16 recall. Dr. Milroy is the Chief Forensic Pathologist, 17 Forensic Science Service and Consultant Pathologist to 18 the UK home office. He is also Professor of Forensic 19 Pathology at the University of Sheffield. In addition to 20 his forensic pathology training, Dr. Milroy holds a 21 Bachelor of Laws from the University of London. 22 Welcome again, Dr. Milroy. 23 DR. CHRISTOPHER MILROY: Thank you. 24 MS. LINDA ROTHSTEIN: Seated next to Dr. 25 Milroy is another forensic pathologist who's already
81 known to you, Commissioner, Dr. Michael Shkrum. Dr. 2 Shkrum is the Director of the Southwestern Regional 3 Forensic Pathology Unit which is located in London, 4 Ontario. 5 He is a professor provost -- in the 6 Department of Pathology, Faculty of Medicine and 7 Dentistry at the University of Western Ontario. He's 8 currently the Chair of the Subspecialty Committee on 9 Forensic Pathology for the Royal College of Physicians 10 and Surgeons. 11 Thank you for joining us again, Dr. 12 Shkrum. 13 DR. MICHAEL SHKRUM: Thank you. 14 MS. LINDA ROTHSTEIN: Seated next to Dr. 15 Shkrum is Dr. Stephen Cordner. Dr. Cordner is the 16 Director of the Victorian Institute of Forensic Medicine. 17 He is responsible for the administration of the Institute 18 which has seventy-five (75) medical, scientific, 19 technical and administrative staff. It is responsible 20 for forensic pathology, clinical forensic medicine and 21 related fields in Victoria, which of course, is in 22 beautiful Melbourne, feeling, I'm sure, much more 23 beautiful at this moment. 24 Dr. Cordner hails from Australia, without 25 a coat. There's just that macho Australian thing that no
91 doubt is -- is at play. He is a Professor of Forensic 2 Medicine at Monash University and is responsible for 3 administering the Monash University National Centre for 4 Coronial Information. 5 Welcome Dr. Cordner, and we hope you have 6 a good week. 7 We have seated next to him, of course, Dr. 8 Michael Pollanen, who everyone will know, not only from 9 reputation, but from his many days here. Here is the 10 Chief Forensic Pathologist for the Province of Ontario, 11 employed in the Forensic Pathology Unit in the Office of 12 the Chief Coroner. 13 He is an Associate Professor of Pathology 14 in the Department of Laboratory Medicine and Pathobiology 15 in the Faculty of Medicine at U of T. He holds an 16 appointment as an Associate Professor of Forensic 17 Scientists at the University of Toronto, Mississauga. 18 And last but not least, Professor Avrum 19 Gotlieb. Professor Gotlieb is the Chair of the 20 Department of Laboratory Medicine and Pathobiology 21 Faculty of Medicine at U of T. He is a cardova -- 22 Cardiovascular Pathologist at the University Health 23 Network and a senior scientist at the Toronto General 24 Research Institute. Dr. Gotlieb played a leading role in 25 developing and initiating a new undergraduate medical
101 curriculum in the early 1990s. 2 Thank you very much for joining us, 3 Professor Gotlieb. 4 So we have a lot of ground to cover, and, 5 Commissioner, I've had a chance to meet with all our 6 panellists and discuss with them some of the boundaries 7 of this mornings conversation. 8 As you will know, sir, it's not always 9 easy to put boundaries around the systemic issues that 10 confront you, but this morning's roundtable is devoted to 11 the topic of growing and credentialing pediatric forensic 12 pathology in Ontario and so we are focussed primarily on 13 the issues of recruitment, training, and retaining 14 forensic pathologists in Ontario. 15 There will be some crossover, I expect -- 16 a little of discussion about organization -- but I have 17 asked our panellists to try and keep that fundamental 18 focus in mind when they answer some fairly broad 19 questions. 20 So, I want to begin, if I can, by getting 21 a little bit of a sense of the world outside our 22 jurisdiction, because thanks to Drs Pollanen and Shkrum 23 we have a fair understanding of what the recruitment 24 challenges have been to date for forensic pathology in 25 Ontario.
111 And I'd like to start with Dr. Hanzlick 2 and ask him if he can give us a brief summary of to what 3 extent those -- those challenges are present in the US 4 and what, from his experience in a very different 5 jurisdiction have been, some of the key ways of 6 addressing the challenges of recruitment and training of 7 forensic pathologists. 8 DR. RANDY HANZLICK: Okay, thank you. I 9 can probably best answer this by just telling a little 10 history story about Georgia where I work. Georgia has a 11 hundred and fifty-nine (159) counties and each of those 12 counties through history has had an elected lay coroner 13 to basically -- to -- to be the coroner you had to be 14 twenty-five (25) years of age and not be a convicted 15 felon and be able to win an election. 16 And in the 1950s, prior to the days of 17 forensic pathology, the autopsies that were done were 18 done in part by just good willed physicians that were 19 trying to help the system -- been a large part by 20 forensic sciences -- scientists who were not medical 21 doctors. 22 In the 1960s Fulton County, where I work, 23 was the first county to abolish the office of lay coroner 24 and create in its place an appointed medical examiner 25 appointed by the county government who had to be a
121 physician with death investigation training and 2 experience -- that was in 1965 -- and then over the next 3 couple of decades four (4) other counties in the 4 metropolitan area followed suit. 5 It wasn't until the late 1970s that the 6 first forensic pathology training program was developed 7 in the office where I work in Fulton County where people 8 could go and spend a year and train. I began there in 9 1982 and was one (1) of the first trainees there. I 10 finished my training in 1984 and the training program 11 grew after that and we have trained about thirty (30) 12 people in that office over the years. 13 Most of the people now who have come to 14 work in Georgia have either come to that office or have 15 trained in that system. When I started in 1982 there 16 were about four (4) forensic pathologist in the state, 17 now we have about twenty-five (25) or twenty-six (26). 18 The counties that don't have those medical 19 examiner systems still have elected coroners, but through 20 the years that lay system of having forensic scientists 21 do the autopsies has evolved into where there's a central 22 laboratory near Atlanta with a full staff of forensic 23 pathologists, and there are five (5) branch laboratories 24 throughout the state in strategic locations, each of 25 which serves multiple counties, and those are staffed
131 with board certified forensic pathologist or pathologists 2 that have at least had forensic pathology training. 3 So we've evolved from a system that was 4 totally non-medical to one now where we have physicians 5 throughout the state that are specifically trained in 6 death investigation. 7 And I think the keys are this all started 8 with a training program that became accredited. If 9 people are going to train in a specialty they want to get 10 something for it other than the experience; they want to 11 become certified, they want to have some credentials. 12 The system has grown to where the caseload has become 13 reasonable for pathologists; they're not overworked, they 14 have caseloads that are within the limits of recommended 15 standards, the salaries are reasonable. 16 So we've -- in terms of recruiting, we've 17 done that basically through a training program. People 18 have tended to stay there, the job situation has grown, 19 that the jobs are attractive, and people stay. We've had 20 a few leave the State, but we've been fortunate that 21 every couple of years a new position opens up and people 22 take those jobs and like to stay in the State. 23 So it's really a success story that you 24 start with almost nothing and over a period of a couple 25 of decades build a system that's functional.
141 MS. LINDA ROTHSTEIN: How many do you 2 train a year, Dr. Hanzlick? 3 DR. RANDY HANZLICK: We are accredited 4 for two (2), but we have dropped back to one (1) in our 5 office at the current time. We've had as many as three 6 (3) before. Of course, you have to have a certain case 7 load to train people. You have to have a minimum number 8 of autopsies per fellow. You have to have one (1) more 9 Board certified pathologist on staff than you have 10 fellows. 11 It's become more complex to have training 12 programs in recent years, so we've voluntarily dropped 13 back to one (1). 14 And, unfortunately, in the United States 15 right now the applicant pool is small. There's seventy 16 (70) positions among thirty-seven (37) training programs 17 in the United States and only about thirty-six (36) of 18 those positions are filled. 19 MS. LINDA ROTHSTEIN: And what are the 20 components and -- and -- and -- how long is the training 21 program? 22 DR. RANDY HANZLICK: You can train a 23 minimum of -- you can become Board certified in forensic 24 pathology in a minimum of four (4) years if you do a 25 combined certification program. You can do a couple of
151 years of anatomical pathology, another year in a sub- 2 specialty area, and a year in forensic, and that's a 3 little shorter than the options here. 4 It's my understanding that here, it's a 5 five-year (5) basic program and then a sixth year level 6 in forensic training. And that's one thing that might be 7 looked at in other panels or whatever, to -- to perhaps 8 modify that track somehow to -- to make the number of 9 years required appropriate for what you're going to be 10 doing, but to minimize the time that you have to spend 11 training so it's more attractive for people to go into. 12 MS. LINDA ROTHSTEIN: Dr. Milroy, the UK, 13 I -- I don't expect you to speak to the entire British 14 Isles, although I'm sure you could if given the 15 opportunity, but can you tell us about your experience in 16 England and what it tells you about the importance of 17 training? 18 DR. CHRISTOPHER MILROY: Well, the 19 training programs that we have are -- there are two (2) 20 ways I think you can train in forensic pathology in the 21 UK. You can actually train directly which means that 22 after five (5) years that you come out trained as a 23 forensic pathologist. You are limited then to doing 24 forensic pathology. 25 Or you can do essentially what happens in
161 Canada and the States and you can train in anatomic 2 pathology, but that takes five years in the UK, and then 3 you can do fellowships which are -- they're not really 4 time limited quantity in the same extent but I think 5 they're going to extend to about eighteen (18) months to 6 two (2) years is the -- and -- and one (1) of the reasons 7 why I think we have slightly longer training is you have 8 to cater for people who are going to be in solo practice 9 and four (4) years we would perceive as being too short. 10 And that's, obviously, one (1) thing that 11 if you've got people going into institutions where they 12 have got more support, then you can have shorter training 13 and -- and -- and further supervision. And that's -- 14 that is, I think, a better, probably a better system. 15 What attracts people into forensic 16 pathology? Well, I think the job attracts people into 17 forensic pathology, but also proper structures. They've 18 got to have jobs they can apply for. I mean, one (1) of 19 the things is people aren't going to train if then when 20 they have come out of their training program they don't 21 see that there is a full-time or an appropriate post for 22 them to go to. 23 So I think you cannot divorce the training 24 from the -- from the structure. But we do have variable 25 training programs. Most of them are linked to the large
171 institutions and there is some university input. 2 MS. LINDA ROTHSTEIN: Large institutions 3 being hospitals primarily? 4 DR. CHRISTOPHER MILROY: Hospitals or 5 university-based units therein because often -- for 6 example, if you're training in forensic pathology, you've 7 also got to train at the same time in anatomic pathology. 8 So we rotate them around the various specialities which 9 are not always -- which -- which are going to be separate 10 from forensic pathology: neuropathology, pediatric 11 pathology, general, surgical pathology. 12 So I think that we also have a slightly 13 different focus to -- to America, in that our forensic 14 pathologists come out primarily at the moment to do 15 suspicious death work, not the wider community-based 16 death investigation work. And I think that that neglect 17 of that side of forensic pathology in the UK is bad and 18 it -- it has had problems with narrowing the speciality 19 and not fully appreciating the worth of people. 20 So, I mean, I suppose to summarise the 21 thing, attractive training programs, attractive posts for 22 them to go to after, because if you don't have the 23 structure in place then people aren't going to come in. 24 They want to see that they've got a future. 25 But once you've got that, we haven't had
181 difficulties recruiting people into the training posts 2 and we don't have any empty training posts. There, 3 again, we don't have any -- I mean, Georgia has nearly as 4 many forensic pathologists as England and we have a 5 population of 50 million. 6 MS. LINDA ROTHSTEIN: Mm-hm. 7 DR. CHRISTOPHER MILROY: So -- 8 MS. LINDA ROTHSTEIN: So you're -- 9 DR. CHRISTOPHER MILROY: -- so there is-- 10 MS. LINDA ROTHSTEIN: -- still under- 11 serviced? 12 DR. CHRISTOPHER MILROY: I think we are 13 under-serviced but we have a much more narrow definition 14 of what we need to do, because we have a lot of hospital- 15 based -- as you do in Canada -- hospital-based non- 16 forensic pathology-trained people doing medicolegal 17 autopsies. But we -- we exclude from there, hopefully, 18 the suspicious deaths. 19 MS. LINDA ROTHSTEIN: Right. 20 DR. CHRISTOPHER MILROY: But who -- who 21 decides it's a suspicious death, which is a different 22 question -- 23 MS. LINDA ROTHSTEIN: Right. 24 DR. CHRISTOPHER MILROY: -- is -- is not 25 the forensic pathologist.
191 MS. LINDA ROTHSTEIN: Okay. Interesting. 2 Dr. Cordner, I'm going to turn to you and 3 ask you to speak about the Australian, or at least the 4 Victoria experience in training and recruiting forensic 5 pathologists. 6 DR. STEPHEN CORDNER: Yes. Well, 7 Commissioner, I've been thinking about how to talk about 8 this in a few minutes and I find myself really wanting to 9 go back to the basics and the beginnings. 10 I've been privileged to be the first 11 appointee of a new forensic pathology system in Victoria. 12 The previous forensic pathology arrangements were run 13 directly by the coroner, a magistrate. And a group of 14 pathologists saw the poverty of the total arrangements, 15 which were subsequently described by a government entity 16 departmental committee as quote "a disgrace" to the State 17 of Victoria, such that no suitable graduate would be 18 enticed to work there. 19 And I think there's already been mention 20 about how you can't divorce the issue we're talking about 21 this morning, the attraction -- the attracting and 22 retaining of pathologists from the arrangement within 23 which they work. 24 And the poverty of those arrangements in 25 Victoria were both physical, appalling physical
201 circumstances, but also very ordinary organizational 2 arrangements, and those were a barrier to attracting 3 suitable medical staff. And at the time, when I was 4 training, it was impossible to actually get a training 5 anywhere in Australia but also in Victoria, and I had to 6 go to the UK to get my training in forensic pathology. 7 So with those sort of barriers, you've not 8 only got a barrier to attracting the staff, you've got a 9 barrier to producing reliable and credible results. If 10 you can't even get the staff then you're not going to be 11 able to rely on the results. 12 So to -- it seems to me that to deliver 13 credible and reliable results on a sustainable basis 14 you've got to have coherent structural arrangement, to 15 attract the right people and to do the right work. And 16 then you've got to understand -- and I'm -- I don't mean 17 to put it in those terms -- but the indivisibility of and 18 the inter-relationship between the service, research, 19 research which sustains the discipline, which -- which 20 keeps the knowledge current, which informs the service 21 delivery, and teaching and training which adds to 22 sustainability to the service. 23 MS. LINDA ROTHSTEIN: Right. 24 DR. STEPHEN CORDNER: Now, in our case, 25 five (5) of our seven (7) pathologists have all been
211 trained locally, and that is, I think, a beautiful part 2 of the strength of the place. So these -- 3 MS. LINDA ROTHSTEIN: How many -- 4 DR. STEPHEN CORDNER: -- interdependent 5 elements, I believe -- that is, service, research, 6 teaching and training -- should all be delivered from 7 within one (1) entity. 8 And I think if you end up having a service 9 over here and your teaching and research over here, you 10 are starting down a troubled path. I think you're 11 setting up appositional. If you've got a head of a 12 service over here and a head of teaching and research 13 over here, you might well end up with unhealthy, unhappy 14 competition. 15 So I reckon you need one (1) unified 16 entity in the jurisdiction, whatever jurisdiction it is-- 17 MS. LINDA ROTHSTEIN: Mm-hm. 18 DR. STEPHEN CORDNER: -- led by the best 19 academic and service forensic pathologists you can find. 20 MS. LINDA ROTHSTEIN: Mm-hm. 21 DR. STEPHEN CORDNER: And -- and I do 22 emphasize that leadership, because I think if there is 23 uncertainty about the leadership, that will be ultimately 24 corrosive for all elements of the service. 25 And then just to complete that -- complete
221 that picture, that entity's objects and functions must be 2 defined by statute, and the interaction of that entity 3 and its service with the Chief Coroner defined in the 4 statute. 5 So these, I believe, strong institutional 6 arrangements for a unified forensic pathology service, I 7 reckon they are the fundamental and the surest way of 8 growing a credible and reliable service, and it will be a 9 key part of attracting the best medical graduates and the 10 best pathologists, and holding them to ensure that in the 11 longer term you've got results that you can rely on. 12 MS. LINDA ROTHSTEIN: How many do you 13 train a year in Victoria, Dr. Cordner? 14 DR. STEPHEN CORDNER: Well, now we have 15 fallen by the wayside in recent years in that training, 16 and that has been mainly budgetary constraints and that's 17 a matter of regret. 18 We believe we are making progress with 19 those that hand out the budget, who are seeing the strain 20 that that imposes in the medium and longer term. They 21 can see that we're not producing enough people to be able 22 to do the work into the future. 23 MS. LINDA ROTHSTEIN: Mm-hm. 24 DR. STEPHEN CORDNER: So highly likely 25 that in the -- that soon we will have budget for more
231 trainees. And then, if the arrangement are strong, the 2 medical graduates -- because you'll be competing with 3 graduates who want to go and do surgery, who want to do 4 other branches of pathology, or want to become 5 physicians, you're in a very highly competitive situation 6 where the medical graduates have lots of choices, so 7 they're not going to pick weak choices. The discipline 8 has to look strong to be attractive to the best graduate, 9 and you need the best graduates in forensic pathology. 10 MS. LINDA ROTHSTEIN: What's the 11 population of Victoria, and what would you see is the 12 ideal number to trainee, or in light of that population? 13 DR. STEPHEN CORDNER: Yes. Well, we have 14 a population of 5 million. The number of bodies that are 15 admitted to our facility is about four thousand (4,000) 16 bodies, of whom two thousand five hundred (2,500) undergo 17 an autopsy. So -- and what constitutes a proper 18 medicolegal death investigation does vary a bit, 19 according to circumstances, but we believe two hundred 20 and fifty (250) to three hundred (300) cases is a very 21 productive case load. 22 As it happened, we're not -- we've never 23 been able to achieve that caseload. It's always been 24 more than that. 25 So -- but in terms of trainees, we
241 probably need two (2) trainees permanently on the staff 2 because some, after their training, will chose to perhaps 3 go back into clinical pathology, and do a little bit of 4 forensic pathology. Others will become so enthusiastic 5 about the discipline that they will want to stay, and you 6 hope that you've got a consultant position for them, and 7 if they can't get a position with you, they'll -- they'll 8 move to another state, or occasionally even another 9 country. 10 MS. LINDA ROTHSTEIN: Dr. Shkrum, you've 11 been instrumental in developing the training program that 12 is still in it's development for forensic pathologists in 13 Ontario. Can you tell us about that and where we're at. 14 DR. MICHAEL SHKRUM: Well actually the -- 15 the final documents have been submitted for approval, so 16 February 19th is the magic day. So we're hoping that the 17 -- those documents are approved, and once that occurs 18 then that information will be available on the Royal 19 College website, and be disseminated to the medical 20 schools across -- across Canada. 21 And then -- obviously then hopefully 22 various institutions will come forward to -- to propose 23 training programs. Of course there'll be an 24 accreditation process, and that will be the next step 25 after that.
251 MS. LINDA ROTHSTEIN: Okay. So just tell 2 us a little bit about what's happened to date to get thus 3 far with the Royal College of Physicians and Surgeons, 4 and how many trainees you see coming out of this program 5 once it's certified. 6 DR. MICHAEL SHKRUM: Well, it's been 7 actually a very long process. I mean this -- this has 8 been discussed for decades, you know, going back to the 9 '70s actually. Dr. David King was instrumental in -- for 10 pushing this. This is a forensic pathologists now 11 retired in Hamilton. 12 There were formal applications made in 13 2001, and then a reapplication in 2003 for recognition of 14 forensic pathology as a subspeciality. And there was 15 approval finally granted in 2003. So since that time, 16 we've actually been working on a -- a number of documents 17 that had to be processed to allow this recognition to 18 occur. 19 So it's been a long sort of drawn out 20 process, but as I said, we are hopeful that very soon 21 there'll -- there'll be a -- be a -- it will be rolled 22 out as a -- training programs will be -- hopefully start 23 in July. 24 MS. LINDA ROTHSTEIN: And do you see 25 Western as being one (1) of the sites of the training
261 program, or not? 2 DR. MICHAEL SHKRUM: Well, again I think 3 it's been touched on. There has to be a certain critical 4 volume of cases, and again whether we have enough cases 5 to -- to qualify for training. 6 We currently do about five hundred (500) 7 medicolegal autopsies a year and I think there are some 8 guidelines actually from the -- from the US where I think 9 the -- a program has to have at least five hundred (500) 10 cases for -- for at least one (1) fellow, so I think 11 we're just at the -- at the bare minimum. But certainly 12 institutions like Toronto would certainly qualify because 13 they certainly have the case volume. 14 MS. LINDA ROTHSTEIN: Right. 15 DR. MICHAEL SHKRUM: But I think -- I can 16 say Western, actually, we have a strength particularly in 17 forensic neuropatholgy. A colleague of mine, Dr. David 18 Ramsay, who I've mentioned before at the previous 19 hearing, is -- that's -- that is his main strength, so 20 there may be some potential for liaisons between, say, a 21 program in Toronto and other institutions across the 22 Province. 23 MS. LINDA ROTHSTEIN: And, Professor 24 Gotlieb, I'm going to turn to you before I do Dr. 25 Pollanen on the issues. From your perspective, sitting
271 much closely in the University and dealing with 2 undergraduate medical students, how do you see the 3 oncoming specialisation of forensic pathology working 4 with the interests, and hopes and aspirations of young 5 medical students? 6 DR. AVRUM GOTLIEB: Can I just step back 7 for one (1) moment -- 8 MS. LINDA ROTHSTEIN: Absolutely. 9 DR. AVRUM GOTLIEB: -- and just -- 10 because this question came up before in our discussions 11 about lab medicine and pathobiology in Ontario and Canada 12 and actually in North America. 13 So, again, from a historical perspective, 14 in the mid '90s it was very difficult in lab medicine for 15 a variety of reasons. It was difficult to -- to recruit 16 medical students. Laboratory budgets were being slashed 17 as part of cost containment in -- in healthcare across 18 the Province, but of -- across Canada in general. And we 19 also had reduced the number of medical students, due to, 20 I guess, a some type of Federal initiative. 21 So we were not in good shape, but I -- I 22 can say today, ten (10) to twelve (12) years later, we 23 are in fact in -- in very good shape. 24 And so we have regrouped very well. We're 25 -- we're still suffering from overload in terms of -- of
281 work, and that will just take some time to bring on new - 2 - new folks because it -- it takes five (5) years to -- 3 to train minimally a pathologist, and if it's an academic 4 pathologist you can put in another two (2) years. 5 But I -- I think the -- so I think the -- 6 the feeling of the laboratory medicine group as a whole 7 has been very positive and I think we're getting a lot of 8 positive feedback from our colleagues, as well, and we -- 9 we understand that about 70 percent of the medical 10 decisions are based on laboratory tests of one sort or 11 another, so that we play a very important role. 12 So on the basis of that, and I think it's 13 already been said here, that the medical students are 14 looking for a career which will suit them intellectually, 15 which will suit them in a lifestyle way, and which will 16 also make them feel good about themselves in terms of 17 joining a group that is on its way up. And so in lab 18 medicine I think that fulfills those criteria very well. 19 Statistics from across the border show 20 that there's been an increase in the number of medical 21 students entering residency programs in pathology for the 22 last several years, and so the news is -- is actually 23 very good. And -- and part of the reason is because for 24 many medical students it offers a very strong career path 25 which allows clinical work, research, and teaching, and
291 many medical students hold this -- these three (3) 2 pillars very dear to what they would like to see in their 3 future education. 4 So, turning to lab medicine -- to forensic 5 pathology we don't -- as you've already heard, we don't 6 have formal training programs, but we're clearly on the 7 way to doing this. 8 We do have a fellowship training program 9 and that will actually form the basis of the program that 10 we'll be submitting once we get the okay from the Royal 11 College to move forward. And -- and I think that 12 certainly will send a message to medical students that 13 we're for real. 14 Up till now, medical students had to go, 15 or I should say, residents, if they wanted forensic 16 pathology training, had to go to the US. There was no 17 program here in Canada. 18 So I think that was certainly sending a 19 message that was not encouraging to these folks. So once 20 we'll have our own in-built program, I -- I think we're 21 -- we're going to see an enhanced interest. 22 There is interest in -- in the -- in 23 medical students. It's not as if medical students are 24 not interested in forensics. I do a lot of interviewing 25 of our potential candidates coming into our residency
301 programs, and many of them express an interest in 2 forensics. 3 But again, at the end of the day, up till 4 now, we have to say to them, Well there actually is no 5 formal certification and -- and I agree with previous 6 speakers, certification is extremely important. 7 So I think that's very encouraging for 8 moving ahead. And I -- I think now we'll be able to move 9 ahead rapidly in that particular direction. And in terms 10 of trying to encourage students to follow forensic 11 pathology, I think by making it a valued career will -- 12 will certainly induce lots of students to look at it 13 seriously. 14 And then just like we did with our lab 15 medicine program, which we've grown from twenty-two (22) 16 residents in '02/'03, to almost forty (40) today. We'll 17 be able to apply the same so-called marketing techniques 18 just to get the students interested. 19 We offer electives now to medical students 20 in -- in forensic pathology. So I think those who are 21 interested will have a good opportunity to sample it 22 while in medical school. 23 MS. LINDA ROTHSTEIN: Dr. Pollanen -- I'm 24 just going to ask Dr. Pollanen for the moment, Dr. 25 Hanzlick, about the fellowship program, which you've been
311 so instrumental in creating in combination with the 2 University of Toronto, and what the challenges have been 3 in creating that prog -- program, and what it tells you 4 about the future of recruiting young forensic 5 pathologists in Ontario? 6 DR. MICHAEL POLLANEN: The most important 7 initial concept in this is that we are at a very exciting 8 point in the history of the development of forensic 9 pathology in Canada. 10 The development of the Royal College 11 training program will create a new era for forensic 12 pathology. And our challenge right now -- the challenge 13 for all forensic pathologists in Canada -- is to harness 14 that opportunity to grow the profession. 15 And what we've tried to do in -- in the 16 Toronto Unit, in collaboration with the University of 17 Toronto, with great support from Professor Gotlieb, is 18 develop a fellowship training program within our unit. 19 And because we have not had the Royal 20 College Certification, the trainees have been from 21 overseas. So I've trained -- we now have our third 22 fellow that's being trained from overseas. 23 And the spinoffs, or the benefits of that 24 -- were immediately realized in our department. Because 25 the first thing that happened was it changed the entire
321 dynamic from the straight-forward provision of autopsy 2 services to a focal point where you have linked training, 3 education, with the provision of service. 4 This is the most sustainable and effective 5 model to achieve both goals. So it was a critical poin - 6 - it was actually a critical thing for the development of 7 our department in -- in the last few years, to marry to 8 the two (2). 9 Now, in fact, there is a third limb that 10 needs to be married, and that's the University-based 11 research activities, but we'll come to that later. 12 MS. LINDA ROTHSTEIN: We'll come to that. 13 DR. MICHAEL POLLANEN: But the -- but the 14 main issue there is to -- is to link the service 15 activities with the training activities, and the barrier 16 to success has been the lack of formal recognition of 17 training. 18 I can tell you that I'm very optimistic 19 that my department will be a Royal College training site, 20 and on that basis, I have already hired two (2) fellows 21 to start. And I can tell you that despite some of the 22 disruptive events that this history -- the recent history 23 of this Commission of Inquiry has had in the pathology 24 community, there is an -- a sense of optimism for 25 residents and many pathologists in choosing forensic
331 pathology as a specialty. They see this now as a viable 2 career path with, you know, Royal College blessing as it 3 were. 4 So we are really at a -- we're at a point 5 in time where we have great opportunities, but we have to 6 seize those opportunities in the correct manner to bring 7 us into the future. 8 MS. LINDA ROTHSTEIN: Dr. Hanzlick, did 9 you have a comment? 10 DR. RANDY HANZLICK: Yeah, I just 11 wondered if it's okay to put it in numerical perspective? 12 In the United States, there's about 13 eighteen thousand (18,000) medical students per year that 14 enter medical school. And after it's all said and done, 15 depending on the year -- it's been as low as three 16 hundred (300) as high as seven hundred (700) -- but let's 17 just say about five hundred (500) go into pathology, so a 18 relatively small percentage of all medical students. 19 And then, of course, you have to be a 20 pathologist to go into forensic pathology. So if you're 21 going to try to recruit, you've got to start in medical 22 school to get people interested in pathology and then get 23 the pathologists interested in forensic pathology. 24 MS. LINDA ROTHSTEIN: So assuming that 25 you've got some pathologists that are -- that are your
341 pool of potential forensic pathologists. 2 I do want to go back to the comment that 3 at least you hinted at, Dr. Pollanen, and ask the extent 4 to which there has been a chilling effect as a result of 5 the work of this Inquiry and whether you see that as 6 having any long-term consequences for the recruitment of 7 forensic pathologists in this Province. 8 DR. MICHAEL POLLANEN: Well, to be 9 perfectly frank, there have been some chilling effects of 10 the Inquiry. There have been some community hospital 11 pathologists that have declined to do post-mortem 12 examinations citing as one (1) of the reasons, this 13 Inquiry. 14 There has also been challenge. You know, 15 the profession has been challenged by these events 16 because forensic pathologists and all pathologists, in 17 general, want to do a good job, are committed to doing a 18 good job in their surgical pathology and their autopsy 19 pathology. And the press, as it were, has not been 20 highly complimentary. 21 But despite that, there are -- there's a 22 core group of -- of residents that are interested in 23 making forensic pathology as a career, that, like me, 24 view these events as being a catalyst for further 25 advancement.
351 So I think that there is a general sense 2 of optimism. That's not, of course, limited to trainees. 3 That is, you know, generally viewed in -- in the broader 4 community as well; that with the -- with the negative 5 also comes a great sense of positive advancement. 6 MS. LINDA ROTHSTEIN: Dr. Cordner, with 7 your twenty (20) years experience training pathologists 8 to become forensic pathologists, do you have any words of 9 wisdom about how one encourages pathologists to think 10 about the forensic discipline and what the challenges are 11 in light of sometimes the very high media attention that 12 is given to the work of forensic pathologists as opposed 13 to other pathologists? 14 DR. STEPHEN CORDNER: Well, if I may say 15 so, that's a loaded question asking for words of wisdom. 16 But just to follow up one (1) comment that 17 Dr. Pollanen made. I don't think it's unique to Toronto 18 that clinical pathologists often work in -- in regional 19 locations -- not capital city locations -- who find 20 themselves because of the absence of local forensic 21 pathology capacity, filling gaps out of professional -- 22 out of sense of professional obligation. 23 Increasingly, around the world in many 24 parts, finding themselves under serious pressure getting 25 involved with cases that, in their heart, they don't
361 actually feel completely comfortable in getting involved 2 with, but they sort of have to because they're the only 3 people there who are remotely able to deal with the 4 issues. 5 So I think the increased complexity of 6 this part of medical practice is being felt in many 7 jurisdictions for different reasons. 8 Obviously, this Inquiry, in this 9 jurisdiction, but just being involved with a particular 10 case that becomes controversial in a regional location 11 can be -- have a serious impact on the reputation of the 12 particular pathologist in that area, and -- and these 13 cases start to become less attractive. 14 So it's -- it's an issue not confined to 15 this part of -- this part of Canada. 16 So I think it -- it is worth putting a 17 very large amount of effort into being able to train your 18 own medical graduates to provide your future forensic 19 pathology workforce. And that's where the major effort 20 should go, as opposed to trying to attract, in the 21 shorter term, pathologists from other countries or other 22 jurisdictions. The planning and the effort should be in 23 the medium -- to produce the medium and longer term 24 benefits. 25 I think we have benefited enormously from
371 having people who we've been able to shape being as 2 staff, and -- and because of that, I think feeling very 3 comfortable about working in the institution without 4 thank. 5 Having said that, I don't think it 6 important that those trainees get exposure to other 7 systems, and perhaps, it a bit different versus Australia 8 being relatively further away from much of the list of 9 this panel -- the world in Europe -- that we do actively 10 encourage our trainees to spend some time, either in 11 Europe or -- or North America, so we find that a very 12 valuable life but also there's no experience. 13 And -- and a very important experience 14 that so many of us at this table know each other, and 15 that's not just a pleasant thing. That is actually a 16 practically beneficial thing when I can engage, at least, 17 two (2) members of this table with particular cases so 18 easily these days to get -- to get a view which is 19 outside -- outside the local view about particular cases. 20 Randall's already mentioned the tiny size 21 of forensic pathology, and so we do need to be able to 22 think not only between jurisdictions -- bigger than just 23 our local jurisdiction -- but also internationally. 24 MS. LINDA ROTHSTEIN: Dr. Shkrum, and 25 I'll -- I'll take your questions in a moment -- the
381 process that is almost completed before the Royal College 2 of Physicians and Surgeons, what impact will it have on a 3 need for grandfathering or retraining some of those 4 pathologists who lack the certification, but have been 5 actually practicing as forensic pathologists for some 6 years? 7 DR. MICHAEL SHKRUM: The Royal College 8 defines a -- what's called a "Practice Eligibility 9 Route", and actually, that will probably be a subject -- 10 well, actually, it would be probably the main focus of a 11 discussion in a spring meeting probably in May to -- to 12 address that particular issue. 13 So you -- it does recogi -- the Royal 14 College does recognize that there are people out there 15 that do have varying levels of experience or training, 16 probably obv -- obviously elsewhere in -- in the world 17 that have to be, in quote -- quote/unquotes, 18 "grandfathered". 19 There's no really grandfathering clause. 20 Just because you practice, you can't sort of be 21 grandfathered into the Royal College. You have to be 22 declared eligible to actually write a certification 23 examination, and that eligibility will be based on a 24 number of criteria. 25 The Royal College does recognize American
391 Board pathology certification as -- as one (1) criteria, 2 but there are other criteria that we still have to 3 discuss. This includes audit of one's practice, direct 4 observation of one's practice, and also what's called a 5 360 degree review. 6 In other words, questionnaires are sent 7 out to coworkers of an individual -- they could be 8 superiors or people working for that individual or 9 working beside them -- and there'll be some assessment 10 made. 11 The challenge will be is that this 12 assessment has to be done by two (2) other individuals 13 and how will they be recognized. The trouble in -- in 14 Canada is that there's such -- such a small pool of 15 people to draw from to do these assessments of 16 grandfathers and grandmothers. 17 It's also a challenge we're having right 18 now to -- to form our Examination Board. There's not a 19 lot of people around that -- that want to be on the 20 Examination Board because some of these people actually 21 want to write the examination. So we -- we face a lot of 22 challenges trying to get enough people to -- to staff 23 these different areas of assessment examination. 24 MS. LINDA ROTHSTEIN: Okay. Professor, 25 Gotlieb, you had a point you wanted to make.
401 DR. AVRUM GOTLIEB: Yeah, I just wanted 2 to make the comment that relating anatomic pathology 3 training to forensic pathology; all our anatomic 4 pathology residents have to do a mandatory elective in 5 forensic pathology. So all of their going through that 6 program, there is an opportunity to expose them to the 7 sub-specialty and for the forensic pathologists to mentor 8 them, and that -- that's a very good opportunity to 9 attract individuals from the AP Program into forensic 10 pathology. 11 MS. LINDA ROTHSTEIN: Okay. And, Dr. 12 Milroy, did you have a point? 13 DR. CHRISTOPHER MILROY: Well, I was just 14 going to say -- well, two (2) rather disparate points. 15 On grandfathering; we've had to face that when we 16 expanded the home office list to the whole of the country 17 because historically London wasn't involved, and I have 18 to say I'm rather against grandfathering it, per se. 19 MS. LINDA ROTHSTEIN: Right. 20 DR. CHRISTOPHER MILROY: I think you've 21 got to look at qualifications and experience. But the 22 second thing is that the exposure -- if you look at most 23 forensic pathologists, actually they got interested as 24 undergraduates. 25 And it's -- it's key that there is an
411 undergraduate access, either by part of the undergraduate 2 curriculum, or the option to do special study modules, 3 electives, whatever, as an undergraduate. 4 That's certainly how I got in, and that's 5 how many of my colleagues got in. 6 MS. LINDA ROTHSTEIN: Okay. And, Dr. 7 Hanzlick, did you have a point as well? 8 DR. RANDY HANZLICK: Yeah, just to 9 reinforce what was said. The National Association of 10 Medical Examiners did a survey about people going into 11 forensic and what attracted them. 12 And the two (2) main things were that they 13 had a positive experience when they did their rotation as 14 a pathology resident with the local medical examiner, and 15 that it was instructional with an interested teacher who 16 served as a mentor. 17 Those were the two (2) most important 18 things that spurred their interest. 19 MS. LINDA ROTHSTEIN: Okay. So with that 20 context, Dr. Pollanen, that it's not the driver, what 21 changes to remuneration should be made in order to 22 encourage both the recruitment and retention of forensic 23 pathologists in Ontario, understanding that's not the 24 only issue? 25 DR. MICHAEL POLLANEN: Well, the issue is
421 very interesting because in the Province of Ontario, all 2 hospital-based pathologists derive their income from the 3 Ministry of Health, and that salary is set for all 4 pathologists across the Province through something called 5 the LMFFA, the Laboratory Medicine Funding Framework 6 Agreement. 7 And the forensic pathologists that work in 8 our Regional Forensic Pathology Unit, such as Dr. Shkrum, 9 and others, have a salary which is standardized to that 10 level. 11 Whereas, the forensic pathologists that 12 work in my department are excluded from that agreement. 13 This -- what this creates is a very odd dynamic, because 14 we -- my department, and -- and myself in particular -- 15 have a very large administrative role for the system, and 16 yet we are paid less than everybody else. 17 And that is a -- that's a huge barrier to 18 recruitment. That is -- there -- there are linked issues 19 with that, including the fact that when -- when forensic 20 pathologists work in academic environments, like teaching 21 hospitals, there is a -- there is a built-in 22 infrastructure to facilitate the practice of medicine, 23 which is what forensic pathology is. 24 So that includes, for example, monies for 25 continuing medical education, which are not provided to
431 us on a yearly basis for -- for continuing a medical 2 education, because we are -- we are immersed in a 3 separate type of structure. We're not immersed in a 4 practice of medicine structure, we're immersed in a 5 governmental structure. 6 So -- so there are straight-forward 7 differences related to level of compensation, and then 8 sort -- other hidden variables which we do not benefit 9 from that are present in the hospital sector. 10 And this -- this will continue to be a -- 11 a major barrier to recruitment in the Toronto department 12 unless there is, you know, equality of -- of 13 compensation. 14 MS. LINDA ROTHSTEIN: Dr. Cordner, as 15 someone who's been involved for twenty (20) years in 16 trying to negotiate fair remuneration for your forensic 17 pathologists, what can you tell us about what the 18 challenges are in other jurisdictions on this issue? 19 DR. STEPHEN CORDNER: Well, what Dr. 20 Pollanen just described is absolutely the case in 21 Victoria, even. In our unified system, which I think the 22 arrangements are very good -- in which the arrangements 23 are very good for the provision of a reliable service, 24 what we have not got, and what -- what must be made 25 available in any new service system in this Province is -
441 - is the healthcare benchmarks are not met for the terms 2 and conditions of our pathologists. 3 Very important, because that is where the 4 traffic will be if pathologists choose to move. And in 5 my case, it's a dis -- it's an incentive for people to 6 leave our forensic pathology system, and go into the 7 hospital system because there is a substantial difference 8 in -- in pay that we haven't been able to bridge. 9 So using the healthcare system as a 10 benchmark for the terms and conditions of employment in 11 the -- in our case -- in a justice system forensic 12 pathology service -- is absolutely critical to the 13 sustainability of the service. 14 Despite that, we haven't been successful 15 in Victoria in -- in being able to establish that, and we 16 just -- we continue to make the case. 17 MS. LINDA ROTHSTEIN: But, if I can just 18 follow up on this, Dr. Cordner, because having talked to 19 you, I understand that notwithstanding, you haven't been 20 able to get parity, if you will, with your hospital 21 pathologist colleagues, you favour a system in which 22 forensic pathologists are paid out of a Justice budget -- 23 DR. STEPHEN CORDNER: Yes. 24 MS. LINDA ROTHSTEIN: -- broadly 25 described. Can you tell us about that?
451 DR. STEPHEN CORDNER: Well, I think -- I 2 don't have any doubt that we are better off in a justice 3 portfolio than in a health portfolio. 4 I can -- despite the grizzle I've just 5 made, I can get a hearing at a higher level in a Justice 6 Department which understands what we do much more easily, 7 than I would ever get a hearing at any level in a Health 8 Department where the main issues are crowded emergency 9 department, waiting lists for elective surgery, hospitals 10 which have gone on by-pass because they're full. 11 Those are the massive political issues for 12 which a tiny group of pathologists who are doing 13 autopsies -- dealing with the dead, for God's sake, you 14 know -- what -- what are you doing in a Health 15 Department? 16 So, I mean, notwithstanding, if we do make 17 a contribution to health in terms of public health and 18 safety, the political realities are that you don't get 19 much of a hearing, it seems to me, in a Health 20 Department. So I think organizationally, generally 21 speaking, we have been much better off, but we have not 22 succeeded in the terms and conditions of pathologists 23 because they haven't walked. They haven't actually left 24 us, I believe, because of the -- the value of the other 25 arrangements; you know, the organizational arrangements,
461 the mix of work, the teaching and research that goes 2 hand-in-hand with the service in a collegiate 3 environment, with all the other services there to look 4 after the pathologists in their professional work. 5 MS. LINDA ROTHSTEIN: Dr. Shkrum and then 6 Dr. Pollanen. 7 DR. MICHAEL SHKRUM: Yes, I admit I'm one 8 (1) of those hospital-based pathologists. 9 But I think it brings up another very 10 important point. That -- I mean, a lot of people that do 11 forensic work do it in a hospital-based setting. And I 12 think it's very important to realize that, you know, 13 there has to be funding available for positions like 14 that. 15 My -- my career did not start as a full 16 time forensic pathologist. I started as a surgical 17 pathologist with -- with a sub-specialty of forensic 18 pathology, but over 90 percent of my practice was devoted 19 to doing surgical pathology and cytopathology. And it's 20 only in the last four (4) or five (5) years that I've 21 actually gravitated to almost full-time forensics. 22 So I like to know that when I -- when I 23 step down, that I will be replaced by, hopefully, 24 somebody that does either full-time forensics or a fair 25 amount of it.
471 I think the other thing is to realize that 2 it's not just a -- a position -- it may be full-time 3 equivalent positions -- that there should be funding 4 available and that full-time equivalent positions, 5 particularly in a hospital-based setting, may actually be 6 split. There may be two (2) people doing 50 percent of 7 their time or four (4) people doing 25 percent of their 8 time doing forensic pathology. 9 So I think you have to realize there might 10 be sort of this hybrid-type of condition; that there will 11 be people practicing, particularly in hospital-based 12 settings, that will continue to do forensic pathology but 13 maybe not full-time. 14 And I think that stands to reason. I 15 mean, the primary certification of pathologists working 16 in that kind of system -- or in a hospital-based system - 17 - is they've been certified in anatomical pathology most 18 likely. They've had five (5) years of training. They 19 develop a very important skill set. There are clinical 20 needs -- hospital-based needs -- that have to be 21 addressed. 22 So I think those people may choose to have 23 a career that is actually a hybrid-type of career, so I 24 think that has to be recognized too. 25 MS. LINDA ROTHSTEIN: Dr. Pollanen...?
481 DR. MICHAEL POLLANEN: Professor Cordner 2 indicated that there's not been a movement of 3 pathologists out of his institution. But that is, in 4 fact, the sorry history of our department. 5 What happens is that we -- we have failed 6 to retain the majority of people that have ultimately 7 been recruited and all of those people have left for the 8 hospital sector; some practicing forensic pathology in 9 the hospital sector. 10 So it has been a very important barrier 11 for retention in -- in Toronto to the point that you can 12 -- you can track our history by the flux of full-time 13 forensic pathologists coming and going. 14 And that is a -- that's a -- that's a 15 major problem that needs to be solved. 16 There is a linked other problem and that 17 is that the service provision model in the Province of 18 Ontario is a fee-for-service model. 19 There -- there are exactly three (3) 20 forensic pathologists that are paid a salary by the 21 Coroners Office and those three (3) people are in my 22 department. 23 And all of the other autopsies that are 24 performed in the province are on a fee-for-service model, 25 not an FTE model. And, in fact, the only other monies
491 that are distributed across the system outside of the 2 fee-for-service model are the inadequately sized grants 3 that go to the regional forensic pathology units. 4 So the -- the entire model for service 5 provision currently is not along the FTE thinking -- 6 MS. LINDA ROTHSTEIN: Right. 7 DR. MICHAEL POLLANEN: -- it's on a fee- 8 for-service provision model. And that model is not 9 particularly compatible with sustainability of -- of 10 practitioners in -- in the discipline. 11 MS. LINDA ROTHSTEIN: Given the number of 12 pathologists in Ontario who perform forensic pathology 13 some of the time, is it realistic to change to an FTE 14 model in Ontario? 15 DR. MICHAEL POLLANEN: Not entirely. I 16 believe it would have to be a blended model. 17 MS. LINDA ROTHSTEIN: Can you give us any 18 specifics around that? 19 Obviously, Toronto is going to stay with 20 hopefully a growing number of full-time equivalent 21 pathologists working out of the Toronto Forensic Unit, 22 but in addition to that where would you see building FTEs 23 and reducing the number of fee-for-service pathologists? 24 DR. MICHAEL POLLANEN: Well, that -- that 25 is actually a fairly complicated exercise that would
501 involve looking at how cases are distributed geographical 2 over -- over the province and to what extent you could 3 move cases to regional centres. So those are, in fact, 4 very complicated -- 5 MS. LINDA ROTHSTEIN: Right. 6 DR. MICHAEL POLLANEN: -- calculations 7 and would have to come within the context of some type of 8 greater strategic planning for how to deliver autopsy 9 services. 10 But clearly right now, the -- the -- if we 11 were to engage that type of FTE model, it -- it would be 12 a bizarre hybrid because the FTEs, currently defined, 13 would be Health, Department of Health FTEs -- 14 MS. LINDA ROTHSTEIN: Right. 15 DR. MICHAEL POLLANEN: -- as opposed to 16 FTEs from our Ministry. So, as a result, you know, even 17 if you defined we needed X number of FTEs, the reality is 18 that our Ministry is not paying for them. The -- the 19 majority of full-time forensic pathologists are funded 20 currently by the Ministry of Health. 21 MS. LINDA ROTHSTEIN: Dr. Milroy...? 22 DR. CHRISTOPHER MILROY: Well, I just 23 wanted to say the -- the fee-for-case model is the one 24 that's -- that is the entire funding, essentially, of 25 forensic pathology in England and Wales and I think it's
511 a very pernicious model because it encourages people to 2 do the case work; it discourages them to do any teaching, 3 any training or any research. 4 And I think it's a downward slope towards 5 a fragmented, poor service and I think that's what -- my 6 colleagues don't think so but I do -- that they're facing 7 in England and Wales. There's -- there's a lack of 8 teaching, there's a lack of research being carried out 9 and that means that the speciality doesn't move forward, 10 it moves backwards. 11 And I really do think you've got to -- 12 it's patently obvious that with the size and geography of 13 Ontario, you're not going to have everybody as a full- 14 time forensic pathologist. But I think that you need to 15 encourage more full-time equivalent with probably the -- 16 the, if you like, the part-timers, however they're looked 17 at. You want to make sure they're doing a minimum number 18 of cases and also linked in with the big regional units. 19 MS. LINDA ROTHSTEIN: Dr. Hanzlick, what 20 are -- what are the compensation challenges and successes 21 in your State? 22 DR. RANDY HANZLICK: Well, we've 23 addressed those in a couple of different ways 24 progressively with -- by raising the requirements to hold 25 the jobs, as salaries have risen to competitive levels.
521 At the place that I work, the medical 2 examiners are funded primarily by the county government 3 in those counties where there's a County Medical Examiner 4 system. But at my office in Fulton County the medical 5 examiners get a stipend from the university for their 6 teaching involvement. We have medical students coming 7 through there. We have pathology residents. We have a 8 forensic fellowship. We have investigative interns at 9 local colleges and they do a fair amount of teaching so 10 their salaries are a mixture of county funding and -- and 11 university funding which has been a real benefit. 12 And then we also have the university 13 assets available to us to help us with the graduate 14 medical education programs and the pre-inspections and 15 all the paperwork we need to do for training. 16 So, you know, the -- the -- I think the 17 salaries across the country are somewhat based on cost of 18 living there. You can -- the salaries across the country 19 for a Chief Medical Examiner, believe it or not, range 20 from one hundred thousand dollars ($100,000) to two 21 hundred twenty (220)/two hundred twenty-five thousand 22 dollars ($225,000) sometimes more, especially if you 23 include the ability to gain outside income. 24 But, you know, the average is hundred 25 forty/hundred and fifty (140/150) for an experienced
531 pathologist, which is far below the salary for a hospital 2 based pathologist. The same situation that you -- you 3 have here in Canada basically. 4 MS. LINDA ROTHSTEIN: Okay. And, 5 Professor Gotlieb, is there anything the Commissioner 6 should know about just the compensation or remuneration 7 issues that affect clinical pathologists that should be 8 added to the mix? 9 DR. AVRUM GOTLIEB: So at the University 10 of Toronto, basically we don't pay anybody to teach per 11 se. So people have an academic position, and that 12 academic position has a specific job description and that 13 includes clinical service, it includes research, and it 14 includes teaching. 15 And it will vary depending on the training 16 of the individual, of their career development. So we 17 may have people who are doing 80 percent research and 20 18 percent clinical work. We may be have -- we may have 19 people all over the map in terms of -- of the 20 distribution. 21 What we'd like to see is the chair's in 22 Ontario, and we've been working on this with respect to 23 work load, is to have a situation where our FTEs, which 24 are 100 percent FDEs, 50 percent would be devoted to 25 clinical work and teaching, because we've linked our
541 teaching so closely to clinical work that it's really 2 hard to separate, and then 50 percent for research. And 3 the research includes the very basic bench work. It's 4 the translational research that brings discoveries from 5 the lab to the clinic, and also clinical researchers as 6 well. 7 So -- so that's -- that's our essential 8 strategy and that's consistent. The numbers are -- are 9 not totally consistent, but the -- the approach is 10 consistent to the alternate payment plans that the 11 Government of Ontario is going into with various 12 physician groups. 13 So there is such a thing as an academic 14 physician. In this case we're talking about an academic 15 laboratory physician and pathologist, and they have a 16 particular job description which they fill -- fill out. 17 MS. LINDA ROTHSTEIN: Okay. I want to 18 talk a little bit with you all about relationships with 19 universities, and try and get a better feel for what 20 those are like. 21 Starting with you, Dr. Hanzlick, we know 22 that you're a Professor of Forensic Pathology, you're the 23 Director of the training at -- at Emory University, is it 24 just your relationship with the University? 25 Is it a relationship that is broader than
551 that, that actually is with the Office of the Chief 2 Medical Examiner for Fulton county? Help us with those 3 relationships and how they work. 4 DR. RANDY HANZLICK: There's always been 5 an affiliation between -- well, one (1) or two (2) years 6 accepted -- between the Fulton County Medical Examiner's 7 Office and Emory in terms of the fellowship training. 8 The have funded the fellowship positions, at least one 9 (1) of them, pretty much routinely. The faculty have 10 always been given some sort of a stipend and faculty 11 appointment. 12 It became a little bit more formalized 13 when I became the Chief Medical Examiner ten (10) years 14 ago, because I was already working for Emory, so the -- 15 Emory contracted with the county for my services rather 16 than myself being a county employee. 17 But the -- the relationship with the 18 University mainly revolves around its need to provide 19 forensic experience for medical students and pathology 20 residents and the forensic pathology training program. 21 MS. LINDA ROTHSTEIN: And do any of the 22 other medical examiners at Fulton County also hold 23 University appointments? 24 DR. RANDY HANZLICK: Yes, they all do. 25 MS. LINDA ROTHSTEIN: They all do?
561 DR. RANDY HANZLICK: They're all Clinical 2 Assistant Professors and -- and they get a supplement to 3 their county income. 4 MS. LINDA ROTHSTEIN: Okay. So starting 5 with you, Dr. Hanzlick, how do you divide your time 6 between research, teaching, and every day service? It's 7 not every day, but I mean -- 8 DR. RANDY HANZLICK: Yeah. 9 MS. LINDA ROTHSTEIN: -- pure -- 10 DR. RANDY HANZLICK: And -- and -- 11 MS. LINDA ROTHSTEIN: -- forensic 12 medicine. 13 DR. RANDY HANZLICK: -- you have -- it's 14 kind of a complicated answer, because I also have 15 administrative experience in terms of running a county 16 office. 17 MS. LINDA ROTHSTEIN: Right. 18 DR. RANDY HANZLICK: So I basically just, 19 kind of like was said earlier, on a concept of having 20 equal amounts of service, scholarly activity, teaching, 21 is all just kind of equal proportions part of the job. 22 MS. LINDA ROTHSTEIN: Okay. 23 DR. RANDY HANZLICK: There's no specific 24 -- we -- we have to fill out, you know, a time sheet 25 every quarter on how we allocated that, but it's pretty
571 much equal amounts of those things. 2 MS. LINDA ROTHSTEIN: Okay. Tell us a 3 little bit about your research interests, what those look 4 like in a university setting that's been, you know, 5 established for some time. 6 DR. RANDY HANZLICK: Yeah, my research 7 interests have mainly been actually outside of the 8 laboratory and I think that's a major difference than 9 what many people are talking about here, of using the 10 recruitment -- or the facilities available to do basic 11 research and laboratory research. Mine have been more in 12 systemic issues of death investigation systems, 13 development of professional guidelines, professional 14 standards, reviewing casework and publishing case series; 15 that's basically been the relationship we've had in -- in 16 the research area. 17 MS. LINDA ROTHSTEIN: Okay. And maybe 18 it's self evident, but tell us what you think about the 19 importance of cementing those relationships between the 20 university on the one side and the death investigation 21 system on the other. 22 DR. RANDY HANZLICK: I think it's 23 critical because you can get stale when you -- it has -- 24 has already been mentioned -- if you go out in the 25 community and you're a solo practitioner and you don't
581 have people to run cases by, you don't have anybody 2 keeping you on your toes, you're not keeping up with new 3 developments in the field, is simply -- you may just lack 4 having a professional conversation with another 5 colleague. And when you have a training program, that 6 brings all of those things in automatically, it brings in 7 an automatic availability of experts on the faculty and 8 other disciplines when you need them. 9 It's just a healthy thing to do. 10 MS. LINDA ROTHSTEIN: Okay. Dr. Milroy, 11 tell us about your experience with Sheffield. 12 DR. CHRISTOPHER MILROY: Well, I'll -- 13 I'll just expand it, actually, a little bit to start 14 with. Stephen Cordner trained in -- forensic training in 15 London at Guy's Medical School and that forensic 16 department is shut. Sharon Croft's (phonetic) Medical 17 Hospital London, that department is shut. The Royal 18 London Medical Hospital, that department is shut. St. 19 Georges Medical Hospital, that department is shut. 20 London has no -- the largest city in 21 Europe has no academic bases for forensic pathology. 22 MS. LINDA ROTHSTEIN: You're going to 23 tell us why? 24 DR. CHRISTOPHER MILROY: And I'm going to 25 tell you why. Leads shut, Birmingham, closed, Bristol,
591 closed, Sheffield, gone. They -- the universities had 2 divested themselves in the UK of forensic pathology 3 departments and it's for two (2) reason: 4 One (1) is the clinical side, they don't 5 want to run the risk of these high profile bad news 6 specialities at times. You know, we've had our problems 7 in the United Kingdom with miscarriages of justice and 8 forensic practitioners being criticised, so there was 9 that side. 10 The other side is that in the UK 11 especially -- or maybe elsewhere, as well -- universities 12 have focussed on primary research. Forensic pathology 13 and forensic medicine in general doesn't really fit into 14 that profile for two (2) reasons: 15 One (1) is there isn't any grant money out 16 there. There just isn't. It's very difficult to get 17 grant money. Health research aren't interested in 18 forensic medicine, and if you to say police research 19 budgets, they're more interested in helicopters, and 20 surveillance, and CTTV, and so on. Going along and 21 saying I want to do a study on bruising doesn't really 22 excite the guy who's going to be able to, you know, look 23 at fantastic new surveillance procedures. 24 So that -- that has been the tension. I 25 mean -- and I could go on. Scotland's lost its regius
601 chairs. These were, you know, highly significant 2 established chairs whi -- which the monarch used to sign 3 your -- sign your form to -- your contract, you know. 4 So there has been this tension, but I -- I 5 still think it is fundamental that forensic pathology has 6 a research and teaching basis which is -- clearly is best 7 carried out in universities. 8 And there are some -- there is a lack of 9 evidence base in a lot of forensic medicine; it's based 10 on anecdote. And a classic example is on aging of 11 injuries and people have just made assumptions about it. 12 When people have done what little research as there has 13 been, all of our anecdotal assumptions have been wrong. 14 And there is a great need for much research in forensic 15 pathology to bring an evidence base. 16 And I -- just mention one (1) thing on 17 evidence base. There is an attempt to form an 18 organisation called the Cochrane Group. Cochrane groups 19 exist across all of clinical medicine where you look at 20 the literature and you say whether one (1) treatment is 21 better than another or you look for the -- what the 22 evidence base is. 23 And these groups exist internationally. 24 And we are trying to develop the Cochrane Group 25 internationally for forensic medicine that we hope,
611 although its -- its come initially from UK, but Stephen I 2 think has been involved, I think Michael may well have 3 been involved. We have gone to -- possibly going to ask 4 the Dutch Government whe -- whether they would 5 contribute. 6 This is something that internationally 7 people could put money into, to resources, where we can 8 actually begin to try and have an important organisation 9 to look at research, and often founded in universities, 10 but extending out into the community. 11 Because if somebody does a piece of 12 research on forensic medicine in Australia, it's going to 13 apply in Canada as much as it's going to apply in -- in 14 England, in the States, and so on. 15 So I do think that the University is 16 important. But sadly in the United Kingdom, we have been 17 pushed out of Universities. 18 MS. LINDA ROTHSTEIN: Dr. Cordner, 19 you're, as we've heard, a huge proponent of the 20 indivisibility of research, teaching, and clinical work - 21 - service anyway. 22 Explain to us why that's worked in 23 Australia, and how you devote your time to the research, 24 and teaching side of your practice. 25 DR. STEPHEN CORDNER: Well, like the
621 previous two (2) speakers, we have never had any choice. 2 The founders and the government who wrote the statute for 3 the Institute, included in our statutory obligations that 4 we must teach and we must research. 5 And, so they had the vision that I was 6 required to implement. And that was given form, I 7 suppose, by the Director of the Institute actually being 8 the University appointed professor. 9 So that provides some sort of mechanism, 10 if you like, for the person who's responsible for 11 providing the service is, indeed, the person appointed by 12 the University to the Chair of Forensic Medicine. 13 And it had the additional benefit of 14 setting the stamp of independence upon the service 15 entity, so that I actually can't be fired by the 16 Department of Justice. They've got to convince the 17 University to fire me. 18 So that is a slightly harder stick to 19 take, and it has been a wonderful position for myself 20 personally, and I think it has been a wonderful sort of 21 way of setting a stamp on the -- on the Institution. 22 So the Institution has a dual character. 23 It is both a governmental statutory authority, but we're 24 also a University department. 25 And there's a -- a document between the
631 Attorney General and the University, which makes 2 available to the University for all of it's academic 3 purposes, the physical structure and the staff of the 4 government statutory authority to actually document where 5 the government says, We give this to the University for 6 your academic purposes. 7 Obviously it's got to meet service needs. 8 So I actually don't think you need to worry too much 9 about, Oh should it be in the University, or should it be 10 out of the University. 11 I think actually you can have the luxury 12 of thinking of what the content of the thing should be, 13 and then the arrangement can be made to meet -- to meet 14 those needs. 15 If I can only just lend a word of support 16 to that Cochrane initiative. Despite all of the 17 distractions that have been going on here for forensic 18 pathology, there has been under Dr. Pollanen's -- in Dr. 19 Pollanen's department some primary valuable forensic 20 pathology research, which isn't actually all that common. 21 And the Cochrane Group, because of the 22 small nature of forensic pathology, is desperately needed 23 to get some critical mass of people and funds to answer 24 really critical questions, many of which have been, you 25 know, brought to the surface by this Inquiry.
641 I'm sure -- you may not be aware, but this 2 Inquiry is on the lips of forensic pathologists around 3 the -- around the world and it throws up questions that 4 have cause for with concern, not just -- not just here. 5 Just lastly, you said personally -- 6 MS. LINDA ROTHSTEIN: Yep. 7 DR. STEPHEN CORDNER: -- my own split of 8 time. We haven't done so much primary forensic pathology 9 research. 10 We have an obligation to do research, so 11 we have to -- we sometimes conform ourselves a bit to 12 where the money is, so you think, Oh, I'd be interested 13 in doing that, and there's actually somebody who's 14 prepared to pay for it. 15 The sort of research that we've been in 16 is; you mentioned the National Coroners Information 17 System. So we have a database of every death reported to 18 coroners in Australia since the year 2000; a hundred and 19 forty thousand (140,000) deaths on there; the autopsy 20 report; toxicology report; police report of the death; 21 the coroner's ultimate finding. 22 So that's a massive resource which is 23 being used on a daily basis to identify hazards in the 24 community. 25 Other contributions to public health and
651 safety or prevention of death and injury include 2 workplace deaths, a funded unit to concentrate on those 3 in a research framework -- 4 MS. LINDA ROTHSTEIN: Right. 5 DR. STEPHEN CORDNER: -- from the Work 6 Cover, the statutory authority to look at workplace 7 injuries, a similar unit for adverse events in the -- in 8 the Hospital System, a big research project looking at 9 the emergency management of road traffic fatalities, so 10 the first response to those in -- in people who die 11 subsequently from road trauma. 12 That led to quite a major injection of 13 funds from the government -- $50 million -- to re-fashion 14 the trauma system because the emergency services and the 15 emergency departments were -- had lots of problems 16 associated with the early management of trauma patients. 17 So these are major contributions which can 18 be made if there are obligations imposed upon the 19 service, which has got some sort of critical mass about 20 it to go and do some of this work, and there's -- there's 21 masses of work to do. 22 MS. LINDA ROTHSTEIN: Mm-hm. 23 Commissioner, that's the time for our new break, and we 24 will continue this conversation when we resume. 25 COMMISSIONER STEPHEN GOUDGE: Thank you.
661 I have found this morning very interesting. 2 We will rise for fifteen (15) minutes. 3 4 --- Upon recessing at 10:47 a.m. 5 --- Upon resuming at 11:05 a.m. 6 7 THE REGISTRAR: All rise. Please be 8 seated. 9 10 CONTINUED BY MS. LINDA ROTHSTEIN: 11 MS. LINDA ROTHSTEIN: I want to turn to 12 you now, Dr. Shkrum, on the same issue about the 13 connection to the University. I'd be grateful if you 14 would tell the Commissioner about what your research 15 activities are currently, what your relationship is with 16 the University of Western Ontario, and how much of your 17 time you devote to those tasks. 18 DR. MICHAEL SHKRUM: I'm a -- as you 19 mentioned, a Professor at the University of Western 20 Ontario. I'm part of a group of about two (2) dozen 21 pathologists, all sub-specialized in different areas of 22 hospital-base practice. 23 Anybody that's appointed to our department 24 has a University appointment. They start off as an 25 assistant professor and then rise progressively through
671 the ranks. 2 There is a mandate that anybody that's 3 appointed has a teaching responsibility in the 4 University. 5 So personally, I juggle between service, 6 teaching, administration and research. I'm given -- 7 about 20 percent of my time is devoted to -- to research, 8 but maybe, that's even not enough time to do all that. 9 Research: I'm actually very fortunate 10 that I -- for -- since the '90s, I've been a member of 11 the Multi-Disciplinary Accident Research team. It's in 12 the Faculty of Engineering at Western. This team is 13 actually one (1) of about half a dozen across the country 14 that's funded by Transport Canada, which is a federally 15 funded agency, which investigates traffic collisions; 16 various types. 17 And its mandate is to enforce safety 18 standards and to investigate that, you know, various 19 types of injuries and deaths that occur in the traffic 20 accident or traffic collision situations. 21 So I've had that good fortune to be 22 involved with that team, and obviously, it has spin-offs 23 for my practice in forensic pathology. 24 But it really is a delicate balancing act 25 between service, teaching, administration and research.
681 COMMISSIONER STEPHEN GOUDGE: Dr. Shkrum, 2 can I just ask you a little about whether you have had an 3 experience with grants from the typical granting agencies 4 that would fund say primary research in the medical area 5 or whether forensic pathology has difficulty getting 6 grants from that sort of source. 7 DR. MICHAEL SHKRUM: Well, the -- the 8 Accident Research Team, as it says, one (1) of half a 9 dozen teams, and it -- it operates under the auspices of 10 Transport Canada, but there is a five (5) year grant that 11 is given to that team, so I -- I'm a -- 12 COMMISSIONER STEPHEN GOUDGE: So the 13 permanence of it makes up for the fact that it might not 14 be seen as a typical granting agency within the 15 University of Canada? 16 DR. MICHAEL SHKRUM: That -- that's 17 right. I mean -- but for me to sort of just do forensic 18 pathology research, I think that would be much more 19 problematic because there's really no granting agency 20 that would say -- you know, that would fund sort of 21 forensic pathology. 22 There -- there would be seed money in the 23 hospital or through our -- you know, monies that we get 24 through the Office of the Chief Coroner that some of that 25 money could be devoted to -- to do research, but
691 certainly on the -- not on the scale of other -- other 2 granting agencies. 3 COMMISSIONER STEPHEN GOUDGE: Yeah. 4 MS. LINDA ROTHSTEIN: I think, Profess -- 5 COMMISSIONER STEPHEN GOUDGE: Dr. 6 Cordner, where does your grant money come from? 7 DR. STEPHEN CORDNER: Yeah, I've found it 8 very -- very difficult to think in the Australian context 9 of where we could get money -- research money -- for the 10 sort of fundamental forensic pathology research that is 11 needed to answer some of the questions that arise in this 12 sort of Inquiry, particularly around pediatric forensic 13 pathology, shaken babies -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. STEPHEN CORDNER: -- and that sort of 16 thing. The -- you get caught in the -- you get caught 17 between -- you've got to develop your research profile in 18 a particular area to be attractive to the -- 19 COMMISSIONER STEPHEN GOUDGE: To the -- 20 DR. STEPHEN CORDNER: -- body and you -- 21 but you can't get the research profile because you can't 22 get the funding to do the research in the first place. 23 So it might be doing the National Health 24 and Medical Research Counsel a little of a disservice to 25 say they don't fund forensic pathology, because they've
701 never really been confronted with forensic pathologists 2 with a good primary fundamental research basis in 3 forensic pathology, but the -- the sense is that they 4 would prefer to fund fundamental research which has a 5 healthcare benefit. 6 The public health type research funding is 7 more available. There's public health staff to become a 8 stronger discipline in -- in medicine generally. 9 COMMISSIONER STEPHEN GOUDGE: Dr. 10 Pollanen, how do you see attacking this problem in the 11 future; that is the traditional granting agencies look a 12 little bit askance at forensic pathology research as 13 something that's a little foreign to them? 14 DR. MICHAEL POLLANEN: Well, there are 15 several mechanisms. The first is you create an 16 institutional base of relevant forensic work and 17 demonstrate benefit, and that in -- that can be done 18 within institutional settings with seed money from the 19 University and other stakeholders. 20 And you create what is the CIHR -- one (1) 21 of the federal granting agencies -- calls emerging 22 research teams, and you -- you look for problems that 23 have a healthcare dimension or an epidemiological 24 dimension that must be answered. 25 And without answering those questions,
711 there will be a barrier to further progress. And then 2 you -- you develop research programs in those areas, and 3 you apply, and you reapply, and you reapply until you are 4 successful. 5 That's the way it works in -- in all 6 branches of research. The fact is that there are 7 barriers to research in forensic medicine, but those 8 barriers can be overcome. I'll give you some ca -- 9 tangible examples. 10 In the heyday of SIDS research in the 11 Province of Ontario in Canada, it was Sick Kids. Sick 12 Kids did -- attracted large amounts of extramural funding 13 through granting agencies and endowments to fund their 14 research into neuroepithelial bodies in the lung, so 15 there are mechanisms for doing it. 16 In my own area, which is -- you know, I -- 17 I have a graduate student that is -- that I'm supervising 18 in a project related to Shaken Baby Syndrome -- Patrick 19 Kim, who is not a doctor, who is a scientist, and -- and 20 he is going to develop fascinating new results developing 21 experimental models. 22 fellows -- when we trained fellows, an 23 integral part of that process is to teach them how to 24 write papers, how to do simple experiments that can be 25 done in the context of our environment, and then those
721 people will potentially develop research programs of 2 their own, and -- and go in these directions. The other 3 major mechanism is through collaboration. 4 We know that the University of Toronto has 5 a major platform in interdisciplinarity and forensic 6 disciplines are by their very nature defined by inter- 7 disciplinarity. So we've -- we've noticed in forensic 8 science, and I'm sure everybody's noticed, that the -- 9 some of the most profitable areas of research occur at 10 the margins of overlap between major forensic 11 disciplines. 12 And so, for example, as Dr. Shkrum has 13 done, link into another group in which the forensic 14 pathological input is necessary for realizing the overall 15 research objectives. 16 These -- what I'm talking about are 17 mechanisms that take years and years and years to 18 develop, but there must be first a start. 19 COMMISSIONER STEPHEN GOUDGE: Right. And 20 it's clearly vital. 21 Dr. Gotlieb, does this dimension of 22 forensic pathology, that is the modest uniqueness at 23 least of the research dimension of forensic pathology, 24 does that present any challenge for the discipline 25 developing good links with the University, or will there
731 be a sense in the University that this is a relatively 2 different beast for which one has to have a certain 3 degree of skepticism? 4 I mean, I'm linking to what Dr. Milroy 5 described, as I take it, to be the UK experience with 6 grant money. 7 Am I right about that, Dr. Milroy? 8 DR. CHRISTOPHER MILROY: Yes. 9 COMMISSIONER STEPHEN GOUDGE: What's your 10 sense about where we sit today in Ontario on that issue, 11 Dr. Gotlieb? 12 DR. AVRUM GOTLIEB: Well I -- I think the 13 sense is that we would like to work with the forensic 14 pathology group to make it -- make their type of 15 research fundable. And I use that term in very general 16 terms. 17 Because I -- I think -- 18 COMMISSIONER STEPHEN GOUDGE: Is that 19 changing research or changing funding attitudes? 20 DR. AVRUM GOTLIEB: I -- I think it's 21 changing both. So I think we have to make sure -- and 22 we've -- we've had this in the past, funding certain 23 elements that are now funded by CIHR which were more 24 social aspects and -- and things along those lines. 25 COMMISSIONER STEPHEN GOUDGE: Give me an
741 example of that. 2 DR. AVRUM GOTLIEB: Well, funding a lot 3 of child development activities whereby it was 4 psychologists and sociologists who obviously didn't have 5 the -- the basic fundamental training that say a basic 6 scientist would have. 7 And if you looked at CIHR, that was 8 essentially their mandate. Now that has changed over the 9 last several years and I would think that forensic 10 pathology could be included in that type of paradigm 11 where it doesn't fall into the strict or stringent rules 12 of -- of experimentation in terms of the basic science 13 that -- that we have been funding for many years, but 14 that it requires just looking at things in a little bit 15 of a -- a different way. 16 But I think a dialogue has to occur. I -- 17 I'm -- I'm -- Michael is optimistic that just by plugging 18 away at it eventually it'll happen, but I think that 19 there really needs to be a dialogue between either the 20 forensic group or -- or others with groups like CIHR who 21 have a national funding activity to indicate that these 22 types of funding are -- these types of questions to be 23 funded are -- are reasonable within the mandate of CIHR. 24 Now I haven't reviewed their mandate, but I would suspect 25 that many of the questions would be.
751 So it would be up to the forensic 2 community to come up with quality proposals and quality 3 research. But it's up to the funding agencies to be 4 willing to actually listen with an -- in an unbiased way 5 at what -- what was coming forward to them. 6 And also to -- to provide a little bit of 7 -- of, you know, of the score for the value to the 8 community as well. But I -- I think the -- the funding 9 agencies get very nervous if they think they're funding 10 research that's not high quality. So I think that has to 11 be overcome and I think that can be overcome. 12 If you look at Michael's Unit, there are 13 three (3) full time pathologists. Michael himself has a 14 PhD from our old pathology -- Department of Pathology, 15 and Jacqueline Parai has a -- a clinical epidemiology 16 degree. 17 So two (2) out of three (3) have, you 18 know, degrees. So I think with that kind of model system 19 in place, and with opportunities to bring on a couple of 20 new people with that -- with that kind of training, I 21 think that that should be accomplished. 22 But I'm not sure leaving it to just -- to 23 kind of chance will do it. I -- I think there has to be 24 a bit of a jump from one (1) platform to the next now. 25 COMMISSIONER STEPHEN GOUDGE: Dr.
761 Hanzlick, what is the American perspective on this? What 2 is your sense of -- 3 DR. RANDY HANZLICK: Yeah. 4 COMMISSIONER STEPHEN GOUDGE: -- the best 5 way to viable research in this field? 6 DR. RANDY HANZLICK: There's very little 7 grant money out there for forensic pathology. Most of 8 what we have gotten in recent years has come through the 9 Forensic Sciences Improvement Act where you can apply for 10 discretionary funding. 11 But that was limited to things that could 12 improve the quality of service or the turn-around-time. 13 COMMISSIONER STEPHEN GOUDGE: Is that a 14 Federal Act -- 15 DR. RANDY HANZLICK: Yeah -- 16 COMMISSIONER STEPHEN GOUDGE: -- or a 17 State Act? 18 DR. RANDY HANZLICK: -- Federal, yeah. 19 Most of the standard granting agencies -- the National 20 Institute of Health -- very little information there 21 about studies that we could participate in. 22 The Centres for Disease Control and 23 Prevention typically will have programs that they may 24 fund short term but not a lot of money to actually carry 25 out research.
771 Health Department money is -- is the same 2 way. Our typical experience, for instance, somebody 3 approached me last week from Emory in the psychiatry 4 department. They got a Federal grant to -- to develop 5 treatment programs for the survivors of suicide victims. 6 Well, they got the grant, but they come 7 down to our office and want to use our client base, but 8 we were never included in the original grant application. 9 We got no funding to participate. 10 They just want us to make the referrals, 11 and that's the typical situation. 12 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 13 Milroy, the UK experience? 14 DR. CHRISTOPHER MILROY: Well again, 15 they're limited. I mean, there are national funding 16 bodies. The -- there are research counsels for medicine, 17 for engineering, social science. 18 They are very difficult to get into, and 19 forensic pathology -- 20 COMMISSIONER STEPHEN GOUDGE: Why? 21 DR. CHRISTOPHER MILROY: Because forensic 22 pathology has -- just doesn't fit their profiles, is what 23 -- of what they want. 24 The home office did have budgets, but they 25 weren't ring-fenced for forensic pathology. I also think
781 there was just a lack of people wanting to do it because 2 of the service work. 3 There is another factor, actually, that 4 comes into it, which is impact -- sort of impact factors. 5 How -- how big a journal can you publish your research 6 in? And all the forensic pathology journals failed to 7 meet the -- the standard that required -- that most 8 Universities expect. 9 So that there -- there is I think an 10 impact -- they expect you to publish in impact factors 11 above four (4). The highest rated impact factor journal 12 in forensic medicine, I think, is one point eight (1.8). 13 So if you publish in your area where your 14 colleagues will read and understand, you won't -- you 15 won't hit the -- the quality -- 16 COMMISSIONER STEPHEN GOUDGE: The 17 threshold. 18 DR. CHRISTOPHER MILROY: -- you know, the 19 threshold. So -- so that's another problem that, you 20 know, so do you -- do you then try and publish in -- in 21 your non -- in your non-specialist journals? 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 Right. Well, all of you have emphasized the importance 24 of service, teaching, and research. 25 And, so this is obviously an area where
791 some thought has to be given. I apologize to take so 2 much time. You see my pent-up set of questions from 3 having sat behind you for an hour. 4 DR. CHRISTOPHER MILROY: I just wanted to 5 make one (1) other point if I may, Commissioner, about 6 the importance of people -- prac -- ordinary 7 practitioners doing research and writing papers, that 8 Michael has emphasized. 9 If you don't know how to write a paper, 10 how can you understand how to interpret the literature 11 that's out there? Because often the problem that you are 12 faced with when you go to Court may be a relatively 13 unique one (1) for you, and you are, therefore, having to 14 read the literature to interpret in that case. 15 Unless you have an understanding of 16 methodology and whether it's a good paper, or it's a bad 17 paper, which will come from your ability to write and do 18 research, you may be picking up a bad paper and using 19 that. 20 And, if you like, misleading -- 21 potentially misleading the Court as to the value of 22 something. 23 COMMISSIONER STEPHEN GOUDGE: Yeah. I 24 just want to ask one (1) unrelated question, Ms. 25 Rothstein, arising out of what happened in the first half
801 of this morning. 2 And it has to do, Dr. Shkrum, with the 3 documentation that is going forward to the Royal College. 4 Is there, in that, any kind of threshold that would have 5 to be maintained in order to maintain ones sub-speciality 6 qualification? 7 That is, if one were thinking of an FTE 8 regime, what percentage of one's time would one have to 9 spend in forensic pathology in order to maintain the 10 qualification? 11 DR. MICHAEL SHKRUM: You're talking about 12 people that are -- not trainees, but people that -- 13 COMMISSIONER STEPHEN GOUDGE: Yes. 14 DR. MICHAEL SHKRUM: -- are currently in 15 practice? 16 COMMISSIONER STEPHEN GOUDGE: Yes. And 17 once the system gets rolling, in other words. And it has 18 to do obviously with the challenge of service delivery in 19 Ontario, you know. 20 DR. MICHAEL SHKRUM: At the present time, 21 there's no absolute requirement. But I think that -- 22 that would certainly be a topic for the practice 23 eligibility route. 24 We have not defined the minimum number of 25 cases that a pathologist would have to do in their
811 continued practice to, you know -- 2 COMMISSIONER STEPHEN GOUDGE: But give 3 me some sense of what you think would be a reasonable 4 threshold. 5 I mean, obviously this has to do with the 6 degree to which one could do what some of you were 7 talking about and that is move from a fee-for-service- 8 based system to one (1) that emphasized FTEs more. 9 Would it be half your time, a quarter 10 (1/4) of your time? 11 DR. MICHAEL SHKRUM: Well, I think I used 12 the example of FTE's could be divided, you know, to 50 13 percent of their time to maybe 25 percent. I think that 14 might be the limit. 15 COMMISSIONER STEPHEN GOUDGE: So you 16 would have to do at least 25 percent of your -- 17 DR. MICHAEL SHKRUM: I would -- 18 COMMISSIONER STEPHEN GOUDGE: -- time -- 19 DR. MICHAEL SHKRUM: I would -- well, I 20 mean, that may be arguable by other panellists here, but 21 I think, you know, you obviously have to do a significant 22 amount of cases every year. 23 COMMISSIONER STEPHEN GOUDGE: Yes -- 24 DR. MICHAEL SHKRUM: What that 25 significant number is, I don't think I can answer that at
821 this point. 2 COMMISSIONER STEPHEN GOUDGE: I would 3 ask each of you -- just -- let me just -- 4 DR. CHRISTOPHER MILROY: We have a -- we 5 have a proposed figure in the home office that, you know, 6 you should do half. Half -- 7 COMMISSIONER STEPHEN GOUDGE: Fall below 8 half and you may be at risk of losing your -- 9 DR. CHRISTOPHER MILROY: Yes -- 10 COMMISSIONER STEPHEN GOUDGE: -- 11 qualification? 12 DR. CHRISTOPHER MILROY: -- you're not 13 doing enough. You're not doing enough work to maintain 14 your standards. 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 DR. CHRISTOPHER MILROY: And there is a 17 second point; that to be an examiner for the Royal 18 College in the autopsy for the non-forensic -- because we 19 make our anatomical pathologists do an autopsy under 20 examine conditions, let alone our forensics -- we make 21 them do it for their -- to pass their exams. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. CHRISTOPHER MILROY: You've got to do 24 a minimum of fifty (50) medicolegal autopsies a year 25 before you're allowed to maintain -- to maintain your
831 examiner-ship. 2 COMMISSIONER STEPHEN GOUDGE: Yes. 3 DR. CHRISTOPHER MILROY: So those are two 4 (2) sort of benchmark figures. 5 COMMISSIONER STEPHEN GOUDGE: Dr. 6 Cordner, I get the sense that in Victoria most of the 7 people are relatively full-time? 8 DR. STEPHEN CORDNER: Yes. 9 COMMISSIONER STEPHEN GOUDGE: If you had 10 to answer the question: What's the bare minimum you 11 would have to serve to maintain professional 12 qualification? 13 DR. STEPHEN CORDNER: Well, the 14 formalities are quite different to what we would think is 15 sufficient in our institutional setting. 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. STEPHEN CORDNER: So the formalities 18 are weak. In other words, the Royal College of 19 Pathologists of Australasia requires you to only 20 demonstrate one hundred (100) hours of continuing medical 21 education per year to sustain or retain your fellowship 22 with the College, which is clearly a weak -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. STEPHEN CORDNER: -- standard. 25 COMMISSIONER STEPHEN GOUDGE: Right.
841 DR. STEPHEN CORDNER: And you provide 2 your -- 3 COMMISSIONER STEPHEN GOUDGE: Just as a 4 standard of practice, forget the qualification threshold. 5 DR. STEPHEN CORDNER: Yeah, but in terms 6 of what I -- I reckon is necessary in order to sustain an 7 interested, engaged, involved forensic -- 8 COMMISSIONER STEPHEN GOUDGE: Informed. 9 DR. STEPHEN CORDNER: -- practitioner, 10 it's of the order of 33/40 percent is the sort of time 11 that should be devoted to academic activity. 12 COMMISSIONER STEPHEN GOUDGE: Yes. Dr. 13 Pollanen...? 14 DR. MICHAEL POLLANEN: I think you have 15 to have -- recognizing there are different types of 16 people, right? There are some people in a department -- 17 in an academic department -- that will do 100 percent 18 service work. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. MICHAEL POLLANEN: They will be 21 employed to perform post-mortems. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. MICHAEL POLLANEN: And then you will 24 have other people that will split their time between 25 research commitments and then, you know participate --
851 participate in service work. So I think, you know, the 2 standard sort of general model is a 50/50 split. 3 But if you're working in a highly 4 productive environment where there's a lot of 5 professional interaction, a lot of sharing of cases, you 6 may, in fact, do less, you know, in terms of an absolute 7 caseload and still maintain a standard -- 8 COMMISSIONER STEPHEN GOUDGE: Yes. 9 DR. MICHAEL POLLANEN: -- because you're 10 having fruitful interaction with people. 11 COMMISSIONER STEPHEN GOUDGE: Yes. What 12 I was getting at in terms of the split, I was talking 13 about, Dr. Pollanen, just to make sure I'm clear is the 14 kind of situation that exists, for example, in Dr. 15 Shkrum's case, where he is doing hospital pathology for a 16 portion of his time -- far less than he used to. But 17 that would be inevitable at some point in some parts of 18 Ontario; that we cannot move because of geography 19 entirely to those who engage full-time in forensic 20 pathology. 21 What is the component of forensics -- 22 forget whether for the moment, it's academic research or 23 teaching or actual service delivery -- by comparison to 24 hospital pathology, to take the obvious other part of a 25 person's career in --
861 DR. MICHAEL POLLANEN: So, we're talking 2 now forensic as opposed to medicolegal. 3 COMMISSIONER STEPHEN GOUDGE: Yes, yes. 4 DR. MICHAEL POLLANEN: So we're talking-- 5 COMMISSIONER STEPHEN GOUDGE: Well, no, 6 I'm -- 7 DR. MICHAEL POLLANEN: Criminally -- 8 COMMISSIONER STEPHEN GOUDGE: By 9 forensic, I mean done under warrant, okay, so everything 10 that one would consider to be forensic pathology, as 11 opposed to hospital pathology where one is engaged in an 12 institution doing hospital pathology that isn't forensic. 13 DR. MICHAEL POLLANEN: That is a very 14 challenging question, because I -- I can tell you 15 statistically that the, you know, 50 percent or more of 16 our routine medicolegal autopsies that occur outside of 17 forensic pathology units in the Province are performed by 18 pathologists that are doing less than twenty (20) in some 19 case -- in many cases, less than ten (10) autopsies per 20 year. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. MICHAEL POLLANEN: So we're talking 23 about the vast majority of the approximately two hundred 24 (200) pathologists that are performing medicolegal 25 autopsies are performing very few of them, and they are
871 the backbone of the system. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. MICHAEL POLLANEN: So, you know, if 4 you -- if you were to say -- 5 COMMISSIONER STEPHEN GOUDGE: Well, just 6 think of it in terms of to maintain qualification, that's 7 one (1) thing that would be achieved, and to be 8 considered as a full-time equivalent, okay, a component 9 of a full-time equivalent. 10 In other words, somebody who has as a 11 significant portion of his or her enterprise, forensic 12 pathology, going with that is the skill set that comes 13 with doing enough of it to be considered a forensic 14 pathologist in some general sense. 15 What percentage of your professional time 16 do you need to do to meet that threshold? 17 DR. MICHAEL SHKRUM: I can maybe answer 18 that just based on my experience of practicing as a 19 hospital based surgical pathologist for the first twenty 20 (20) years. I -- probably about 10 percent of my time 21 was devoted to doing coroner's autopsies, and I think on 22 an average, every year I did about fifty (50) cases which 23 included some homicides, so if that's maybe a rough guide 24 as to absolute numbers -- 25 COMMISSIONER STEPHEN GOUDGE: Looking
881 forward at the system that is unfolding with college 2 recognition, Dr. Shkrum, would that be enough to maintain 3 a qualification or would you need more than that? 4 DR. MICHAEL SHKRUM: Well, I would have 5 to refer to Dr. Pollanen because he -- I think you want 6 to form a registry of pathologists and I think that's 7 obviously a number that -- 8 COMMISSIONER STEPHEN GOUDGE: Okay, take 9 that -- take that as a measure. What's it going to take, 10 Dr. Pollanen, to get onto your registry? 11 DR. MICHAEL SHKRUM: To do homicide and 12 criminally suspicious cases, that -- that's the -- 13 COMMISSIONER STEPHEN GOUDGE: That's the 14 narrow -- 15 DR. MICHAEL SHKRUM: Yeah. 16 COMMISSIONER STEPHEN GOUDGE: -- tough 17 category. 18 DR. MICHAEL POLLANEN: You'll essentially 19 need to be full-time. 20 COMMISSIONER STEPHEN GOUDGE: What about 21 doing the other broad range of forensic cases; 10 percent 22 satisfy you with Dr. Shkrum, I mean recognizing he's 23 outstanding? 24 DR. MICHAEL POLLANEN: Well, I think -- I 25 think that that 10 percent is getting a bit low --
891 COMMISSIONER STEPHEN GOUDGE: Okay. 2 DR. MICHAEL POLLANEN: -- from my point 3 of view, but I recognize that Dr. Shkrum is in an 4 enriched environment -- 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. MICHAEL POLLANEN: -- where he is 7 collaborating with his colleagues to jointly provide high 8 quality service -- 9 COMMISSIONER STEPHEN GOUDGE: So maybe 10 there's no threshold that depends on a combination of 11 factors, including environment? 12 DR. MICHAEL POLLANEN: Correct, because 13 if you're a solo practitioner in a peripheral hospital -- 14 COMMISSIONER STEPHEN GOUDGE: Fair 15 enough. That's the point you made before. 16 DR. MICHAEL POLLANEN: Right. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 Thanks, Ms. Rothstein. 19 20 CONTINUED BY MS. LINDA ROTHSTEIN: 21 MS. LINDA ROTHSTEIN: Thanks, 22 Commissioner. I was going to ask Dr. Pollanen to turn to 23 Tab 17, that I -- I understand, Doctor, is the -- you are 24 the lead author on the proposal to establish a Centre for 25 Forensic Medicine and Science at U of T, and you have
901 provided a preliminary version of that document to the 2 Dean of Medicine, and your Steering Committee includes 3 Professor Gotlieb and others, so this has been in 4 development for some time. 5 Before you take us through the -- the 6 specifics of your proposal on how you think that might 7 work, I'm hoping you can tell the Commissioner, Dr. 8 Pollanen, about whether you'd created this proposal with 9 a view to the existing environment -- the existing 10 organizational structure for forensic pathology in 11 Ontario -- or whether it -- it contemplates a different 12 structure and to what extent the proposal might change 13 depending on whether there were to be a different one. 14 DR. MICHAEL POLLANEN: This proposal is 15 based upon existing structure. In other words, there is 16 a -- there is currently at the University of Toronto and 17 at the Office of the Chief Coroner, no mechanism of 18 creating a completely integrated service and research and 19 teaching mechanism. 20 For example, the University of Toronto 21 does not create new departments of -- of service related 22 to academic and scholarly achievement, so the -- this 23 proposal that -- that the Steering Committee has put 24 together tries to achieve the goal; the -- the goal 25 that's been described by every member of this panel, of
911 creating an integration, a unification, of the pillars of 2 teaching, research, and provision of service by using a 3 mechanism that is well-developed at the University of 4 Toronto, that flows out of their policy of 5 interdisciplinarity. 6 And essentially, what this means is that, 7 at the University of Toronto, they -- there is a 8 mechanism to create something called an Extra- 9 Departmental Unit, which is a cross-disciplinary 10 amalgamation of different streams from different 11 faculties to produce a stand-alone physical structure 12 called a Centre; sometimes called an Institute, depending 13 on a magnitude and whether or not you build something. 14 And these -- these Centres -- these 15 interdisciplinary Centres, or extra-departmental units -- 16 then become homes for the scholarly achievement, and 17 research achievement, and educational platforms, within 18 the University's structure, and then are linked to the 19 provision of service through other organizations or other 20 structures; as opposed to the complete integration, for 21 example, that is achieved at the VIFM, which by -- by the 22 creation of statute has produced a corporate body, which 23 has all mandates. 24 And -- and the reality in the University 25 of Toronto, the way to achieve the same goal is to create
921 a Centre and link it with a service of. That's the -- 2 that's the current reality. 3 COMMISSIONER STEPHEN GOUDGE: How is that 4 linkage made now? I mean, I think of teaching hospitals, 5 you know, which clearly are service providers, front and 6 centre, but also engage in the other two (2) pillars that 7 Dr. Cordner described. 8 DR. MICHAEL POLLANEN: Correct. And 9 teaching hospitals would be -- would be a VIFM equivalent 10 in a non-forensic area in -- in Toronto, or in any 11 University setting that offers medical training. 12 The -- the point is, there's no such 13 mechanism that currently exists to produce all of those 14 three (3) pillars under one (1) institutional framework. 15 There's no statutory basis to do it. The 16 University is not interested in creating departments in 17 that manner, or at least, the main platform to achieve 18 those outcomes are through the Extra-Departmental Unit 19 mechanism. 20 COMMISSIONER STEPHEN GOUDGE: Their major 21 missions are teaching and research, as opposed to service 22 delivery. 23 DR. MICHAEL POLLANEN: Well, they're -- 24 they're inextricably linked in health care, in fact. 25 COMMISSIONER STEPHEN GOUDGE: Yes.
931 DR. MICHAEL POLLANEN: And that's -- 2 COMMISSIONER STEPHEN GOUDGE: That is why 3 I used the teaching hospital as the paradigm. 4 DR. MICHAEL POLLANEN: And -- and I agree 5 with that paradigm, except again, we find this -- this 6 interesting juxtaposition of where forensic falls. 7 We don't clearly fall in a healthcare 8 mandate. We don't clearly fall into a traditional 9 departmental structure in an existing University. 10 So we have to find creative mechanisms to 11 achieve the three (3) pillars. And, so what we need to 12 do is we need to look at opportunities and mechanisms 13 that exist to provide that. 14 And I'm -- I'm going to contrast this 15 with, or just highlight this point, with an interesting 16 paradox. And that is that -- it's a historical paradox; 17 that we have chosen to deliver forensic pathology service 18 in an integrated fashion with the three (3) pillars in 19 every location but Toronto. 20 So in Hamilton; in Ottawa; in Kingston; 21 London; everything is integrated into the teaching 22 hospital environment. 23 Toronto is the only Centre in -- in 24 forensic pathology in the Province where that integration 25 has not yet occurred.
941 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. MICHAEL POLLANEN: And, so the 3 challenge -- of the Chief Forensic Pathologist at the 4 current moment -- the challenge is how to do it; what 5 mechanisms exist to do it. 6 Because that is -- that is the goal that 7 has been realized everywhere else in the Province. 8 COMMISSIONER STEPHEN GOUDGE: Okay. To 9 come to your proposal then, you talked of the proposal 10 with linkages then to the service component? 11 DR. MICHAEL POLLANEN: Correct. 12 COMMISSIONER STEPHEN GOUDGE: Describe 13 the linkages. 14 DR. MICHAEL POLLANEN: The linkages would 15 largely be through faculty. So, in other words, the -- 16 the forensic pathologists that would exist in my 17 department, which is a -- which is a government 18 structure, would be linked to the centre, or the putative 19 centre, in a way to allow achievement in both arenas. 20 Let me give you a concrete example. The 21 fellowship training program would be formally delivered 22 in the -- in my department but it would be linked into 23 the centre for academic achievement, meeting training 24 objectives, educational seminars, research opportunities. 25 That's one sort of way to formally link in. The other
951 way is to -- to link in the -- the system, the service 2 provision to the centre is through continuing medical 3 education activities. 4 For example, one (1) of my -- one (1) of 5 the things that's in my job description is I have an 6 educational mandate. And that's very difficult to 7 deliver in the absence of infrastructure able to provide 8 me with the tools to do it, so I have to go and find the 9 tools. 10 And, you know, I think our office does a 11 fairly good job in delivering certain types of education 12 but the tools that are provided in an -- in an 13 interdisciplinary centre, like the one that I'm proposing 14 in the context of the steering committee, provides 15 further opportunities to -- to -- to deliver that. 16 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 17 Cordner, can I ask you when -- when the Victoria 18 Institute was set up, was this option considered; that 19 is, creating a university based institution that did not 20 have the breadth of mandate that your statutory based 21 institution has, but had, in Dr. Pollanen's terms, 22 linkages with the service deliverer? 23 DR. STEPHEN CORDNER: I don't think that 24 really that was ever considered in our setup and I think 25 it's little bit different because we're a smaller
961 geographical institution. There weren't so many 2 significant other centres with established sort of 3 performance, if you like. So there's really only the 4 capital city of Melbourne. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. STEPHEN CORDNER: There's Jalong 7 which is a fairly provincial city, and then the rest, 8 provincial, larger towns with relatively small coronial 9 workloads. 10 So it was much easier to think of a -- of 11 a jurisdiction-wide -- jurisdiction for forensic 12 pathology and coronial matters, operating out of a -- a 13 central institution in Melbourne but with regional 14 service provision on a fee-for-service basis by hospital 15 based pathologists doing a small amount of coronial work. 16 So -- 17 COMMISSIONER STEPHEN GOUDGE: But just 18 taking the two (2) models, one could argue that Dr. 19 Pollanen's proposal in the context of his current 20 committee runs a risk of minimizing the linkage with 21 service delivery. One could argue that the VIFM model 22 runs the risk of minimizing the teaching and research 23 because of the importance of and the time taken in 24 service delivery. 25 Which is better?
971 DR. STEPHEN CORDNER: Yes. Well, without 2 actually -- without actually directly answering your -- 3 4 CONTINUED BY MS. LINDA ROTHSTEIN: 5 MS. LINDA ROTHSTEIN: And you thought I 6 asked the hard questions. 7 DR. STEPHEN CORDNER: Without directly 8 answering your question, I can only say that an issue 9 that I think would need to be addressed with Dr. 10 Pollanen's model is the risk of almost having two (2) 11 separate things. You have something in the university, 12 headed by a person, and you have something over here 13 delivering the service, headed by a person. There's 14 nothing that necessarily says they're both going to be 15 the same person. 16 If they're not the same person, then the 17 linkage of research and teaching with the service may be 18 weak. This research and teaching might go off on a 19 tangent on stuff that's not actually terribly relevant to 20 the service. The service may not be benefiting from the 21 research and teaching. 22 So there may be competition and -- and 23 unhappy dynamics developed between the two (2) key people 24 in institutions. So, from my own point of view, I can 25 say, and maybe I haven't understood it completely, but I
981 can actually say that if there isn't unity of this, you 2 know, very important initiative with the service, I think 3 there are -- there are potential down sides. 4 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 5 Gotlieb, what is your sense of what the University's 6 attitude would be to the unified concept that Dr. Cordner 7 speaks of; that is, one (1) where there is an express 8 recognition in the mandate of the institution of service, 9 teaching and research? 10 DR. AVRUM GOTLIEB: Well, generally 11 speaking, the University is not involved with service in 12 the -- in the large scheme of things. So you refer to 13 the teaching hospitals -- 14 COMMISSIONER STEPHEN GOUDGE: I mean, 15 that is what I keep having in my head, you know, the -- 16 DR. AVRUM GOTLIEB: Right. So the 17 teaching hospital -- so take my job. I'm the University 18 professor and my job is to make sure that we provide, at 19 the University, the various infrastructures necessary to 20 run our -- our department and our specialty. And, in 21 Canada, all the residency teaching and medical school 22 teaching, et cetera, comes from the University, so that's 23 our prime responsibility in those particular areas. 24 In terms of service, the responsibilities 25 are that everyone at the teaching hospital must have a
991 University appointment. And so I sit on all the search 2 committees, and we have a very good discussion about the 3 qualifies of individuals coming into the system. 4 And then Clinical Faculty, at our teaching 5 hospitals, are governed by a Clinical Faculty Policy 6 which -- on which in some parts of it involve the 7 University and the hospital and some are based between 8 just the hospital perhaps and the -- and the individual. 9 And this is -- it's a complex interaction 10 because an individual who's working at a -- at a 11 hospital, at a -- you know, University of Toronto 12 hospital, has reporting responsibilities to their 13 hospital and to the MAC and to their hospital Chiefs; to 14 the University and to the department -- to the chair of 15 the department; and then to the Dean and also has 16 professional to CPSO and various other bodies. 17 So there are a variety of bodies which 18 kind of govern your activities and which you have to be 19 responsible for. 20 So there is a well-defined policy now 21 existing in the last couple of years for Clinical Faculty 22 to deal with these kinds of -- of issues. 23 But generally speaking, looking at 24 Michael's proposal, and we've had quite a bit of 25 discussion about this. First of all, the Dean of
1001 Medicine, Cathy Whiteside, and the Provost, Vivek Goel, 2 are very supportive of this particular initiative and 3 they've had a look at it and they've had some 4 discussions. And so in general terms, they're supportive 5 of this kind of an initiative. 6 What I -- what I think the real strength 7 of this initiative is that it's -- it's an inter- 8 disciplinary initiative, and to me, this is very 9 refreshing in a sense. It's not just dealing with 10 forensic pathology but it's bringing in the whole 11 forensic community at the University of Toronto and 12 elsewhere. 13 Because I think once this gets up and 14 going, I -- I would suspect there will be interest from 15 the, certainly, five (5) other main medical schools to 16 look at this and become involved with this. 17 But it really brings together, I think, 18 the players in forensic medicine and forensic sciences in 19 a way that we have not been able to do. And pro -- I 20 shouldn't say we haven't been able to, we haven't even 21 tried to do this. 22 We do have a forensic sciences program at 23 the University of Toronto Mississauga and -- and the -- 24 Michael's group does a lot of teaching for us. But the 25 two (2) groups don't really talk to each other and
1011 there's no platform in which to do this. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. AVRUM GOTLIEB: There's also -- 4 COMMISSIONER STEPHEN GOUDGE: The 5 question that I am left with, that I confess is a 6 conundrum, is how one insures against Dr. Cordner's 7 concern of having in effect, silos, where teaching and 8 research go on remote from service. 9 DR. AVRUM GOTLIEB: Well, I think if that 10 happens, then obviously we've -- we've failed in -- in 11 our mission. So the idea here is to actually make them 12 into three (3) pillars supporting the same -- 13 COMMISSIONER STEPHEN GOUDGE: Of one (1) 14 thing. 15 DR. AVRUM GOTLIEB: -- of -- of one (1) 16 thing. I think one (1) way that it's -- I suspect that 17 it will happen is that the people who are heavily 18 interested on -- in the clinical side are, in fact, going 19 to be heavily involved in this particular activity. 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 Right. 22 DR. AVRUM GOTLIEB: And I think it's 23 likely that this will find it's home in the faculty of 24 medicine. So by virtue of that, it will already define 25 itself in -- in that way.
1021 COMMISSIONER STEPHEN GOUDGE: Right. 2 Right. Okay. Thanks. 3 Sorry, Ms. Rothstein. I have taken up an 4 awful lot of time, and I know you have got a lot of 5 ground to cover. Away you go. 6 7 CONTINUED BY MS. LINDA ROTHSTEIN: 8 MS. LINDA ROTHSTEIN: Well, there's not - 9 - there's actually only two (2) other things I was going 10 to try and cover before I turn it over to my colleagues, 11 Commissioner, to ask whether they have any questions. 12 The first one (1) was what the actual core 13 education for resident forensic pathologists looks like 14 in your various jurisdictions, and the extent to which it 15 focuses on what we've seen as one (1) of the unique 16 challenges for a forensic pathologist as opposed to a 17 clinical pathologist, which is giving evidence. 18 Can you tell us about that in -- in your - 19 - in your jurisdiction, Dr. Hanzlick? 20 DR. RANDY HANZLICK: Well, they -- the 21 basic pathway to forensic pathology in the United States, 22 there's a couple of them. 23 You can do combined anatomic and clinical 24 pathology which has rotations through the standard areas 25 in clinical pathology, microbiology, immunology; all of
1031 those things and then do a forensic year. 2 Or you can do a combined program where you 3 do two (2) years of anatomic; one (1) year in a 4 speciality area, such as tox -- medical toxicology, or it 5 could be neuropathology, or cardiac pathology, and then a 6 year of forensic pathology; all of this having to be done 7 in an accredited -- and that's the key, an accredited 8 training program by the American College -- or the 9 Accreditation Council of Graduate Medical Education. 10 So it's a four (4) year common pathway to 11 the forensic pathology training. Within the program 12 itself, the Accreditation Council has a standard set of 13 common -- what they call "Common Program Goals", and it's 14 very similar to some of the publications we had in our 15 handouts here, where you learn how to be a communicator, 16 and you learn how to be responsible, and you know, these 17 various types of principles. They call them the "Core 18 Competencies." 19 All programs have to have those. And then 20 they have discipline-specific requirements in forensic 21 pathology. So once you meet those basic competencies and 22 basic requirements, then you have to meet certain 23 criteria such as you have to have a minimum of five 24 hundred (500) autopsies in a medicolegal office before 25 you can have a fellowship.
1041 A hundred (100) or whatever, have to be 2 done -- cases have to be to the direct effects of 3 violence. So there's a common set of standards that the 4 training programs have to have to be accredited; the 5 quality with which they're delivered varies and things 6 like that. 7 MS. LINDA ROTHSTEIN: How much -- how 8 much time is devoted to teaching forensic pathologists to 9 be about giving evidence? 10 DR. RANDY HANZLICK: In a -- in a 11 forensic pathology program in the United States? That 12 would be mostly done through experience in Court or 13 perhaps mock trials or specific lectures on the topic. 14 But in terms of the time that's spent on 15 that, it would be a relatively small amount of the 16 training. 17 MS. LINDA ROTHSTEIN: Dr. Milroy, 18 England? 19 DR. CHRISTOPHER MILROY: Well, as I think 20 the Commissioner has all ready heard, we have a formal -- 21 we -- we do now have a formal element of our -- of the 22 training, where they have to do Criminal Justice studies. 23 And it -- where they have essentially a 24 week of being -- being inculcated with the ethics; how to 25 give evidence; ending up with mock -- mock trials with
1051 proper lawyers coming in. 2 And that is given to all forensic 3 pathologists now who wish to go on the -- well, it is 4 compulsory to have done it, to go on the home office 5 register. 6 Interesting enough, we are rolling it out 7 to some other people. We have a neuropathologist who 8 wants to get involved in doing forensic neuropathology, 9 and one (1) of the things we've told him is you should do 10 that training so that you know what your duties and 11 responsibilities are when you go to Court. 12 Because, of course, it isn't just about 13 forensic pathologists. There are other -- as you have 14 heard, there are plenty of other disciplines that go to 15 give evidence in criminal trials who could also benefit 16 from this training. 17 And then apart from that, they also come 18 and they watch, and we discuss their evidence. And -- I 19 mean, one (1) of the things that I had thought might also 20 be beneficial is -- is to get them -- if you like to do 21 slightly less high profile cases. 22 For example, doing injury work in -- in 23 living people where at the moment, you know, we have, for 24 example, emergency physicians at training level are asked 25 to go and give evidence.
1061 Well, I get mine to -- to try and review 2 some of the cases that we get on a consult basis and then 3 go and give evidence where it's, if you like, the issues 4 possibly, I mean, are serious, but are less serious. 5 And so that's another way of getting a 6 practical experience of what it's like to go to Court 7 albeit with a lower level, you know. They're -- they're 8 not being cross-examined by our senior lawyers -- our 9 Queen's counsel -- but they would be by junior lawyers 10 and -- and so they'll -- they'll learn there. 11 So that is something else I think we could 12 expand more, and that's certainly the first time I ever 13 gave evidence in a criminal trial; it was no -- it was in 14 a non-fatal case. 15 MS. LINDA ROTHSTEIN: Mm-hm. 16 DR. CHRISTOPHER MILROY: And so that's 17 another area that I think we -- that can be looked at to 18 train people. And we also have to -- it has to be said, 19 I mean, it's interesting -- I was discussing how often we 20 give evidence in different jurisdictions and there is 21 some people that give evidence very rarely given the 22 nature of the case. I personally have given evidence in 23 criminal trials, it must be hundreds of times. I don't 24 keep a record. 25 But then if you add -- someone says to me,
1071 How often have you given evidence? Well, if I added 2 inquests, then it's well over -- I must have given 3 evidence in inquests probably well over a thousand 4 (1,000) times because we just -- there's so many. 5 And whilst there is a separate issue as to 6 the value of them, certainly for -- for the young 7 pathologist, that's a -- that's the start of their 8 training in giving evidence in a public forum. 9 MS. LINDA ROTHSTEIN: All right. Dr. 10 Cordner, in Australia what emphasis is given to the 11 evidence-giving challenges? 12 DR. STEPHEN CORDNER: You -- you just 13 need to understand the concept that post med -- medical 14 training is apprenticeship-type training. It's on the 15 job training supplemented by a lot of self-directed 16 learning in accordance with syllabus and support with 17 that self-directed learning leading up to examinations. 18 And I think you can certainly say that -- 19 that no part of the examination process includes anything 20 about the provision of evidence, but the on-the-job 21 training means that when one (1) of us is going off to 22 Court to give evidence and one (1) of the trainees isn't 23 in the mortuary or doing something, come with us -- come 24 and sit in Court while we give evidence, and we'll talk 25 about it afterwards. It's relatively informal.
1081 There are some advantages along the lines 2 that Chris has just mentioned of being in the same 3 building as the state coroner. So whereas, we may not be 4 called to give evidence in a particular inquest, we would 5 make sure that if the trainee has been involved with the 6 autopsy that is the subject of the inquest, we can make 7 sure that the coroner does indeed call said trainee so 8 that they start to build up their experience in a less 9 controversial environment and develop the confidence to 10 be able to give their evidence and -- and answer 11 questions about it. 12 And just to finish that off, we have post- 13 graduate diplomas for forensic physicians, the police 14 surgeon and post-graduate diplomas for oversees trained 15 doctors in forensic pathology that has a subject in it, 16 evidence, medical evidence, which Professor Ranson has a 17 law degree developed, and that includes moot Court type 18 experiences. 19 And we have provided in the past moot 20 Court experiences for undergraduate medical students. 21 But I think the -- your key point is that there's 22 relatively little in a formal sense for homegrown 23 trainees in forensic pathology. 24 MS. LINDA ROTHSTEIN: Okay. 25 COMMISSIONER STEPHEN GOUDGE: Do you have
1091 any method of assessing whether standards have been 2 achieved in learning how to give evidence, Dr. Cordner, 3 before the fellowship is considered a success? 4 DR. STEPHEN CORDNER: Are there any 5 standards? 6 COMMISSIONER STEPHEN GOUDGE: Yes, I mean 7 is it part of the qualifying process? You say there's 8 nothing examined upon. 9 DR. STEPHEN CORDNER: No, as I don't 10 think -- 11 COMMISSIONER STEPHEN GOUDGE: Can you do 12 that? 13 DR. STEPHEN CORDNER: Yeah, well, that 14 would be -- I think it would hard. I'm just trying to 15 think. Dr. Ranson, from our perspective, might be better 16 to -- to answer that question. 17 COMMISSIONER STEPHEN GOUDGE: It's a 18 little like learning how to be an advocate. You sort of 19 have got to try it and if you try it in a difficult case, 20 problems arise. 21 Dr. Shkrum, is there anything in the 22 material you've put forward to the Royal College about 23 this aspect of the training? 24 DR. MICHAEL SHKRUM: Just in a very 25 general way that there will an expectation that trainees
1101 will -- will be able to observe inquests or -- or 2 criminal cases, obviously mock trials, interaction with 3 the, you know, faculty of law. 4 You know there -- there is a sort of a 5 general statement, and for very good reason, because 6 realizing a person's only training one (1) year, that 7 case may not go to Court until they've completed their 8 training. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 MS. LINDA ROTHSTEIN: Right. 11 DR. MICHAEL SHKRUM: So it may take some 12 time before they get actually into the Court System. 13 14 CONTINUED BY MS. LINDA ROTHSTEIN: 15 MS. LINDA ROTHSTEIN: So I'm going to ask 16 you each in turn one (1) final question, and I hope that 17 will leave us at least ten (10) minutes for my colleagues 18 to ask you some questions. So starting with you, Dr. 19 Hanzlick. 20 What is the one (1) or two (2) most 21 important thing that could be done to ensure there are 22 enough properly trained forensic pathologists to do 23 forensic pediatric pathology in Ontario? 24 DR. RANDY HANZLICK: I think the key 25 there is to develop the fellowship programs that are
1111 accredited; offer certifications. There needs to be a 2 training program in pediatric pathology which there is 3 not. We haven't even talked about that really. We've 4 been talking about forensic, but there's not accredited 5 training in pediatric pathology -- if you want to grow 6 those two (2) things together. 7 And I think the main thing is to include 8 in the Statute some provision to enable the forensic 9 pathology services; they're not really addressed in 10 there. It talks about coroners but there needs to be 11 some statutory change to enable that system, make it 12 required, and describe its relationship to the Coronial 13 System. But I think the training programs are the key. 14 So as we did in Georgia, kind of grow your system. 15 MS. LINDA ROTHSTEIN: Dr. Milroy...? 16 DR. CHRISTOPHER MILROY: Well, I agree. 17 I think it's training and structure. I mean, because if 18 you train people and there's no structure for them to go 19 into, they won't come into the training programs. So 20 that's -- that's self-evident, I think. 21 And I think that with the structure, the 22 pathologists have got to -- and I think the training 23 should be in Canada. I mean, because I know that it's 24 been proposed -- it was even proposed in the UK at one 25 (1) stage, Oh, send them to America. But you really do
1121 have to have your home-grown -- home-grown trainees. 2 Because one (1) of the experiences you 3 find is that if you send people to nice countries like 4 Australia, they don't come back. 5 And indeed, there was a comment made that 6 we have to train for Australia as well as for the UK 7 because a lot of British graduates go and work in 8 Australia at the moment. I don't know why, but anyway, 9 that's another matter. 10 So I think that training is important, and 11 I think that structure is important. And I think that 12 the pathologist has got to see that they are in control 13 of a lot of what they do and that, you know, who decides 14 which. 15 You know, if you have a pediatric forensic 16 case and you have a forensic pathologist, he wants to 17 know that he has some control over who is going to do 18 that autopsy, and he can select the appropriate people to 19 bring on board. 20 MS. LINDA ROTHSTEIN: Dr. Shkrum...? 21 DR. MICHAEL SHKRUM: I think funding and 22 the political will to -- to realize that funding to 23 support the training and the structure that's been 24 mentioned. 25 MS. LINDA ROTHSTEIN: Dr. Cordner...?
1131 DR. STEPHEN CORDNER: Most -- or many 2 medical specialties are finding difficulty getting 3 sufficient numbers of medical graduates. It's a highly 4 competitive situation. 5 So I go back to the fundamental 6 arrangements for the provision of the service 7 supplementing -- supplemented by teaching and research to 8 be attractive to highly intelligent graduates who have 9 got a range of choices in front of them. And the 10 fundamental arrangements allow for a very fulfilling 11 professional and intellectual life. 12 MS. LINDA ROTHSTEIN: Dr. Pollanen...? 13 DR. MICHAEL POLLANEN: There are three 14 (3) issues the way I see it based upon what's emerged 15 here. 16 The first is that we need to develop these 17 training programs, the Royal College fellowship Training 18 programs. That will require sustained funding of the 19 spots. 20 So it's insufficient to just create 21 programs, then there has to be guaranteed funding for 22 fellowship spots. For example, in a department of my 23 size, we should have at least two (2) funded spots every 24 year, you know, for time immemorial. 25 Second, and this is -- this is a challenge
1141 for the forensic pathologists, is that we need to create 2 environments that foster excellence. 3 So we can't go to the mortuary and do our 4 routine post-mortems and then go home or go to Court. We 5 need to -- we need to create -- somehow create these 6 environments that bring the best out of the people that 7 are dedicated to do this work. 8 And then the third is something that we 9 haven't really touched upon in any great detail, but it - 10 - it sort of forms the base of all of what we've 11 discussed, and that is there needs to be some basic 12 structural changes to the Act that recognize the primacy 13 of forensic pathology; that recognize that it is a -- a 14 unique discipline within death investigation and 15 recognize the role that the pathologist plays. 16 MS. LINDA ROTHSTEIN: Well, Mr. Sandler 17 will be pleased to take up that -- that question this 18 afternoon, as you know. 19 Finally, you, Professor Gotlieb. 20 DR. AVRUM GOTLIEB: Well, I agree with 21 training and structure. I think that's a good way of 22 putting it. 23 And I think in the training, in terms of 24 what we have here in Ontario, I -- I think we're well on 25 our way. In terms of the structure, I think there are
1151 still barriers. 2 I would certainly think that a really top 3 notch job description which gives room for teaching and 4 research and clinical service which has teeth in it, and 5 which has funding to allow it to -- to occur. 6 And I would think certainly that the 7 University would be a good place for this to evolve, 8 because that's -- that's really what we do best. And 9 going back to the analogy of the affiliated hospitals, we 10 work very well with the affiliated hospitals to pro -- 11 provide excellent service. 12 So that's never been a problem. And in 13 fact, there's the added value both to the -- it works 14 both ways. The affiliated hospitals give added value to 15 the research and teaching mission of the University and 16 vice versa, so. 17 MS. LINDA ROTHSTEIN: Okay. So, Mr. 18 Gover, Mr. Carter, Ms. Craig and Mr. Ortved, you have a 19 few minutes each. I know it's not much. You're welcome 20 to cede your time to the Commissioner. 21 22 QUESTIONED BY MR. BRIAN GOVER: 23 MR. BRIAN GOVER: Well, gentlemen, I'm 24 happy to cede most of my time to the Commissioner, I can 25 assure you. I have one (1) question, and it would follow
1161 up on what the Commissioner asked you about testimony. 2 And it sounds like there is actually 3 little in -- in training that is offered for forensic 4 pathologist candidates, if I can call them that, before 5 becoming full- fledged forensic pathologists. 6 And one (1) of the concerns that we've had 7 in the course of this Inquiry, as you're probably aware, 8 is dogmatic testimony by forensic pathologists. Is there 9 merit in including some testimony component in the 10 credentialing process before one can be called a forensic 11 pathologist? 12 And the model that came to mind when the 13 Commissioner asked his question of you, was the one (1) 14 that is used by the program in Investigative and Forensic 15 Accounting, which is sponsored jointly by the Institute 16 of Chartered Accountants and the University of Toronto, 17 through the Rothman School. 18 And every summer as part of their 19 qualifications to be investigative and forensic 20 accountants, these candidates endure cross-examination by 21 experienced lawyers, and each candidate signs a 22 confidentiality agreement so that the problem can get 23 used over and over. 24 Undoubtedly there's some leakage from 25 time-to-time as to what the problem is, but should --
1171 should the ability to testify in an even-handed way as 2 guaranteed through cross-examination by experienced 3 counsel on a standardized problem -- should that be part 4 of the process that we implement here in Ontario before 5 one can hold oneself out as a -- a forensic pathologist? 6 Dr. Hanzlick...? 7 DR. RANDY HANZLICK: Okay. I think, you 8 know, they do get instruction on recognizing evidence and 9 obtaining it and preserving it, and that's no problem. 10 It's -- it's the issue of the delay in cases coming to 11 trial. 12 But certainly any case that's done by a 13 forensic fellow trainee is going to have a staff 14 supervisor, and there can probably, at least, be a 15 requirement that they have to have, at least, observed 16 testimony at some point. 17 That's not even a requirement now. You're 18 -- you're supposed to do it, but they should, at least, 19 observe it in a courtroom. You could run issue -- into 20 issues, I guess in the real world, if you had to have 21 trial experience, because the first time you went, you'd 22 have to say, I don't have any experience. 23 And that would cause problems in the 24 courtroom. So it would have to -- it would have to be 25 some sort of a synthesized scenario which is doable. But
1181 I think you could easily require that you've observed 2 testimony on one (1) or more occasions to see how cross- 3 examination works and whether or not leading questions 4 are permitted, and all those types of things. 5 MR. BRIAN GOVER: Okay. Dr. Milroy...? 6 DR. CHRISTOPHER MILROY: Well, it's sort 7 of kind of what we do at the moment, in that we do have 8 this course that we make people go on in England. So -- 9 so I guess we are trying to address it. 10 And we make them bring along cases that 11 they then have to present, and then they are cross- 12 examined by lawyers. So it's -- and now these are, you 13 know, they're -- they are real nasty lawyers. 14 If you need to put the word nasty in or if 15 it's a tautology I don't know, but -- 16 MR. BRIAN GOVER: That sounds like an 17 excellent system. And, Dr. Cordner -- 18 DR. STEPHEN CORDNER: Well, it seems to 19 me that the main issue you're worried about is the 20 dogmatism, so that's an attitude that you bring to the 21 Court with you. It's not only exposed by the giving of 22 evidence. 23 So that attitude is likely to be evident 24 in the -- in the institution, and it -- I would like to 25 think that part of the training that trainees get at our
1191 place is to actually break down tendencies to dogmatism; 2 and to understand the uncertainties and to ensure that 3 they're expressed in the -- in the group meetings we have 4 and the one-on-one discussions that -- . 5 The -- the giving of evidence certainly is 6 a skilled -- certainly requires experience and there's 7 certainly knowledge about how Court works and the -- the 8 obligation of parties and the obligation of witnesses and 9 they are very important things to -- to learn. 10 But -- and I -- the -- if the major issue 11 is dogmatism, then they are otherwise to -- to identify 12 that attitude and to make that an important issue in the 13 development of the trainee doing their training. 14 MR. BRIAN GOVER: And, Dr. Shkrum and Dr. 15 Pollanen, I don't know if you want to weigh in on this 16 issue. Dr. Shkrum...? 17 DR. MICHAEL SHKRUM: It's a great idea. 18 MR. BRIAN GOVER: Thank you, I think I'll 19 leave it there. 20 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 21 Gover. 22 Ms. Craig...? 23 MS. ALISON CRAIG: I think this morning 24 I'm happy to cede all of my time. 25 COMMISSIONER STEPHEN GOUDGE: Mr.
1201 Carter...? 2 MR. WILLIAM CARTER: Well, I -- I'll take 3 a chance. 4 5 QUESTIONED BY MR. WILLIAM CARTER: 6 MR. WILLIAM CARTER: We've heard a good 7 deal of evidence about the interface between pediatric 8 pathology and forensic pathology and from the evidence, 9 as I understand it, in this country, there is no one who 10 is currently certified jointly in the two (2) sub- 11 specialties. 12 There was one (1) in England who may now 13 have retired, as I recall the evidence of Dr. Milroy. 14 DR. CHRISTOPHER MILROY: He's retired, 15 but still practising. 16 MR. WILLIAM CARTER: Well, that may be 17 because if he fully retired, there would be a complete 18 backing. 19 DR. CHRISTOPHER MILROY: There would. 20 MR. WILLIAM CARTER: I understand from 21 the material that I saw from Dr. Hanzlick that there are 22 about a half a dozen in the United States. I don't know 23 about the rest of the world, but would it be fair to 24 conclude that they're as scarce as hens teeth? There 25 just are very few people who have the time and
1211 inclination to be specialized in the two (2) sub- 2 specialties. 3 What I'm curious about is whether that's 4 just because it's not important that we have people with 5 these dual qualifications because the job can be done by 6 specialists who have either or whether there is some 7 other explanation. 8 So, as I understand, the work of this 9 Commission, we've been exploring the role of forensic and 10 pediatric pathology as it relates to the -- that group of 11 cases that have a direct involvement with the Criminal 12 justice system, as opposed to the -- the broader forensic 13 case which are merely coroner's cases where natural 14 disease is likely the cause of death. 15 And I would just like some of your -- some 16 of your views, gentlemen, on the need and desirability to 17 have physicians qualified in the two (2) sub-specialties 18 and how that might be accomplished. And I'm -- I'm 19 asking you to focus for the time being, when I say the 20 need -- on the need -- to address those cases which are 21 criminally suspicious. 22 So, I'll start with Dr. Hanzlick, who -- 23 DR. RANDY HANZLICK: Okay. 24 MR. WILLIAM CARTER: -- looks eager. 25 DR. RANDY HANZLICK: I -- I think one (1)
1221 of the problems you have to realize is, number one (1), 2 most people who train in forensic pathology are thirty 3 (30) or thirty-one (31) years old when they get out of 4 their training. 5 And then to do another year of training, 6 now they're thirty-two (32) and they are hundreds of 7 thousands of dollars in debt and they'll never recover 8 from it, so there -- there's a natural incentive there 9 not to do that. 10 There's also a limitation on the number of 11 sub-specialties you can have. I think it's -- it's two 12 (2), I think, with the American Board of Pathology and 13 some of them already have sub-specialties in other areas, 14 so that limits it. 15 My inclination would be to include more 16 pediatric pathology training in the forensic programs, 17 and give that emphasis. And then rely on the pediatric 18 path -- pathologists that you do have, whether or not 19 they practice on the basis of experience or whether 20 they're certified. 21 But I don't think it's realistic to expect 22 people to be certified in both. 23 MR. WILLIAM CARTER: Right. 24 DR. RANDY HANZLICK: I -- I think you 25 just got to rely on what you have, and -- and maybe
1231 include more pediatric pathology in the forensic training 2 arena. 3 MR. WILLIAM CARTER: All right. Can you 4 give us some idea of what is currently the amount of 5 pediatric training in the forensic training in most 6 programs? 7 DR. RANDY HANZLICK: What you have is if 8 you are lucky enough to have a pediatric pathology 9 rotation in your general anatomic pathology, you have 10 that one (1) month or whatever it was. 11 And then you have your exposure to your 12 infant and childhood cases during your fellowship where 13 you learn about Sudden Unexplained Infant Death and 14 nothing really formal in most areas. 15 MR. WILLIAM CARTER: Okay. Is that in 16 sort of -- in any other -- 17 DR. CHRISTOPHER MILROY: We -- well we -- 18 I don't think there's a need for dual qualification, 19 because -- and I think that -- that if you have 20 established census with pediatric pathologists and 21 forensic pathologists, the double doctoring system, I 22 think, works quite well. 23 And we make our forensic pathologists have 24 a minimum six (6) months training in pediatric pathology, 25 plus what they see in their other forensic training.
1241 MR. WILLIAM CARTER: Yes. 2 DR. RANDY HANZLICK: But it takes longer. 3 DR. CHRISTOPHER MILROY: But it takes 4 longer. Yeah, well, it takes -- we -- we will do an 5 extra year of training, but we have to have six (6) 6 months neuro, six (6) months pediatrics. 7 But you see if you train for a year of 8 pediatric pathology, a lot of what you will be doing will 9 be surgical pediatric pathology. It really will not be 10 relevant to your role as a forensic pathologist. 11 And you really want to have directed 12 training towards what you are going to encounter as a -- 13 as a forensic pathologist. 14 MR. WILLIAM CARTER: Well, that -- that's 15 a matter of curriculum, I suppose. If you're in the 16 right environment, and it's being focussed in the right 17 way, you're going to overcome that. 18 DR. CHRISTOPHER MILROY: Yes, if you're - 19 - if you are in a forensic training program. 20 MR. WILLIAM CARTER: Yeah. 21 DR. CHRISTOPHER MILROY: But of course, 22 if you're in just a pediatric training program, by 23 definition, you're going to be doing what the other 24 pediatric pathologists are going to be doing, and just to 25 say, Do you need a hybrid of pediatric forensic
1251 pathology, the answer is no. 2 MR. WILLIAM CARTER: So if I could ask 3 Professor Gotlieb to comment for the University's 4 perspective on the -- first of all, how -- do you know, 5 sir, how much time is devoted to pediatrics in the 6 anatomical pathology training course at the moment? 7 DR. AVRUM GOTLIEB: There is a mandatory 8 elective. It's probably three (3) months. I'm not 9 totally sure, but -- 10 MR. WILLIAM CARTER: I'd understood it 11 had been three (3) months, but I understood it was now 12 one (1) month. 13 DR. AVRUM GOTLIEB: That could be the 14 case. 15 MR. WILLIAM CARTER: Is that -- is that 16 fair? And given the -- the outline prepared by Dr. 17 Pollanen of this vision of a -- of a Centre for 18 forensics, would it be your view that the -- this would 19 provide an opportunity for the University to play a 20 greater role in the development of a -- a forensic-based, 21 or oriented curriculum, in the -- the clinical service 22 area of the affiliated hospitals? 23 DR. AVRUM GOTLIEB: I'm not sure what you 24 mean by the clinical service area. 25 MR. WILLIAM CARTER: Well, in the
1261 clinical service area, I mean the department, or Division 2 of Pathology, which as we know, provides a number of 3 services including surgical and autopsy pathology. 4 So if -- if the University, through its -- 5 this -- this kind of multi-disciplinary forensic 6 Institute, or Centre, was to be -- I assume, it would 7 play a greater role in the development of a forensically- 8 oriented curriculum. 9 Would that be reasonable? 10 DR. AVRUM GOTLIEB: Yes. 11 MR. WILLIAM CARTER: Okay. And -- and 12 through the affiliated hospitals, it would ensure that 13 this curriculum was delivered? 14 DR. AVRUM GOTLIEB: Okay. So the 15 curriculum would be a -- a University-based curriculum? 16 MR. WILLIAM CARTER: Yeah. 17 DR. AVRUM GOTLIEB: The curriculum is not 18 developed by the hospitals, per se? 19 MR. WILLIAM CARTER: Yes. 20 DR. AVRUM GOTLIEB: So what you are 21 asking, I assume, is would there be a change in the 22 forensic pathology training in our AP and GP programs, 23 and -- and that's certainly a possibility if there was a 24 specific need. 25 And I think the -- the issue around the
1271 Institute would be that they would have the capacity to 2 explore different needs that would come up, looking at it 3 from an inter-divisional and sort of across -- across- 4 the-board approach. 5 MR. WILLIAM CARTER: Okay. 6 DR. AVRUM GOTLIEB: So we would have good 7 input in terms of how we might want to change. 8 MR. WILLIAM CARTER: So as I understand 9 it -- 10 COMMISSIONER STEPHEN GOUDGE: Mr. Carter, 11 at some point you're going to have to wind up pretty 12 quickly because -- 13 MR. WILLIAM CARTER: Okay. 14 COMMISSIONER STEPHEN GOUDGE: -- Mr. 15 Ortved -- 16 MR. WILLIAM CARTER: I have one (1) 17 question then of -- 18 COMMISSIONER STEPHEN GOUDGE: One (1)? 19 20 CONTINUED BY MR. WILLIAM CARTER: 21 MR. WILLIAM CARTER: -- Dr. Pollanen 22 following on your comments, Dr. Gotlieb. 23 As I understand it, the model that you 24 envision would enable a multi-disciplinary approach to 25 inform the development of a forensic component to the
1281 clinical services that are provided in the affiliated 2 hospitals? 3 DR. MICHAEL POLLANEN: Correct. And the 4 -- and the major mechanism was -- and this -- this came 5 out of meetings with individuals on the steering 6 committee and others -- was to, in the first instance, 7 identify Royal College training programs that currently 8 exist, for example, emergency medicine, obstetrics, 9 gynaecology, pediatrics, and then determine what type of 10 forensic education those medical specialities would 11 require. 12 And that's one (1) of the -- the goals 13 that the -- that the centre would have -- the putative 14 centre -- would be to -- to look at the various curricula 15 at the post-graduate level and say, What injection of 16 forensic relevance do we -- do you need, and then the 17 best instantiation of that being the -- the Royal College 18 program in forensic pathology being sort of a stand- 19 alone. 20 But, for example, we could see this as 21 also a catalyst, for example, to develop a Royal College 22 certification of special competency in forensic 23 pediatrics, which is clearly required, but this would be 24 the -- this would be the hub, as it were, to -- to launch 25 such an issuance.
1291 MR. WILLIAM CARTER: Thank you, Doctor. 2 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 3 Carter. 4 DR. MICHAEL SHKRUM: Actually, just for 5 clarification -- 6 COMMISSIONER STEPHEN GOUDGE: Yes, you 7 can sit down, Mr. Carter. 8 DR. MICHAEL SHKRUM: -- if that's okay? 9 COMMISSIONER STEPHEN GOUDGE: Sure. 10 DR. MICHAEL SHKRUM: Just for thirty (30) 11 seconds here. 12 COMMISSIONER STEPHEN GOUDGE: Absolutely, 13 Dr. Shkrum. 14 DR. MICHAEL SHKRUM: Just your -- your 15 first question. Pediatric pathology is not recognized by 16 the Royal College. 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. MICHAEL SHKRUM: To do pediatric 19 forensic pathology would be in the context of a forensic 20 training program. And as it stands right now, it's not 21 written in stone, but right now the training requirements 22 are a hundred (100) to a hundred and fifty (150) 23 autopsies for a fellow in a given year, of which fifteen 24 (15) will be of a pediatric nature. 25 MR. WILLIAM CARTER: Very good. Thank
1301 you. 2 MS. LINDA ROTHSTEIN: Mr. Ortved has one 3 question. 4 COMMISSIONER STEPHEN GOUDGE: Yes, Mr. 5 Ortved? 6 While he's coming up, Dr. Cordner, what's 7 the -- what's the teaching component devoted to 8 pediatrics at the Victoria Institute? 9 DR. STEPHEN CORDNER: Well, the -- the 10 training component in the Royal College of Pathologists 11 of Australasia does require a rotation of six (6) months 12 into pediatric pathology. 13 But if that is impossible to organize 14 because there's only one (1) pediatric pathology -- only 15 one (1) pediatric hospital in a capital city, it may not 16 actually be possible to organize. Then it can be 17 bypassed. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. STEPHEN CORDNER: So -- but if I 20 could just make a comment about -- I can see why it's 21 attractive for people to think, Ahh, we need more 22 pediatric forensic pathologists but I do agree that it is 23 unrealistic to think that that is actually going to 24 happen now or at any time soon. 25 COMMISSIONER STEPHEN GOUDGE: Could you
1311 devise a rotation that somehow directed a forensic 2 pathologist fellow to a kind of pediatric pathology that 3 was central to the work of forensic pathology? 4 DR. STEPHEN CORDNER: Well, in our 5 situation, you're only going to get that at our place, 6 not at the -- not at the pediatric hospital. And -- 7 COMMISSIONER STEPHEN GOUDGE: Because, as 8 Dr. -- 9 DR. STEPHEN CORDNER: -- at our place 10 with both a pediatric pathologist and a forensic 11 pathologist present around the deceased which is the same 12 as when we have a forensic pathologist and a 13 neuropathologist present for a particular case, or a 14 forensic pathologist and a hospital-based anatomical 15 pathologist who is particularly -- who know about tumours 16 of -- of the immune system, for example. 17 So it's -- it's only a particular example 18 of the way a multi-disciplinary forensic pathology 19 service should be provided in an increasingly complicated 20 medical world that we live in. 21 COMMISSIONER STEPHEN GOUDGE: Thanks. 22 Mr. Ortved...? 23 24 QUESTIONED BY MR. NIELS ORTVED: 25 MR. NIELS ORTVED: Thank you, Mr.
1321 Commissioner. So I don't know whether this question is 2 directed to Dr. Shkrum or Dr. Pollanen, but I'm 3 interested in what Dr. Milroy has told us about this law 4 and trial procedure course that's required as an 5 accreditation step in, in the UK. 6 And -- and can you just tell us whether, 7 in the materials and the program you have designed, 8 whether there is such a component? 9 DR. MICHAEL SHKRUM: No, I said the 10 comment in our training requirements is quite general. 11 It's going to be up to the individual training programs 12 to devise how they're going to get this component into 13 the -- into the fellowship -- fellowship training. 14 MR. NIELS ORTVED: So just -- and that's 15 what I did understand. And -- and with that in mind, I'm 16 just wondering, Dr. Milroy, whether the materials that 17 are utilized for this aspect of the program in the UK, 18 are they generally available and can they be obtained? 19 DR. CHRISTOPHER MILROY: I'm sure they 20 can be obtained. It's a matter of speaking to the people 21 who run the -- the show. And, I mean, I've been in -- 22 peripherally involved in it, so I'm sure that we could 23 give you a structure of what we do and I'm sure that that 24 can be obtained. 25 It's actually run through my employers at
1331 the moment, so the Forensic Science Service run it, 2 because they run it for the -- it's not just for -- for 3 physicians, it's for forensic scientists as well. 4 MR. NIELS ORTVED: Right. 5 DR. CHRISTOPHER MILROY: So it's -- it's 6 a broad -- it's a broad training program in which we slot 7 the -- slot the pathologists in. 8 And I should add that in our -- in our 9 Royal College forensic exams, we do expect our candidates 10 to have knowledge of -- of relevant law. 11 So they certainly have to have knowledge 12 of -- of some aspects of tissue ret -- our tissue 13 retention laws -- they can be examined on that -- 14 coronial law, fiscal law, because we have to cater for 15 the various jurisdictions we have, and a bit of -- and a 16 bit of criminal law as well. 17 MR. NIELS ORTVED: And the fact that 18 experts -- forensic pathologists testifying, owe their 19 duty to the court? 20 DR. CHRISTOPHER MILROY: Yeah. That's 21 obviously one (1) of the things that we drill into 22 people. I mean we actually sign a declaration now in all 23 of our reports to that effect. 24 So if you just read the report you should 25 have an indication of that, if nothing else.
1341 MR. NIELS ORTVED: Thank you. 2 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 3 Ortved. Just following that up with Dr. Pollanen, I take 4 it the proposal that you've tabled, that we see in the 5 materials, has implicit in it, perhaps not as explicit as 6 it might be, the role that the Faculty of Law at the 7 University could play in this kind of education dimension 8 that we've had described. 9 Is that right? 10 DR. MICHAEL POLLANEN: Faculty of Law is 11 a huge player, both in the context of delivering inter- 12 professional education to the law students, you know, in 13 -- through different mechanisms. 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. MICHAEL POLLANEN: But also, for 16 example, we already have a relationship with the trial 17 advocacy -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. MICHAEL POLLANEN: -- you know, et 20 cetera, but to -- to solidify those relationships further 21 around issues relating to testimony and evidence. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 Thank you. 24 Ms. Rothstein...? 25 MS. LINDA ROTHSTEIN: Commissioner, we're
1351 scheduled to end at 12:15 and break till 1:30. We can do 2 that, or we could break a little longer, because our 3 afternoon panels end at 4:15. 4 What's your -- 5 COMMISSIONER STEPHEN GOUDGE: Why don't 6 we break a little longer. We'll have an hour and fifteen 7 (15) minutes for lunch so people can actually get 8 something to eat. And then we'll come back and perhaps 9 run ten (10) or fifteen (15) minutes longer this 10 afternoon -- 11 MS. LINDA ROTHSTEIN: Okay. 12 COMMISSIONER STEPHEN GOUDGE: -- if 13 people can manage that. 14 MS. LINDA ROTHSTEIN: Thank you all very, 15 very much. 16 COMMISSIONER STEPHEN GOUDGE: Yes, thank 17 you all. This morning was very, very enlightening and a 18 great start to these policy discussions. 19 We'll rise then until an hour and fifteen 20 (15) minutes from now, whatever that may be. 21 MS. LINDA ROTHSTEIN: Twenty (20) to. 22 23 --- Upon recessing at 12.26 p.m. 24 --- Upon resuming at 1:41 p.m. 25
1361 THE REGISTRAR: All rise. Please be 2 seated. 3 4 (BRIEF PAUSE) 5 6 ORGANIZING PEDIATRIC FORENSIC PATHOLOGY IN ONTARIO PANEL: 7 MICHAEL POLLANEN 8 RANDY HANZLICK 9 GLENN TAYLOR 10 DAVID RANSON 11 DAVID CHIASSON 12 13 QUESTIONED BY MR. MARK SANDLER: 14 MR. MARK SANDLER: Good afternoon. 15 Commissioner, you've -- you've met all of our panellists, 16 some of whom were in the roundtable this morning, so I 17 intend to be very, very brief in the introductions. 18 Dr. Hanzlick this morning was introduced 19 as the Chief Medical Examiner for Fulton County, Georgia, 20 and unless something's changed over lunch, you remain the 21 Chief Medical Examiner for Fulton County, Georgia. 22 Welcome again. 23 DR. RANDY HANZLICK: Thank you. 24 MR. MARK SANDLER: Dr. Ranson is the 25 Deputy Director of the Victorian Institute of Forensic
1371 Medicine in Australia. He's also the Director of the 2 National Coroners Information System, which you heard 3 about this morning, Commissioner, in Australia. 4 He's a practising forensic pathologist. 5 Has also practised in the field of clinical forensic 6 medicine and is Associate Professor at Monash University 7 and holds a law degree from the University of Western 8 England. Welcome, Dr. Ranson. 9 Dr. Chiasson, of course, testified earlier 10 in these proceedings. He is the Director of the Ontario 11 Pediatric Forensic Pathology Unit at the Hospital for 12 Sick Children. 13 He is the former Chief Forensic 14 Pathologist and the former Deputy Chief Coroner of 15 Pathology for the Province of Ontario. Welcome, Dr. 16 Chiasson. 17 DR. DAVID CHIASSON: Thank you. 18 MR. MARK SANDLER: Dr. Taylor, again, who 19 testified earlier at this Inquiry is the current head of 20 the Division of Pathology at the Hospital for Sick 21 Children. He is also an Associate Professor, Department 22 of Laboratory Medicine and Pathobiology, University of 23 Toronto. Good afternoon, Dr. Taylor. 24 DR. GLENN TAYLOR: Good afternoon. 25 MR. MARK SANDLER: And finally, Dr.
1381 Pollanen, the Chief Forensic Pathologist for the Province 2 of Ontario, who certainly needs no introduction at this 3 point. Good afternoon again, Dr. Pollanen. 4 DR. MICHAEL POLLANEN: Good afternoon. 5 MR. MARK SANDLER: Well, this afternoon 6 we're going to be dealing with a topic entitled 7 "Organising pediatric forensic pathology in Ontario" and 8 we're going to explore a number of issues around how the 9 delivery of Pediatric Forensic Pathology Services in 10 Ontario should take place. 11 I want to start here, if I may, and I'm 12 going to pose my first question to Dr. Pollanen. Let's 13 take a scenario, if we may. A young child two (2) months 14 old dies in the crib in a -- in a house, say an hour's 15 drive north of Toronto. It's a sudden and unexpected 16 death. The police and other emergency personnel attend 17 at the scene. There are no obvious circumstances that 18 would cause it to be characterised as a suspicious death. 19 So the question arises: What kind of 20 pathologist should conduct the autopsy in that case, who 21 should decide who conducts the autopsy in that case, and 22 where should the autopsy in that case be conducted? 23 DR. MICHAEL POLLANEN: So you've outlined 24 the -- the typical undifferentiated pediatric case that 25 would come to any death investigation system in the
1391 western world, and there are many different options 2 available to us on how to manage such a case. 3 The two (2) different options, given the 4 proximity to Toronto in your example, would include a 5 post-mortem examination at the Toronto Forensic Pathology 6 Unit or at the Ontario Pediatric Forensic Pathology Unit 7 at the Hospital for Sick Children. Those are the two (2) 8 options. 9 And you have essentially two (2) types of 10 pathologists that could perform the post-mortem: 11 pediatric pathologist at the Sick Kids or a pediatric 12 pathologist -- I'm sorry, a forensic pathologist working 13 in the Toronto Unit or working at Sick Kids, so those are 14 the sort of range of options. 15 We know from looking at how these cases 16 have been managed historically that the majority of those 17 undifferentiated cases will not be of interest to the 18 criminal justice system, and that we know statistically 19 that those cases will typically benefit from a pediatric 20 forensic pathology-based autopsy, recognizing the -- 21 pediatric pathology autopsy -- recognizing the fact that 22 that many of the diseases that present in that age group 23 are best detected by pediatric pathologists. 24 That, of course, must be balanced, as it 25 always is, by concerns, evidentiary concerns, and
1401 concerns that we would have for the detection of a 2 concealed death by injury. And so the challenge then 3 really is to harness both the pediatric pathology and the 4 forensic pathology component at the front end and there 5 is on reproducible way of doing so. I mean, we've looked 6 at that statistically and we know that there's no 7 reproducible way of screening these cases at the front 8 end. So -- 9 MR. MARK SANDLER: So just stopping there 10 for a moment. When you say there's no reproducible way, 11 what you're saying in essence, you just can't determine 12 at that stage of the process whether this will ultimately 13 be a medicolegal case or not. 14 DR. MICHAEL POLLANEN: Suspicious or not, 15 correct. Yes. 16 So -- so then you -- you basically have to 17 decide, and it's really a policy level decision, about 18 how best to utilize your resources, your human resources, 19 particularly in this case, the pediatric pathologist. 20 So in our current system, and I believe 21 there's merit to this, such a case would be streamed to 22 the Sick Children's Hospital where the case would benefit 23 from the presence of a pediatric pathologist and in fact 24 a forensic pathologist, because Dr. Chiasson is -- is on 25 staff there.
1411 The -- and the other ancillary services 2 that are available also at the Children's Hospital can be 3 brought to bear on the case. So it's a -- it's a 4 reasonable approach. The -- there, of course, is a 5 downside or a counter-argument to that, but that, in our 6 current structure, in our current policy for triaging of 7 these cases, that's how it would proceed. 8 MR. MARK SANDLER: Okay. I'm going to 9 come back to that in a moment. 10 Dr. Ranson, if that case takes place in 11 Australia, what type of pathologist is going to conduct 12 that autopsy? 13 MR. DAVID RANSON: It's going to be a 14 forensic pathologist and that forensic pathologist is 15 going to be operating in -- essentially in a team within 16 the institute, which will include a pediatric pathologist 17 being present at the autopsy and helping to review the 18 materials and slides and all of those factors. It will 19 include a pediatric radiologist reviewing all of the X- 20 ray films and the CT scan that will be performed as part 21 of the routine. 22 And if there's a trainee in the forensic 23 department, which there inevitably will be, they will 24 almost certainly be engaged in that case, because 25 pediatric cases are not that frequent within the overall
1421 scheme of forensic pathology practice and that will be an 2 important part of their training, to be involved in that 3 case. 4 And I suppose my -- my view in respect to 5 that is to say that where you're talking about issues of 6 who should conduct a -- an autopsy in that scenario and 7 whether it should be led by a pediatric component of 8 pediatric pathologist or forensic pathologist, my view, 9 coming from my side of the organization, is that it 10 should be a forensic pathologist. 11 And my rationale for saying that is, and I 12 think Michael has picked up on that, is you don't know 13 what a case is when you start the process. Suspicion may 14 creep in at various stages of the investigation but it is 15 not easy to predict that. 16 The problem for forensic and pediatric in 17 this process is that if you have conducted the autopsy 18 process within a forensic framework, a framework that is 19 going to support the court system all the way along the 20 line, you couldn't -- you -- you've never lost ground. 21 If you started without that forensic framework and 22 evidential control and evidential administration and 23 those sort of processes, to rebuild it is almost 24 impossible. 25 If you started in forensic and had that
1431 sound forensic base to bring in the clinical expertise of 2 pediatricians and pediatric neurosurgeons, or whatever it 3 happens to be, you can do that almost at any -- at any 4 point in the process. 5 So I think that that's one (1) of the 6 reasons why I would say that it's important to have that 7 mechanism organized, that the administration, the 8 fundamental framework of investigation, take place within 9 a -- within a forensic leadership. But that does not 10 mean to say that all of the critical expertise will come 11 from the forensic pathologists. 12 MR. MARK SANDLER: Okay. Dr. Hanzlick, 13 how would that case be dealt with Georgia? 14 DR. RANDY HANZLICK: It would also be 15 done in the forensic pathology setting at one (1) of the 16 medical examiner's offices, using consultants as needed. 17 We -- we're fortunate in Georgia, just 10 18 miles from our office we do have a person who's board 19 certified in forensics and pediatric pathology that's 20 glad to come down on cases. And we have the faculty at 21 Emory in the children's hospitals, the pediatric 22 pathologists, so we would use them as consultants, call 23 them if we need it, but it would be primarily done 24 through the forensic pathology system. 25 MR. MARK SANDLER: And -- and do agree
1441 with the rationale that Dr. Ranson has given for why the 2 emphasis should be on the forensic as opposed to the 3 pediatric? 4 DR. RANDY HANZLICK: Yeah, because if you 5 look at these cases, these are actually the hardest 6 cases, in reality, when you don't have any obvious 7 findings, and you're not going to find something 8 unexpected unless you specifically look for it. 9 And a lot of these cases, you know, you're 10 taking information at face value from -- from family 11 members or witnesses, you don't really know the exact 12 circumstances, you may not have even been out to the 13 scene where the body was to be able to recreate exactly 14 what happened, and so you're going into these cases 15 blind, so to speak, and to me, tho -- those are the more 16 difficult cases and should have the forensic emphasis. 17 MR. MARK SANDLER: All right. Dr. 18 Taylor, make the case for me for the foren -- for the 19 pediatric pathologists, if you would. 20 DR. GLENN TAYLOR: Well, our -- our 21 numbers are about -- 20 percent of the cases that we do 22 at the Pediatric Forensic Pathology Unit are in this kind 23 of SIDS or SIDS like presentation group, and of those, 24 the large majority, 95 percent, are going to be deaths 25 due to pediatric disease or perhaps even the
1451 complications related to treatment of pediatric disease. 2 I fully agree that there has to be proper 3 evidentiary base and that things have to be done 4 appropriately so that if something untoward does come to 5 light that the evidence has been appropriately obtained 6 and the documentation has been appropriate. 7 On the other hand, doing them at a place 8 like Sick Kids where there's access to the consultants in 9 pediatric diseases that treat living -- living kids and 10 the ancillary and important technical assistance that we 11 get through people like the diagnostic imaging 12 technologists that are used to ex -- doing x-rays on kids 13 of all ages, and the other facilities that are available, 14 like the microbiology lab, the biochemistry lab for 15 metabolic considerations, and so on, makes the job a lot 16 easier on that 95 percent, which turn out not to be of 17 interest to the criminal justice system. 18 So I think there's good reason for doing 19 those cases in an institution like Sick Kids, but I also 20 fully agree that there has to be in place the mechanisms 21 to make sure that those cases that do turn out to have 22 inflicted injury are appropriately dealt with. 23 MR. MARK SANDLER: Dr. Chiasson, where do 24 -- where do you weigh in this issue? 25 DR. DAVID CHIASSON: Well, I noticed I've
1461 been positioned in the middle of this table and I'm 2 already feeling a tug on -- on either arm, and in fact 3 there's two (2) tables here and there's a split and it's 4 -- it's two thirds (2/3)/one third (1/3) right now. 5 Well, I think you're -- you're -- going to 6 back to your fact scenario as -- as you presented, that 7 case now would be sent to Sick Kids to -- to our unit. 8 We have a pathologist on call -- it -- it may be me as a 9 forensic pathologist or it may be a pediatric pathologist 10 who's on call -- who would be the one (1) primarily 11 dealing with the -- the case. 12 Whether it's myself or the pediatric 13 pathologist, the protocol for the autopsy in how that 14 would performed, addressing Dr. Ransom's concerns about 15 issues of -- of a forensic nature, are in place and the 16 autopsy would be -- would be done in essentially the same 17 -- same fashion, regardless of whether it's a pediatric 18 pathologist or myself that performs the -- the autopsy. 19 And -- and I fully respect that, you know, 20 the -- the idea that, you know, the forensic pathologist, 21 and as a forensic pathologist I -- I certainly know where 22 the thought's coming from that, you know, they -- they 23 should be primarily in charge, but having -- the system 24 we've developed at the Ontario Pediatric Forensic 25 Pathology Unit I think is -- is actually -- does address
1471 forensic concerns. 2 As the Director who's a forensic 3 pathologist, we have -- we have protocols in place which 4 address the forensic concerns, at the same time address 5 Dr. Taylor's concerns as a pediatric pathologist and the 6 reality that 90 percent of these cases of -- of sudden 7 unexpected death really fall within a pediatric category. 8 And yes the justice system -- and we need 9 to respectful of that, and of course, that's what's 10 driven the -- this Commission into being, are problems 11 within the justice system, but at the same time there are 12 families who are very much interested in knowing why 13 their -- their infant or child has -- has died, and if -- 14 yeah, I think we -- that we do have a responsibility to 15 them as well, from a more pediatric pathology point of 16 view. 17 And suffice it to say, I -- I think that 18 the current setting of a Pediatric Pathology Unit with a 19 Director who's a forensic pathologist in this setting, 20 with all the ancillary applications that are available 21 within the hospital setting is -- is really quite a -- a 22 good system. 23 And I think as it stands now, this is 24 where the body would come, and I think would be dealt 25 with in a very appropriate fashion, addressing both
1481 forensic and pediatric slash medical concerns. 2 MR. MARK SANDLER: Okay. 3 DR. MICHAEL POLLANEN: Just to enlarge on 4 that for a moment, and it's -- it's very important for 5 everybody to recognize as well, that this is -- this 6 operation that is occurring in the Ontario Pediatric 7 Forensic Pathology Unit is worth -- is occurring within 8 the context of a greater provincial system. And that -- 9 MR. MARK SANDLER: Which I'm going to 10 change the scenario -- 11 DR. MICHAEL POLLANEN: Right. 12 MR. MARK SANDLER: -- to address a little 13 bit later on, but -- go ahead. 14 DR. MICHAEL POLLANEN: But -- but the 15 point being there that while the -- the unit at Sick Kids 16 is geographically separated from my Department, there are 17 important linkages. 18 So for example, there are occasions where 19 I will go over to review a case that's being done at Sick 20 Kids, while the body is still on the table. And that 21 type of interaction is also very fruitful. 22 So it's not as is if we have, you know, a 23 loan department in which bodies are arriving; autopsies 24 are occurring. It's an integrated service and that's 25 something that -- that -- it's a challenge to deliver,
1491 but it's a challenge that we have to accept if we want to 2 maintain these important partners that are dis -- 3 distributed geographically across the -- the Province. 4 MR. MARK SANDLER: All right. So -- so 5 just staying with you, Dr. Pollanen, for a moment. Lets 6 say one (1) of the parties at this Inquiry were to make a 7 submission to the Commissioner. And the submission would 8 be, one (1) of the concerns that we've seen in this case 9 is siloing as between the pediatric side, and the adult 10 side, and -- and we want the pediatric forensic pathology 11 to have the benefit of what we know about adult forensic 12 pathology. 13 So I'm urging you, Commissioner, to 14 disband the Ontario Pediatric Forensic Pathology Unit, 15 and why don't we do all the cases at the Toronto morgue. 16 What would you say about it? 17 DR. MICHAEL POLLANEN: I would say that 18 we're losing an opportunity to harness pediatric 19 pathology, and we are maximizing the use of forensic 20 pathology, but not in a -- in it's most effective way. 21 MR. MARK SANDLER: So how can we 22 accomplish what -- what that person making the 23 submissions would like to get at, namely preventing 24 siloing while preserving the Unit, and the -- and the 25 benefits that we've heard described by Dr. Taylor, and
1501 Dr. Chiasson, and yourself? 2 DR. MICHAEL POLLANEN: Well, I think that 3 there are things to be done on multiple levels. I think 4 an important -- one (1) of the most important things is 5 communication across the system. 6 So in other words, when a case is 7 identified in the first instance, there needs to be a 8 meaningful discussion of participants in deciding how to 9 proceed. 10 One (1) of the -- one (1) of the flaws in 11 -- in the current way of triaging cases is to simply 12 triage on the basis of age. Well, this is not correct. 13 And the reason for that is that we 14 recognize that children can be killed using violent 15 means, and because they're 2 years old, that dying a 16 violent death does not automatically put them into a 17 pediatric environment. 18 In many of those cases, they're more -- 19 more appropriate to come to a forensic environment. So 20 there has to be an engagement of the issue at the -- in 21 the first instance. 22 We also have to recognize that the 23 forensic pathology service, and in particular the 24 leadership in the forensic pathology service has to play 25 an important role in determining how the cases distribute
1511 across the Province. 2 And specifically what I'm talking about 3 there is that this is not -- how -- how to distribute a 4 case is not a decision to be made purely by the local 5 coroner, or perhaps in conjunction with their regional 6 supervising coroner. That's -- that is a professional 7 decision that needs to be engaged at the level of 8 forensic pathology. There needs to be sub -- substantive 9 input on that level. 10 MR. MARK SANDLER: Did you say -- 11 COMMISSIONER STEPHEN GOUDGE: Can I ask, 12 Dr. Ranson, where does your pediatric pathology 13 assistance come from? Is it on staff? 14 DR. DAVID RANSON: It come -- it comes 15 from the -- indirectly from the Children's Hospital, but 16 what we have done in the previous few years is that the 17 person who'd retired as the director of pediatric 18 pathology at the hospital has come and worked part-time 19 with us. 20 So he's been employed by us on a part-time 21 basis and essentially has been working as one of our 22 pathologists within that -- within our organization. 23 COMMISSIONER STEPHEN GOUDGE: So 24 pediatric death, that pathologist would be involved 25 essentially as --
1521 DR. DAVID RANSON: Directly involved -- 2 COMMISSIONER STEPHEN GOUDGE: -- as a 3 consultant? 4 DR. DAVID RANSON: Absolutely, as a 5 consultant to the forensic pathologists now. A few years 6 ago, he would take some of those cases himself, with a 7 forensic pathologist, if you like, acting as a support 8 consultant. 9 At the principle, I suppose, is -- is what 10 I'm really interested in here, and the principle is that 11 we really don't practice medicine anymore as individual 12 practitioners, most medicine is really practised in the 13 concept of a team. And what we try to build is a team of 14 expertise that addresses each case. 15 And, indeed, clearly from the pediatric -- 16 or from the Children's Hospital, that is what they are -- 17 they are offering in -- in that particular sense. 18 From my point of view, I suppose I'm less 19 concerned with the geography as I am with the principle 20 that you try to have the right team relevant to that case 21 with -- in an environment with the right facilities, that 22 might live in a variety of different places. 23 Once you, however, you start splitting up 24 your resources, both manpower and also your technical 25 physical resources, you have an increased cost component
1531 and an -- and in an environment where it is difficult to 2 recruit, you also have risks of limiting and weakening 3 your manpower environment. 4 So I suppose that's my reason for trying 5 to bring it together and bring those people together 6 under one (1) umbrella -- 7 COMMISSIONER STEPHEN GOUDGE: You maybe 8 going -- you maybe getting into this, Mr. Sandler, but at 9 some point I'd like to ask this very erudite group 10 whether the considerations change if the death is 11 criminally suspicious. 12 MR. MARK SANDLER: Yeah, we're -- we're 13 going to go there as one (1) of our scenarios. 14 COMMISSIONER STEPHEN GOUDGE: All right. 15 All right. Slapped down again. 16 DR. DAVID CHIASSON: If I could address 17 your -- your siloing concern and -- and to echo what -- 18 what Dr. Pollanen has just said, and I certainly see the 19 Ontario Pediatric Forensic Pathology Unit as an integral 20 part of a -- of a larger forensic pathology service 21 within -- within Ontario, under the aegis of the chief 22 forensic pathologist. 23 And, you know, part of that is that we, in 24 fact, as -- as one (1) of our staff pathologists at the 25 hospital -- and to make it clear, it's -- it's only a
1541 select group of pathologists at the hospital who are, in 2 fact, doing coroner's cases. It's not all the 3 pathologists. It's those with interest, experience, and 4 that -- that have -- and it's a small number -- besides 5 Dr. Taylor, Dr. Summers, Dr. Wilson -- really constitute 6 the pediatric pathology component of the unit from a 7 manpower point of view. 8 We have Dr. Pollanen as a consultant 9 forensic pathologist and -- and he's certainly taken part 10 in -- in autopsies on a primary basis. He's been on call 11 for -- for -- at certain times. And -- and importantly 12 provides a backup for myself when I'm not available to -- 13 to take over a case or -- because it's criminally 14 suspicious, to -- to take primary responsibility. And so 15 we have, I think, established over the last couple of 16 years a strong network. 17 The other thing, and it comes off of what 18 I heard this morning in terms of training, when you're 19 looking at pediatric forensic pathology training, it is, 20 as I think was the message that came across and, 21 certainly, was my experience, you train in a forensic 22 pathology setting. The number of pediatric cases is 23 relatively small. 24 And even as a fellow in -- in an office, I 25 was -- only a small percentage. Despite my interest in
1551 pediatric pathology back when I trained, I only did a 2 small number of -- of -- of cases. 3 The -- the option I think that, from a 4 training point of view, I think the -- the Ontario 5 Pediatric Forensic Pathology Unit, the usual mouthful 6 there, is -- really provides an excellent place to 7 provide relatively intensive training by people who are - 8 - who are dedicated in that specialized area. 9 And one (1) of the -- the disadvantages 10 for pediatric forensic pathology to develop within a 11 comprehensive forensic pathology environment is that it 12 is a small percentage of case -- cases. By the time you 13 divide it up among a number of forensic pathologists, any 14 forensic pathologist will not have done -- will not 15 really have -- have -- it would take many years to evolve 16 a comprehensive experience to -- to doing those case. 17 And, in fact -- and I think the reality 18 is, and Dr. Hanzlick could probably speak to this, is 19 that in many offices, there's a tendency to -- to shy 20 away from the pediatric forensic pathology cases because 21 they do represent a lot of work. 22 So for a lot of these -- these issues, 23 having this -- this unit, I think, would provide a 24 wonderful opportunity to work in conjunction with a 25 fellowship program at the Toronto Forensic Pathology
1561 Unit. And then we'd have this comprehensive place where 2 you have the specialized people. 3 And I think not only from an Ontario 4 perspective, I think from a Canadian perspective and I 5 think from a, really, an international perspective, 6 there's an opportunity here as currently set up to, in 7 fact, see this as a -- as a place to provide 8 comprehensive training in pediatric forensic pathology. 9 And that's not even addressing the whole potential for -- 10 for research activity -- 11 12 CONTINUED BY MR. MARK SANDLER: 13 MR. MARK SANDLER: Right. 14 DR. DAVID CHIASSON: -- which is the 15 other thing. 16 MR. MARK SANDLER: Let me get at this 17 issue another way. And Dr. Taylor, I'm going to turn to 18 you. 19 Take our scenario, but I'll -- I'll now 20 change it slightly. We're still -- we're still in an 21 environment where the death has occurred fairly close 22 proximity to Toronto. The case comes in but either the 23 coroner or the investigating officer attends and advises 24 that the caregiver made a statement such as "I always 25 wanted to kill that child", or x-rays that are done prior
1571 to the autopsy demonstrate a suspicious healing fracture. 2 What would you do with that case if you'd 3 been assigned to conduct the autopsy? 4 DR. GLENN TAYLOR: Well, I'd certainly 5 stop there and talk -- talk it over with Dr. Chiasson if 6 he's available; or if he wasn't available, call Dr. 7 Pollanen and get some advice. 8 I certainly would not feel comfortable in 9 pursuing the case without getting some advice and some 10 guidance from one (1) of the forensic pathologists that 11 we have been dealing with. 12 MR. MARK SANDLER: And typically -- just 13 carrying that through; and I take it that's because it's 14 now a suspicious death or potentially a criminal -- 15 DR. GLENN TAYLOR: Yeah. It's -- 16 MR. MARK SANDLER: -- case? 17 DR. GLENN TAYLOR: It's shaded from grey 18 to more black, and under those circumstances, I think my 19 threshold would have been reached. And I'm sure that my 20 two (2) other pediatric pathology colleagues doing these 21 cases would -- would also have reached their threshold 22 and would certainly have looked for advice. 23 MR. MARK SANDLER: All right. So now, 24 that being the case, what is likely to happen as a result 25 of your consultation? Is it likely that a forensic
1581 pathologist such as Dr. Chiasson would take over the 2 autopsy or is it likely that you'd do it together with 3 Dr. Chiasson? Or is it likely that you would continue 4 the autopsy with feedback from them on û- on what you 5 might look for? 6 DR. GLENN TAYLOR: Yeah. That would 7 depend on what the information was that was brought to 8 our attention. 9 If it was sort of hearsay evidence and 10 there wasn't really anything else with regards to the 11 examination of the external features of the -- of the 12 deceased or through the x-rays, then we may -- I may go 13 ahead with that case with guidance and with the assurance 14 that Dr. Chiasson or Dr. Pollanen was close by in case 15 anything additional was found. 16 If the information was fairly strong, then 17 I would prefer that it would be done by one (1) of the 18 forensic pathologists. 19 MR. MARK SANDLER: All right. Dr. -- 20 COMMISSIONER STEPHEN GOUDGE: Can I just 21 ask, Dr. Taylor, I take from what you have just been 22 talking about that your threshold of consulting is met 23 just by the history? 24 DR. GLENN TAYLOR: The history, I think, 25 is very important, but I also recognize that things can
1591 chance, so. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 Right. But the history, at least, gets you consulting? 4 DR. GLENN TAYLOR: Yes. 5 COMMISSIONER STEPHEN GOUDGE: And that is 6 history either from the coroner or from the police? 7 DR. GLENN TAYLOR: Yes. And sometimes 8 information comes across sort of after things have been 9 started. So the information that may be important to 10 making that decision might not be in the Coroner's Form 11 6; might not be -- 12 COMMISSIONER STEPHEN GOUDGE: Yes. 13 DR. GLENN TAYLOR: -- in the Sudden 14 Death -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. GLENN TAYLOR: -- Homicide Report 17 from -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. GLENN TAYLOR: -- the police. 20 COMMISSIONER STEPHEN GOUDGE: But I was 21 really in my own head, contrasting history with something 22 that you would observe. 23 DR. GLENN TAYLOR: Yes. 24 COMMISSIONER STEPHEN GOUDGE: Okay, 25 thanks. Thanks, Mr. Sandler.
1601 2 CONTINUED BY MR. MARK SANDLER: 3 MR. MARK SANDLER: Dr. Pollanen, we've 4 heard a lot at this Inquiry from various experts about 5 double-doctoring in other jurisdictions. And -- and the 6 notion of double-doctoring has been -- has been utilized 7 to mean that both a pediatric pathologist and a forensic 8 pathologist might well conduct the autopsy in these cases 9 as a matter of course even before the suspicious 10 circumstances that I outlined had presented themselves. 11 What about the notion of mandatory double- 12 doctoring for certain kinds of cases? Do you agree with 13 that process or disagree with it? 14 DR. MICHAEL POLLANEN: Disagree. 15 MR. MARK SANDLER: Why? 16 DR. MICHAEL POLLANEN: I think the 17 concept that we want to get at here is fruitful 18 collaboration of members working together in a team. 19 So I think instead of creating protocols 20 like that, it is better to engage the professionals in 21 the content of the matter and then decide how to proceed 22 on a rational basis. 23 So I can see, for example, in -- in some 24 circumstances that the double-doctoring approach might, 25 in fact, be the way to go. You find certain findings at
1611 post-mortem examination and then you have both the 2 forensic pathologist and pediatric pathologists together. 3 That might be the best way to manage the case, based upon 4 information that one gleans from various sources. 5 In other cases, for example, let's say a 6 case comes as a, you know, undifferentiated slightly 7 criminally suspicious, and the body is open and there's 8 congenital heart disease. There's no point to double- 9 doctoring that case because the pediatric pathologist is 10 well able. 11 Or a case of apparent SIDS, and upon 12 dissection there is liver laceration with hemoperitoneum. 13 Then, you know, the forensic pathologists would take the 14 lead. 15 So I think that we need to be -- we need 16 to be responsive to the challenges as they come as 17 opposed to setting up blanket policies. 18 I think also the double-doctoring process, 19 and if you just change it slightly and call it 20 "collaboration between relevant professionals", can look 21 different as the case evolves. 22 For example, I, not infrequently, will 23 have a case involving a placenta if I'm at the Children's 24 Hospital doing a post-mortem examination. And my daily 25 practice does not include the placenta, but Dr. Taylor is
1621 a very skilled placental pathologist so I'll show the 2 slides to Dr. Taylor. I mean, this is -- this is the 3 sort of thing. That's a double-doctoring, but it's 4 occurring later on in the process. And I think the -- 5 the pathologists are best able to determine when that 6 occurs. 7 MR. MARK SANDLER: Now, I'm going to stay 8 with you for a moment, and then I'm going to go to other 9 members of the panel. 10 You say the pathologist is best able to 11 determine that process. So let's assume that one agrees 12 that instead of mandating double-doctoring in certain 13 kinds of cases, one should build in a high degree of 14 flexibility that is very much case-specific. That's what 15 I hear you saying -- 16 DR. MICHAEL POLLANEN: Yes. 17 MR. MARK SANDLER: -- right? 18 DR. MICHAEL POLLANEN: Yes. 19 MR. MARK SANDLER: Who decides that? 20 First of all, does the coroner have any role in deciding 21 who will perform the autopsy? That's the first question. 22 And the second question is: Would there 23 be some benefit to the existence of guidelines as to the 24 kinds of cases that should be done by the pediatric, the 25 kinds of cases that presumptively should be done by the
1631 forensic pathologist, or the kinds of cases that 2 presumptively might be done collaboratively? 3 DR. MICHAEL POLLANEN: Well, let's start 4 with the first issue which is the role of the coroner. 5 I think the -- the modern approach to 6 forensic pathology recognizes -- and we're talking about 7 in a -- functioning in a medical coroner system. I think 8 the modern incarnation of forensic pathology is to -- is 9 to recognize that the coroner's major role is to decide 10 when an autopsy is performed; if an autopsy is required 11 for the death investigation. 12 But beyond that, we're getting into 13 professional, content-related decision-making that the 14 forensic pathologist is best able to perform. 15 In other words, the value added by having 16 a forensic pathologist starts once the decision to do an 17 autopsy is made the coroner. 18 So I would -- it's my view that the -- the 19 forensic pathologist needs to be in the lead position in 20 that circumstance. 21 Now, we have to remember that we do 22 function as a team, so that means that we need to be open 23 to receiving information from the coroner and under -- 24 and hearing the coroner's view on the matter. 25 But I think ultimately, the -- the
1641 responsibility for that decision-making has to be with 2 the forensic pathologist. 3 Now, in terms of guidelines, I think that 4 we can generate guidelines. For example, I think -- I 5 think everybody would identify the polar extremes as 6 being simple. 7 The child who is in a hospital that dies 8 shortly in the -- you know, the post-operative period 9 after, you know, brain surgery, that's probably best done 10 by a pediatric pathologist in an in -- in the Sick 11 Children's institutional setting. 12 The rape homicide of a four (4) year old 13 is probably best done in my department where, you know, 14 we have the -- the different forensic emphasis. 15 So I think in the polar extremes, it's 16 quite -- quite easy to identify streaming factors, but in 17 the undifferentiated case, which represents the majority 18 of our work, there has to be this engagement. 19 And -- and again, I just -- I just 20 emphasize that if you're functioning within this de- 21 localized but efficiently network system of forensic 22 pathology service provision, I think there is a place for 23 the pediatric pathologists functioning in that -- in that 24 mechanism. 25 For example, it would be -- it would be
1651 incorrect to say that the -- that all of these cases on 2 the basis of a strict age cutoff will be done at the 3 Hospital for Sick Children without any realistic 4 communication with the forensic pathology service in 5 general. That would be incorrect. 6 But evolved in the fashion that I'm 7 talking about, I think it -- it can work well. 8 MR. MARK SANDLER: All right. Dr. 9 Hanzlick, what about the notion of mandatory double- 10 doctoring. Where do you stand on that issue? 11 DR. RANDY HANZLICK: I agree totally with 12 everything Dr. Pollanen said, basically. I don't think 13 it needs to be mandated. 14 I mean, these cases -- every one (1) of 15 them is unique. They occur at a different place, you -- 16 you know, most of the time. 17 The location of your expert staff relative 18 to the location of that case varies. You know, you have 19 pediatric pathologists in some areas and not others. 20 The circumstances are different in the 21 cases, and the amount of information you have is -- is 22 different from case to case. 23 And to me, the best way to do it would be 24 to have a policy that allows the Chief Forensic 25 Pathology, or the pathology service, to use the resources
1661 that are available as appropriate for that individual 2 case. 3 It may be sending it to Sick Children's 4 one (1) day. It may be having somebody go to another 5 location another day, but to mandate that creates a whole 6 layer of things that you don't really need. 7 MR. MARK SANDLER: All right. Dr. 8 Ranson, I know you're familiar with double-doctoring as a 9 mandatory provision from your study of other 10 jurisdictions. 11 So where do you weigh in on that issue? 12 DR. DAVID RANSON: I would -- I would 13 agree with both Randy and -- and Michael on this. I 14 don't think that mandating double-doctoring is actually 15 solving the fundamental problem. 16 And the fundamental problem is how do you 17 ensure that the appropriate team is engaged to deal with 18 a particular case that is bringing together the right, 19 and -- and correct experts that that case demands. 20 And that -- that may change, that team, 21 during the course of the investigation. Your initial 22 information might determine a particular team, and -- 23 and, so on. 24 I'm quite happy for a coroner to be 25 involved in that process, and that's what would happen in
1671 our organization. The coroner, as a judge, would be part 2 of that process and -- and that discussion, but would be 3 receiving the professional advice of a professional 4 pathologist as to the benefits of a particular team in 5 that situation. 6 It might involve three (3) doctors. It 7 might involve four (4) doctors. It might involve a 8 situation where one (1) of the experts says, Well I'm a 9 neuropathologist. I want to see this brain. It needs to 10 be fixed, or it needs to be retained, but I don't need to 11 be there when it is removed and fixed. I can come deal 12 with that in a weeks time or whatever. 13 And that may be the entirely appropriate 14 way to deal with it. So the principle really is the -- 15 is the establishment of the team, and the reason I think 16 a forensic pathologist is quite good at establishing that 17 team is again their familiarity with the exigencies of 18 the legal system, because there may be indeed civil legal 19 issues that might emerge out of the crises, as well as 20 criminal issues. 21 And there may be -- and I don't believe 22 forensic pathologist are any less able to deal with the - 23 - the grief and the follow up reactions, and -- and 24 information flow to families, as we deal with that all 25 the time routinely anyway.
1681 So I think that we are able to -- to bring 2 those things in. If a case was a complex medical issue 3 from a hospital involving a neurosurgical procedure on a 4 child, then we would be taking very, very strong advice 5 from our clinical colleagues as to the best way of doing 6 that, and we would be consulting with them. 7 MR. MARK SANDLER: Okay. Dr. Pollanen, 8 we take the scenario that I've presented, and we pose it 9 that it's taking place in Timmins. How does the analysis 10 change? 11 DR. MICHAEL POLLANEN: Well, currently 12 what happens is that we have regional forensic pathology 13 units that have geographical catchment. And all of the 14 decedents that are not within the direct catchment of 15 those units come to Toronto. 16 So if it's an adult, it will come to the 17 adult Toronto department. And if it's a child or an 18 infant, that case would go to the Sick Kids. 19 MR. MARK SANDLER: All right. And is 20 that the way it should be? 21 DR. MICHAEL POLLANEN: Again, I think 22 we're -- we're not really engaging the -- the geography 23 issue. We're -- we have to engage the content of the 24 case. 25 So, for example, if the -- if the
1691 parameters are still the same, undifferentiated in the 2 SIDS spectrum-type case, the same analysis applies. 3 MR. MARK SANDLER: Okay. Ottawa...? 4 DR. MICHAEL POLLANEN: Well, Ottawa 5 functions as a regional forensic pathology unit which is 6 augmented for its pediatric service using CHEO. In the 7 current structure, the case would be referred to CHEO 8 without very formal linkages to the Ottawa Forensic 9 Pathology Units. 10 That -- that would be the -- that's the 11 historical arrangement right now for the Ottawa area. 12 That -- that will change. 13 COMMISSIONER STEPHEN GOUDGE: I take it 14 there are fewer linkages, Dr. Pollanen, between CHEO and 15 the Ottawa Forensic Pathology Unit than there are between 16 the unit at HSC and your operation? 17 DR. MICHAEL POLLANEN: Correct. 18 COMMISSIONER STEPHEN GOUDGE: I mean, one 19 (1) of the things that was emphasized this morning, and I 20 guess I look to Dr. Chiasson and Dr. Taylor for this, is 21 the importance of an accumulated expertise that can 22 provide the working atmosphere that is important for 23 quality assurance. 24 Are there ways that there can be enhanced 25 actual interchanges between the pathologists at HSC and
1701 the Toronto morgue? 2 I mean, I am thinking, for example, one 3 (1) of the -- we heard a lot of evidence about how, in 4 the last decade, there was very little interaction 5 between the two (2) sort of silos, you know. 6 I mean, is it feasible to think of the 7 four (4) of you and your three (3) colleagues, apart from 8 Dr. Chiasson, who do this, Dr. Taylor, having more 9 interchange with Dr. Pollanen and his colleagues at 10 regular rounds or that sort of thing? 11 DR. GLENN TAYLOR: I -- that's certainly 12 possible, whether it's of value, in a sense, because the 13 focus of the cases that we do is on pediatric disease. 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. GLENN TAYLOR: The problem is 16 recognizing when things are outside of pediatric disease. 17 So there -- 18 COMMISSIONER STEPHEN GOUDGE: Exactly. 19 DR. GLENN TAYLOR: So there is definitely 20 some value in having that kind of training. 21 Another way of getting at it is to hire 22 somebody like Dr. Chiasson who is there to review the 23 cases and to help us to deal with the -- 24 COMMISSIONER STEPHEN GOUDGE: To 25 basically stream the cases.
1711 DR. GLENN TAYLOR: -- basically stream 2 the cases. 3 I think there needs to be ongoing training 4 and continuing medical education between the people that 5 are doing sudden unexpected death investigations at -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. GLENN TAYLOR: -- the pathology 8 level. 9 COMMISSIONER STEPHEN GOUDGE: I am not 10 thinking so much of you, Dr. Taylor, because you have had 11 obviously very considerable experience at doing cases 12 that have a forensic dimension. 13 I am thinking of the generation coming 14 behind you, you know, who come to a world-class hospital 15 that desperately needs hospital pathology and yet there 16 is this forensic component that requires or, at least, 17 profits from the atmospherics of a highly-skilled 18 forensic pathology operation. 19 DR. GLENN TAYLOR: Well, we do have 20 educational activities with regards to that with our 21 forensic pathology rounds that Dr. Pollanen and members 22 of the Office of the Chief Coroner do attend. So we have 23 it on our site and there are other opportunities through 24 Michael's initiatives with the Office of the Chief 25 Coroner for continuing education.
1721 So what it comes down to is having good, 2 continuing interaction -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. GLENN TAYLOR: -- and communication 5 between the two (2) geographically separate, but 6 hopefully of a similar mind, places. 7 COMMISSIONER STEPHEN GOUDGE: And 8 fortunately, they are not that far apart, geographically. 9 DR. GLENN TAYLOR: So that is another 10 issue. If they were further apart, that would come down 11 to some logistical -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. GLENN TAYLOR: -- and practical 14 issues. 15 COMMISSIONER STEPHEN GOUDGE: Right, 16 right. And, Dr. Chiasson, this is an unfair 17 question to ask of you. But is it essential for your 18 position to be filled by a forensic pathologist? 19 DR. DAVID CHIASSON: The Director's 20 position? I think that's the preferable way to -- to go. 21 I -- I think given that the nature of this Inquiry and 22 what we're looking at, it is a Pediatric Forensic 23 Pathology Unit, so I -- I think it's time to emphasis the 24 forensic. 25 I -- I -- as I see it, one (1) of the
1731 issues certainly was that the former Director was not a 2 forensic pathologist. And I mean, I -- I think to -- to 3 suggest that somehow we can go back to having a pediatric 4 pathologist Direct -- I -- I think the way to go is to 5 have a forensic pathologist. 6 And -- and to go back to your question in 7 terms of ties with the Toronto Unit, I -- I would -- I 8 would welcome and -- and -- you know, and I -- I know 9 there's resources issues, as I think you're aware, I -- I 10 do continue to do adult -- 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. DAVID CHIASSON: -- forensic work. 13 And I think it's important for any forensic pathologist 14 working in a pediatric forensic pathology environment to, 15 in fact, continue to do adult forensic pathology work. I 16 think it's complimentary. 17 I don't think you want to -- 18 professionally want to silo yourself off. That's not to 19 say that the pediat -- I -- I don't think the pediatric 20 for -- pathologists are going to benefit from doing 21 forensic adult work and I think that's asking -- 22 COMMISSIONER STEPHEN GOUDGE: What about 23 the pediatric pathologists who are doing forensic work in 24 the grey area? 25 DR. DAVID CHIASSON: Well, the grey area
1741 I think is -- is -- as long as it's monitored and -- and 2 there is an out from a forensic pathology point of view. 3 I thi -- I think ultimately the -- the pediatric pathol - 4 - there are going to be occasions where the pediatric 5 pathologist is going to get stuck, if you will, in a 6 forensic -- in a criminally involved case, but I -- I 7 think what we're trying to do is avoid that as best we 8 can. 9 It's not a perfect world. A case of SIDS 10 may turn out to be a case of smothering and there's no 11 way, no matter how you -- you monitor, you know, 12 investigative information, you're going to be able to -- 13 to pick that up. I think that's a reality, but I think 14 you're -- we're trying to avoid that as -- as much as we 15 can. 16 So, I would argue that what I would like 17 to see, and certainly from a staffing point of view, 18 currently, I do all -- if I -- if I'm on, I do pediatric 19 cases, medical cases, still births, whatever comes across 20 the board. 21 I -- I don't have the opportunity as much 22 as I wish sometimes to -- to divulge myself -- divest 23 myself of those cases to a pediatric pathologist. On the 24 other hand, the pediatric pathologist, and it's set up 25 this way, if they get a criminally suspicious case and
1751 they're uncomfortable or I -- I'm uncomfortable with them 2 doing it -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. DAVID CHIASSON: -- I will take that 5 on. What I would like is, in fact, more forensic 6 pathology support than -- than beyond what's provided by 7 Dr. Pollanen himself and -- and actually see the adult 8 Forensic Pathology Unit pathologist to be more involved 9 in doing pediatric cases. 10 DR. MICHAEL POLLANEN: Well, and that -- 11 that is certainly the vision because the -- one (1) of 12 the very obvious corollaries of the training program is 13 that you're not going to train up a generation of -- or 14 generations of forensic pathologists that don't know how 15 to do pediatric autopsies. 16 You're going to -- you're going to train 17 them to do everything. And one (1) of the -- one (1) of 18 the great interests of -- of forensic pathology actually 19 comes from pediatric forensic pathology. 20 Everybody I'm sure is very aware now that 21 this is a -- this is a fascinating subset of cases that 22 challenge us. 23 COMMISSIONER STEPHEN GOUDGE: All of 24 which are challenging. 25 DR. MICHAEL POLLANEN: Exactly. And so
1761 they're very professionally enriching. And I just want 2 to come to -- to a very important point that, you know, 3 cannot be overemphasized. 4 The last thing that we want to do in this 5 system right now is concentrate these highly challenging 6 cases on a very small group of people. One (1) of the 7 things that we need to do in the Province of Ontario is 8 build capacity around these challenging cases so we're 9 not concentrating all of the homicidal and criminally 10 suspicious infant deaths on one (1) or two pathologists. 11 We need to develop Provincial capacity to do that because 12 otherwise we will get into trouble. 13 And so our service provision and our 14 training programs need to be very much in tune to that. 15 16 CONTINUED BY MR. MARK SANDLER: 17 MR. MARK SANDLER: All right, that's 18 helpful. Dr. Ranson, you look like you're itching to say 19 something. 20 DR. DAVID RANSON: I -- I think it's 21 getting, and I don't want to be -- appear rude to my pani 22 -- fellow panellists, it's getting very complicated. 23 It's getting complicated because we have -- you know the 24 -- the range of possibilities in the case are huge and 25 the -- the team we need to build is diverse and variable.
1771 And you have two environments sitting 2 there. Some resources live in one (1) -- one (1) 3 environment. Some resources live in another 4 environment. And you're -- you have to shuffle and 5 choose the one (1), and then you have to develop policies 6 and guidelines for -- 7 And this is in a culture or an environment 8 in which very much it's based on the personalities, 9 again, and the skills of the particular people and the 10 particular job at the time. 11 And that, I think, could be a recipe for 12 future problems, rather than building a systematic 13 infrastructure which has that in one (1) place, which 14 allows for a much safer, long-term environment. 15 And that's not to say I'm denigrating the 16 skill sets or the importance and the -- the significance 17 of the players I've had. I -- I have -- very -- have a 18 very strong sympathy for Dr. Taylor's view, for example, 19 about having the pediatric autopsies in the Children's 20 Hospital to allow all the clinical staff in the hospital 21 to gain the benefit from seeing the pathology. 22 It's a very important way of educating and 23 maintaining medical education. But that can also be 24 dealt with within a -- a centralized unit and good 25 communication structures.
1781 It's not -- 2 MR. MARK SANDLER: Dr. Chiasson doesn't 3 look like he agrees. 4 DR. DAVID CHIASSON: Well, I -- I 5 disagree with this notion that -- that individuals who 6 are very busy at the Coroner's Office are going to come 7 over to the Hospital for Sick Children to present cases 8 in a -- in a setting which they're -- they're feeling 9 unfamiliar with. 10 And I know that in the adult world, we -- 11 we -- sir, I don't know if it's happened since then but 12 we -- we did not go to the hospitals to present what 13 sometimes were -- were -- were fascinating cases. 14 You -- you -- you find out very quickly as 15 you get within your comfort zone and largely, you stay 16 within your comfort zone because it's a question of time 17 and -- and, you know, what's your responsibility, where 18 your primary responsibilities are. 19 Unlike, in my situation, where I am an 20 employee of the hospital and if I started saying no, I 21 don't feel like going off to this M and M -- medical -- 22 morbidity and mortality round, or I don't want to do 23 this, the guy next to me is going to come down on me 24 very, very quickly. 25 So I think that you -- you know, this
1791 notion, I think, that somehow you can maintain all these 2 -- these wonderful liaisons with the -- the teaching 3 hospitals and particularly with -- with Sick Kids. From 4 working at the Coroner's Office, I think that's being a 5 bit idealistic. So that's my head nodding. 6 MR. MARK SANDLER: Well, talking about 7 liaisons, Dr. Pollanen, I mean, you conduct rounds at the 8 morgue. Who should participate in those rounds, other 9 than your own people? 10 For example, should the Sick Kid's 11 pathologists participate in those rounds? Should the 12 pathologists at the various regional Centres of 13 Excellence participate in those rounds? How can they 14 participate in the rounds? 15 DR. MICHAEL POLLANEN: I think you have 16 to accept as the -- as the starting point that we have a 17 geographically distributed service delivery system, and 18 that our -- our core values are collaboration, 19 reliability, quality, all of these things. 20 And then the challenge is how do we best 21 link everybody together. And there are straight-forward 22 technological solutions to that. And, you know, that's 23 telepathology where you -- where I -- I can see having a 24 -- a situation where we have all of the forensic 25 pathology units linked in the morning at 8:30 for a
1801 morning conference, where we talk about the cases that 2 are going to be autopsied that day across the province. 3 We need not get into all of the details in 4 every matter and, certainly, we can't -- not everybody 5 can walk around the mortuary with our group to see the 6 bodies for dissection that day, but we can talk about 7 issues. We can talk about how best to manage cases. I 8 mean, there are options, you know, reasonable options to 9 -- to engage people across -- across geography. 10 So I actually think that we just need to 11 think about how we're going to do it, once we've 12 committed to that ideal, and then implement it. 13 I think -- I think it's a great idea, 14 frankly, to -- to link in with the Hospital for Sick 15 Children in the morning and -- and if they have an 16 interesting case, discuss that, you know, across this 17 larger group. Or -- or, for example, if the -- if, in 18 the middle of the case, an unusual finding is 19 demonstrated, an unusual lesion or injury, and people are 20 perplexed and it can be disseminated on -- onto screens 21 throughout the entire province. 22 DR. DAVID RANSON: I should say, we 23 actually do that in Australia with the Australian capital 24 territory which is an entirely different province. 25 And we actually -- we actually run the
1811 service for clinical forensic medicine there, and on 2 regular morning meetings, we discuss cases, and they're 3 up on the screen, and we use that as a -- as a formal way 4 of getting opinions on both sides in relation to clinical 5 forensic medical case work. 6 So there's certainly no difficulty with 7 the technology. 8 COMMISSIONER STEPHEN GOUDGE: How 9 expensive is it, Dr. Ranson? 10 DR. DAVID RANSON: Sorry? 11 COMMISSIONER STEPHEN GOUDGE: How 12 expensive is it? 13 DR. DAVID RANSON: Well, the initial set- 14 up of that is expensive in the sense that it's no 15 different from any other video conferencing facility for 16 Court or witness delivery. It's very similar. 17 COMMISSIONER STEPHEN GOUDGE: I have no 18 idea what they're -- 19 DR. DAVID RANSON: I could -- a lot of 20 the -- it's not on my -- but I could certainly find out. 21 It's -- it's -- yeah -- 22 COMMISSIONER STEPHEN GOUDGE: I wanted -- 23 24 CONTINUED BY MR. MARK SANDLER: 25 MR. MARK SANDLER: The Commissioner
1821 wanted -- the Commissioner not only wants the answer, but 2 in Canadian dollars. 3 DR. DAVID RANSON: Yeah. 4 COMMISSIONER STEPHEN GOUDGE: Yeah. Do 5 you have anything like that in Georgia, Dr. Hanzlick? Do 6 you link your regional centres that we were speaking 7 about earlier? 8 DR. RANDY HANZLICK: Well, remember I 9 don't work in those regional centres. 10 COMMISSIONER STEPHEN GOUDGE: Yeah, but 11 you have full-time forensic pathologists there. 12 DR. RANDY HANZLICK: Yeah, and we have 13 the morning meeting, and we go over the cases, and we 14 have the rounds -- 15 COMMISSIONER STEPHEN GOUDGE: That 16 involve them as well, the -- 17 DR. RANDY HANZLICK: No, no. Just our 18 office in Fulton. 19 COMMISSIONER STEPHEN GOUDGE: Yeah. 20 DR. RANDY HANZLICK: They have their own 21 individual rounds in those branch offices at the GBI, but 22 they do -- they do use computers quite often because of 23 digital images and histology slides -- 24 COMMISSIONER STEPHEN GOUDGE: To send 25 slides back and forth --
1831 DR. RANDY HANZLICK: -- can send an email 2 to one of their colleagues across the state and say, Hey, 3 look at this, and let me know what you think. 4 It's almost the same thing. There's -- in 5 many instances, there's no reason why that has to be 6 live. 7 COMMISSIONER STEPHEN GOUDGE: Yes. 8 DR. RANDY HANZLICK: You can work off of 9 digital images. 10 COMMISSIONER STEPHEN GOUDGE: The notion 11 of rounds are live, I take it -- 12 DR. RANDY HANZLICK: Yeah. 13 COMMISSIONER STEPHEN GOUDGE: -- but the 14 histology, for example -- 15 DR. RANDY HANZLICK: Yeah. 16 COMMISSIONER STEPHEN GOUDGE: -- can be 17 done digitally quite easily. 18 DR. RANDY HANZLICK: Yeah. You find 19 something weird in a heart, you take a picture of it, and 20 shoot it off to the pediatric pathologist -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. RANDY HANZLICK: -- and say, Hey, 23 what's this. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 Right.
1841 DR. MICHAEL POLLANEN: Now we have 2 colleagues, for example in Santiago that send us 3 interesting cases to -- to look at. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. MICHAEL POLLANEN: I mean, we're -- 6 we're all sort of digitally linked all over the world. 7 There's no reason why we can't be digitally linked within 8 the Province. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. RANDY HANZLICK: And you're going to 11 have to be, if -- if the thirty (30) year old morgue is 12 going to move further away from the pediatric centre. 13 You're going to have to do that just to 14 communicate there. 15 DR. MICHAEL POLLANEN: Yes. 16 DR. DAVID RANSON: Just to follow up one 17 (1) quick issue that -- that David mentioned in relation 18 to, you know, the facilities and also the time for people 19 to go over to places. 20 I mean, at the end there, that comes 21 simply back to the resourcing level that you've put into 22 your primary forensic pathology service. 23 Now it -- it's a simple question of the -- 24 the cost of the infrastructure, finding the people. If 25 you had a team here of twelve (12) forensic pathologists,
1851 and the capacity, with your own CT scanner, and your own 2 mortry (phonetic), and your MRI scanner and your 3 microbiology lab around the corner, and so on, the actual 4 interface there would not to difficult to -- to create. 5 So it depends what your underlying policy 6 consideration that defines what is best practice, and 7 then it's looking at the resources. If those resources 8 aren't there, then you have to move to a different 9 modality to think about how you're going to implement 10 that policy. 11 But one (1) of the issues you've always 12 got in this environment to say is this is what we have 13 now. What should we have to meet the underlying policy 14 based issue which is best people doing the best job with 15 the best resources, in -- in the best environmental 16 structure. 17 COMMISSIONER STEPHEN GOUDGE: Dr. 18 Chiasson, from the perspective of your Unit, what's your 19 reaction to a teleconference link with the Toronto morgue 20 for morning rounds of forensic cases being done that day 21 in both places? 22 DR. DAVID CHIASSON: I -- I would welcome 23 that -- that type of initiative, realizing that at the 24 Hospital for Sick Children, in terms of coroners cases, 25 we average three (3) to four (4) a week --
1861 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID CHIASSON: -- so we're not 3 talking every day we're going to have a case, but 4 certainly -- 5 COMMISSIONER STEPHEN GOUDGE: No, you may 6 not be talking every day, but you might be listening 7 every day, and every third day you might be talking. 8 DR. DAVID CHIASSON: Yes, or as it turns 9 out -- I mean, I -- I attend morning rounds those days 10 where I happen to be working at the Coroners Office as -- 11 as part of my -- my other job there. 12 And, so I'm very familiar with the rounds, 13 and if -- 14 COMMISSIONER STEPHEN GOUDGE: Yes. 15 DR. DAVID CHIASSON: -- it was available 16 to -- to do it on a telecommunication modality -- 17 COMMISSIONER STEPHEN GOUDGE: As the 18 person responsible for the department, Dr. Taylor, what 19 is your sense of those involved -- you and your 20 colleagues -- participating in that -- the three (3) or 21 four (4) of your colleagues who actually do cases under 22 warrant? 23 DR. GLENN TAYLOR: Well, it comes down to 24 interest and sort of your experience, and -- 25 COMMISSIONER STEPHEN GOUDGE: And time.
1871 DR. GLENN TAYLOR: -- and time, because 2 we have a lot of rounds at Sick Kids that -- 3 COMMISSIONER STEPHEN GOUDGE: And 4 pressures of hospital work. I mean that is -- 5 DR. GLENN TAYLOR: Yeah. 6 COMMISSIONER STEPHEN GOUDGE: -- one (1) 7 of the tensions, that -- 8 DR. GLENN TAYLOR: So if there are cases 9 that -- that Michael was doing of a child death, and 10 they're interesting findings, and we knew about it, then 11 it would be very worthwhile for the -- the three (3) of 12 us to -- four (4) of us, with David, to see those rounds. 13 And I would have no problem with discussing the cases 14 that we are doing for the day with Michael and his -- his 15 team over there. 16 That wouldn't necessarily be a long period 17 of time; it would maybe be ten (10) minutes or fifteen 18 (15) minutes -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. GLENN TAYLOR: -- perhaps. And it 21 might be very valuable to be able to do that on a regular 22 basis. 23 And we try to do some of that now with 24 kind of pre -- pre-alerting Michael if there's a 25 difficult case coming through or something like that.
1881 But it might be -- with a -- with the 2 setup, spend five (5) or ten (10) minutes before we start 3 a case just to discuss it with -- with the home unit, it 4 would be worthwhile for us. 5 COMMISSIONER STEPHEN GOUDGE: Thanks. 6 7 CONTINUED BY MR. MARK SANDLER: 8 MR. MARK SANDLER: Dr. Pollanen, back to 9 you. And there's undoubtedly, and I suspect I know what 10 it is, an obvious answer to the question, but I'll pose 11 it nonetheless. 12 We've heard a position very eloquently 13 advocated for preserving the Ontario Pediatric Forensic 14 Pathology Unit, but there's certainly a lack of symmetry 15 between that approach in Toronto than the approach taken, 16 for example, in Hamilton on London or elsewhere. 17 Can you justify the lack of symmetry 18 between what's being advocated for in Toronto and what 19 exists elsewhere? 20 DR. MICHAEL POLLANEN: On first glance it 21 appears incompatible, doesn't it? Because what we're 22 saying is that we should offer this type of service in -- 23 through the Sick Children's Hospital, but in all other 24 circumstances across the Province we're going to go back 25 to the -- to the usual sort of adult service provision
1891 model. 2 But it's actually not as simple as that. 3 The first consideration is if you're trying to deliver a 4 quality service and you have a resources that's -- that's 5 available for you to utilize you should utilize it. And 6 that's -- and that's what we have in the Hospital for 7 Sick Children. 8 So, I mean, I think that to say, you know, 9 to preserve symmetry across the Province all infants and 10 children should be brought to the Toronto facility 11 because that's the way it's done everywhere else in the 12 Province is just a lost opportunity to -- to engage 13 people like Dr. Taylor in -- in these cases. 14 The second reality is that in -- in the 15 Forensic Pathology Units that are in the regions, all of 16 them are based in academic teaching hospitals, so they 17 have certain infrastructure that's delivered not because 18 they're Forensic Pathology Units but because they're co- 19 localized with academic health science centres. 20 And this raises the rather bizarre 21 paradox, as I've indicated before, of the fact that the 22 only unit that exists in our system without such a link 23 currently -- 24 COMMISSIONER STEPHEN GOUDGE: Head 25 office?
1901 DR. MICHAEL POLLANEN: -- is Head office, 2 which is -- which is a perplexing historical nuance. But 3 in any event -- but that's the truth. 4 So, in a way one could sort of turn it 5 around and say, How could we make the Toronto department 6 more like everywhere else in the Province? 7 In other words, how could we harness the 8 good things that are happening in the Units in our 9 department and -- and, at the same time, maximize the 10 contribution that our department can made because of its 11 critical mass of forensic pathologists and our forensic 12 framework, et cetera. That's the challenge. 13 MR. MARK SANDLER: Okay. On that note, 14 Commissioner, I see it's time for the afternoon break. 15 COMMISSIONER STEPHEN GOUDGE: Okay. We 16 will take fifteen (15) minutes now and we may ask the 17 four (4) -- five (5) of you to stay five (5) or ten (10) 18 minutes beyond the advertised quitting time, since we 19 started a little late. Thanks. 20 21 --- Upon recessing at 2:45 p.m. 22 --- Upon resuming at 3:09 p.m. 23 24 THE REGISTRAR: All rise. Please be 25 seated.
1911 2 CONTINUED BY MR. MARK SANDLER: 3 MR. MARK SANDLER: Dr. Pollanen, just -- 4 just one (1) point where we left off, and what I hear you 5 saying is that you wouldn't adverse to a recommendation 6 that -- that telecommunications facility be enhanced as 7 between home office, so to speak, and your various units 8 not only at the Hospital for Sick Children, but in the -- 9 in the centres of excellence across the Province. 10 am I right? 11 DR. MICHAEL POLLANEN: Yes. 12 MR. MARK SANDLER: And help me out as to 13 this. I mean, are we talking about a major expenditure 14 in order for that to take place? 15 DR. MICHAEL POLLANEN: Well, it would be 16 a moderate expenditure. You have to recognise, as I've 17 indicated, that all of the forensic pathology units are 18 situated in teaching hospitals which are already linked 19 into this technology, so it may simply require 20 augmentation and -- and hooking into preexisting nodes 21 within a hospital. 22 So it's probably not a massive initial 23 outlay to pro -- to produce a system that doesn't exist 24 at all; it's probably something that can be piggybacked 25 on a orig -- on a preexisting system.
1921 MR. MARK SANDLER: Okay. And I'm going 2 to stay with you for a moment because we -- we've been 3 provided with a document entitled "The future of Forensic 4 Pathology Services in Ontario", and as I understand it, 5 there's a joint coroner and pathologist working group on 6 the provision of Forensic Pathology Services in Ontario 7 that -- that have been working towards a model for -- for 8 the delivery of those services. 9 Dr. Pollanen, could you outline for -- for 10 the Commissioner what consensus, if any, has been reached 11 by that working group? 12 DR. MICHAEL POLLANEN: Yes. This is 13 actually in a document at Tab 7 of today's -- this 14 afternoon's binder and the -- I'll just give you some 15 sort of background to the genesis of this document. 16 And the point of departure was -- was 17 recognising that there is a shared interest in the 18 coronial side of death investigation and the provision of 19 Forensic Pathology Services, such that we needed to have 20 a joint visioning process for the future. 21 so a group was constructed, a working 22 party, that included senior forensic pathologists, as 23 well as senior coroners from across the Province, to get 24 together and really define what -- define those things 25 that should characterise the future of Forensic Pathology
1931 Services in Ontario. 2 Now, this -- we met over two (2) separate 3 days to workshop various points and this was derived from 4 a document that I originally produced, sort of a scaffold 5 of -- a starting point. 6 And I think the -- the shared view or the 7 common ground that forms the underpinnings of the 8 document is that Forensic Pathology Services in the 9 Province need to be modernised, and that requires a re- 10 visioning and a reorganisation of Forensic Pathology 11 Services in a rather fundamental way. 12 So, this is not tinkering at the edges, 13 this is fundamental structural change within the system 14 to increase reliability and quality of forensic pathology 15 results to all members -- all consumers of our product, 16 as it were, which include not only the coroner, but also 17 the criminal justice system, the child welfare system, 18 the insurance sector, the Civil Courts, and I can go on. 19 so that's -- that was sort of the starting point. 20 And also, the recognition that forensic 21 pathology is a discipline of medicine that is practised 22 by forensic pathologists that are specially trained 23 medical practitioners who are in the best position to 24 provide direction, supervision, priority, selection and 25 administration of forensic pathology services.
1941 And this is a -- this is a departure from 2 the classical model that derives from the Act, the 3 present Act, where essentially the coronial system is 4 responsible and ultimately accountable for forensic 5 pathology services. 6 So just to give you an example of that, 7 I'm the Chief Forensic Pathologist, I have no budget, I 8 have no authority, the Chief Coroner is ultimately 9 responsible for all decisions made about forensic 10 pathology and my interaction in the system is to give 11 advice on those matters, as opposed to make term -- 12 determinative decisions. 13 And so we've now realized as a -- as an 14 agency that forensic pathology needs to be in a more 15 primary position to make decisions and be accountable for 16 those decisions within the system. 17 So the document goes on to describe 18 essentially the early parts of a strategic planning 19 process, including a mission and our values and what sort 20 of goals we -- we have visioned in this new forensic 21 pathology service. But perhaps what I'll do is I'll just 22 go directly to the eight (8) points that came out of 23 committee discussion. 24 And these eight (8) points are under three 25 (3) major categories. The first is direction, which
1951 includes oversight. The second is resources and the 2 third is education. 3 So if we start with direction. It was 4 generally agreed by the -- by the group that in the 5 medical coroner's system and forensic pathology service 6 that we currently have in the Province, we have two (2) 7 different types of physicians. 8 We have on the one (1) end of the 9 spectrum, coroners, who are medical doctors and have -- 10 and bring with their experience and qualifications 11 something very positive to the system of death 12 investigation. 13 And these practitioners essentially deal 14 with the twenty-two thousand (22,000) death 15 investigations that occur in the Province. But seven 16 thousand (7,000) of those cases will go to post-mortem 17 examination and therefore engage the forensic pathology 18 apparatus. 19 And those services are provided by another 20 type of doctor called a pathologist or a forensic 21 pathologist in specific circumstances, and that the 22 provision of those services are in the gam -- in the 23 ambit of the forensic pathologist. And that while we 24 have these two (2) different types of physicians, there 25 has not been a recognition within our system of how their
1961 roles and responsibilities, duties and accountabilities 2 cleave along their lines of -- of expertise. 3 So the -- the first issue that was 4 identified by the group, was that there needed to be some 5 type of symmetry in the Act, in the Coroners Act, 6 recognizing a hierarchical structure for forensic 7 pathology that mirrors that of the coroner's system. 8 So in other words, we have a Chief Coroner 9 who supervises, directs and controls coronial death 10 investigation, the Coroner has Deputy Chief Coroners and 11 Regional Coroners, and then we have therefore a built-in 12 statutory hierarchical structure and the wisdom of the 13 group was that that should be mirrored on the forensic 14 pathology side. 15 COMMISSIONER STEPHEN GOUDGE: So it 16 should include the duties of the Chief Forensic 17 Pathologist? 18 DR. MICHAEL POLLANEN: Yes. And the 19 duties -- 20 COMMISSIONER STEPHEN GOUDGE: The one (1) 21 example you give is conduct programs for the instruction 22 of pathologists in their duties. I suspect there's a 23 good deal more to the description of duties than that. 24 DR. MICHAEL POLLANEN: Yes, yes. And -- 25 and the major duty of the Chief Forensic Pathologist
1971 would be to organize, create point number 2, which is a 2 new structure, a new concept, which is the Ontario 3 Forensic Pathology Service, in which the Chief Forensic 4 Pathologist and the -- and the hierarchy of forensic 5 pathologists that would be defined in the Act by Order in 6 Council in -- in parallel to the cor -- coroners side, 7 this would be a -- a service. 8 And the service would be mandated to 9 provide forensic autopsies for the coroner, and the other 10 relevant stakeholders that access the services of 11 forensic pathology through our system. 12 COMMISSIONER STEPHEN GOUDGE: Did the 13 group engage in any detailed discussions, Dr. Pollanen, 14 about the range of duties that might be prescribed if one 15 were to put a definition in the Act? 16 DR. MICHAEL POLLANEN: Well, the major 17 duties would be centred, of course, around the post- 18 mortem examination and -- but there was no further 19 detailed discussion about what additional duties would 20 occur, for example, outside of the post-mortem. 21 COMMISSIONER STEPHEN GOUDGE: 22 Supervision, for example. What kind of line authority 23 the Chief Forensic Pathologist might have over forensic 24 pathologists employed by hospitals, not the Office of the 25 Chief Coroner of Ontario. That kind of thing?
1981 DR. MICHAEL POLLANEN: Yes. Well being -- 2 COMMISSIONER STEPHEN GOUDGE: I mean, I 3 do not want to get into any of that. 4 DR. MICHAEL POLLANEN: Right. 5 COMMISSIONER STEPHEN GOUDGE: All I am 6 saying is that if one talks about mirror images, the 7 Coroners Act provides for a list of duties that go with 8 the Office of the Chief Coroner. 9 DR. MICHAEL POLLANEN: Correct, and that 10 -- and those duties -- 11 COMMISSIONER STEPHEN GOUDGE: And I -- 12 DR. MICHAEL POLLANEN: -- would be 13 mirrored in analogy. 14 COMMISSIONER STEPHEN GOUDGE: We would 15 have to figure out what they were? 16 DR. MICHAEL POLLANEN: Yes. 17 COMMISSIONER STEPHEN GOUDGE: Yes. 18 DR. MICHAEL POLLANEN: And -- and I 19 should just point out by saying that, you know, this is a 20 skeleton framework document -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. MICHAEL POLLANEN: -- that will be 23 more fully developed at some later time, but -- 24 COMMISSIONER STEPHEN GOUDGE: Thanks. 25 DR. MICHAEL POLLANEN: -- but the --
1991 MR. MARK SANDLER: How much later? 2 DR. MICHAEL POLLANEN: -- but the point - 3 - the point of the matter here was to develop a common 4 framework upon which to -- to go forward. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. MICHAEL POLLANEN: So the type of 7 detail that you're talking about will be dev -- delivered 8 in the submissions of our organization. 9 COMMISSIONER STEPHEN GOUDGE: Yes, I mean 10 they -- that's implicit in the dialogue you and I are 11 having. 12 I mean, obviously this is something that 13 if one moves forward with it, one would have to give 14 serious consideration to, and they are not easy 15 questions. 16 DR. MICHAEL POLLANEN: Yes. The -- the 17 char -- the system would be characterized though in -- in 18 rough sketch by certain features. 19 For example, it's very important to have 20 what we've termed a Forensic Pathology Advisory 21 Committee, which would not so much be a governance 22 structure, but would be a coalition of forensic 23 pathologists in the regional forensic pathology units 24 that would come together as a professional body to, you 25 know, produce the -- the quality processes, the peer
2001 review processes, everything that would characterize the 2 quality of the system. 3 This also, in my view, would include some 4 of the relevant stakeholders, recognizing that the 5 autopsy replot -- report flows to different people. 6 We've been very focussed historically on the autopsy 7 report flowing to the coroner, who's an extremely 8 important recipient of the autopsy report, but not the 9 only recipient. 10 For example, the criminal justice system 11 has very considerable interests in -- in the nature of 12 the autopsy report and the duties of the pathologist. 13 14 CONTINUED BY MR. MARK SANDLER: 15 MR. MARK SANDLER: What does that -- just 16 stopping there for a me -- for a moment. What does that 17 mean, the development of an Ontario Forensic Pathology 18 Service? 19 Is that a statutory service? 20 DR. MICHAEL POLLANEN: Well, the wisdom 21 of the group was that the service would be created out of 22 the appointments. So in other words, that the -- the 23 Chief Forensic Pathologist, the Deputy Chief Forensic 24 Pathologist would be defined in statute by 0rder in 25 Council, as it were, and then create the Ontario Forensic
2011 Pathology Service really as a matter of -- through 2 policy, and administration. 3 MR. MARK SANDLER: Let me just -- let me 4 just stop you there for a moment. Dr. Ranson -- 5 DR. DAVID RANSON: I have a -- 6 MR. MARK SANDLER: -- what do you say 7 about that? 8 DR. DAVID RANSON: -- I have a concern 9 about the -- simply the defining of the positions within 10 the legislation. 11 There is a -- and this is in fact almost a 12 -- a pragmatic issue of government, and policy, and 13 funding arrangements. Once you establish the positions, 14 the money is provided for a position because that is 15 provide -- the position is being created in legislation. 16 However, a position is in effect -- in 17 essentially ineffective without the resources to allow to 18 do those thing. I would be arguing that if you created 19 the network, or the service, as an organization, as a 20 corporate entity, you could certainly define the leader 21 of that corporate entity, and you gave that entity the 22 responsibility, and the charge for providing the service, 23 providing the education, maintenance of continuity of 24 service, all those things that will be part of any 25 operational business, whether it be government business,
2021 whole of government business, or whether it be a private 2 corporation. 3 You enshrine that in the legislation and, 4 therefore, the legislators and government effectively 5 need to provide the resources for that entire service for 6 which the employed chief or whatever is -- is -- is part 7 of it. That, I suppose -- and in a sense I'm making sure 8 the legislators aren't let off the hook in providing the 9 necessary resources for ensuring that a full service is, 10 in effect, implemented. 11 Now whether that is part of the Coroners 12 Act as it is in Victoria, that -- that establishment of 13 the organization, the -- the institute, or whether it is 14 structured as a statutory authority by some other 15 enabling legislation, I think is -- is a moot point. 16 There has been some argument in Victoria 17 that the reform of the current Coroners Act should 18 effectively mean that the Act should be split and there 19 should be a separate legislation for the institute in 20 relation to its broader services, because we provide 21 services not just for the coroner but for a wide variety 22 of other agencies: clinical services for the police, a 23 variety of services for transport organizations, 24 licencing authorities, and so on. 25 And so by setting that -- that -- that
2031 structure that way, I think you -- you have a greater 2 likelihood that, in the future, appropriate resources 3 will be put in place to maintain the service. 4 MR. MARK SANDLER: Okay. Everybody else 5 want to weigh in on that issue? All right. 6 Dr. Pollanen -- 7 DR. MICHAEL POLLANEN: One (1) of the -- 8 MR. MARK SANDLER: -- carry on, if you 9 would. 10 DR. MICHAEL POLLANEN: One (1) of the 11 very, very important features of the Ontario Forensic 12 Pathology Service in the way that we've described it 13 would be to create a registry of pathologists. 14 And that would entail a mechanism of 15 identifying pathologists that would be credentialed by 16 the Forensic Pathology Service to perform certain types 17 of post-mortem examinations. That would necessarily 18 include with it a mechanism to reappoint people, based 19 upon criteria such as continuing medical education, 20 involvement in a peer review process of courtroom 21 testimony monitoring; would also involve participating in 22 the peer review of others in -- in the autopsy reports; 23 and would also necessarily include mechanisms which would 24 -- would amount to a disciplinary tribunal to remove 25 people from the register, as opposed to this being a
2041 unilateral act made by an administrator or the chief 2 forensic pathologist, there would actually be a process 3 engaged and this would be similar in model to that of the 4 home office list. 5 MR. MARK SANDLER: Now just -- now just 6 stopping there for a moment, would one have to be an 7 accredited forensic pathologist to make it onto the list? 8 DR. MICHAEL POLLANEN: Well, I think the 9 -- the first point is that we would have to define a 10 relevant membership on the -- on the steering committee 11 of the registry and then decide what constituted the 12 qualifications to be on the list. But most obviously, 13 being a qualified forensic pathologist would be 14 necessary. 15 COMMISSIONER STEPHEN GOUDGE: Do I 16 understand this registry to contemplate the service 17 provision of all autopsies done under warrant? Is that - 18 - is that what I read in doing medicolegal autopsies? 19 DR. MICHAEL POLLANEN: Yes. So, for 20 example -- 21 COMMISSIONER STEPHEN GOUDGE: So there'd 22 at least be a transition period in which qualification as 23 a forensic pathologist would be impossible? 24 DR. MICHAEL POLLANEN: Well, I mean, 25 again, the -- the --
2051 COMMISSIONER STEPHEN GOUDGE: Just to get 2 the work done. 3 DR. MICHAEL POLLANEN: To envisage the -- 4 the scenario where we have fee-for-service community 5 hospital pathologists providing routine coronial work, 6 autopsy work, I think that would continue. These people 7 would be on the register to do those types of cases, but 8 not streamed onto the register to do homicide and 9 criminally suspicious cases. 10 COMMISSIONER STEPHEN GOUDGE: So you have 11 categories within the registry? 12 DR. MICHAEL POLLANEN: Correct, yes. 13 14 CONTINUED BY MR. MARK SANDLER: 15 MR. MARK SANDLER: Because, again -- I 16 mean, the reason I asked you about forensic pathologists 17 is going back to Dr. Taylor. I mean, there -- what I'm 18 hearing is that there's an important role for the 19 pediatric pathologist to be performing in connection with 20 a number of these autopsies. 21 DR. MICHAEL POLLANEN: Well, I -- 22 MR. MARK SANDLER: So one wouldn't want 23 to disqualify a pediatric pathologist, would one, from 24 doing any of the medicolegal autopsies that would be 25 contemplated by the service?
2061 DR. MICHAEL POLLANEN: Well, I think when 2 you -- when you start actually looking at the whole 3 concept of a list, the type of people who would be on 4 such a list in different categories multiplies. Because 5 in addition to forensic pathologists we're now talking 6 about community hospital pathologists doing routine 7 coroner's autopsies, we're talking about pediatric 8 pathologists, and possibly other consultants. 9 So, I mean, now, clearly there has to be 10 some finality in terms of who gets on a list and -- et 11 cetera, but the most important part of this is that this 12 is a way of ensuring credibility of those people 13 performing medicolegal autopsies. And it would provide a 14 mechanism of the Ontario Forensic Pathology Service to -- 15 in a transparent way, identify those people who will be 16 sequentially reappointed and re-accredited to do 17 medicolegal autopsy work. 18 So in addition, for example, to -- to 19 having your primary certification as a forensic 20 pathologist, there would be a way of ensuring that 21 individuals who are doing cases and going to court meet 22 some minimal professional standard. 23 And it would also have the advantage of 24 when you are in a circumstance where there is suboptimal 25 performance or an error correction mechanism needs to be
2071 invoked in a particular case, that there is a 2 destination, a transparent destination, within the system 3 to deal with the issue as opposed to it being dealt with 4 in an ad hoc manner. 5 COMMISSIONER STEPHEN GOUDGE: How many 6 categories would you contemplate the registry having? 7 DR. MICHAEL POLLANEN: Minimally three 8 (3). 9 COMMISSIONER STEPHEN GOUDGE: Criminally 10 suspicious. 11 DR. MICHAEL POLLANEN: Pediatric -- 12 COMMISSIONER STEPHEN GOUDGE: Pediatric. 13 DR. MICHAEL POLLANEN: -- and routine. 14 COMMISSIONER STEPHEN GOUDGE: Does Dr. 15 Taylor get on to the criminally suspicious? 16 DR. GLENN TAYLOR: No. 17 DR. MICHAEL POLLANEN: I think you would 18 -- that -- that raises another very interesting element. 19 COMMISSIONER STEPHEN GOUDGE: I mean, 20 there are line drawing questions -- 21 DR. MICHAEL POLLANEN: Yes. 22 COMMISSIONER STEPHEN GOUDGE: -- that any 23 division produces, Dr. Pollanen. 24 DR. MICHAEL POLLANEN: That's true and 25 we've seen an example of self-selection. So it's not a
2081 matter of imposing -- necessarily imposing specific 2 criteria, it's also volunteering for the task. 3 So anyway, this is one (1) of the 4 characteristic features of the Ontario Forensic Pathology 5 Service. This would -- this would ensure a level of 6 accountability to service provision and transparency on 7 that point. 8 9 CONTINUED BY MR. MARK SANDLER: 10 MR. MARK SANDLER: I'm just wondering, 11 Dr. Pollanen, because I -- I know our time is limited, if 12 you could buzz through fairly quickly the other points 13 and then I'm going to direct some questions to your 14 fellow panellists. 15 DR. MICHAEL POLLANEN: So the other 16 issues are currently forensic pathology services do not 17 have a discreet budge; and in fact there's no funding 18 model beyond paying the bills of a -- of a fee-for- 19 service allocation. So there needs to be some rational 20 thinking about how to develop a budget. 21 We've already talked about equality of 22 salaries as being a very important issues, because those 23 are barriers to recruitment and retention in the, as it 24 were, government forensic pathology service. 25 We need to develop -- and I've talked
2091 about this on previous occasions -- a hierarchical career 2 structure within the forensic pathology service so there 3 is -- like in a hospital practice, there is a place to 4 enter and a place to go, as opposed to the career path 5 being very flat. And therefore, with those -- those 6 opportunities, people will develop through the career 7 path as forensic pathologist. 8 COMMISSIONER STEPHEN GOUDGE: That would 9 be through the Regional Pathology Unit? 10 DR. MICHAEL POLLANEN: It could be 11 through, as I say, the entire Ontario Forensic Pathology 12 Service. 13 So, for example, one (1) of the -- one (1) 14 of the, I think, quite reasonable models that flows from 15 this is having two (2) Deputy Chief Forensic 16 Pathologists: one (1) appointed in Toronto, assisting 17 the Chief Forensic Pathologist in Toronto, and another 18 Deputy Chief Forensic Pathologist situated in a Regional 19 Forensic Pathology Unit. 20 COMMISSIONER STEPHEN GOUDGE: What other 21 steps on the ladder would you conceive of below that? 22 DR. MICHAEL POLLANEN: Directors. 23 COMMISSIONER STEPHEN GOUDGE: Of the 24 Regional Unit? 25 DR. MICHAEL POLLANEN: Yes. And then
2101 staff pathologists. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. MICHAEL POLLANEN: So you'd have a 4 gradation of career path of seniority through the system. 5 COMMISSIONER STEPHEN GOUDGE: Right. And 6 the staff pathologists could be FTEs in a way? 7 DR. MICHAEL POLLANEN: Correct. And of 8 course, not forget the fellows. fellows -- 9 COMMISSIONER STEPHEN GOUDGE: Yes. 10 DR. MICHAEL POLLANEN: -- staff 11 pathologists -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. MICHAEL POLLANEN: -- directors, 14 Deputy Chief, Chief. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. MICHAEL POLLANEN: Essentially 17 mirroring every other structure in medicine. I mean, 18 this is not something unique. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. MICHAEL POLLANEN: And then we would 21 have -- I talked about modernization of facilities. That 22 goes not only for our facility but also the Regional 23 Forensic Pathology Units, which are currently funded by 24 the Ministry of Health, not our Ministry, and therefore 25 their facilities -- management facilities -- upkeep is
2111 provided for by the Ministry of Health, but if we're 2 really going to provide a coordinated service, we need to 3 think about how we are providing for physical plant and 4 modifications to physical plant. 5 COMMISSIONER STEPHEN GOUDGE: Is that 6 feasible within the hospital setting? 7 DR. MICHAEL POLLANEN: I don't know. I 8 mean, I think that's something that needs to be explored. 9 We have identified that the Regional Forensic Pathology 10 Units, many of them could benefit from upgrade. 11 And -- and exactly how in the machinery of 12 government we do that, whether it's through the Ministry 13 of Health portfolio or through our Ministry, it needs to 14 be explored. 15 COMMISSIONER STEPHEN GOUDGE: All right. 16 DR. MICHAEL POLLANEN: We need to -- on 17 the education front -- we need to improve professional 18 development programs, and I'm talking specifically about 19 continuing medical education, and finally, and this is a 20 recurring theme and I -- and I feel very strongly about 21 this, the only way that we are going to produce a 22 sustainable work force domestically is by training our 23 own forensic pathologists, so we need to have a mechanism 24 within the Ontario Forensic Pathology Service that 25 guarantees a certain number of training positions.
2121 2 CONTINUED BY MR. MARK SANDLER: 3 MR. MARK SANDLER: Okay. Do any of the 4 panellists want to comment upon what Dr. Pollanen has 5 presented before I move to the next topic on -- on the 6 agenda, any comments up and down the panel? 7 Dr. Hanzlick...? 8 DR. RANDY HANZLICK: I would just say 9 that the list of things that I've personally put together 10 that I thought might help the Province corresponds almost 11 exactly to what's in his plan; of which I did before I 12 even knew there was a plan. 13 So, I think -- I think it means that 14 people looking from the outside maybe see the same thing 15 as the people looking from the inside. 16 DR. DAVID RANSON: And I would -- I would 17 agree with that. The only structural issues I would have 18 is found the service in an organizational framework which 19 allows for the service to determine some of those 20 internal structures rather than trying to bind them down 21 through ministerial or health department type employment 22 structures. 23 You don't know in the future how Regional 24 issues will change, how manpower shifts or moves, and if 25 you have the ability to, within your institutional
2131 structure that you wanted the job being of the Chief 2 Forensic Pathologist, to determine, Well, I'm going to 3 have it by having a deputy here or here. 4 But that might be different in five (5) 5 years time, and it might be that the career structure, 6 we've got a blockage of personnel of a particular age. 7 We need to reinvigorate the structure to give people a 8 chance to grow and develop their professionalism. 9 You need to do that as a part of business 10 planning of an organization, and I think you need that 11 flexibility within your institute structured and not have 12 that too bound down in some legislative framework. 13 COMMISSIONER STEPHEN GOUDGE: One (1) of 14 the characteristics that Dr. Pollanen spoke of that might 15 go with a registry is some mechanism -- an arm's-length 16 mechanism -- for removal or qualification of somebody 17 who's on the registry about whom concerns have been 18 raised somehow or other. 19 Do you have that in Victoria, and do you 20 have that in Georgia, either of you? 21 DR. RANDY HANZLICK: We -- what we have 22 in Georgia is that although in the counties that have the 23 County Medical Examiner System, they're appointed by the 24 County Board. They are supposed to be also given a 25 certificate to work by the state crime lab system, so
2141 they basically authorize you to work in the state, and 2 there is a review, and they've had that -- used this 3 where they've had to take people out of service and 4 that's done -- 5 COMMISSIONER STEPHEN GOUDGE: Is there an 6 arm's length component to that review mechanism, Dr. 7 Hanzlick? How does it work? 8 DR. RANDY HANZLICK: In Georgia, it's -- 9 it's not real formal. It would just be when -- when an 10 incident occurred, it would reviewed and somebody's 11 certificate could be revoked to work as a County Medical 12 Examiner, or a Regional Medical Examiner, or a State 13 Medical Examiner even. 14 COMMISSIONER STEPHEN GOUDGE: Right. And 15 has that been satisfactory? 16 DR. RANDY HANZLICK: So far, yeah. 17 COMMISSIONER STEPHEN GOUDGE: Dr. Ranson, 18 what happens in Victoria? I'm sure -- 19 DR. DAVID RANSON: It's -- it's a 20 little -- 21 COMMISSIONER STEPHEN GOUDGE: -- you may 22 not have any complaints in Victoria. 23 DR. DAVID RANSON: Oh, we -- that -- 24 that's never the case in any organization -- 25 COMMISSIONER STEPHEN GOUDGE: Yes.
2151 DR. DAVID RANSON: -- I think. I think 2 what we're talking about here is the two (2) elements. 3 One (1) is what's called credentialing, where you 4 actually dif -- look at the people who are coming into 5 your system, are they suitable Direc -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. DAVID RANSON: -- in a direct sense. 8 Another is privileging within the organization who will 9 be doing what -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. DAVID RANSON: -- based on their 12 credentials. 13 COMMISSIONER STEPHEN GOUDGE: Right, 14 and -- 15 DR. DAVID RANSON: And those two (2) 16 elements are very important. 17 COMMISSIONER STEPHEN GOUDGE: How is it 18 determined then -- who determines if they have fallen 19 below that? 20 DR. DAVID RANSON: The process that we 21 have is that we have a performance assessment process for 22 our staff that takes place on annual review processes. 23 We have a system in the organization which is very 24 similar to many other laboratories of a quality 25 management system which has a continuous improvement or
2161 program build within it, which is basically a -- a 2 comprehensive complaint, and a big slap on the back or 3 tick system, to evaluate what has gone wrong. 4 We -- our approach is to link through 5 disciplinary process within the public service, so that 6 we have the capacity to use the governments ordinary 7 disciplinary process should something get to that level. 8 COMMISSIONER STEPHEN GOUDGE: But that 9 would not be for a professional falling short. That 10 would -- 11 DR. DAVID RANSON: It -- it could come to 12 a professional -- 13 COMMISSIONER STEPHEN GOUDGE: Could it? 14 DR. DAVID RANSON: -- falling short if -- 15 if it was considered to be something that was of a -- of 16 a significant nature. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 DR. DAVID RANSON: And after that, you've 19 got the Medical Board, or the registration -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. DAVID RANSON: -- authority. 22 COMMISSIONER STEPHEN GOUDGE: Dealing 23 just with your own internal mechanism, and by using the 24 word internal, I flagged the question. 25 Is that independent enough?
2171 DR. DAVID RANSON: We -- because we can 2 actually invoke the use of our governing council in this 3 process -- 4 COMMISSIONER STEPHEN GOUDGE: Which is 5 your stakeholder -- 6 DR. DAVID RANSON: That's right, but they 7 are they are also the responsible -- effectively the 8 Directors, if you like, of the business. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. DAVID RANSON: And that includes 11 several judges -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. DAVID RANSON: -- including the Chief 14 Justice. 15 COMMISSIONER STEPHEN GOUDGE: So that is 16 where you get your -- 17 DR. DAVID RANSON: -- so at the end of 18 the day, we have a -- a group who are not the day-to-day 19 managers of the service -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. DAVID RANSON: -- but are the 22 Directorial Board, and they would deal with that issue at 23 the end. And that's built -- 24 COMMISSIONER STEPHEN GOUDGE: Fair 25 enough.
2181 DR. DAVID RANSON: -- into our policy and 2 procedures. 3 COMMISSIONER STEPHEN GOUDGE: Okay. That 4 is helpful. 5 Mr. Sandler...? Sorry. 6 7 CONTINUED BY MR. MARK SANDLER: 8 MR. MARK SANDLER: That's all right. Now 9 we know that under the current Ontario regime that there 10 are a large number of pathologists, many of whom are not 11 Board Certified at present in forensic pathology, that do 12 conduct medicolegal autopsies. 13 And there's been some discussion this 14 morning about fee-per-service. So I'd like to start with 15 Dr. Hanzlick, and then -- and then ask the others. 16 What are the implications for the future 17 to the fee-for-service pathologist, and what role should 18 they play in a structure such as that contemplated by Dr. 19 Pollanen? 20 DR. RANDY HANZLICK: I think you have to 21 realize right now there's something like a hundred and 22 ninety-two (192), or so different physicians doing 23 autopsies around the Province. Some of them as have been 24 mentioned doing very few per year: ten (10) or less, many 25 doing twenty (20) or less.
2191 And to me, the idea there might be to 2 reduce -- first of all, it's hard to get a hundred and 3 ninety-two (192) people to do things the same -- to just 4 reduce the numbers of those people, and transfer those 5 part-time things to more full-time regional positions, if 6 that can be done. 7 But there's always going to be instances 8 where you're going to have to have some part-time help, 9 either to assist in busy areas, or to fill in when 10 somebody's gone, or there just may be a geographic region 11 that doesn't warrant having one FTE. 12 So there has to be some, but it strikes me 13 that a hundred and ninety-two (192) is a lot. 14 MR. MARK SANDLER: Dr. Chiasson, you had 15 to wrestle with this issue when you were the Chief 16 Forensic Pathologist as well. 17 DR. DAVID CHIASSON: Yes, and it is a 18 difficult issue. I think back then, there was even more 19 than a hundred and ninety (190). 20 And in fact, we did attempt back in the -- 21 in the mid '90s to -- to narrow down the number of 22 pathologists to do homicides, and -- and criminally 23 suspicious death by developing a regional coroner's 24 pathologist system, if you will. 25 And we did go through a accreditation
2201 process. We -- we moved carefully, if you will, in the 2 sense that it is a big Province, and there are many 3 geographic areas where, you know, if -- if your criteria 4 were too -- too strict, you wouldn't have anybody to -- 5 to do the work. And we didn't really have the resources 6 in terms of -- of units to take up the slack. 7 It -- I mean, we continue to have 8 problems, from a resource point of view. To suddenly 9 say, Okay we're going to compress the number of 10 pathologists, well, the -- the cases have to go 11 somewhere, and the Units, you know, are one (1) 12 possibility certainly, but you know, we're all strapped 13 as far as resources from that point of view. 14 So it's a very difficult problem and would 15 have to be, I think, taken in a -- a step-wise process. 16 But the ultimate goal, I think, is certainly to reduce 17 the number of pathologists that we have doing -- 18 COMMISSIONER STEPHEN GOUDGE: A number 19 that I do not know, and I am sure it is in the material 20 somewhere, but either you, Dr. Chiasson, or you, Dr. 21 Pollanen, may know. 22 Of the seven thousand (7,000) autopsies 23 done under warrant each year, how many are done at one 24 (1) of the five (5) centres? 25 DR. MICHAEL POLLANEN: Fifty percent are
2211 done in the Forensic Pathology Units. 2 COMMISSIONER STEPHEN GOUDGE: And 50 3 percent therefore are done fee-for-service elsewhere? 4 DR. MICHAEL POLLANEN: Correct. 5 COMMISSIONER STEPHEN GOUDGE: Okay. That 6 is helpful. 7 8 CONTINUED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: Now just to be clear, 10 and if we look just at the pediatric cases, as I 11 understand it, the -- almost all of those cases are now 12 being done by -- within the Regional Centres, or the 13 Unit. 14 Am -- am I right as to that? 15 DR. MICHAEL POLLANEN: Yes. 16 DR. DAVID CHIASSON: They're -- under age 17 five (5), they're mandated to come to a forensic 18 pathology unit of some sort. 19 MR. MARK SANDLER: All right. 20 DR. DAVID CHIASSON: So if you define 21 "pediatric," it's under five (5). That's true. 22 MR. MARK SANDLER: Okay. 23 COMMISSIONER STEPHEN GOUDGE: But just so 24 I will understand, Dr. Pollanen. Dealing with the full 25 range of forensic work in the Province, to go to
2221 something that was close to a full FTE model, you would 2 be moving an additional thirty-five hundred (3,500) 3 bodies to the Unit, say? 4 DR. MICHAEL POLLANEN: Correct. Which 5 have no capacity to perform -- 6 COMMISSIONER STEPHEN GOUDGE: Yes, I 7 mean -- 8 DR. MICHAEL POLLANEN: -- that service 9 now, but -- 10 COMMISSIONER STEPHEN GOUDGE: -- obviously 11 there is no -- there is no horse power there to do it, 12 but I was just trying to think what kind of logistical 13 issues at the front door, so to speak, are created. 14 DR. MICHAEL POLLANEN: And let me just -- 15 there's another very interesting issue that sometimes 16 gets forgotten when we talk about the movement of bodies. 17 Because one (1) of the -- one (1) of the 18 issues is cost. That's the most obvious issue -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. MICHAEL POLLANEN: -- the cost of 21 moving bodies, but there are two (2) other issues that 22 are less apparent. The first is that often police attend 23 post-mortem examinations and legitimately so. And it is 24 a -- it puts a major stress on smaller police -- 25 COMMISSIONER STEPHEN GOUDGE: Right.
2231 DR. MICHAEL POLLANEN: -- forces to move 2 their personnel to another location. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. MICHAEL POLLANEN: That's number one 5 (1). 6 And number two (2), we really do need to 7 be sensitive to the issues of moving bodies out of some 8 communities. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. MICHAEL POLLANEN: So there's -- 11 there's always this delicate balance of all of these 12 competing variables for us to consider. 13 COMMISSIONER STEPHEN GOUDGE: I mean, 14 recognizing the unique situation of pediatric deaths, 15 which is obviously our main focus, the document that we 16 just went through with you, Dr. Pollanen, does that have 17 implicit in it the change in the numbers serviced at the 18 units? 19 That is, does have it implicit in it that 20 the units, the FTE performers, if I can put it that way; 21 that is, that is where it is easiest to create the job 22 streaming that you are talking about and the full-time or 23 full-time equivalent positions? 24 DR. MICHAEL POLLANEN: Correct. Correct, 25 yes.
2241 COMMISSIONER STEPHEN GOUDGE: Is it 2 implicit in this that there will be more than half the 3 cases done at the Units; that is, more than there are 4 now? Or is this premised on a steady state? 5 DR. MICHAEL POLLANEN: This is premised 6 currently on a steady state with intention to increase. 7 COMMISSIONER STEPHEN GOUDGE: Increase 8 the proportion? 9 DR. MICHAEL POLLANEN: Correct, yes. 10 COMMISSIONER STEPHEN GOUDGE: To what...? 11 I mean, is there a sense of what the optimal target would 12 be in the eyes of the working group? 13 DR. MICHAEL POLLANEN: Well, I can tell 14 you I'll answer the question over the next nine (9) 15 months, because -- 16 COMMISSIONER STEPHEN GOUDGE: Too late. 17 DR. MICHAEL POLLANEN: -- because we're 18 studying that right now; looking at the distribution of 19 autopsies across the Province, -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. MICHAEL POLLANEN: -- who's doing 22 how many -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. MICHAEL POLLANEN: -- how they're -- 25 how they're being done.
2251 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. MICHAEL POLLANEN: So -- so those 3 questions can be -- can be answered with simple 4 descriptive statistics. It just takes time to produce 5 those answers. 6 COMMISSIONER STEPHEN GOUDGE: All right. 7 Thanks, Mr. Sandler. 8 9 CONTINUED BY MR. MARK SANDLER: 10 MR. MARK SANDLER: All right. 11 What I want to do is ask each of you, 12 because our time is running short, to express any wish 13 list that you've thought about; or in the case of Dr. 14 Hanzlick or Dr. Ranson, some suggestions that you might 15 have for the Commissioner that would inform the 16 recommendations that he would be making. 17 So I'll turn to you first, Dr. Hanzlick, 18 if I may. The floor is yours. 19 DR. RANDY HANZLICK: Okay. Maybe if I 20 could just read my list of things that I've put together 21 to re-emphas -- a few of things we haven't talked about. 22 But first of all, what I'm going to say is 23 done with the assumption that the Coroner's System is 24 going to remain, and there's not discussion of just 25 converting to a Medical Examiner System:
2261 Formalize the Forensic Pathology Services 2 in the Statute. 3 Have a tiered level of forensic pathology 4 services. 5 Credential and oversee and review the 6 forensic pathologists' work. 7 Establish forensic pathology and pediatric 8 pathology training programs that are accredited by the 9 Royal College and the ACGME, if possible. 10 Establish a forensic pathology 11 certification exam. 12 Have Regionalized Centres with Chief 13 Forensic Pathologist oversight. 14 Put the forensic pathologist in the 15 decision-making process with the coroners. 16 Reduce the number of part-time 17 pathologists working in the system. 18 Modify and possibly shorten the training 19 path to forensic pathology, working with the Royal 20 College. 21 Utilize a collaborative approach for the 22 pediatric cases following the guidelines developed by the 23 Chief Forensic Pathologist, which are based on the skills 24 of the available staff. 25 Get the Offices accredited.
2271 Increase the per capita funding to improve 2 services. 3 Attract and keep personnel, and make 4 salaries equitable or in parity, as has been said. 5 Promote the concepts of pathology, 6 forensic pathology and death investigation at the college 7 and medical school levels. 8 Improve the training and required 9 qualifications for coroners. 10 Consider the establishment of a 11 freestanding ministry for death investigation which would 12 include a policy advisory board to assist pathology and 13 coronial services and provide budgets for those. 14 Use the American Board of Medicolegal 15 Death Investigator model for coroners and others who 16 investigate death scenes. 17 Have strong ties with universities and 18 medical schools to facilitate service, research and 19 teaching and fund forensic pathology training. 20 MR. MARK SANDLER: I just want to ask you 21 about, at least, one of those -- 22 DR. RANDY HANZLICK: Okay. 23 MR. MARK SANDLER: And that is that you 24 did speak in your paper about -- about the inspection and 25 accreditation of offices which does take place under the
2281 National Association of Medical Examiners. 2 DR. RANDY HANZLICK: Yeah. 3 MR. MARK SANDLER: Could you just explain 4 to the Commissioner? We haven't heard that much about 5 accreditation of offices, per se. Perhaps you could just 6 tell the Commissioner a little bit about that process. 7 DR. RANDY HANZLICK: Okay. Yeah, the 8 National Association of Medical Examiners has an 9 accreditation process that offices can apply for. 10 There's an inspection check list; a set of policies and 11 procedures. Both Coroner's Offices and Medical 12 Examiner's Offices are eligible to undergo that 13 inspection. 14 It costs about twenty-five hundred dollars 15 ($2,500). You can be pre-inspected to see how you rate 16 with the standards before you're officially inspected. 17 You can have an audit, if you request, 18 from the NAME office to do a more comprehensive view of 19 the system and make recommendations. 20 But then once the office does its self- 21 inspection and turns in their check list and addresses 22 weaknesses that they may or may not have, an inspector 23 goes to the facility, double checks policies and 24 procedures, makes sure things are being done the way 25 they're said they're done in the policies and procedures,
2291 and that there's adequate facilities. 2 And then if the office passes inspection, 3 they're given a five-year (5) accreditation period after 4 which it has to be reviewed. 5 There's also a provisional status that can 6 go for a varying amount of time. For example, you can 7 say, You're provisionally accredited for a year but 8 you've got to fix this problem within a year or you're -- 9 you're unaccredited, but full accreditation goes for a 10 five-year (5) cycle. 11 Out of the offices in the United States, 12 there's about fifty-three (53) right now that have been 13 accredited, and I think Singapore is accredited. 14 MR. MARK SANDLER: All right. And -- and 15 just holding that thought for a moment, just briefly, Dr. 16 Pollanen, should we be thinking about accreditation of -- 17 of offices here? 18 DR. MICHAEL POLLANEN: Yes. 19 MR. MARK SANDLER: All right. 20 DR. MICHAEL POLLANEN: Well, I mean, I 21 could tell you that I've gone through the NAME checklist 22 and, you know, we're simply just not even in the running 23 right now because of various physical plant 24 considerations and -- and certain organizational 25 administrative nuances of our system.
2301 So -- but that is, I think -- it's correct 2 we haven't really talked about accreditation, but that is 3 another sort of pathway to ensuring quality processes and 4 talking more about standard operating procedures and how 5 things flow through the -- the mortuary, et cetera. 6 And it also is a very good way of sending 7 messages to the government about what minimum physical 8 plant requirements are -- are needed for the provision of 9 forensic pathology services. 10 So it's -- it's a very good -- a very good 11 model as part of this more general approach to quality. 12 MR. MARK SANDLER: Dr. Taylor, I haven't 13 called upon you for a while so what would your wish list 14 be? 15 DR. GLENN TAYLOR: So I'm going to take a 16 bit of a different tact and have as my constituency the 17 90 to 95 percent of pediatric deaths that are 18 investigated under coroner's warrants that are not of 19 interest to the Criminal justice system. 20 And I'm going to start by saying that I 21 think it's of a two-way benefit to have those kind of 22 cases done within a pediatric hospital or a hospital that 23 has a strong pediatric department. 24 And the reason I say that it's two-way is 25 that I think the people of the province, through the
2311 coroner's office, have the best opportunity to try to 2 learn what disease process or what was the cause of death 3 related through natural causes by the application of all 4 of those resources that are applied to understanding 5 diseases and diagnosing diseases in the living children. 6 The second part of the benefit is that the 7 hospitals benefit and the staff benefit by having a large 8 number of those cases accessible through the limitations 9 in the Coroner's Act and with the approval of the Office 10 of the Chief Coroner for their activities: Quality 11 assurance activities, mortality and morbidity rounds, and 12 under certain circumstances, research and other academic 13 activities. 14 They -- those activities may not be lost, 15 but I think they would be diminished if they were having 16 to be transported from some other geographic centre back 17 to the hospital of origin. 18 That being said, there needs to be broad 19 bridges between the Unit and the sub-units that are doing 20 pediatric death investigations with their Regional 21 Offices or with -- and with the Toronto main office of 22 the Chief Forensic Pathologist. 23 So all of the technical matters that may 24 come into play to broaden that bridge should, I think, be 25 put in place.
2321 There's one (1) sort of delicate issue 2 with regards to this and that is the hands -- or hands- 3 off or arm's-length approach that needs to be considered 4 when a child who died in a hospital is investigated in 5 that hospital. 6 So there has to be, I think, a 7 strengthening of that understanding of the roles and 8 somehow, perhaps, a little bit of separation of -- of the 9 investigator and the investigator's relationship with the 10 hospital. 11 And that could be done through having, I 12 think, a fairly simple approach and that is to have an 13 administrative structure put in place within the hospital 14 that reports to the Chief Forensic Pathologist or the 15 Office of the Chief Coroner rather than being part of the 16 administrative structure of the hospital. 17 And that in a sense would set-up -- set-up 18 kind of a role definition between the -- the Office of 19 the Chief Coroner and the hospital. 20 MR. MARK SANDLER: Thank you very much. 21 Dr. Chiasson, if you were making a 22 Christmas list what would be on it? 23 DR. DAVID CHIASSON: Well, it would be a 24 very long list but I won't go into all the details. 25 I think that -- and some of this certainly
2331 will echo what Dr. Taylor has just said. I think the 2 solution -- the practical solution -- the one (1) that is 3 really looking us in the face in terms of how to deal 4 with pediatric forensic pathology cases is the current 5 model that we now have at the Hospital for Sick Children. 6 It's not to say that it's a perfect model. 7 It's not to say that there's not problems that need to be 8 addressed. But I think my number one (1) wish and my 9 core wish, if you will, is that the Commissioner strongly 10 endorse the Ontario Forensic -- Pediatric Forensic 11 Pathology Unit model that's now in place; endorse it and 12 argue for -- for strengthening of -- of the concept. 13 And really, I look at it in terms of a 14 vision of the Unit; I think there's three (3) things. 15 There's a performance of services to the 16 Coroner's Office. And I think we need to, as Dr. Taylor 17 just said, have very strong links to the -- to the Chief 18 Forensic Pathologist; to the Coroner's Office in our 19 role. We are -- in fact, although we're within the 20 context of the hospital the work we do is -- is for the 21 Coroner's Office within the Pediatric Forensic Pathology 22 Unit. 23 Not only that though; I think there's a 24 very important education role that needs to be enhanced 25 and -- and that's not only the education of -- of
2341 residents, pediatric -- or sorry, pathology residents, as 2 now is being carried on, but the training of -- of 3 forensic pathology fellows; again, closely tied with the 4 -- the fellowship program to be developed at the 5 Coroner's Office. 6 And as well, and I would argue, there's a 7 wonderful opportunity to, in fact, market ourselves -- 8 the Unit -- to train forensic pathologists -- fully 9 qualified forensic pathologists in pediatric forensic 10 pathology as a, if you will, a sub-sub-speciality; which 11 is really what -- what it is. 12 And I think there would be a market to 13 actually train -- not necessarily talking about a full 14 year fellowship, but three (3) -- three (3) month, six 15 (6) month periods of time for individuals who are in 16 practice or in -- early on. 17 And this could be certainly marketed to -- 18 to the rest of Ontario. Because clearly if we're going 19 to have forensic pathology fellowships outside of 20 Toronto, I think that we need to be tied to any forensic 21 pathology fellowship training -- we being the -- the Unit 22 -- in order to provide the training in this specific 23 area, but as well to act as a -- as a focus so that if 24 you're having your farin -- fellowship training in -- in 25 Alberta, that it could be arranged that you could spend
2351 some time in a -- in the concentrated environment that we 2 have at the hospital. 3 The third aspect of -- of this, and -- and 4 this is a pretty classic university teaching hospital 5 mantra, is -- is service, education, and the third part 6 is research. 7 And the amount of information and data, we 8 -- we keep hearing about evidence-based medicine, and -- 9 and I think we all agree that there are major deficits 10 that are present in -- in pediatric forensic pathology 11 literature, that the Unit houses information on -- on a 12 large number of cases, a large variety of cases that -- 13 it's -- it's a -- an unmined field to be -- that really 14 needs to be looked at and -- and a lot of information 15 there to be gleaned, which would require a research 16 mandate to the Unit in pediatric forensic. 17 And this could be -- again, this is -- 18 often is and could be certainly tied to -- to fellowship 19 training programs. Part of the -- the training could be 20 in doing research, but also it needs to be tied with 21 certain personnel issues and -- and having, in fact, a 22 dedicated data analyst, a dedicated research assistant 23 would be of great benefit and would -- would make it very 24 visible. The -- the research commitment that -- that I 25 think is -- is -- it's a very important part of what
2361 needs to be done. 2 And I will stop. 3 MR. MARK SANDLER: All right. Dr. 4 Ranson, over to you. 5 DR. DAVID RANSON: Okay. Well, I have a 6 great deal of support for a very large percentage, if not 7 all of the list that Dr. Hanzlick's already put forward, 8 and indeed, many of the academic issues and -- and 9 training issues that have been mentioned by others. 10 If I try to put one (1) word about what I 11 think should happen, it will be the professionalization 12 of forensic pathology here in -- in this territory. I 13 think the -- that is not to say that the pro -- people 14 doing it are not professional. I should add that in 15 majorly. 16 I'm not talking about the individual 17 people. I'm talking about the professionalization of the 18 operation of the forensic pathology service, and by that, 19 I mean allowing it to operate and giving it the resources 20 and facilities to operate in a way that is self- 21 sustaining in the future. 22 That means it needs it's own resource-base 23 to look at its own recruitment, its education, its 24 service provision, the flexibility about how it will 25 deliver that service provision across a wide array -- a
2371 variety of areas. 2 We've heard about topics such as 3 accreditation and how important that is in the process 4 and -- and I fully agree with that. It's something we 5 spend a great of deal of time and effort engaged in. 6 The importance of that professionalization 7 bringing with it a degree of corporatisation in current 8 government service models, I think, is inevitable and 9 probably essential. 10 Governments these days are very interested 11 in operating in a business-type environment; therefore, 12 the agencies that are operating within government need to 13 have a clear business focus. 14 This means business case model 15 development, it means bus -- business cycle reviews, 16 development of proper strategic plans, plans that are 17 developed in such a way that they will achieve 18 appropriate funding and approbation from the relevant 19 hierarchy. 20 I'm a very, very strong believer in the 21 notion of the council. I can't imagine operating now in 22 an environment which doesn't have the council that I have 23 in my organization, and perhaps, it would just worth -- 24 just spending a just sort of minute on -- on why that I 25 think is so important.
2381 We are -- have a governing council of 2 respect of the Board of Directors which is chaired by the 3 Chief Justice, has Judges from senior Courts on it, has 4 representation from the Health Ministry, from police, 5 from the Universities, from the Royal College, from a 6 wide variety of government ministers or who have an 7 interest. 8 The point is really reinforcing the point 9 that Michael made earlier that there are many, many 10 clients of the forensic pathology service, and it is also 11 important that no one (1) client really should be able to 12 dominate the agenda, and if you don't have that flexible 13 board structure which allows collegiate decision- making 14 to take place at a hall-of-government-type approach, then 15 I think there's a very great risk that from time-to-time, 16 one group will dominate the process. 17 Maybe they dominate simply because they 18 provide the funding, for example, or maybe they dominate 19 because there's some new legislation, and they feel 20 themselves mandated to take control of certain aspects of 21 prioritization of the workflow. 22 These are the sorts of things that I think 23 accounts as very, very important in doing because it 24 allows all of the clients to appreciate the needs of 25 other clients and to come to a collegiate way in which
2391 they want those services to be provided from a hall-of- 2 government approach. 3 So I've -- I've listened to all of those, 4 the elements that have come from other people. The -- I 5 have, obviously, no issues at all of the importance of 6 education, recruit and so on. 7 But if you corporatise, if you 8 institutionalize and you allow professionalism to take 9 place, you will find your forensic pathologists will be 10 only too happy to engage in all of those things that will 11 provide long-term continuity of service. 12 That is, after all, what they're about as 13 medical professionals within a sub-specialty discipline. 14 That's all I'll say. 15 MR. MARK SANDLER: Thank you, very much. 16 Dr. Pollanen, the last word to you. 17 DR. MICHAEL POLLANEN: It's very clear 18 that forensic pathology needs to come of age in Ontario. 19 We have -- we have evolved to a point now where we need 20 major structural change. 21 The Act -- these -- these changes need to 22 be reflected at a -- in a fundamental way in the 23 Coroner's Act. There needs to be a very clear 24 demarcation of the -- the roles of the different types of 25 physicians that populate our death investigation system.
2401 And this can be embodied, I think, in 2 three (3) ways. The first is the formation of the 3 Ontario Forensic Pathology Service. That service would 4 be governed by forensic pathologists because the forensic 5 pathologists have the skill set, the educational 6 requirements to effectively discharge the duties and -- 7 and provide service in forensic pathology. 8 Second, we must make, as a very important 9 focus in -- in our go-forward position in Ontario, 10 training of a domestic workforce of forensic 11 pathologists. This requires appropriate resourcing of 12 fellowship positions and the creation of environments 13 which will allow forensic pathology to grow and flourish. 14 Whether those environments are in the 15 Regional Forensic Pathology Units or in -- in the Toronto 16 Unit, we -- we need to find mechanisms and resources to 17 ensure that. 18 The third is that we need to harness the 19 three (3) pillars that Professor Cordner told us about. 20 And the way we do so, within the current structure of the 21 University of Toronto, is through the model of -- of 22 interdisciplinarity. 23 And that supports the concept of the 24 development of the Centre of Forensic Medicine and 25 Science at the University of Toronto as being a hub for
2411 the research and education elements that balance the -- 2 the other needs of forensic pathology. 3 In other words, simply creating a system 4 of service delivery at this juncture is entirely 5 inadequate. What we need is we need the three (3) 6 pillars. 7 The challenges will be how to link those 8 institutionally and fund them and -- and -- but those -- 9 those, I believe, are the three (3) major areas. 10 MR. MARK SANDLER: All right. Thank you 11 very much. 12 I'll just canvass the room to see whether 13 there are any questions from any counsel. 14 Commissioner, I'm delighted to see that 15 I've completed my questioning for the day. It appears 16 that counsel are either exhausted or feel that all the 17 questions that can be asked have been asked. 18 COMMISSIONER STEPHEN GOUDGE: Oh, it's 19 been a wonderful afternoon and I -- you know, the last 20 twenty (20) minutes have been great. I really appreciate 21 the thought all five (5) of you have put into it; that's 22 for what I have to do, very helpful. 23 MR. MARK SANDLER: Thank you very much to 24 you all and that concludes today's roundtable. Thank 25 you.
2421 (BRIEF PAUSE) 2 3 COMMISSIONER STEPHEN GOUDGE: This is 4 very informal, you know. We are not going to do the all 5 rise thing, okay? 6 7 --- Upon adjourning at 4:09 p.m. 8 9 10 11 12 Certified Correct 13 14 15 ___________________ 16 Rolanda Lokey, Ms. 17 18 19 20 21 22 23 24 25