1 2 3 THE INQUIRY INTO PEDIATRIC FORENSIC 4 PATHOLOGY IN ONTARIO 5 6 7 8 ******************** 9 10 11 BEFORE: THE HONOURABLE JUSTICE STEPHEN GOUDGE, 12 COMMISSIONER 13 14 15 16 Held at: 17 Offices of the Inquiry 18 180 Dundas Street West, 22nd Floor 19 Toronto, Ontario 20 21 22 ******************** 23 24 February 28th, 2008 25

2
  1                        Appearances
  2  Linda Rothstein           )     Commission Counsel
  3  Mark Sandler              )
  4  Robert Centa        (np)  )
  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      (np)   )
 12  Jill Presser        (np)  )
 13  
 14  Brian Gover               )     Office of the Chief Coroner
 15  Luisa Ritacca             )     for Ontario
 16  Teja Rachamalla     (np)  )
 17  
 18  Jane Langford       (np)  )     Dr. Charles Smith
 19  Niels Ortved        (np)  )
 20  Erica Baron         (np)  )
 21  Grant Hoole         (np)  )
 22   
 23  William Carter      (np)  )     Hospital for Sick Children
 24  Barbara Walker-Renshaw (np))
 25  Kate Crawford             )

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

4
  1                 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            )     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

1 TABLE OF CONTENTS Page No. 2 PANEL 1 - THE DELIVERY OF FORENSIC PATHOLOGY SERVICES: 3 DR. ROGER STRASSER 4 DR. WILLIAM MCCREADY 5 DR. DAVID EDEN 6 DR. BONITA PORTER 7 DR. DAVID CHIASSON 8 DR. MARTIN QUEEN 9 10 Questioned by Mr. Mark Sandler 9 11 Questioned by Ms. Jackie Esmonde 89 12 13 PANEL 2 - THE ORGANIZATION OF PEDIATRIC DEATH INVESTIGATION 14 MR. JAMES SARGENT 15 DR. SHELAGH McRAE 16 DR. DAVID EDEN 17 DETECTIVE INSPECTOR DENNIS OLINYK 18 DR. DAVID CHIASSON 19 DR. MARTIN QUEEN 20 21 Questioned by Mr. Mark Sandler 99 22 Questioned by Mr. Brian Gover 180 23 Questioned by Ms. Jackie Esmonde 182 24 25 Certificate of transcript 189

1 --- Upon commencing at 10:35 a.m. 2 3 COMMISSIONER STEPHEN GOUDGE: Are we 4 ready to go, Mr. Sandler? 5 MR. MARK SANDLER: Yes, we are, 6 Commissioner. 7 COMMISSIONER STEPHEN GOUDGE: First, let 8 me express my thanks to all those who were a part of the 9 logistics in getting it set up. This is an even better 10 arrangement than we have in Toronto, so we are very 11 grateful. 12 Mr. Sandler, away you go. 13 14 PANEL 1 - THE DELIVERY OF FORENSIC PATHOLOGY SERVICES: 15 DR. ROGER STRASSER 16 DR. WILLIAM MCCREADY 17 DR. DAVID EDEN 18 DR. BONITA PORTER 19 DR. DAVID CHIASSON 20 DR. MARTIN QUEEN 21 22 MR. MARK SANDLER: Thank you. Good 23 morning, everyone. Good morning, Commissioner. 24 This morning we will be discussing how the 25 capacity of pediatric forensic death investigation in

1 remote -- or northern communities can be enhanced. 2 Tomorrow we will be consider -- continuing 3 that discussion, but focussing upon the unique challenges 4 in delivering pediatric forensic services to Aboriginal 5 communities. 6 If I can introduce today's panel, starting 7 at your far left, Commissioner, Dr. Roger Strasser is the 8 founding Dean of the Northern Ontario School of Medicine. 9 Prior to 2002, Dr. Strasser was Professor of Rural Health 10 for Monash University, and head of the Monash University 11 School of Rural Health in Australia. Between 1992 and 12 2004, he was the Chair of the Working Party on Rural 13 Practice for the World Organization of Family Doctors. 14 And as you'll hear, the Northern Ontario 15 School of Medicine is a joint initiative of Lakehead 16 University in Thunder Bay, and Laurentian University in 17 Sudbury. 18 Immediately beside him is Dr. William 19 McCready. He is the Associate Dean of Clinical Affairs 20 at the Northern Ontario School of Medicine. He graduated 21 in medicine from Queen's University in Belfast, and did 22 post-graduate training in Belfast, Toronto, and 23 Saskatoon. He has been in clinical practice as an 24 ephrologist for some 25 years, and has taught students 25 through the Northwestern Ontario Medical Program since

1 1982. 2 Immediately beside him is Dr. David Eden. 3 You've already been introduced, of course, to Dr. Eden, 4 Commissioner. He is the Regional Supervising Coroner for 5 North Region. He was originally appointed a coroner in 6 1992, and became Regional Supervising Coroner for Niagara 7 in 1998. 8 Immediately beside Dr. Eden is Dr. Bonita 9 Porter. Again, she's well-known to you, Commissioner, as 10 the Chief Coroner of the province of Ontario. She was 11 appointed Regional Coroner for Niagara in January of 1991 12 and Deputy Chief Coroner, Inquests in May of 1996. She 13 was appointed the Chief Coroner in September of last 14 year. 15 Beside her is Dr. David Chiasson, again, a 16 very familiar face to us all. He is the Director of the 17 Ontario Pediatric Forensic Pathology Unit at the Hospital 18 for Sick Children. Prior to his appointment as Director, 19 he was the Chief Forensic Pathologist in the Office of 20 the Chief Coroner until October of 2000, and also served 21 as the Deputy Chief Coroner, Pathology from October 2000 22 until June of 2001. 23 And last but not least, Dr. Martin Queen 24 is a forensic pathologist operating out of the 25 Northeastern Regional Forensic Pathology Unit in Sudbury.

1 He received his forensic pathology training in Baltimore, 2 Maryland, and was employed as a staff forensic 3 pathologist with the Office of the Chief Coroner from 4 August 1996 until 1999. 5 Welcome to you all, and thank you for 6 joining us this morning. 7 8 QUESTIONED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: I'm going to start, if 10 I may, with Dr. Strasser and Dr. McCready. I should 11 indicate to you that in a previous -- in previous 12 testimony that was given at our Inquiry, the Commissioner 13 received some information about the Northern Ontario 14 School of Medicine. 15 And if we can develop what has previously 16 been said with the benefit of your expertise, can I ask 17 Dr. Strasser and/or Dr. McCready to outline, first of 18 all, the demographics of the student body of the Northern 19 Ontario School of Medicine. And from there, perhaps we 20 can explore some of the issues that are relevant to our 21 Inquiry. 22 Dr. Strasser, I'll turn to you first then. 23 DR. ROGER STRASSER: Well, thank you for 24 the opportunity to -- to meet with the Inquiry and -- and 25 thank you for your question.

10
  1                 The Northern Ontario School of Medicine
  2  was established with a social accountability mandate,
  3  which is a commitment to be responsive to the needs of
  4  the people and the communities of Northern Ontario. 
  5  We've translated that mandate in various directions,
  6  including in setting ourselves the target of reflecting
  7  the population distribution of Northern Ontario in each
  8  class of the -- of the medical school MD program.  And,
  9  in fact, we've been quite successful in that so far.
 10                 So, we have fifty-six (56) students in
 11  each year and we've had three (3) intakes.  For each of
 12  those intakes, we've had over two thousand (2,000)
 13  applications for the fifty-six (56) places in the school. 
 14  And somewhere around 80 to 90 percent of the students in
 15  each class have grown up in Northern Ontario.  The
 16  current first year class or the intake from September of
 17  2007, fifty-one (51) of the fifty-six (56) students have
 18  grown up in Northern Ontario, so that's 91 percent of the
 19  class.  
 20                 And the distribution within Northern
 21  Ontario is -- is, again, comparable with the distribution
 22  of people in Northern Ontario.  So, just under 50 percent
 23  of the students come from rural and remote communities in
 24  Northern Ontario.  That's -- "rural and remote" being
 25  defined as outside of Thunder Bay, Sudbury, Sault Ste.

11
  1  Marie, North Bay, and Timmins.  All the other --
  2  everywhere outside of those communities is rural and
  3  remote by the -- the standard definition.
  4                 In fact, the other five (5) students -- I
  5  said fifty-one (51) of the fifty-six (56).  The other
  6  five (5) students come from rural and remote communities
  7  outside of Northern Ontario.  So, in fact, we -- in our
  8  current first year class, we -- the only students who
  9  come from cities come from cities within Northern
 10  Ontario.  So that makes the class profile very different
 11  from the other medical schools in Ontario. 
 12                 We also have a focus on populations of
 13  special interest.  In addition to rural and remote,
 14  population of special interest of Aboriginal and
 15  Francophone, and in our current first-year class, 9
 16  percent of the class are Aboriginal people and 27 percent
 17  of the class are Francophones, and -- and in both cases,
 18  by standard, quite strict definitions of Aborig -- being
 19  an Aboriginal person or a Francophone person.
 20                 MR. MARK SANDLER:   Thank you.  And, Dr.
 21  McCready, maybe I can turn to you and...  
 22                 One (1) of the issues that has arisen in
 23  the course of some of the questioning at this Inquiry has
 24  to do with the content in -- in medical schools that --
 25  that pertains to forensic pathology or pathology.  Could

1 you address that issue? 2 To what extent does your curriculum 3 contain content relevant to those topics? 4 DR. WILLIAM MCCREADY: Each of our 5 students, in their first two (2) years, is required to 6 attend an autopsy, which they do in either Sudbury or 7 Thunder Bay, many of them with Dr. Queen at the far end 8 here. 9 That is, we believe, a relatively unique 10 feature of medical schools, but many medical schools 11 don't require their students to attend autopsies. As 12 I've learned, most of the autopsies conducted these days 13 in hospitals are coroner-induced autopsies. 14 Our pathologists who teach our students 15 take the opportunity when the student comes to witness 16 the autopsy to educate the student about the coroner's 17 system and what the requirements are for reporting deaths 18 to the coroner, so that's been our ex -- our -- sort of 19 our exposure. 20 In their modules they -- they -- in their 21 first two years they have a number of modules which are 22 organ-based systems, though they're not taught exactly 23 that way, they're taught as -- as cases based in the 24 community, but they're -- nevertheless, the focus is on a 25 particular organ system and the student is also exposed

1 to at -- anatomy, and pathology, and histology as they 2 learn about the organ systems as they go through it, and 3 they have examinations on those things. 4 They have bell-ring -- bell-ringer exams 5 where they need to identify tissue and -- both 6 pathological and normal, and have anatomical quizzes that 7 they have to go through with each module as well, so, 8 it's integrated throughout the first few years. 9 We don't run a specific course in 10 pathology, but it's integrating throughout the course of 11 our undergraduate curriculum. 12 COMMISSIONER STEPHEN GOUDGE: Can I ask 13 you a little bit, Dr. McCready? I mean, one (1) of the 14 issues we've heard about is the absence of exposure to 15 something that one might call forensic medicine in the 16 undergraduate medical programs generally. 17 You referred to your mandatory attendance 18 at an autopsy for your students as quite unique. I mean, 19 do you know whether you're the only medical school that 20 does that in Ontario? 21 You must have some sense from describing 22 it as relatively unique that this is an attribute that 23 you're proud of and that's quite unusual. 24 DR. WILLIAM MCCREADY: I'm told by my 25 pathological colleagues it's relatively unique, but I

1 wouldn't say it was absolutely unique. 2 COMMISSIONER STEPHEN GOUDGE: Right, 3 right, and how do you work it into the program; that is, 4 is there a module that is dealing with, for example, an 5 internal system in which an autopsy would be a natural 6 adjunct? 7 Is that the way it works or how do you 8 actually work it into the program? 9 DR. WILLIAM MCCREADY: Much of our 10 learning is self directed. 11 COMMISSIONER STEPHEN GOUDGE: Yes. 12 DR. WILLIAM MCCREADY: So students are 13 given the task of attending an autopsy and they're given 14 the contact information, so they make their own 15 arrangements -- 16 COMMISSIONER STEPHEN GOUDGE: I see. 17 DR. WILLIAM MCCREADY: -- with our 18 pathologist to attend these autopsies and they -- they 19 would not necessarily be attending an autopsy related to 20 a specific system. 21 COMMISSIONER STEPHEN GOUDGE: Okay, so 22 they would contact Dr. Queen and determine when he was 23 going to be doing an autopsy in Sudbury and then -- or in 24 North Bay and the students would go there, and the ones 25 who were at Sudbury and the ones who were here would do

1 autopsies that he did here; is that right? 2 3 DR. WILLIAM MCCREADY: That would be 4 correct. 5 COMMISSIONER STEPHEN GOUDGE: Yes. 6 DR. WILLIAM MCCREADY: Our current 7 charter class is out in intermediate sizes of town in 8 northern Ontario at the moment, towns like Timmins, and 9 North Bay, and Fort Francis and Sioux Lookout and 10 Kenora -- 11 COMMISSIONER STEPHEN GOUDGE: Yes. 12 DR. WILLIAM MCCREADY: -- where they also 13 have the opportunity to participate in all aspects of the 14 medical care in that community -- 15 COMMISSIONER STEPHEN GOUDGE: I see. 16 DR. WILLIAM MCCREADY: -- so many of our 17 third year students would also have the opportunity, al - 18 - although it is again self directed to participate in 19 autopsies -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. WILLIAM MCCREADY: -- that might be 22 carried out in any of those communities. 23 COMMISSIONER STEPHEN GOUDGE: Right. And 24 can I just ask you, Dr. Strasser, your student body is 25 split between Sudbury and Thunder Bay, is that right?

1 DR. ROGER STRASSER: Well, when the -- 2 the first two (2) years, the four (4) year MD program, 3 the first two (2) years the classroom learning is at one 4 (1) or other of the two (2) university campuses, so like 5 in university -- 6 COMMISSIONER STEPHEN GOUDGE: Would the 7 whole class attend either in Sudbury or Thunder Bay or is 8 there parallel learning in the two (2) places? 9 DR. ROGER STRASSER: Right, there's 10 parallel learning, so -- so most of the classroom 11 learning is in small groups of eight (8) -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. ROGER STRASSER: -- so there are 14 three (3) groups of eight (8) at -- at Lakehead and 15 Thunder Bay and four (4) groups of eight (8) at 16 Laurentian in Sudbury, so it's thirty-two (32) and fifty- 17 six (56) is the split -- that's thirty-two (32) and 18 twenty-four (24) is the split for the fifty-six (56). 19 Much of the learning, as I said, is in 20 small groups and so whether the students -- the -- the 21 other groups are down the corridor or 1,000 kilometres 22 away isn't -- isn't really an issue for that. 23 We do have what we call whole group 24 sessions, which are like lectures or seminars and they're 25 two (2) site video conferences, so that's how the whole

1 class is connected for -- for those whole group sessions. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. ROGER STRASSER: We make extensive 4 use of electronic communications, so the cases that -- 5 that Dr. McCready referred to, which is the main focus of 6 our small group learning, are delivered to the students 7 electronically and we have a highly developed electronic 8 digital library service so that most of the -- the -- the 9 library resources that the students access are -- are 10 electronic as well. 11 This means that it's possible -- in fact, 12 our students do undertake quite a lot of their learning 13 away from the two University campus sites, so -- and in - 14 - in -- in a real sense we see the whole of Northern 15 Ontario as the campus of the Northern Ontario School of 16 Medicine. 17 In first year the students have -- they 18 all have a four (4) week experience of living and 19 learning in Aboriginal communities. And we have two (2) 20 students in each community, fifty-six (56) students. So 21 twenty-eight (28) -- twenty-eight (28) Aboriginal 22 communities host our students for four (4) weeks. 23 In second year the students have two (2) 24 four (4) week integrated community experiences in 25 communities that we describe as rural or remote

1 communities. These are communities that have usually 2 around between five (5) and ten (10) physicians and a 3 local hospital and health team. 4 And so that the students are attached to 5 those communities. As Dr. McCready said, in third year 6 the students actually are living and learning for the 7 whole year in what we describe as large rural, small 8 urban communities. 9 This year there are ten (10) communities 10 that are hosting our students for their third year and 11 they're there for the whole year, and -- and those 12 communities are not Sudbury or Thunder Bay. 13 And then the fourth year the students 14 are in Sudbury and Thunder Bay, or will be, because I -- 15 we haven't got there yet, but they will be doing clinical 16 rotations in the major regional hospitals, Sudbury 17 Regional and Thunder Bay Regional. 18 COMMISSIONER STEPHEN GOUDGE: I see. And 19 is the thesis or part of the thesis behind this 20 reflection of the northern population in your student 21 body, that if you do that your graduates are more likely 22 to remain to service these communities than to migrate 23 elsewhere? 24 DR. ROGER STRASSER: Yes. In fact, the 25 research evidence from this country and around the world

1 shows that the three (3) factors most strongly associated 2 with going into rural practice after training are, first 3 of all, a rural upbringing, so having grown up in a rural 4 area, and hence, our focus on recruiting students who 5 come from northern Ontario or similar northern rural, 6 remote Aboriginal, Francophone sort of backgrounds. 7 The second factor associated with going 8 into rural practice after training is positive clinical 9 and educational experiences in the rural setting as part 10 of the MD program. So, we have what we call Distributed 11 Community Engaged Learning. 12 So our students undertake a lot of their - 13 - their clinical learning in a whole range of different 14 hospital and health service settings and a whole range of 15 different community settings. 16 So they don't just learn about in the 17 classroom the diversity of communities and cultures in 18 northern Ontario, they experience that for themselves. 19 The third factor most associated with 20 going into rural practice after training is targeted 21 training at the post-graduate level, that's residency 22 training. 23 So we -- we have already in place a family 24 medicine residency program, Northern Ontario School of 25 Medicine Family Residency Program which has a -- a focus

1 on graduating family physicians who -- who have the 2 skills to -- to practice in the -- the -- the different 3 kinds of communities in northern Ontario. 4 This particular Family Medicine Residency 5 Program is actually a continuation of residency programs 6 in the -- one (1) in the North West, one (1) in the North 7 East that started in '90/'91. 8 So there's a long history of medical 9 education -- although there has not been a medical 10 school, there's been a long history of medical education 11 in Northern Ontario. And those -- those former Family 12 Medicine Residency programs were successful as measured 13 by the fact that over two thirds (2/3) of their graduates 14 are practising in Northern Ontario. 15 COMMISSIONER STEPHEN GOUDGE: That's very 16 interesting. Thanks. Sorry, Mr. Sandler. 17 18 CONTINUED BY MR. MARK SANDLER: 19 MR. MARK SANDLER: No, that's fine. And 20 I'm -- I'm neglecting other panel members for a moment, 21 but if we can just stay with the theme of -- of -- of the 22 content of the education at -- at your medical school. 23 Dr. McCready, I'll direct this question to 24 you. One of the things that we've heard about at this 25 Inquiry is some concern about the extent to which

1 pathologists or -- or experts, generally, truly 2 understand the role of the expert in the criminal justice 3 system. 4 And by "the role of the expert in the 5 criminal justice system," I'm including objectivity, the 6 importance of -- of articulating in -- in plain language 7 what the opinion is. The importance of articulating the 8 limitations upon the opinion, the importance of not being 9 an advocate. 10 All of the kinds of skill-sets that should 11 be associated with -- with the very fine expert, whether 12 pathologist or otherwise. So the question is: 13 Does any of that content make its way into 14 the medical school's curriculum? Can you help me out as 15 to that? 16 MR. WILLIAM MCCREADY: You know, I think 17 that the model of education that we're using, that of 18 self-directed learning, and the small group sessions that 19 Dr. Strasser described are facilitated by non-experts. 20 So I want to turn this around for you, in 21 fact, that our students learn their limitations very 22 early and they learn the limitation of their facilitator 23 in the small group. 24 So, for instance, I'm a kidney specialist 25 in my non-academic life and we don't ask kidney

1 specialists to facilitate our small group sessions on 2 kidney disease. They're facilitated by people who -- in 3 fact, one (1) of them is a dentist. 4 So their skills are in -- in teaching our 5 students how to learn and to make certain that they're 6 going on the right path as they -- as they work through 7 the material that we give them. 8 And so I think that, in itself, helps them 9 to understand their own limitations and so I've kind of 10 turned it backwards. We don't specifically try to teach 11 students that -- I have to sort of answer in a more 12 obtuse way. 13 One (1) of the issues in -- in medical 14 education in Canada, in particular, is our difficulty in 15 attracting our -- our graduates to enter family practice 16 training. 17 And one (1) of the reasons that that 18 happens is that -- is that they get educated in a model 19 where they're exposed to the expert and not to the 20 generalist. And so their -- their role models become 21 expert. Their -- they walk around wards with guys in 22 white lab coats who have their hands in the pockets and 23 say things like, "In my opinion." 24 COMMISSIONER STEPHEN GOUDGE: Sort of 25 like lawyers, Dr. McCready.

1 DR. WILLIAM MCCREADY: I -- I think there 2 -- yeah, there's a -- there's a bit of a crossover 3 probably. 4 So, we've turned that educational model 5 around and we're exposing our students to generalists and 6 their general knowledge. And they're seeing how our 7 generalists in family practice in -- in these smaller 8 communities end up using guys like me for our expert 9 opinion. So we're modelling it as opposed to teaching 10 it, I would say is the answer to your question. 11 DR. ROGER STRASSER: Could I -- 12 13 CONTINUED BY MR. MARK SANDLER: 14 MR. MARK SANDLER: Yes, Dr. Stasser? 15 DR. ROGER STRASSER: -- just add to what 16 Dr. McCready said? A couple things. The first is that 17 the design of our curriculum is -- is organized around 18 five (5) themes that run through the four (4) years of 19 the program. We don't have courses in the conventional 20 way, like we don't have a course on anatomy or pathology 21 or -- or surgery. 22 We have five (5) themes and the five (5) 23 themes are: northern and rural health, personal and 24 professional aspects of medical practice, social and 25 population health, foundations of medicine, and clinical

1 skills in healthcare. 2 And I think that the issues that are 3 behind the question that you asked are addressed 4 particularly in theme 2, that's -- that's personal and 5 professional aspects of medical practice, but actually 6 come through in exploring some of the other themes, as 7 well. So that's -- that's the first point. 8 MR. MARK SANDLER: So just stopping you 9 there for a moment. 10 DR. ROGER STRASSER: Yes. 11 MR. MARK SANDLER: If, as a result of 12 this Inquiry, additional information was learned about 13 the kinds of things what we've talked about, that's where 14 you'd infuse it into -- into your medical education? 15 DR. ROGER STRASSER: Right. So one of 16 the rather neat things about the design of our curriculum 17 is being case based. So, I mean, I honestly don't know 18 all the cases that the students learn. So there might 19 well be already a case scenario which involves a, you 20 know, an unexplained death and a coroner, et cetera, et 21 cetera. I -- I would have to go back and -- and check 22 through the whole database to be able to answer that 23 question specifically. 24 But if there isn't, we can design a case 25 like that quite -- quite easily and so give the students

1 the cues -- the cues so that when, in their small groups 2 and they're exploring the issues, as Dr. McCready 3 described, that they actually learn about that so that 4 they -- as part of their self-directed learning, they 5 look into the -- the -- the legislation and they look 6 into the Coroner's Office and how that functions and they 7 -- they learn about forensic pathology and the functions 8 of forensic pathology in the real world of northern 9 Ontario. 10 MR. MARK SANDLER: Dr. Eden, you'll know 11 where the questions that I've been asking up and to this 12 point come from because we had this discussion back when 13 you were on a panel with Dr. Legge and Dr. McCallum. 14 And one of the challenges that you 15 identified is -- is -- is getting students interested 16 from the earliest time in doing coronial work in 17 particular. 18 Any other suggestions as to how we might 19 promote a heightened interest in doing coronial work and 20 particularly in the North? 21 DR. DAVID EDEN: I think you raise a good 22 point that coroner recruitment is something that's 23 provincial but there are specific challenges in the 24 North. As I mentioned during the -- the last time I 25 testified, the -- the opportunity for physician trainees

1 to work with coroners is useful. 2 And the other thing, of course, is 3 providing education in forensic medicine as part of the 4 curriculum; however, I -- I'm respectful of the fact that 5 the Dean of Medicine deals with many requests, and it's 6 been estimated that if all of the requests to -- to be 7 put in medical education were met, then we'd be 8 graduating people around age 60/65. 9 So the -- so -- so obviously the Dean of 10 the Medical School has a difficult job to do in ensuring 11 the curriculum allows people to graduate, you know, while 12 -- while they're still young, and ready to practice. 13 With that being said, exposure as part of 14 the curriculum to issues in forensic medicine, and that 15 is the case in -- in Britain, for instance, and -- and it 16 is already happening that -- that medical students have 17 direct exposure to coronial work in their placements with 18 family doctors. 19 COMMISSIONER STEPHEN GOUDGE: Can I ask, 20 Dr. Strasser, would you contemplate in the residency you 21 are developing for family practice having a component of 22 it that might address something like the coronial 23 service? 24 Because I take it from what I have been 25 told so far, that in the North investigating coroners are

1 frequently family practitioners. 2 DR. ROGER STRASSER: Yes. So our family 3 medicine residence, much of their residency program is 4 attached to practising family physicians in Northern 5 Ontario. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. ROGER STRASSER: And, so if the 8 family physician they're attached to is a coroner, then 9 that's part of the experience for that particular 10 resident. 11 And we have a number of -- of our family 12 medicine residency program teachers who are coroners as - 13 - as you've observed. So the answer is, yes, the 14 residents get that experience. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 17 CONTINUED BY MR. MARK SANDLER: 18 MR. MARK SANDLER: Dr. Strasser, just 19 while we're on that topic. Dr. Eden was being very 20 respectful of the content of -- of the medical school 21 curriculum, understanding all the demands that are placed 22 upon you. 23 I noted, for example, that -- that there 24 is no elective in your list of electives on forensic 25 medicine. Is that something for consideration?

1 DR. ROGER STRASSER: The short answer is 2 yes. In fact, our list of electives is relatively 3 modest. At the moment, the school is in the process of - 4 - of developing its electives program. And, so we -- we 5 would see it as something that would be exciting, and of 6 great potential for our students to have the opportunity 7 to do an elective in forensic pathology. 8 MR. MARK SANDLER: All right. Dr. 9 Porter, you've -- you've heard this discussion that's 10 been taking place, in part, directed to the issue of what 11 initiatives can be taken to increase the supply of family 12 physicians who will, and can serve as -- as coroners. 13 Is there anything else that the OCCO can 14 do, or any role that it should play in -- in any 15 recruitment initiatives in that regard? 16 DR. BONITA PORTER: I'd be very 17 interested in -- in participating in the develop of some 18 problem-based studies for -- for the University. 19 I think that's a great way of learning, 20 and that's certainly the -- the training that I came 21 from. I went to -- graduated from McMaster, so I would 22 be very interested in -- in assisting and develop some of 23 those problem based. 24 And you can tie the forensic aspects into 25 many different scenarios in family medicine. Not just if

1 the patient dies, but tie into also other aspects of -- 2 of medicolegal issues. 3 And there are medicolegal societies in the 4 province that have outreach programs for Universities, 5 for medical schools, law -- law schools. 6 I think there's a great opportunity for 7 some collaboration. 8 MR. MARK SANDLER: Thank you. Dr. Queen, 9 I'm going to turn to you now. First of all, we've got 10 you here, and it's a welcome opportunity for you to 11 describe for the Commissioner what happens at your Unit. 12 Could you just take a few months, and 13 describe for him the -- the nature of -- of your Unit, 14 the kind of work that it does? 15 DR. MARTIN QUEEN: Our Unit in Sudbury is 16 presently a very informal Unit. The way this happened 17 was, a couple years ago we did a major renovation of the 18 morgue in what will eventually be our single site 19 hospital. 20 And we went from being probably one (1) of 21 the worse morgues in the province to, I think now, 22 probably one (1) of the better ones. 23 The issue at that time, a couple of years 24 ago, was what we were going to call ourself. And I had a 25 number of conversations with the Chief Coroner at that

1 time, Barry McLellan, and eventually he agreed that we 2 would be given the name of the Northeastern Regional 3 Forensic Pathology Unit. 4 Now this was quite informal. There -- 5 there is no specific recognition, or -- or contract per 6 se with -- with the -- with Toronto. 7 There's no specifically designated 8 director. There's no specific funding at the present 9 time for the Unit, or for the director. Nevertheless, we 10 do function as a regional unit. 11 Would you like me to go on now with the 12 area that we cover and -- and the kind of cases we do? 13 MR. MARK SANDLER: Yes, please. 14 DR. MARTIN QUEEN: Basically I'm the only 15 forensic pathology -- pathologist at the unit. We have 16 ten (10) pathologists in Sudbury and we all do different 17 things, and I'm the forensic pathologist and I do all of 18 the autopsy work in -- in Sudbury. 19 I presently cover all of the Sudbury and 20 Manitoulin regions. I cover most, if not virtually all, 21 of the Timmins and Cochrane regions and up the James Bay 22 coast. More recently, I've taken over coverage for 23 homicides and -- and suspicious cases and other 24 complicated cases for the North Bay and Thunder Bay 25 regions. I also do all of the decomposed cases from the

1 North Bay region because they just don't have the 2 facilities in their general hospital to deal with that 3 kind of case. 4 We're doing, on average, about two hundred 5 and fifty (250) cases a year. Close to 90 percent of 6 those are coroner's cases; the rest are mostly hospital 7 cases. I do some private cases. We're doing -- Sudbury 8 probably gets an average of half a dozen or so homicides 9 a year, and at least an equal number of suspicious cases. 10 The other regions of northeastern Ontario probably double 11 those numbers, so -- so we're dealing -- I'm dealing with 12 perhaps, you know, a dozen or so homicides a year and at 13 least an equal number of -- of suspicious cases and -- 14 and additional other complicated cases. 15 MR. MARK SANDLER: And -- and pediatric 16 cases? 17 DR. MARTIN QUEEN: My pediatric caseload 18 at the moment is -- is limited. I do a fair number of 19 stillbirths. Those are mostly hospital cases. The odd 20 one (1) has been a coroner's case. I do neonatal deaths. 21 Again, those are usually medical hospital cases; the odd 22 one (1) is a coroner's case. I do some straightforward 23 pediatric cases, the odd car accident, witness drowning, 24 cases like that. 25 When I first arrived in Sudbury nine (9)

1 years ago, I was doing some SIDS and SID-like cases, but, 2 as you know, those cases now are -- are directed south. 3 I'm not presently, and haven't for some time, done the -- 4 you know, the real, most serious and complicated 5 pediatric cases. Those are -- continue to be sent to -- 6 to Toronto. 7 COMMISSIONER STEPHEN GOUDGE: Can I just 8 ask, Dr. Queen, just looking at the map of Ontario, I was 9 reminded again of the huge geography that exists, really, 10 from Sault Ste. Marie north. 11 If I said to you, take the geography 12 centred around Sudbury, how far west would your forensic 13 cases extend; that is, presumably forensic cases are done 14 here in Thunder Bay -- and let's exclude, for the moment, 15 pediatric forensic cases, okay? 16 DR. MARTIN QUEEN: About as far west as - 17 - as I generally get cases is Kapuskasing. 18 COMMISSIONER STEPHEN GOUDGE: Is there 19 any sort of bright line? 20 DR. MARTIN QUEEN: There's not really a 21 bright line, but Kapuskasing is about as far west, and -- 22 and I do get cases from there. 23 COMMISSIONER STEPHEN GOUDGE: So a 24 Marathon, Wawa case would come to you in Sudbury, or 25 would it go here?

1 DR. MARTIN QUEEN: No, those generally go 2 to Sault Ste. Marie unless they're homicides or 3 suspicious cases. 4 COMMISSIONER STEPHEN GOUDGE: Okay. So 5 there's forensic pathology done west of you at Sault Ste. 6 Marie and here in Thunder Bay; is that right? 7 DR. MARTIN QUEEN: Yes, but -- but I 8 believe -- I believe homicides are still done in Thunder 9 Bay. I'm not that familiar with what's going on here in 10 Thunder Bay, but at -- 11 COMMISSIONER STEPHEN GOUDGE: Okay. 12 DR. MARTIN QUEEN: -- Sault Ste. Marie, 13 homicides and suspicious deaths come to me. 14 COMMISSIONER STEPHEN GOUDGE: Okay. And 15 then going the other way? 16 DR. MARTIN QUEEN: Going east, North Bay 17 again takes care of most of their own coroner's work, but 18 if it's a suspicious case, a homicide or some other 19 complicated cases, and decomposed cases, they will come 20 to me. 21 COMMISSIONER STEPHEN GOUDGE: Okay. And 22 for that entire area you've just describe, the pediatric 23 forensic work that was -- well, I guess all the pediatric 24 forensic work now goes to Dr. Chiasson? 25 DR. MARTIN QUEEN: Yes.

1 COMMISSIONER STEPHEN GOUDGE: Okay. And 2 just in terms of logistics, where there's a case -- to 3 take your western extremity, Kapuskasing, is the 4 transportation issue an issue, or is that one (1) that's 5 readily addressed? 6 DR. MARTIN QUEEN: It doesn't seem to 7 generally be a problem. We're -- we're not dealing with 8 a large number of cases -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. MARTIN QUEEN: -- that are coming 11 down from Kapuskasing, Timmins, and -- and Cochrane and 12 up the James Bay coast, so there are adequate facilities 13 in -- in terms of the body removal services and the -- 14 and the funeral homes -- 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 DR. MARTIN QUEEN: -- and -- and 17 sometimes the cases from up north are transported by the 18 police veh -- like by air -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. MARTIN QUEEN: -- so sometimes 21 they'll come through the Ontario Provincial Police. 22 COMMISSIONER STEPHEN GOUDGE: Okay, I'm 23 sure we'll get into it, but things like site visits are 24 an obvious followup and, Mr. Sandler, I'm sure we'll get 25 to that.

1 2 CONTINUED BY MR. MARK SANDLER: 3 MR. MARK SANDLER: Yes, Dr. Eden...? 4 DR. DAVID EDEN: There is an area that 5 was raised by Dr. Queen, if I may, and I don't know if 6 it's been brought up by the -- before the Commission 7 before, and that's still births, that the distribution of 8 autopsies in still births is different from those in -- 9 in newborns and -- and other -- well, and people older 10 than that in that in Ontario most autopsies of newborns 11 and older are in the coroner's system. 12 There's relatively few medical autopsies, 13 and I don't know the numbers, but my understanding is 14 that that ratio was adverse for still births; that while 15 we do some still births at the Coroner's Office, most 16 still birth autopsies are medical and done in the 17 hospital system. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 That's helpful. Thanks, Doctor. 20 21 CONTINUED BY MR. MARK SANDLER: 22 MR. MARK SANDLER: Just staying with -- 23 with Dr. Queen for a moment, we've see some evidence at 24 our Inquiry that during the time period in which Dr. 25 Young was the Chief Coroner consideration was being given

1 when the centres of excellence were being set up to a 2 centre of excellence in the north. 3 I'd be interested in your views as to 4 whether or not your unit should have some of the same 5 characteristics that are now attached to the centres of 6 excellence that exist in London, Hamilton, and et cetera. 7 DR. MARTIN QUEEN: Yes, I -- I was never 8 part of whatever dis -- discussions went on back when Dr. 9 Young was the -- the Chief Coroner; I only got involved 10 in those discussions with Dr. McLellan. 11 There -- there are a number of things I -- 12 I did want to talk about in terms of a unit in -- in 13 Sudbury and in northeastern Ontario which I was going to 14 bring up at the end, but if I have the time now I -- I 15 could perhaps go into it. 16 It's clearly my -- my hope and -- and my 17 feeling that there should eventually be a properly 18 designated, and -- and recognised, and financed regional 19 forensic unit in Sudbury with a properly designated and - 20 - and a director for that unit. 21 If we look at the numbers -- if we look at 22 the numbers for northeastern Ontario -- that's so -- 23 basically that includes what I'm presently doing, plus 24 all the cases in -- in Sault St. Marie and North Bay that 25 I'm not doing, the numbers would be roughly equivalent to

1 what's being presently done in the units in Ottawa and in 2 Hamilton. 3 So, in fact, if this came about, we're -- 4 you know, we're not talking about a small backwoods 5 organi -- you know, setup here; we're -- we're talking 6 about a unit that would largely rival the other units in 7 -- in Ontario outside of Toronto. 8 COMMISSIONER STEPHEN GOUDGE: So do you 9 get close to sort of five hundred (500) a year? 10 DR. MARTIN QUEEN: Five (5), six hundred 11 (600), in -- in that -- 12 COMMISSIONER STEPHEN GOUDGE: Yes. 13 DR. MARTIN QUEEN: -- range, yes. And in 14 fact several of the units, presently Ontario, are 15 directed by people who are not board certified forensic 16 pathologists, so in some ways we're -- we're already a 17 little bit ahead of the curve in -- in Sudbury. 18 Now, we already have most of the -- of the 19 infrastructure in human resources in place in Sudbury to 20 do this. As I mentioned, we had our -- a significant 21 morgue renovation a couple of years ago. We could easily 22 handle those kind of numbers. 23 We've got good storage facilities now; 24 we've got a great ventilation system; we've got -- we've 25 got two (2) offices that are right in the morgue with --

1 with the office equipment that I'm going to come to 2 later. 3 One (1) of the advantages of being 4 connected to a large regional hospital is we do have 5 access to a lot of other things that you -- you often 6 don't have in a standalone forensic unit. We have a 7 large radiology department, which is a great help. 8 I've been able to do some things in 9 Sudbury that I never got to do in Baltimore or in 10 Toronto. I -- I -- occasionally I'm able to get post- 11 mortem CT scanning when I need it and they've always been 12 very cooperative with that. 13 We have a large histology department 14 because it's a hospital that does a large amount of -- of 15 surgical pathology, and cytology, and so on. We -- we -- 16 I have excellent computer support through the hospital. 17 We -- you know, we have the secretarial set up. 18 We have -- Sudbury has a board certified 19 neuropathologist, the first and only one (1) that 20 northern Ontario has ever had that I'm aware of; she is a 21 huge help to me. 22 We have an anthropologist at the 23 University. We have an American trained dentist who does 24 -- who's been doing my dental identifications for the 25 last nine (9) year and he does a wonderful job.

1 We have nine (9) other pathologists in -- 2 in Sudbury who help me with the -- with the, you know, 3 the complicated medical stuff; if I need a consult on a 4 liver, or a kidney, or -- or whatever, they're right down 5 the hall. 6 There's the connections to the medical 7 school, and I -- I would like an opportunity eventually 8 to talk about my direct involvement with the medical 9 school because I -- I can answer some of those questions 10 that you asked earlier more -- more specifically. 11 And then we also have the connection with 12 the -- with the University forensic science program, 13 where I -- where I'm also an adjunct professor. 14 So -- we also have a -- a very busy 15 domestic abuse, and sex -- sex assault team that -- that 16 I have some connections with. I'm, in fact, giving a -- 17 a lecture next month to a very large conference that's 18 happening in Sudbury on domestic abuse and sexual 19 assault. 20 So we have a -- a wonderful foundation. 21 Now, clearly, there are some barriers to doing this - one 22 (1) of the big barriers is the manpower in forensic 23 pathology. 24 To have a Unit of five (5) to -- that does 25 five (5) or six hundred (600) cases a year, you'd need --

1 we'd need at least a second time -- a second full-time 2 forensic pathologist. We'd probably also need a part 3 time person that could cover for vacations, and Court 4 time, and so on. 5 Now I understand that they are starting a 6 new fellowship program in Toronto. And, so that's one 7 (1) of my hopes; that that will help supply these people 8 that -- that we're going to need in the relatively near 9 future. 10 The -- the issue of body transport was 11 brought up briefly earlier; that clearly would be a 12 logistic challenge but I don't think it's -- it's 13 something that can't be dealt with. 14 North Bay is only an hour and a half from 15 Sudbury. Sault Ste. Marie is three (3) hours. Timmins, 16 three (3) hours. And the -- and the cases from Timmins 17 and north of there are already coming to me anyway. 18 If -- if I compare it to when I worked in 19 Baltimore, all the cases in the state of Maryland came to 20 Baltimore -- to the one (1) office in Baltimore. Now 21 granted most of those cases were from the city, and were 22 from the area around Washington, D.C., but they did 23 transport bodies, in some cases, a number of hours. The 24 far west border of Maryland was five (5) hours away. 25 So -- so it -- it can be done. The cost

1 of that, you know, obviously is going to be an issue for 2 somebody; that -- that's outside my -- my area. 3 The other obvious issue is that, you know, 4 we have pathologists right now in North Bay and Sault 5 Ste. Marie who are doing lots of coroner's work. 6 They've been doing it, some of them, for 7 many years. They've been doing good work, and I 8 certainly have no interest in stealing their work, and -- 9 and stealing their income and, so obviously this is not 10 something that's going to, you know, that could happen, 11 or should happen immediately, or -- or that quickly. 12 But when you look at the ages of these 13 people, particularly the -- the two (2) in Sault Ste. 14 Marie, it's going to become necessary very soon to 15 replace these people. 16 And -- and whether we're going to be able 17 to replace these people, and particularly whether we're 18 going to be able to replace these people with -- with 19 pathologists that are willing, and interested, and 20 capable of doing forensic work, is -- is a very large -- 21 large question. 22 So it -- it may not only be desirable in - 23 - in the relatively near future to have a Unit in 24 Sudbury, it may become necessary. 25 If I could just finish up with -- with

1 some of the obvious advantages of -- of having a Unit in 2 Sudbury. I -- I think it would improve the quality of 3 the work. 4 I think it would improve the consistency 5 of the work. I think we'd have a critical mass of -- of 6 people that -- that we could do some of the educational, 7 and quality things that are being done in the other Units 8 - have meetings. Have rounds. Have case conferences. 9 You know, these could be multi- 10 disciplinary. If we can get enough people centred in -- 11 in one (1) place, and I'll come back to that at the end 12 when I -- if I have an opportunity to -- to give some 13 more recommendations. 14 COMMISSIONER STEPHEN GOUDGE: Can I just 15 ask, Dr. Queen, a couple of questions that arises from 16 your complete description. 17 You do two hundred and fifty (250) of the 18 roughly five hundred (500) that might be serviced in a 19 Unit that -- such as you described. 20 The other two hundred and fifty (250), I 21 take it, are being done by people who are largely 22 anatomical pathologists? 23 DR. MARTIN QUEEN: Yes. There's two (2) 24 pathologists in Sault Ste. Marie, and there's two (2) 25 pathologists in North Bay who do quite a bit of coroner's

1 work. I don't know their exact backgrounds. I'm 2 assuming they're either general, or anatomical 3 pathologists -- 4 COMMISSIONER STEPHEN GOUDGE: Okay. 5 DR. MARTIN QUEEN: -- who've gained a lot 6 of experience. 7 COMMISSIONER STEPHEN GOUDGE: What I was 8 getting at was, the other two hundred and fifty (250), I 9 take it, are not spread evenly across all the other 10 pathologists in the north. 11 They are concentrated in three (3), or 12 four (4), or five (5), or six (6) pathologists who have, 13 in effect, made this a part of their daily work? Is -- 14 DR. MARTIN QUEEN: Yes, and in 15 northeastern Ontario there only are pathologists in Sault 16 Ste. Marie, North Bay -- 17 COMMISSIONER STEPHEN GOUDGE: But I 18 assume not all -- 19 DR. MARTIN QUEEN: -- Sudbury. 20 COMMISSIONER STEPHEN GOUDGE: -- the 21 pathologists in the Sault do forensic medicine. Some of 22 them do only hospital pathology, or am I wrong about 23 that? DR. MARTIN QUEEN: Well I -- I think 24 there only are two (2) pathologists in -- 25 COMMISSIONER STEPHEN GOUDGE: Okay. So

1 then they do everything. 2 DR. MARTIN QUEEN: And of the -- and 3 there's four (4) pathologists in North Bay, and only two 4 (2) of them do coroner's work. 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 Okay, what I was getting at was whether you could have 7 some kind of full-time equivalent component that might 8 be, although the Unit based in Sudbury might be resident 9 elsewhere, doing hospital pathology as well. 10 Is that realistic? 11 DR. MARTIN QUEEN: Yeah, you're kind of 12 talking about a virtual Unit. 13 COMMISSIONER STEPHEN GOUDGE: Yes. 14 DR. MARTIN QUEEN: And that has some 15 advantages, and it has some significant disadvantages -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. MARTIN QUEEN: -- and for the long 18 term, I would be apposed to that -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. MARTIN QUEEN: -- but -- 21 COMMISSIONER STEPHEN GOUDGE: And we have 22 heard a lot -- 23 DR. MARTIN QUEEN: -- in the -- 24 COMMISSIONER STEPHEN GOUDGE: -- about 25 the advantages of a real Unit, as opposed to a virtual

1 Unit. 2 DR. MARTIN QUEEN: Yes. 3 COMMISSIONER STEPHEN GOUDGE: Part of the 4 issue is, this is Ontario? 5 DR. MARTIN QUEEN: Yes. 6 COMMISSIONER STEPHEN GOUDGE: Thanks. 7 Oh, the one (1) other question I wanted to ask you, what 8 is the forensic sciences program at Laurentian? It's at 9 Laurentian I assume? 10 DR. MARTIN QUEEN: Yes. I -- I don't 11 know the details of it. It's run by the forensic 12 anthropologist, Dr. Scott Fairgrieve, and basically all 13 of his students come to my morgue and watch at least one 14 (1) autopsy. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. MARTIN QUEEN: And I go at least once 17 a year and I give his class a lecture. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 Right. And the career paths of the students in that 20 program, do you have any sense of what that is? 21 DR. MARTIN QUEEN: Not a lot. Some of 22 them I know have applied for jobs at the Centre of 23 Forensic Science in Toronto. 24 COMMISSIONER STEPHEN GOUDGE: Some might 25 be interested in policing and so on?

1 DR. MARTIN QUEEN: I think some go into 2 policing, yes. 3 COMMISSIONER STEPHEN GOUDGE: Okay, 4 thanks. Thanks, Mr. Sandler, sorry. You can turn your 5 mic off, Dr. Queen, unless -- 6 MR. MARK SANDLER: Not yet. 7 COMMISSIONER STEPHEN GOUDGE: Not yet. 8 MR. MARK SANDLER: Not so fast. 9 10 CONTINUED BY MR. MARK SANDLER: 11 MR. MARK SANDLER: Dr. Queen, just one 12 more question along these lines, and that is, that if 13 Sudbury were designated a -- a unit in the way that 14 you've described, or another Centre of Excellence, would 15 you contemplate that the pediatric cases that are 16 currently shipped to Toronto would be done at your unit? 17 DR. MARTIN QUEEN: Yes, I think that 18 should happen. That would require either the second 19 full-time pathologist to be totally competent in -- in 20 that area, or if I was the one that was going to take on 21 that job, I would require some additional refresher 22 training. 23 MR. MARK SANDLER: All right. 24 Dr. Chiasson, you've been very patient. 25 I'm now going to direct a couple of questions to you, if

1 I may. First of all, you've heard what Dr. Queen has -- 2 has had to say, and at current -- currently, the -- the 3 pediatric cases that have been the subject of this 4 Inquiry make their way down to your unit. 5 What do you think of Dr. Queen's proposal? 6 What advantages or disadvantages do you see associated 7 with it? 8 DR. DAVID CHIASSON: Well I'm very 9 impressed with Dr. Queen's proposal, and should it every 10 come to fruition, I'd want an application form for the 11 second position. I'd certainly take that into 12 consideration. This would be his chance to get back at 13 me since I -- I was his boss a few years ago. 14 No, it's -- it's -- it's a model that is 15 really based on the Southern Ontario Forensic Pathology 16 Unit models. And assuming that pediatric cases 17 specifically continue to be done in these other forensic 18 pathology unit models which seem to be, I think, 19 continuing to be alive in the reali -- realistic 20 situation. 21 I would encourage pediatric cases being 22 done there. It -- it actually though -- it really moves 23 into what I think is -- perhaps the message that I didn't 24 get an opportunity to -- to say before, and that I -- I 25 envision a system where the unit in the Hospital for Sick

1 Children would act as a central sort of core unit which 2 would provide whatever expertise these other units -- and 3 I'm not only talking now about a potential unit in 4 Sudbury, but also the other units in southern Ontario 5 where we could offer the -- the specialized pediatric 6 pathology assistance that might be required to -- the 7 pediatric neuropathology, the complex cases, provide 8 consultative expertise. 9 And -- and -- and develop closer liaisons 10 than has been the -- the case to date. I think there's a 11 wonderful opportunity there; not only in terms of -- of 12 working relationships, but also educational 13 relationships. 14 Dr. Queen makes reference to needing a 15 little bit of added training, and I would think that the 16 place to do that would be the unit in -- at Sick Kids 17 where we could arrange some kind of training exposure. 18 And -- and also at the same time, the -- 19 this opportunity for him to come down would -- another 20 advantage would be just developing relationships not only 21 with -- with myself in terms of forensics, but also with 22 the other -- my colleagues in the -- on the more 23 pediatric side of -- of things. 24 I -- I think it's -- I would heartedly 25 support the notion of developing a unit in -- in Sudbury

1 based on what Dr. Queen was saying, and -- and 2 specifically in terms of pediatrics. I would see that 3 being part of the -- the work of -- of such a unit with 4 the -- as already indicated, the appropriate training, 5 and the appropriate personnel with the right kind of 6 experience working within that context. 7 COMMISSIONER STEPHEN GOUDGE: Dr. 8 Chiasson, could I ask you to elaborate a little more on 9 what this specialized support that your unit at Sick Kids 10 might provide, not just to this unit but to the other 11 regional units sort of on a case-by-case basis that as I 12 can envisage the training exchange, the educational 13 exchange and so on? 14 But a difficult case arrives at Dr. 15 Queen's doorstep. How does your unit actually manifest 16 that expert support; is it through telepathology; is it 17 through exchanges electronically of the slides? 18 How do you see that unfolding on a case- 19 by-case basis? 20 DR. DAVID CHIASSON: Well, I -- I see it 21 unfolding from -- from the word go that a coroner becomes 22 aware of a case that is potentially problematic -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. DAVID CHIASSON: -- the triad type of 25 case --

1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID CHIASSON: -- subdural 3 haemorrhage -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID CHIASSON: -- for example. I 6 think there would be discussions early on with the 7 pathologist in Sudbury to say, okay, you know, are you -- 8 are you comfortable with -- with going ahead with this 9 and -- and if not, there may be some cases which -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 Within the -- 12 DR. DAVID CHIASSON: -- the file position 13 should be -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. DAVID CHIASSON: -- transported. 16 COMMISSIONER STEPHEN GOUDGE: But let's 17 take a case where the decision is, we will leave the 18 autopsy in the autopsy suite in the new Sudbury facility. 19 20 How, in sort of on the ground terms, does 21 that specialized support kick in? 22 DR. DAVID CHIASSON: Well, again, I -- I 23 think -- I think you can envision consultation upfront, 24 see what you have, consultation after the autopsy to say, 25 okay, this is what I found or I didn't find. Or, as you

1 suggest, telemedicine, telepathology, some form of, okay, 2 we've got this finding, what do you think? Is there 3 something more to be done? 4 I mean, the main -- the main thing -- the 5 main crux of -- of any forensic pathology investigation 6 is to ensure that the procedures, the appropriate 7 procedures, are done and that whatever needs to be done 8 is done before the body is released. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. DAVID CHIASSON: And as long as you 11 have that material -- if -- if, for example, it turned 12 out to be you had a complicated triad case, yes, there's 13 a -- a neuropathologist in -- in Sudbury and I -- I think 14 that's a very important component of -- of any unit that 15 you do have good neuropathology support. 16 But it may be -- the decision may be, in 17 this case, let's get a pediatric neurpathologist with 18 forensic experience in this specific area. The brain's 19 retained, the brain is sent down. And -- and then we 20 provide that -- that sort of service. We provide a 21 service of reviewing slides in terms of potential medical 22 issues following the autopsies. 23 But -- but as long as the -- the autopsy 24 is done and everything is documented in a reviewable 25 fashion, if down the road there's a necessity to say,

1 okay, these are the findings, there may be -- you may 2 need a second opinion as to how to interpret the 3 findings, as long as you've got that -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID CHIASSON: -- information, 6 everything you can get from the body is gotten in an 7 appropriate way, then I think that's the crux of it. And 8 you can always deal with whatever comes down the road 9 down the road. 10 COMMISSIONER STEPHEN GOUDGE: That's 11 helpful. Thank you. 12 13 CONTINUED BY MR. MARK SANDLER: 14 MR. MARK SANDLER: Dr. Porter, perhaps 15 we'll allow you to -- to express your opinion on -- on 16 what we've been talking about in the last few moments. 17 You've heard what Dr. Queen has had to say about the 18 potential of expanding the Centres of Excellence to 19 include Sudbury. 20 What are your thoughts on that? 21 DR. BONITA PORTER: I would be very 22 supportive of that idea and, indeed, it would -- would 23 add weight to our belief that we need a second regional 24 Coroner's Office in the North. And having a forensic 25 unit in Sudbury would -- would make that the ideal

1 location for it. 2 And the things that we've been talking 3 about, the collaboration, the teamwork, the decision- 4 making could all be facilitated by the regional 5 supervising coroner. So I would be very supportive of it 6 and, indeed, it would add support to our belief that we 7 need a second regional office in the North. 8 COMMISSIONER STEPHEN GOUDGE: As I 9 recall, Dr. Eden, now you go right up the whole way east 10 essentially? 11 DR. DAVID EDEN: That's -- that's 12 correct, sir, from, basically from North Bay to the -- or 13 south of North Bay, Parry Sound, all the way over to the 14 Manitoba border. 15 16 CONTINUED BY MR. MARK SANDLER: 17 MR. MARK SANDLER: And can you refresh 18 our collective memories, Dr. Eden, as to -- as to why 19 that geographical region is -- is defined in that way at 20 present? 21 DR. DAVID EDEN: That was not a decision 22 of the Chief Coroner's Office. It was a decision of 23 government that boundaries for Ministries and agencies 24 within Ministries would be set uniformly across the 25 province. So that was something given to us that was

1 required for us to put into place. 2 MR. MARK SANDLER: And -- and you recall 3 -- I'm going to ask this same question of Dr. Porter in a 4 moment, but you recall that I asked you last time you 5 were here about whether you envisaged a model where -- 6 with breaking the northern region into two (2) separate 7 regions, each with a regional supervising coroner, or 8 maintaining the current geographical region but with two 9 (2) regional supervising coroners. 10 Have you had any further thoughts about 11 which of those two (2) models is more appropriate? 12 DR. DAVID EDEN: Yes. At the time that 13 you asked about those, I had -- I was fairly new on the 14 job. And I'd still say I'm fairly new, but I've had some 15 time to turn my -- my mind to it. 16 If you look just at numbers, the numbers 17 for the north region would balance with other regions. 18 But there are significant differences in the north which 19 I'm getting much more knowledgeable about as time goes 20 by. 21 It is an immense geographic area and -- I 22 won't dazzle you with numbers. From an operational point 23 of view, what that means is that there are substantial 24 logistical issues, including travel time, in that when I 25 was regional coroner for Niagara, I could easily do four

1 (4) meetings in a day in different parts of the region. 2 Unless I'm assigned a Lear jet, that's not going to 3 happen here. 4 And as well, there's weather and other 5 issues that would get in the way, so, an out-of-town 6 meeting, if I can get one (1) done a day, it's good, and 7 sometimes it's two (2) days on the road to get one (1) 8 meeting accomplished. So that there's that aspect. 9 There's also more coroners. There's 10 sixty-one (61) coroners in this region. The region I was 11 in before had twenty-four (24). And it's certainly the 12 region with the largest number of coroners and I think 13 all of those coroners need a supervisor that they see and 14 can -- can call and know. And one (1) of the things I'm 15 doing is -- is going out to meet them as early as I can, 16 but there are more coroners than in the other regions. 17 The demographics here are that this region 18 really is two (2) regions. If you look at the way 19 population is, there -- there really is a northwest and a 20 northeast. It's not an arbitrary division. You have an 21 area which is centred on Sudbury and you have an area 22 which is centred on Thunder Bay, and there's an area 23 between them which has very low population. So there 24 really is a division there. 25 COMMISSIONER STEPHEN GOUDGE: Where would

1 you see the dividing line being, about the Sault? Sault 2 would be in the Sudbury? I mean if you were drawing a 3 line on a map. 4 DR. DAVID EDEN: I think -- well, there's 5 two (2) conflicting things we'd have to take into 6 account. One (1) is catchments of the forensic 7 pathology -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. DAVID EDEN: -- units or the 10 pathology units, and if we did it in that -- if we did it 11 in that way then we'd... 12 COMMISSIONER STEPHEN GOUDGE: -- Sault -- 13 DR. DAVID EDEN: Yeah, we'd probably make 14 a division with Sault Ste. Marie and Kapuskasing, so that 15 then I think would be Cochrane -- yeah, Cochrane and 16 Algoma being the cutoff point I've included in the -- the 17 northeast. 18 However, we would also want to ensure that 19 caseloads are balanced for the two (2) regions because 20 the population of the northeast is greater than the 21 northwest. And so if we wanted to ensure that the two 22 (2) regional offices had comparable caseloads, Algoma 23 numerically might go with the northeast. I think it's an 24 area that would require study to see what's the -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

1 DR. DAVID EDEN: -- best way to do that. 2 COMMISSIONER STEPHEN GOUDGE: -- right. 3 DR. DAVID EDEN: Yeah. And I think the - 4 - the other matter here is that the intensity of cases is 5 -- is greater in northern Ontario. There's many more 6 remote cases which actually are -- can be more time- 7 consuming to manage. 8 The suicide rate is higher in -- in the 9 north, particularly in First Nations, and that's quite 10 reasonably -- that increases the intensity of the cases. 11 I just call "intensity" the amount of time that has to be 12 spent by the investigators on a case. And the accident 13 rate in northern Ontario is also higher. 14 So if we look at numbers, we'd find that 15 there's a slightly higher rate of suicides and accidental 16 deaths in the north, which increases the workload of the 17 regional manager. And, of course, there are specific 18 issues in the north, like liaison with First Nations, 19 which is important but also changes the intensity of the 20 work. 21 So when I had first spoken of this, I was 22 considering it, and I can say now after having had an 23 opportunity to think about it, I think that there is a 24 good business case in terms of providing good services to 25 the members -- to -- to the community to having two (2)

1 regional offices. 2 And I think the other thing, of course, 3 and Dr. Queen has mentioned this, is having the Regional 4 Coroner on site at the two (2) busiest pathology units, 5 Sudbury and Thunder Bay; it's clear that having the 6 Regional Coroner on site adds value there. 7 8 CONTINUED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: All right, Dr. Porter, 10 unless the recommendation were made that Dr. Eden gets a 11 Lear jet which was accepted by government, do you share 12 his view that -- that the preferable model of the two (2) 13 that I put forward is -- is the one (1) that -- that he's 14 advocating for? 15 DR. BONITA PORTER: I get a jet before he 16 does. There are a number of lists -- of things on our 17 priority list before that kind of transport, but I 18 support everything that Dr. Eden has said. 19 I believe that the Regional Supervising 20 Coroner is the key piece to high quality death 21 investigation in Ontario and frequency of visits, having 22 a face in the community, the -- knowing your -- your 23 coroners, knowing the pathologists who are providing the 24 services for you, having good relationships with the 25 police and other -- other members of the team I think is

1 critical to us being able to provide a good service, and 2 -- and you can't do that if it takes you four (4) days to 3 get to any place. So, I think that I would support 4 everything that's being said and I think that's 5 essential. 6 One (1) of the things that I believe we 7 need is additional regional coroner's support in every 8 region and, indeed, whether that be two (2) regional 9 coroners in the north or one (1) regional and one (1) 10 assistant regional, we could certainly work that out, but 11 the regional coroners are -- are the gatekeepers, they're 12 the ones who are -- I hold accountable for the quality of 13 the investigation in the region and they need additional 14 support, and certainly in a region like the north, it's - 15 - it's too big for one (1) person. 16 MR. MARK SANDLER: And just a very quick 17 followup question on that. When Dr. Eden was here last 18 time he also identified a number of supports that he -- 19 he'd like to see in place, and -- and Dr. Legge shared 20 his views having just served in this region, and -- and 21 that included additional administrative support, better 22 computer facilities, and enhanced tele -- telehealth 23 facilities, and also the use of centralized dispatch 24 service, if I remember correctly. 25 And -- and do you agree that -- that those

1 enhancements are again -- are also desirable? 2 DR. BONITA PORTER: Yes, the senior 3 management of the Office of the Chief Coroner spent a 4 full day yesterday reviewing all of the things that we 5 believe are important to put forward as recommendation to 6 the Commissioner, and all of the things that you've 7 mentioned are on those -- are in that list. 8 MR. MARK SANDLER: Thank you. I'm going 9 to go back to education because I've been neglecting our 10 educators here, and before I ask them some further 11 questions, I -- I do want to give Dr. Queen an 12 opportunity to discuss the interplay between you and your 13 unit and the School of Medicine. 14 Could you describe that, please? 15 DR. MARTIN QUEEN: Yes, for about the 16 first year that the Northern Ontario School of Medicine 17 was open, I didn't have any involvement with them. It 18 then came to my attention over time that how the medical 19 students were learning their anatomy and their pathology 20 was quite different than the way that I learned it. 21 When I started medical school in Toronto 22 in the mid '70's, you know, we spent a big chunk of our 23 first year doing a detailed slow dissection of a real 24 human body, we -- you know, there was I think two hundred 25 and fifty (25) something students in our class and -- and

1 we were divided into groups of six (6) and we each had 2 our own body for the first year, so there -- you know, 3 there was a lot of bodies being dissected, and that's -- 4 that's how we learned a lot of our anatomy and some 5 pathology, and these were embalmed bodies; it wasn't 6 perfect, but it wasn't bad. 7 Now, I -- I learned that in -- in the 8 Northern Ontario School they're doing it differently, 9 they -- I believe they're learning their anatomy and -- 10 and some of their pathology through -- through textbooks, 11 I -- probably through computers; they're getting some 12 exposure to some formal in fixed individual organs, I 13 think they're looking at plasticized models. 14 We could probably debate it at length at 15 another time about the advantages and disadvantages of 16 these -- of these systems but, needless to say, I thought 17 that we could add to it. 18 So I approached one (1) of the other 19 pathologists in Sudbury, Dr. Michelle Bonnett (phonetic), 20 who has a fair bit of involvement with the medical school 21 and who is interested in education, and he subsequently 22 had some conversations with Dr. Ascott (phonetic) here in 23 Thunder Bay, and we, ultimately, put together a proposal 24 which was sent to the medical school and ultimately 25 accepted.

1 And -- and the -- basically what's 2 happening now is all the medical students are required to 3 attend at least one (1) autopsy during their medical 4 school. The way it works in Sudbury is they usually come 5 in pairs; they're greeted by my morgue manager; she gives 6 them a package of material that -- that I put together 7 which includes some basic stuff on the coroner's system, 8 what kind of cases they should be calling when there's a 9 death. 10 If, you know, if it -- if it's a coroner, 11 it should be a coroner's case. What -- what kind of 12 people in the family have the -- the authority to -- to 13 give consent for a hospital type autopsy, and basic stuff 14 like that. 15 They then get a tour of our facility by 16 her, and they -- they learn the mechanics of it. And 17 then they observe an autopsy. And, again, these are 18 almost always coroner's cases. And -- and we -- you 19 know, we go over the -- the story of the case, and -- and 20 they watch the autopsy. I -- I generally ask them a lot 21 of questions. They ask -- some of them ask me a lot of 22 questions. 23 And the response has been uniformly 24 extremely positive. One (1) of the most common things 25 that the medical students say to me is, they say I -- you

1 know, I had no idea this is really what the human body 2 looked like inside. 3 The colours are totally different than 4 what I expected. The -- you know, the way that they're 5 learning their anatomy and pathology is -- I -- I don't 6 think they're getting the whole picture. So I -- I think 7 it's important to do this. 8 You're -- you had a question earlier about 9 the -- the elective situation. In fact, when I -- when 10 we negotiated our contract with the Medical School to do 11 this, one (1) of the things that was offered as part of 12 that package is -- is elective time for students. 13 In fact, I already have a student who's 14 going to be spending the whole month of June with me. So 15 the fact that -- you know, it's a relatively small 16 medical school, the fact that we're already getting one 17 (1) student who's -- who's that interested in pathology, 18 and forensic pathology, and is willing to spend a whole 19 month of her elective time with me, I -- to me is a very 20 positive sign. 21 And -- and I'm looking forward to -- to 22 that experience. 23 MR. MARK SANDLER: I've spent the last 24 four months on forensic pathology, do I get credit for 25 that?

1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 DR. MARTIN QUEEN: You have to come and 3 watch one (1) of my autopsies. 4 5 CONTINUED BY MR. MARK SANDLER: 6 MR. MARK SANDLER: If I can turn to Dr. 7 Strasser, and Dr. McCready. You've outlined some of the 8 initiatives that -- that exist in the school that -- that 9 are responsive to -- to the issues that I've raised with 10 you. 11 Another issue that's been identified at 12 our Inquiry is -- is the obvious need, if at all 13 possible, to have Aboriginal doctors and, in particular, 14 Aboriginal coroners serving in the North. 15 Is there anything more that the School of 16 Medicine can do to enhance that objective? 17 DR. ROGER STRASSER: Yes. The Northern 18 Ontario School of Medicine really since -- since the very 19 beginning has -- has worked very hard, and continues to 20 work to develop relationship with Aboriginal communities, 21 and organizations. And -- and, so that's made possible 22 some of the initiatives that I've mentioned. Recruiting 23 Aboriginal people to be students in the Medical School. 24 We have Aboriginal people involved as 25 staff, as faculty members. We have Elders actively

1 involved in -- in all aspects of the school, including 2 the senior leadership group. 3 So essentially, we're working very hard 4 for the school to be an Aboriginal friendly school, and 5 this has created a -- a kind of relationship that -- that 6 opens up other possibilities, and other opportunities. 7 So the students, as I mentioned, the first 8 year of the MD program have -- have four (4) weeks, where 9 they're living and learning in Aboriginal communities. 10 That's lead to those communities -- it's 11 been a very positive experience by and large; not for 12 everybody, and -- and you can imagine there's some -- 13 sometimes some difficulties. 14 But, generally it's been positive both for 15 the students and for the communities. So it's led to -- 16 to the communities looking for more students, residents 17 as well as -- as medical students, and being more 18 involved in education. 19 And -- and the -- and the communities 20 coming forward and -- and suggesting research 21 initiatives, and one (1) of the difficulties when you get 22 into research, and Aboriginal people is that the -- 23 historically, their experience has been quite negative. 24 That they see researchers as people that come and steal 25 their knowledge, and that the research -- they -- they

1 don't find any benefit to them, of -- of the research 2 that's undertaken. 3 So that there's at least suspicion, if not 4 hostility, towards researchers by and large amongst 5 Aboriginal people, people in First Nations. 6 So we have established a -- a different 7 kind of relationship with -- with those -- the people in 8 those communities, which is now leading to some new and 9 different opportunities for working with Aboriginal 10 people, undertaking research, and -- and new 11 opportunities, I guess, for -- for addressing some of the 12 major social and health issues that -- that Aboriginal 13 communities experience. 14 COMMISSIONER STEPHEN GOUDGE: Do you do 15 outreach, Dr. Strasser, into Aboriginal communities to 16 try to attract students? 17 DR. ROGER STRASSER: Yes. We have an 18 extensive recruitment program, and -- and essentially we 19 go to considerable lengths to encourage Aboriginal people 20 to -- to see themselves as potentially -- young people to 21 see themselves potentially future physicians, and get 22 into our medical school. 23 It starts actually with our students being 24 in the community so that -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

1 DR. ROGER STRASSER: -- that those 2 students are kind of role models, really -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. ROGER STRASSER: -- and they take 5 with them a little -- little kits of medical stuff, you 6 know, a -- a stethoscope, and a tendon hammer and stuff 7 and they go into the schools and they talk about Universe 8 -- being a University student and -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. ROGER STRASSER: -- and -- and health 11 and medicine. 12 We have a -- for students at the high 13 school level, we have each year summer science camps, and 14 these are specifically for students who are either from 15 Aboriginal or Francophone backgrounds. 16 They spend a week at -- at the University 17 campuses, and they undertake activities that make the 18 connection between the science they study at high school 19 and health. 20 And they -- they're held in the summer and 21 the -- the -- the past summer. In fact the -- the whole 22 week was organized around a CSI investigation sort of 23 theme. So I guess you could say there's a foren -- 24 forensic element in the way that we do that. The 25 students love it. There's a great response from the --

1 from the high school students. So that's another way in 2 which we're encouraging -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. ROGER STRASSER: -- that. We also 5 have a special Aboriginal admissions stream for the 6 school. The Aboriginal people themselves really demanded 7 that the academic standards and the -- and the admission 8 requirements are the same for their people to our school 9 as -- as for any other entrant to the school, and that is 10 the case. 11 But in every other way we -- we provide 12 support and encouragement for Aboriginal people to apply, 13 so we run special sessions to help them to -- to put in a 14 sound application. 15 And then part of our admissions process is 16 interviews, and we've run special sessions for the 17 Aboriginal applicants to help them trying to perform well 18 in the interviews. 19 So we -- we put a lot of time and effort 20 into encouraging Aboriginal people to become students in 21 our -- in our school, and then -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. ROGER STRASSER: -- future 24 physicians. 25 COMMISSIONER STEPHEN GOUDGE: Right.

1 Thank you. Sorry, Mr. Sandler. I'd just like to come 2 back, and a question I wanted to ask you, Dr. Queen, in 3 terms of your growing role in the educational process. 4 When, take for example, the students 5 you're going to have doing the elective, that will be an 6 elective what, in third or fourth year of the 7 undergraduate medical program, is that right? 8 DR. MARTIN QUEEN: Yes, I'm -- I'm not 9 sure exactly what year she's in -- 10 COMMISSIONER STEPHEN GOUDGE: But it's an 11 undergraduate elective? 12 DR. MARTIN QUEEN: Yes. 13 COMMISSIONER STEPHEN GOUDGE: Would a 14 component of that enable her to sort of work with and 15 watch as you develop, for example, your post-mortem 16 report, and perhaps even watch you, if the opportunity 17 arose, give evidence, that kind of thing? 18 In other words, the aspect of your -- of 19 your work that is perhaps more forensic, if I can put it 20 that way, than pathology? 21 DR. MARTIN QUEEN: Yes. This is going to 22 be a unique experience for me. I've never had an 23 opportunity to have a whole month with one (1) -- one (1) 24 student, and I -- and we haven't actually sat down and 25 specifically designed what's going to -- going to happen

1 in that month. 2 But I see her being involved in the whole 3 process right from the beginning with the interactions 4 with the coroner and the police, and -- and through the 5 autopsy procedure, subsequently sitting down with me at a 6 multi-headed microscope and looking at the -- at the 7 slide. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. MARTIN QUEEN: Work -- in cases where 10 we save the brain, she would go and watch the 11 neuropathologist -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. MARTIN QUEEN: -- dissect the brain. 14 And we would discuss how you put reports together, how -- 15 how you bring everything together to -- to get a good 16 quality product in the end. 17 And if I have to go to court during that 18 month, I would bring her along to watch me testify. So 19 I -- 20 COMMISSIONER STEPHEN GOUDGE: It's 21 clearly the way you interact with the legal system after 22 you've done your work is a significant part of the 23 forensic medicine you do? 24 DR. MARTIN QUEEN: Absolutely. 25 COMMISSIONER STEPHEN GOUDGE: Sorry, Mr.

1 Sandler. 2 3 CONTINUED BY MR. MARK SANDLER: 4 MR. MARK SANDLER: And, Dr. McCready, I 5 want to ask you -- I think you wanted to make a comment 6 on what's just been said. I also want to ask you, if you 7 would, to comment on the importance of telemedicine and 8 how that factors into the work of the school, because 9 we've heard a lot about telemedicine in the course of our 10 Inquiry. 11 MR. WILLIAM MCCREADY: I just wanted to 12 say on the elective side, almost certainly the student 13 Dr. Queen is talking about will be a -- beginning their 14 fourth year in -- in the school. 15 Electives are used by students for several 16 purposes: One (1) is just to increase knowledge, 17 something -- where they may feel they have an educational 18 gap, but more frequently students are using electives to 19 -- to make career choices in fourth year. 20 And we -- we actually front-load our -- 21 our final year of the MD program to allow students to 22 have lots of elective experience early on so that they're 23 able to make application to the residency matching 24 positions that they'll be seeking later. 25 So I would strongly suspect that the

1 student who's going to Dr. Queen is, in fact, 2 contemplating a career in at least pathology, if not 3 forensic pathology, and that's why their interested in 4 coming. 5 So that -- I mean, that really is 6 fulfilling the mandate of the school. In terms of 7 videoconferencing and telemedicine, the school being as 8 geographically divergent as we are, uses technology for 9 multiple purposes, educational purposes. 10 So Dr. Strasser talked about what we call 11 whole group sessions which is what you might consider a 12 lecture. They're conducted on our -- on our -- our two 13 (2) campuses with videoconferencing connections between 14 them. We have "smart" classrooms where students are able 15 to see slides that might be presented, et cetera, at both 16 sites. 17 When our students are out in the third 18 year in the -- in the large rural or small urban centres 19 that Dr. Strasser talked about, they're continuing some 20 classroom work in that time and they may not, in fact, be 21 in the same community as their classmates, and that's all 22 conducted by -- by videoconferencing. The school has put 23 lots of resources into enhancing videoconferencing in 24 these communities so that we don't interfere with 25 telemedicine. We do a lot of our business work in the

1 electronic medium, a lot of teleconferencing and a lot of 2 videoconferencing as well. 3 On top of that, telemedicine is a large 4 part of what I, and other physicians, do in our daily 5 work as -- in taking off our academic hats and putting on 6 our -- our doctor hats. So, for instance, once or twice 7 a month I -- I would have a telemedicine session where I 8 would meet with patients who would live in some of the 9 communities that you have on your map here. 10 Fort Severn stands out. I can recall, in 11 the days before telemedicine, doing a consultation with a 12 patient from Fort Severn who was seeing me for fairly 13 simple hypertension. And I got to talking to the fellow 14 afterwards - he happened to speak very good English - and 15 asked him how long it took to get there, and he said two 16 (2) days because he had to overnight in Sioux Lookout 17 'cause of the connections. 18 MR. MARK SANDLER: And he didn't have 19 hypertension before he came to see you. 20 DR. WILLIAM MCCREADY: Right. So -- and 21 so telemedicine's becoming an increasingly important part 22 of how we deliver health care in the north. The 23 distances, indeed, are huge. 24 I think I mentioned in some pre- 25 conversations that I -- in my nephrology life, I have

1 satellite dialysis units that I'm giving care to patients 2 on in Fort Frances and Sioux Lookout, and for -- if you 3 look at the map, it looks a little -- a little different. 4 I think when -- in -- in the days before the medical 5 school came along, when I was involved in the Northern 6 Ontario Medical Program, we had a saying that if you 7 really wanted someone to appreciate the geography of 8 northern Ontario, you should not let them fly here, you 9 should make them drive. 10 MR. MARK SANDLER: Right. 11 DR. WILLIAM MCCREADY: So to get to Sioux 12 Lookout, it's a four and a half (4 1/2) hour drive as 13 long as the OPP are relatively friendly. And it's a -- 14 it's a three and a half (3 1/2) hour drive to Fort 15 Frances for us to visit our patients, and the same is 16 true for patients who visit us. 17 So telemedicine is an integral part of 18 practice and it's part of what we will be modelling and 19 teaching our students how to -- how to do that 20 effectively as well. 21 COMMISSIONER STEPHEN GOUDGE: As it gets 22 better, Dr. McCready, I assume any deficit in the actual 23 treatment through telemedicine is diminishing; that is, 24 if I said to you, What cost is there in quality of care 25 to the use of telemedicine, what would you say?

1 DR. WILLIAM MCCREADY: I think as we are 2 getting smarter about it, we -- I mean we're -- I'm pre- 3 screening, and I'm sure all my colleagues are, the type 4 of patient we will see by telemedicine. And frequently I 5 will see the patient for the first time in my office, but 6 conduct most of my follow-up visits by telemedicine. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. WILLIAM MCCREADY: But as the 9 technology gets better -- we now have electronic 10 stethoscopes where -- which are really quite 11 sophisticated and it really is as good as listening to 12 the patient's heart yourself. 13 There are cameras dedicated, for instance, 14 to dermatology which give you excellent views of the 15 skin. And I know my dermatological colleague in Thunder 16 Bay is doing a lot of this work and it's -- dermatology 17 is by and large a visual specialty. He looks at it and 18 tells you the diagnosis, so he's able to do that as well. 19 So we are getting better and the technology's getting 20 better. 21 We're hearing of some innovations at the 22 Thunder Bay Regional on minimally invasive surgical 23 suites where they're doing sort of laparoscopic work. 24 We're now starting to see the technology coming that will 25 connect that kind of work out of the operating room so

1 that we can do -- 2 COMMISSIONER STEPHEN GOUDGE: You can do 3 it for both -- 4 DR. WILLIAM MCCREADY: -- educational 5 sessions, for instance, with that. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 That's interesting. Thanks. 8 9 CONTINUED BY MR. MARK SANDLER: 10 MR. MARK SANDLER: Yes, Dr. Strasser? 11 DR. ROGER STRASSER: Just to sort of add 12 to what Dr. McCready said, as you heard in my 13 introduction -- or the introduction of me is that I come 14 from another part of the world. And when I came here and 15 discovered what's now Ontario Telemedicine Network, I was 16 mightily impressed. So the Ontario Telemedicine Network 17 stands out as a world-leading example of -- of 18 telemedicine. And so that the examples that have been 19 mentioned really function as well or better than you find 20 in many other parts of the world. 21 In terms of the relationship with the 22 medical school, as Dr. McCready says, we have added to 23 and supplemented -- complemented the existing facilities 24 and infrastructure that's in place, and we've done that 25 through a partnership with Ontario Telemedicine Network.

1 So our approach has been to build on 2 existing capacity and enhance that rather than 3 duplication and -- and -- and I think that that's been to 4 the benefit, not only of our -- our students and 5 residents and our faculty members, but to Northern 6 Ontario as a whole. 7 MR. MARK SANDLER: All right. We're 8 going to revisit, Commissioner, telemedicine in the 9 context of site inspections in our -- in our next panel. 10 So if I can turn to each of you briefly 11 and invite you to make any final comments or 12 recommendations that you'd like the Commissioner to 13 consider. 14 Dr. Queen, I'll turn to you first. 15 DR. MARTIN QUEEN: Yeah, just to finish 16 the -- what I was saying earlier about having a unit 17 where you have a critical mass of -- of -- of bodies and 18 you have a critical mass of -- of people to -- to take 19 care of that business, and I was talking about having 20 educational meetings and -- and things that improve the 21 quality, and I -- I think I mentioned that, you know, 22 these should be multi -- multi-disciplinary. 23 So I -- I also strongly support that 24 there's some kind of a -- a Regional or Co-regional or -- 25 or Assistant Regional Coroner that -- that would be in a

1 -- in Sudbury, for example, if there was a unit there, so 2 that when we have these meetings we -- we could have the 3 forensic pathologist, the -- the local coroner, the 4 Regional Coroner. We could have the neuropathologist if 5 we need her. We could have the anthropologist and so on. 6 In addition to that, it would be ideal if 7 some other people could regularly participate in these 8 things and -- and the present set-up mitigates against 9 that to some extent. I'm -- I'm thinking of -- of the 10 police, for example. 11 I understand there used to be an OPP 12 forensic unit in Sudbury but, for some reason that I know 13 nothing about, it was removed from Sudbury and there's 14 presently OPP forensic units in North Bay and in Sault 15 Ste. Marie. 16 And as we continue to do more cases from 17 those areas, it means the police have to travel from 18 those cities because we usually need an OPP forensic 19 officer when we're doing these cases. 20 So, I mean, if I was going to be selfish, 21 I -- you know, it would be better for -- for my vision 22 that -- that we had a -- an OPP forensic unit moved back 23 to Sudbury. I -- I have no idea if that's doable or not. 24 The other -- the other, again to be 25 selfish, it would be better for -- for me and if I had a

1 unit in Sudbury, that -- that it was some kind of Centre 2 for Forensic Science there. Presently, most of our stuff 3 goes to the unit in Sault Ste. Marie. I know nothing 4 about the history of why it ended up in Sault Ste. Marie. 5 There presumably are very good reasons. 6 But, again, it would be nice to have a 7 unit in Sudbury and to have a toxicologist in Sudbury 8 that could come to these meetings, because toxicology is 9 a big part of what we do. And I remember when I was in 10 Toronto, we had toxicology meetings, and it -- it often 11 was very helpful to sit across the table from these 12 people. 13 So, again, I have no idea if that's doable 14 or if anybody's considered it. But, again, from a 15 selfish point of view, that's something that -- that I 16 would like. 17 I'm just going to finalize my comments 18 with a little discussion of technology which has come up 19 quite frequently. One of the things that our pathology 20 department has talked about quite -- quite a bit recently 21 with our hospital is this issue of voice-recognition 22 dictation technology. This is basically where, instead 23 of just dictating into a tape recorder, you dictate into 24 a computer system and everything comes up automatically. 25 And this is something that's -- that's

1 getting a lot of play in -- in the surgical pathology 2 side, especially with the cancer cases, because they've 3 developed all these protocols and templates and 4 guidelines and so on. They're kind of ahead of the 5 forensic system in that -- in that scheme of things, and 6 so they're developing that. 7 And it would be ideal for forensic 8 pathology too because we are -- most of us already have 9 templates in our computers. It's kind of a fill-in-the- 10 blank thing. But -- but we still have to usually dictate 11 for a secretary to type it up and so on. 12 And the secretarial burden is something 13 that -- that we deal with a lot. We used to have four 14 (4) secretaries. We presently have two (2). And 15 sometime -- and -- and because I'm competing with the 16 other pathologists for their time, and the live always 17 gets -- the live people's cases always get priority over 18 the dead people's cases, I often have trouble getting 19 access to the secretaries. I sometimes do my own 20 reports. They try their hardest and one (1) of the 21 secretaries often stays after hours, but it's a problem. 22 And, certainly, I think voice-recognition dictation 23 technology would -- would -- would deal with that to a 24 large extent. 25 The other area where I think this could be

1 very helpful and there's been a lot of discussion at the 2 -- at this Commission about it, is the improved 3 documentation, particularly between forensic pathologists 4 and police; what the police say at the beginning of the 5 autopsy, what the -- what the forensic pathologist says 6 at the end of the autopsy, and are we communicating 7 properly. 8 It would be a very simple set-up in -- in 9 my unit, where there's two offices with computers and 10 with printers and fax machines and everything, to have a 11 dictation system where I, at the end of the autopsy, I 12 could say to the police, Just give me another five (5) or 13 ten (10) minutes. I sit down at this system. I do a 14 very quick dictation of the significant gross findings 15 and some organ weights and stuff. I do a one (1) or two 16 (2) sentence dictation on -- on what my understanding of 17 the case is from the coroner and from the police, and 18 then I do a little quick dictation of -- of my 19 preliminary findings and -- and my preliminary diagnosis. 20 I -- I immediately print this up on the 21 printer and right there, in black and white, I -- I have 22 copies of this. I can give one (1) to the police. It 23 goes into their rec -- to their permanent records I 24 assume. One (1) goes into my permanent records, and if 25 any of these issues come up in Court about who said what

1 and -- it's right there in black and white. 2 And I think it would be very easy to do. 3 I don't think it would be that expensive. Presently, we 4 can't do it in our hospital because the hospital doesn't 5 want to put up the money and because our managers are so 6 overworked, they just don't have the time to implement 7 this, but I personally think this would be a huge help 8 for me. 9 Thank you very much. 10 COMMISSIONER STEPHEN GOUDGE: Thanks, 11 Doctor. 12 13 CONTINUED BY MR. MARK SANDLER: 14 MR. MARK SANDLER: Thank you. Dr. 15 Chiasson...? 16 DR. DAVID CHIASSON: Well, Martin and I 17 were talking and I -- I agreed to give him his lion's 18 share of -- of my time, as well, but I -- I'll just come 19 back to one (1) point from what I did speak about earlier 20 on and add that, to really try and -- and develop a 21 system of liaisoning between the Pediatric Unit and the 22 other basically adult or mixed units, I think that's -- 23 that's a concept that's well worth exploring. 24 And one (1) -- one (1) component of that 25 could be -- and -- and I've actually started having

1 discussions with Dr. Shkrum in -- in London about him 2 actually attending physically to our rounds. 3 We have forensic pathology rounds every 4 five (5) to six (6) weeks where we discuss our cases, 5 which are all pediatric, of course, at -- at our unit, 6 and that would provide actually an educational 7 opportunity. 8 I think that could be spread out in a 9 telemedicine type of -- of format to anyone that was 10 interested elsewhere, and so you -- you'd have the 11 opportunity to listen to the cases that we're exposed to 12 on an ongoing basis, and as well have the opportunity. 13 It could be arranged certainly to -- that 14 other pathologists and the -- and the other units could 15 actually present a case and have the benefit of the 16 expertise that we do have at the hospital that could be 17 conveyed to -- to a broader -- a broader audience. Thank 18 you. 19 MR. MARK SANDLER: Thank you very much. 20 Dr. Porter...? 21 DR. BONITA PORTER: I mentioned earlier 22 that we had a meeting yesterday to -- to draft the 23 recommendations and we're working very hard, 24 Commissioner, to give you the thirty-seven (37) pages in 25 a form that you could just endorse, so I will -- I will

1 pass my five (5) minutes on to others who may not have 2 the opportunity to work on that as we are, so that's the 3 format I'd like to present the most. 4 COMMISSIONER STEPHEN GOUDGE: Thanks, Dr. 5 Porter, I look forward to it. 6 7 CONTINUED BY MR. MARK SANDLER: 8 MR. MARK SANDLER: And Dr. Eden...? 9 DR. DAVID EDEN: No, I don't have 10 anything to add at -- at this point, thank you. 11 MR. MARK SANDLER: Dr. McCready...? 12 DR. WILLIAM MCCREADY: I'd just like to 13 put in a word for my pathology colleagues in the north 14 who don't necessarily have the special training in 15 forensic pathology, but who have been doing this work for 16 many, many years, and many of them without any problems 17 at all, so whatever system that you decide to put in 18 place, I would ask that you would remember these hard 19 working pathologists and the expertise that they have and 20 don't leave them out of the system. 21 MR. MARK SANDLER: Thank you. Dr. 22 Strasser...? 23 DR. ROGER STRASSER: Yes, I'd like to 24 cover three (3) points. And I think in some way each of 25 these points have been implicit in the discussion that

1 you've heard, but I want to make them expli -- explicit. 2 The first is that northern Ontario; the 3 geography, the demography, the range of health problems, 4 the social cultural issues are quite different from the 5 rest of Ontario, and it's important to recognize that and 6 understand that and to design system approaches that are 7 right for northern Ontario. 8 So taking a model or a system that -- that 9 works in the big city in Toronto or other parts of 10 Ontario and trying to transfer them or apply them in -- 11 into northern Ontario generally won't work, and -- and 12 unfortunately, it's the lived experience of those who -- 13 those of us in northern rural areas that quite often 14 policy decisions are made to address issues in the city 15 that have quite serious negative unintended consequences 16 in the northern and rural environments. 17 And so I just wanted to -- to emphasize 18 that point, that in considering the situation in northern 19 Ontario and -- and recommendations for the future in 20 terms of forensic pathology, to keep -- to bear that in 21 mind. 22 I think that point has been made in maybe 23 not quite a stark a way already by other speakers, but I 24 just wanted to -- to emphasize that point. 25 The second point I want to talk about then

1 is the relationship between the underground providers, in 2 this case, pathologists and -- and coroners, and -- and 3 the -- the special service units. 4 And again, and Dr. McCready's just 5 commented or made it clear on behalf of his -- his 6 colleague pathologists, the model that works best is, 7 again, a model that's been mentioned implicitly already 8 in the discussion, and that is that -- a model that 9 supports the on-the-ground providers, as the providers of 10 -- of the service. 11 So whether we're talking about the -- the 12 coroners in the communities, or the pathologists in the 13 communities, it's the same principle. 14 And that the role of the -- the 15 specialists, or sub-specialists service unit is to -- is 16 to support those service providers. 17 So it's a true consultant role. That's 18 what works best in terms of a responsive service that -- 19 that meets the needs in the -- in the specific 20 environment, and community settings in -- in northern 21 Ontario and similar sort of rural remote areas. 22 So designing a system -- and of course 23 with the use of -- of -- an increasing use of electronic 24 communications, and telemedicine as been discussed, there 25 is the opportunity for -- for connecting individuals who

1 are -- who are, geographically, quite distant from each 2 other. 3 And -- and there was an example, just 4 mentioned, about the -- the grand rounds having the -- 5 those participating connected by videoconference rather 6 than all having to travel to the same place in Toronto to 7 -- to be able to attend is -- is a good example of -- of 8 that kind of approach. 9 So that's the second point I wanted to 10 make is -- is that designing the system that actually 11 support those who are on the -- the front line, in -- in 12 the field, rather than subverting, or undermining their - 13 - their situation, and -- and unfortunately, that's often 14 what happens. 15 You know, there's a big Inquiry like this, 16 and there's -- and, Oh we've got to get -- make these 17 pediatric forensic pathology services better, and it's 18 all done in Toronto, and in a way that actually 19 undermines, and subverts the good work of -- of local pe 20 -- personnel in the northern rural sort of areas. So 21 that's my second point. 22 My third point is the concept of Centres 23 of Excellence. I think that it's essential that -- that, 24 and especially now there's the Northern Ontario School of 25 Medicine, that there -- that there's active support for

1 the development of Centres of Excellence in Northern 2 Ontario, which -- which have a focus not only on -- on 3 the -- the sort of service dimensions that have been 4 discussed today, but on research as well. 5 So that it's -- it's a true Centre of 6 Excellence -- academic Centre of Excellence in terms of 7 research, education, and -- and service. 8 So that -- and -- and I would suggest that 9 a -- one (1) or more Centres of Excellence in Northern 10 Ontario would develop expertise which is complimentary to 11 the expertise that -- that might be developed in a unit 12 in Toronto, or London, or -- or Hamilton because of the 13 different context. 14 Because of the -- the specific issues and 15 challenges of the -- the First Nations, and be -- and the 16 Francophones and the -- the higher accident injury rate 17 that was mentioned, and the different patents of 18 Aboriginal mortality. 19 So that -- that a Centre of Excellence, or 20 -- or Centres of Excellence in Northern Ontario would 21 actually add a -- a strength to the network of Centres of 22 Excellence in Ontario, and not -- not be just another -- 23 like an outpost of -- of the real Centre of Excellence 24 that's -- that's in -- in Toronto. 25 MR. MARK SANDLER: Thank you very much,

1 Dr. Strasser. Commissioner, one (1) counsel, Ms. 2 Esmonde, has some questions. 3 I -- I think we're going to have to 4 confine it to five (5) minutes or less, given the fact 5 that we're already five (5) minutes over. 6 COMMISSIONER STEPHEN GOUDGE: Okay. Ms. 7 Esmonde...? 8 9 QUESTIONED BY MS. JACKIE ESMONDE: 10 MS. JACKIE ESMONDE: Good afternoon. My 11 name is Jackie Esmonde. I'm one (1) of the lawyers 12 representing a coalition of Aboriginal Legal Services of 13 Toronto, and Nishnawbe Aski Nation. 14 And in the five (5) minutes I have, I'm 15 going to confine my questions to you, Dr. Strasser, and 16 Dr. McCready. 17 I was very interested in your description 18 of the four (4) week placement that your students do in 19 Aboriginal communities, but I -- perhaps, you could 20 explain to us some of the other initiatives in the 21 curriculum that address Aboriginal issues -- Aboriginal 22 health issues. 23 In particular, how are students prepared 24 to go into these communities? 25 DR. ROGER STRASSER: Yes. I mentioned

1 that our four (4) year MD program is organized around 2 five (5) themes. 3 The first theme is northern and rural 4 health, and Aboriginal health is a thread that -- that 5 runs with that theme, right through the four (4) years of 6 the MD program. 7 I mentioned also that -- that we have a 8 considerable involvement of Elders in our school. And, 9 so in the preparation, this -- the four (4) week 10 integrated community experience for the students in 11 Aboriginal communities occurs at the end of the first 12 year. 13 And, so in the cases that -- that the 14 students work their way through in -- in the earlier part 15 of -- of the first year, the -- the stu -- they begin to 16 be introduced to the issues and -- and concepts in terms 17 of culture and social issues and -- for Aboriginal 18 people. 19 There are -- there are opportunities to 20 provide for the students for specific cultural teachings 21 from -- from the Elders, and a focus on -- on traditional 22 medicine as well. 23 And then in the preparation for the actual 24 experience in -- in the communities, we have a local 25 community coordinator in -- in each community. Those

1 local community coordinators come together at -- at each 2 of the two campuses and -- and meet the students, in 3 advance of the students actually going to that community, 4 so that there's a personal connection in preparation for 5 the -- the time that the student -- the two (2) students 6 are in each of the -- the communities. 7 So there's quite a lot of -- of ground 8 work and -- and we did a lot of work -- before we did 9 this the first time, we actually had a pilot. Before we 10 had our own students, we borrowed students from other 11 medical schools and placed them in a small number of 12 communities. 13 And we learned a lot from that experience 14 about the practical issues and the logistics involved to 15 set things up to ensure that the learning objectives are 16 actually met while the students are in those communities. 17 MS. JACKIE ESMONDE: Thank you very much. 18 I -- I understand that's based on an understanding that 19 you can't just drop students into Aboriginal communities 20 without the work that has to be done beforehand. What 21 about afterwards? 22 Is there a -- what kind of follow-up is 23 there with students who have done this placement? 24 DR. ROGER STRASSER: Right. Well, the 25 student -- one (1) of the things I mentioned -- I

1 mentioned earlier already, that -- that they -- the 2 experience of Aboriginal people, in terms of research, is 3 quite negative. 4 But we wanted our students to undertake 5 some kind of research project while they're in the 6 communities. So, in fact, what we decided to do was to 7 make the -- the research a subject that the students 8 study themselves. 9 So they actually do a reflect -- 10 reflective project which -- which they -- where then -- 11 when after they've had their -- their four (4) weeks are 12 returned to their main campus and -- and then present to 13 their colleagues their -- their reflections on the 14 experience of -- of that four (4) weeks living and -- and 15 learning in those communities. 16 For many of our students, this is a life- 17 transforming experience. I mean you know, even though 18 they come from Northern Ontario, it doesn't mean that 19 they have really much of an insight and understanding of 20 -- of what -- Aboriginal life, and -- and the cultural 21 and the social issues and -- and history and tradition of 22 Aboriginal people. So -- so this -- as I say, this is -- 23 this is the immediate follow-up after their -- after 24 their rotation. 25 Then, of course, the -- that thread that I

1 mentioned -- the -- the Northern and rural health thread 2 with Aboriginal health -- Aboriginal health is a thread 3 in that theme -- runs through the -- the rest of the -- 4 the program. 5 So there are learning objectives around 6 Aboriginal issues, not just health, but issues more 7 generally in each of the succeeding years of the program 8 as well. 9 MS. JACKIE ESMONDE: I -- I understand, 10 as well, you have two places that are reserved, 11 specifically, for Aboriginal students in each class, is 12 that right? 13 DR. ROGER STRASSER: I didn't say that. 14 What I said was, that we set a target of reflecting the 15 population distribution of Northern Ontario in each 16 class. It -- what happened was that we first -- our 17 first -- the first public event of the school was a 18 curriculum workshop which we held in Sault Ste. Marie in 19 January of 2003, and we had over three hundred (300) 20 participants at that workshop; people from all over 21 Northern Ontario. 22 And they helped to design the made -- made 23 in Northern Ontario aspects of our curriculum; of those, 24 about fifty (50) were Aboriginal people. And it became 25 clear that to really understand what the Aboriginal

1 people needed and were looking for from their medical 2 school, we needed to have a separate workshop. 3 So we had a separate Aboriginal workshop, 4 in June of 2003, where we had over a hundred (100) 5 Aboriginal people there. And at both of these workshops, 6 there was heated debate amongst -- between the Aboriginal 7 people themselves about -- on the one (1) hand, Look, our 8 people will never get into medical school unless there 9 are reserved seats, and on the other hand, Well, as soon 10 as you have reserved seats, then it gives the impression 11 of a back-door entry of lowering the standards; it 12 stigmatizes our -- our people. 13 So the compromise we came to was that 14 there are two (2) seats reserved for Aboriginal people in 15 its class of fifty-six (56) and that we've never got that 16 low and we expect we never will, so that's a floor rather 17 than a ceiling. 18 MS. JACKIE ESMONDE: The -- the final 19 thing I wanted to ask you about is can you comment on how 20 unique this program is with respect to incorporating 21 Aboriginal -- Aboriginal issues. 22 Is -- how unique is that amongst medical 23 schools in Ontario? 24 DR. ROGER STRASSER: I would say that the 25 way in which we've put all this together and -- and

1 developed the program is truly unique, not only in 2 Ontario. There are elements of what we do in other -- in 3 the -- in the programs of other medical schools including 4 in Ontario. 5 So, for example, there are opportunities 6 for students to have elective experience in an Aboriginal 7 community site for four (4) weeks, okay; every one (1) of 8 our students has that -- has that as part of their 9 program. 10 There -- there are other medical schools 11 also, particularly since we came along, it seems, and now 12 looking to recruit Aboriginal people into their -- into 13 their classes, so, in fact, the other medical schools, 14 some of them, at least, in Ontario, now have numbers of 15 medical -- Aboriginal medical students. 16 You know, there are other examples in 17 other medical schools of some of the other things that 18 I've mentioned, but the whole package that we have is -- 19 only occurs in the Northern Ontario School of Medicine. 20 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 21 Esmonde. 22 MS. JACKIE ESMONDE: Thank you, 23 Commissioner. 24 MR. MARK SANDLER: Thank you. That 25 completes the questioning for -- for this panel, and

1 we're very grateful to you all. 2 I'm not going to be saying goodbye to Dr. 3 Eden, Dr. Porter, Dr. Chiasson or Dr. Queen because 4 they'll be participating in the -- in the roundtables 5 that follow, but I -- I do want to extend the 6 appreciation of the Commission to Dr. Strasser and Dr. 7 McCready for filling in some very, very helpful gaps in 8 our understanding of what was going on at your school of 9 medicine, so thank you so much. 10 COMMISSIONER STEPHEN GOUDGE: And just 11 let me, for my part, say how much I appreciate the 12 thought and the participation, it really is helpful, so 13 thank you for coming. 14 We'll adjourn for how long, Mr. Sandler? 15 16 (PANEL STANDS DOWN) 17 18 MR. MARK SANDLER: Commissioner, I'm 19 going to suggest that we resume at say 12:35, and there 20 will be refreshments available for -- for the 21 participants here in this room in that interim. 22 COMMISSIONER STEPHEN GOUDGE: We will 23 adjourn then until 12:25. 24 25 --- Upon recessing until 12:35 p.m.

1 --- Upon resuming at 12:45 p.m. 2 3 COMMISSIONER STEPHEN GOUDGE: Okay, are 4 we ready to resume then, Mr. Sandler? 5 MR. MARK SANDLER: We are. 6 COMMISSIONER STEPHEN GOUDGE: All yours. 7 8 PANEL 2 - ORGANIZATION OF PEDIATRIC FORENSIC DEATH 9 INVESTIGATIONS: 10 DR. MARTIN QUEEN 11 DR. DAVID CHIASSON 12 DETECTIVE INSPECTOR DENNIS OLINYK 13 DR. DAVID EDEN 14 DR. SHELAGH McRAE 15 MR. JAMES SARGENT 16 17 MR. MARK SANDLER: Thank you very much. 18 Good afternoon, everyone. Good afternoon, Commissioner. 19 We're now going to turn to roundtable 2 20 which is described as the "Organization of Pediatric 21 Forensic Death Investigations". And if I can introduce 22 our panellists, I'll start again at your far left, 23 Commissioner. 24 Our first panellist is Mr. James Michael 25 Sargent. He received his funeral director's licence in

1 Ontario in 1994. He is a past president of the 2 Northwestern Funeral Service Association. Sargent and 3 Son Limited Funeral Home has been operating since 1924. 4 He's the son, as opposed to one of the -- the 5 originators. In fact, he is a fourth generation in his 6 family to operate the funeral home. And that's operated 7 in Thunder Bay, as I understand it. 8 Good afternoon. Thank you for coming. 9 Beside him is Dr. Shelagh McRae. Dr. 10 McRae is a family practitioner in Gore Bay, Ontario. She 11 became an investigating coroner for Manitoulin District 12 in 1991 and in inquest coroner for Northeastern Ontario 13 in 1993. Dr. McRae is a clinical lecturer with the 14 University of Ottawa and an assistant professor of the 15 Northern Ontario School of Medicine. 16 Welcome. 17 Beside her is Dr. Eden, to whom you have 18 already been introduced. And unless something has 19 changed, and I doubt it since the Chief Coroner is here, 20 he is still the Regional Supervising Coroner for North 21 Region. 22 Good afternoon, again. 23 Beside him is Detective Inspector Dennis 24 Olinyk. Detective Inspector Olinyk joined the OPP in 25 March of 1974 after graduating from Lakehead University

1 with a Bachelor of Arts. He started his career in 2 Thunder Bay, ultimately promoted to Detective Inspector 3 in 1987 where he served in the Criminal Investigation 4 Branch in Kenora and Toronto. 5 He has assisted counsel representing the 6 OPP at a number of Inquiries including the Royal 7 Commission of Inquiry into the Air Ontario crash at 8 Dryden, the Inquiry into the Prison for Women in Kingston 9 in 1995, and the SD Royal Commission of Inquiry in 1996. 10 So this process is -- is no -- nothing strange to 11 Detective Inspector Olinyk. He has served a member of 12 the -- as a member of the CIB promotional process and 13 Crime Management Committee. 14 Good afternoon, Detective Inspector. 15 Beside him is Dr. Chiasson. Again, we're 16 well familiar with Dr. Chiasson and I won't reintroduce 17 him. 18 And beside him is Dr. Queen, again with 19 whom we're well familiar. 20 Welcome again, Dr. Queen and Dr. Chiasson. 21 22 QUESTIONED BY MR. MARK SANDLER: 23 MR. MARK SANDLER: This afternoon, if I 24 may, I'm going to start with Detective Inspector Olinyk. 25 And we're looking at some of the

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1 challenges in the north, Detective Inspector, in the 2 North and in the rural and remote communities of forensic 3 death investigations and, most particularly, those 4 involving pediatric components. 5 What I want to ask you at the outset, can 6 you provide the Commissioner with some guidance as to the 7 number of cases that the OPP Forensic Identification Unit 8 and the OPP generally would be involved in in regions 9 that you're familiar with? 10 DETECTIVE INSPECTOR DENNIS OLINYK: Yes, 11 thank you. With respect to those cases involving 12 homicides and suspicious death investigations where the 13 Criminal Investigation Branch is engaged, I've had the 14 opportunity to review those cases over the last fourteen 15 (14) years for the calender years 1994 through to 16 December the 31st, 2007 identifying the -- the number of 17 cases and where the cases took place. 18 I did that initially because it was part 19 of a study that I was doing in-house with -- within the 20 OPP during the OPP efficiency review. But in preparing 21 for today, I -- I referred to that because I think the 22 materials that I put together might put some context into 23 some of the issues that you've asked me to -- to address. 24 For the fourteen (14) years we had a total 25 in the northwest region and that refers to the judicial

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1 districts of Thunder Bay, Kenora, and Rainy River; 2 seventy-four (74) homicides and some forty-two suspicious 3 death investigations where the Criminal Investigation 4 Branch of the OPP was engaged; of those, five (5) 5 involved pediatric homicides, and approximately 76 6 percent of the number of homicide cases took place within 7 the juris -- the ju -- the Judicial District of Kenora. 8 They took place in fly-in First Nation 9 communities, non fly-in communication -- First Nation 10 communities, and as well as in communities that are 11 policed by both the OPP and by municipal police services. 12 A good number of the cases that we became 13 involved in took place within fly-in communities, and the 14 fly-in communities clearly pose a number of logistical 15 challenges that one might not have to deal with in -- in 16 communities such as Thunder Bay, Fort Frances, Kenora; 17 weather is an issue, distance is an issue, and response 18 time is an issue. 19 MR. MARK SANDLER: Let me just stop you 20 there for a moment just to clarify several matters. 21 When -- when we're talking about cases in 22 which the OPP has been involved, as I understand it, the 23 OPP may be involving -- may be involved in providing the 24 primary policing services in connection with the 25 community either because it's -- it's directly involved

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1 in that policing, or it's an OPP administered area, or 2 it's working in support of First Nations or other police 3 services. 4 Am I right as to that? 5 DETECTIVE INSPECTOR DENNIS OLINYK: Yes, 6 that's correct. 7 MR. MARK SANDLER: All right, and can we 8 just take an example just -- just to flesh this out for - 9 - for the Commissioner, Detective Inspector. 10 Let's assume that -- that there was a 11 sudden and unexpected death of a very young child, for 12 example, under the age of -- of 2 in a -- in a remote 13 fly-in community such as that that you've described and, 14 let's say, it's either a community in which -- that the 15 OPP polices or it's a community where the OPP is asked to 16 provide support services for that investigation. 17 Typically, how does the OPP and the 18 community deal with the logistics issues surrounding 19 remoteness, such as you've described? What would 20 typically happen? 21 DETECTIVE INSPECTOR DENNIS OLINYK: What 22 would typically happen would be the CIB inspector, along 23 with the core Criminal Investigation Unit investigators 24 and the core forensic identification officers would 25 assemble at the Kenora Airport, would get on a chartered

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1 air plane and would fly in to the community. 2 And at the very outset the -- the CIB 3 inspector or his designate would, of course, be in 4 communication with the local coroner, and in cases where 5 both suspicious death and/or homicide, where we know it's 6 a homicide early on, the -- both the local, and the 7 Regional Coroner would be notified. 8 We would go into the community and one (1) 9 of the first issues that would be dealt with would be the 10 -- would be the deceased because often at times, we 11 arrive in the community the deceased, in a pediatric 12 case, is at the nursing station, would be to do the 13 forensic work that has to be done immediately there, as 14 well as securing the various scenes. 15 There may be one (1), two (2), three (3). 16 There may be more. And then having the -- the deceased 17 removed from the community, with the forensic 18 identification personnel who are involved, to the -- to 19 the morgue for -- for autopsy. 20 Now the -- the other thing that typically 21 happens, of course, when the -- when the body is en 22 route, and is at the morgue pending the -- the autopsy, 23 the investigation is moving on within the community. 24 And very early on in the investigation, 25 it's been my experience, and certainly the experience of

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  1  my colleagues, that one (1) of the first things we do is
  2  we maintain contact with the Chief and council.
  3                 And -- and we do that for a number of
  4  reasons.  Because -- well, first of all, they are very
  5  interested in knowing what's happening within their
  6  community, and they participate, and assist us in -- in
  7  performing a number of very important functions within --
  8  within the community.
  9                 And identifying with them right -- right
 10  at the very outset is something that has -- has been very
 11  helpful, has been very beneficial, and has worked well
 12  for us.  Because some of the unique challenges is that we
 13  don't have the benefit of, for example, numerous officers
 14  to -- to be available to provide for scene security.
 15                 We may have several scenes that we have to
 16  rely on the local community, whether it be those persons
 17  within the community that provide the function of
 18  peacegate -- peacekeepers, or who may be band constables,
 19  but not police officers, or those people who may be part
 20  of a specific portfolio within the respective community
 21  who -- who take on those -- those tasks.
 22                 And that -- that function -- the -- that
 23  function expands not only to such things as scene
 24  security, but as well as the security of the -- of the
 25  accused, if -- if there -- if there has been an arrest

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1 effected. 2 And if there are multiple arrests, then 3 there are obviously more people that are brought in to -- 4 to help out. So these are the -- these are some of the 5 things that -- that are -- are different than -- than one 6 would experience going to a drive-to community, if you 7 like. 8 MR. MARK SANDLER: Now just stopping 9 there for a moment, because I'm going to unpack some of 10 the things you've said, and ask our various panellists 11 about -- about some of the dynamics of the death 12 investigation in a remote, or rural, or -- or Aboriginal 13 community. 14 And I'm going to focus less on the 15 Aboriginal community, though it's a significant component 16 of the work of what much of you do, since we'll be 17 dealing with it in much more detail tomorrow. 18 But let me ask you this first, Detective 19 Inspector Olinyk. Typically in the northwest region, do 20 the coroners attend the scenes? 21 DETECTIVE INSPECTOR DENNIS OLINYK: 22 Typically -- typically they don't attend at the scenes. 23 I can't recall a coroner attending a fly-in scene ever. 24 In some cases, where the scene is -- is 25 accessible, a drive-to scene, on occasion the coroner

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1 will. But -- but for the most part, the coroner does not 2 attend the scene. 3 MR. MARK SANDLER: And how does the 4 absence of the coroner -- how is the absence of the 5 coroner dealt with? 6 First of all, what is the contact between 7 the OPP, and the coroner, or Regional Supervising 8 Coroner, and how, if at all, does the coroner's role 9 interplay with that of the police who are conducting the 10 investigation? 11 DETECTIVE INSPECTOR DENNIS OLINYK: In 12 the case of a -- of a homicide investigation, the -- the 13 pre-autopsy conference involving the pathologist and the 14 Regional Coroner, and the local coroner has the benefit 15 of -- of the scene being taken to them, if you like, 16 through -- through photography and through -- through 17 that form of technology. So in that sort of -- in that 18 sort of circumstance, the -- the coroner, the regional 19 coroner, the pathologist has the scene brought to him or 20 her. 21 Now, in those cases where it's not a 22 homicide and -- and there's not a -- there's not a 23 coroner on site, the -- the circumstances with respect to 24 the scene is communicated to the coroner and in those -- 25 in those CIB cases, by either the CIB inspector or his or

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1 her designate, but by the forensic identification officer 2 who really serves as the conduit between the -- the 3 scene, if you like, and -- and the coroner, and I suppose 4 to some extent, you know, is looked at in -- in some way 5 as a -- as the extension of the coroner. 6 MR. MARK SANDLER: All right, and I'm 7 going to come back to that in a little bit if -- if I 8 may. 9 I should mention, Commissioner, that we 10 were provided today with a very helpful memorandum that 11 was prepared by Detective Inspector Olinyk that sets out 12 in much more detail than I've taken him to, the -- the 13 numbers that -- that are involved in the northwestern 14 region, and also some of the challenges in -- in policing 15 these kinds of cases in the region, which I will discuss 16 with him in a few moments. 17 So, that's been circulated to all of the 18 parties who are here and will ensure that it's put on the 19 -- put on the electronic distribution list for -- for 20 distribution to all counsel. 21 So if I can just leave that for a moment. 22 And -- and I want to ask Dr. McRae, do you typically 23 attend or do the coroners in your region typically attend 24 the scene of a sudden and unexpected death of a child, 25 talk to us about your experience.

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1 DR. SHELAGH MCRAE: I am coroner on 2 Manitoulin Island; we actually have quite a few -- we 3 have three (3) coroners in the area and it's not a very 4 densely populated area. 5 I think I've been to a total of, I've 6 worked it out here, six (6) or seven (7) child deaths in 7 the fifteen (15) years I've been doing it. None of them 8 went on to any sort of criminal proceedings and I did 9 attend those cases. 10 However, the day-to-day coroner stuff I 11 often don't attend. We've been given guidelines; if it's 12 thought to be criminally suspicious, if it's unusual, if 13 there's a high level of -- of public concern about it, 14 then we are encouraged to attend and do try to, but if I 15 get a call that an elderly person has been found dead, 16 they had a whole bunch of medical issues and it's hours 17 away from where I'm seeing patients at the time, I'm 18 going to say, well, do you see anything suspicious in the 19 scene, are -- are any of the family upset about it, they 20 say, no, no, I say, fine, I'll send you the paperwork. 21 MR. MARK SANDLER: Dr. Eden, this of 22 course was the subject of some discussion when -- when 23 you were with us last time. 24 What are your thoughts on -- on how, if at 25 all, the current system should be improved in -- in the

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1 north or in remote or rural communities to enhance 2 stability of coroners to attend the scene or, failing 3 that, to offer a proxy for the coroner's attendance at 4 the scene? 5 DR. DAVID EDEN: You know, I think to -- 6 to answer that question we look at the purpose of the 7 coroner's investigation which is fact finding about the - 8 - the death and that fact finding should be accurate and 9 impartial. 10 And it's recognised by our office that it 11 is optimal that a coroner attend death scenes. The -- 12 the issue which arises of all the regions in Ontario, 13 most commonly in northern Ontario, is where a coroner for 14 logistical reasons cannot attend a death scene, and then 15 the issue is how should that be handled. 16 That is anticipated in the Act in that the 17 coroner can delegate certain investigative powers to 18 physicians and police; operationally it's almost 19 exclusively two (2) police officers and there -- there 20 are mechanisms that have been devised in northern Ontario 21 that Detective Inspector Ulinyk has described where the 22 police attend and then maintain a line of communication 23 with both the -- the coroner and the regional coroner 24 with respect to what's found at the scene. And there is 25 also an opportunity for case conferencing before the

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1 autopsy to ensure that all the -- all the facts are in. 2 I, certainly, would like to see coroners 3 at the scene wherever possible but it's a reality in 4 northern Ontario that there will be cases where it will 5 not be possible for a coroner to attend, and we need to 6 have a good strategy to deal with those. And, certainly, 7 the one (1) that has been developed in coordination with 8 the OPP, in my opinion, works. 9 And that's not strictly -- it's not 10 exclusively with the OPP in that -- in the time I've been 11 regional coroner I've also done coordinated 12 investigations with NAPS and I've been very impressed 13 with their performance of scene examinations and liaison 14 with the family on my behalf as a corner. 15 COMMISSIONER STEPHEN GOUDGE: Dr. Eden, 16 could you put a percentage on or compare the percentage 17 of scenes you have visited in your experience as a 18 regional supervising coroner in the South and here in the 19 North? 20 I mean, what's the order of magnitude 21 differential that logistics requires? 22 DR. DAVID EDEN: It's largely a -- a 23 geographic issue in -- in most parts of the South. 24 Certainly, urban centres and most rural areas a coroner 25 will attend.

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1 COMMISSIONER STEPHEN GOUDGE: Take 2 Niagara, your experience in Niagara, okay? 3 DR. DAVID EDEN: In Niagara, it would be-- 4 COMMISSIONER STEPHEN GOUDGE: 5 Investigating coroners would go what percentage of the 6 time and compare it to investigating coroners that you're 7 now responsible for? 8 DR. DAVID EDEN: One hundred (100) 9 percent of non-natural deaths with very rare exceptions 10 like a -- a blizzard between the coroner and the scene, 11 but operationally, it's 100 percent of non-natural 12 deaths. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. DAVID EDEN: There may be 15 circumstances but our policy is that the coroner calls me 16 if there's a natural death where the coroner is so far 17 away and the -- and the possibility of value added is so 18 low that it will be investigated remotely. Those are 19 actually uncommon. So I would say that the -- it's 20 unusual for a case in Niagara not to have a coroner at a 21 scene. It happens but it's unusual and only in natural 22 deaths. 23 In the North, particularly in certain 24 communities, and that would be the fly-in communities as 25 an example, coroner's investigations are conducted

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1 without the coroner on scene. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 4 CONTINUED BY MR. MARK SANDLER: 5 MR. MARK SANDLER: Detective Inspector 6 Olinyk, just -- just following up on this issue of the 7 coroners attending the scene and you've heard what Dr. 8 Eden has said, as well, one of the ideas that was 9 floated, for want of a better word, at an earlier -- 10 during an earlier discussion at this Inquiry was whether 11 or not the police could provide photographs or imagery to 12 the coroner in real time as opposed to at the autopsy or 13 at a case conference. 14 Is the technology available to -- to 15 enable the forensic identification officers, in effect, 16 to be filming in real time and transmitting back -- I 17 mean, in real time or in close proximity -- back to the - 18 - the coroner while still on the scene to -- to get some 19 guidance or insight from the coroner on -- on the conduct 20 of the investigation? 21 DETECTIVE INSPECTOR DENNIS OLINYK: 22 Certainly, and in a good number of the communities that 23 you can drive to, yes, that -- the technology is there to 24 do that. I'm not -- I'm not -- 25 MR. MARK SANDLER: Let me just interrupt

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1 you to ask: Could you just explain to -- to the 2 Commissioner, and maybe it's my deficit, but how would it 3 be done? Like, actually talk to us pragmatically about 4 how would you do it in real time. 5 DETECTIVE INSPECTOR DENNIS OLINYK: Well, 6 the -- the -- the photographs would be taken. They would 7 be put on a disk and they would be transmitted through 8 the computer to -- to whomever, whether it be the -- the 9 regional pathologist, the coroner, or the -- the Chief 10 Forensic Pathologist. And -- and -- and that's been 11 done. 12 We -- we had a case here recently where 13 the autopsy was done by the pathologist in Kenora and the 14 -- the pathologist in Kenora had ongoing discussions with 15 Dr. Pollanen. And included in these discussions were the 16 preparation of the photographs and -- and so on. That 17 was the post-mortem photographs that was communicated to 18 -- to -- to Dr. Pollanen. So he -- he had -- he had the 19 view of -- of -- of that. 20 MR. MARK SANDLER: And is the technology 21 available to do that, not only for the still photography 22 but also for -- for other photography, films that are -- 23 that are done at the scene -- which I know traditionally 24 are done by the forensic idents officers? 25 DETECTIVE INSPECTOR DENNIS OLINYK:

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1 Certainly not in the fly-in communities. I think in some 2 of the other communities the technology is there but it's 3 something that I haven't been personally involved in. 4 MR. MARK SANDLER: So just stopping there 5 for a moment, if I -- I'm going to turn to Dr. Chiasson 6 and Dr. Queen. We've also heard about -- about 7 guidelines that -- that now exist on whether forensic 8 pathologists should or -- or when they should attend the 9 scene of -- of a case that is suspicious or may involve a 10 homicide. 11 I'll ask Dr. Queen, because we haven't had 12 the benefit of your views up and to this point in the 13 Inquiry about this. 14 To what extent should forensic 15 pathologists attend the scene? 16 To what extent are you about to attend the 17 scene, and -- and how does that issue factor into the 18 discussion that we had before our morning break about the 19 implications of having a unit based in Sudbury? 20 DR. MARTIN QUEEN: Yes, obviously again 21 there's huge geographical and logistic issues of the 22 forensic pathologist going to the scene. In -- in the 23 nine (9) years I've been in Sudbury, I can remember two 24 (2) occasions. 25 One (1) was not too long after I got there

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1 when I was still doing some pediatric stuff, I went down 2 to the Emergency Department and attended while the 3 coroner and the police officer interviewed the parents of 4 a child that was found dead in a car seat. 5 There was another occasion when we had a 6 death which involved a -- an Aboriginal man, the OPP SWAT 7 team and a lot of rubber bullets, and a coroner who had 8 just started so, and he was very nervous, so I agreed to 9 drive with him a couple hours out to the reserve and -- 10 and attend that scene. 11 And -- I actually like going to scenes. I 12 think it's -- it can be very helpful and very 13 educational, but it's -- it's a real struggle finding the 14 time to do it. And certainly I think if you had a -- a 15 unit with -- with more people and more resources, you 16 could perhaps free up a slightly large percentage of -- 17 of your time pie to that. 18 But under our present system and in -- in 19 northern Ontario, I don't see it being like it was in 20 Baltimore under a medical examiner's system where the 21 medical examiners, you know, have the abilities to go to 22 many, many scenes. I -- I can't see that happening up 23 here. 24 MR. MARK SANDLER: Dr. Chiasson, we may 25 have exhausted your views on -- either you or your views

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1 on this subject in -- in previous round tables, but 2 perhaps we can talk about the -- the technology issue in 3 -- in this context as well. 4 In your view, is it -- is it as helpful or 5 almost as helpful if one had the process in place that 6 Detective Inspector Olinyk described where the 7 pathologist is receiving films or photographs in real 8 time or shortly thereafter of -- of the scene? 9 DR. DAVID CHIASSON: Yes, I think I'm all 10 -- I'm already on the record in terms of -- my experience 11 is very similar to Martin's, and -- and we're really 12 looking at a -- a major impact on -- on a pathologist's 13 time to attend scenes on a regular basis. 14 I, like him, I mean, I would like to have 15 the time to do it more than I do, but it's just not part 16 of the reality, and that's in Toronto where a lot of the 17 cases are, of course, even closer geographically. 18 The issue -- I -- I'll reiterate what -- I 19 think what I've said before, again. The -- the -- every 20 weekend -- this weekend I -- I happen to be on call at 21 the Coroner's Office. 22 IDENT officers are now routinely coming 23 with scene photographs of -- of -- of the -- anything 24 that's -- certainly -- all the homicides, the criminally 25 suspicious, that's -- and it's -- it's invaluable I -- I

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1 think. 2 And that -- that's really been a major 3 positive progress over -- over the years. And certainly 4 from my perspective makes me feel a lot comfort -- more 5 comfortable about having a sense of what's going on. 6 And certainly I don't feel the need to go 7 to -- to scenes as a result of this. 8 The other thing, and I -- I think 9 Detective Olinyk has made reference to is -- is this 10 ability to transmit from a consulting point of view as 11 opposed to individual cases at the time of autopsies, but 12 certainly I -- I think there is a potential that that can 13 be of great value and -- and if there are issues and 14 questions upfront that -- that would like to be -- that 15 there'd be value in addressing sooner than at the time of 16 the autopsy, then this -- this kind of technology iss -- 17 and photographs for the most part, I know there's 18 reference to videotapes. 19 I mean, I've -- I'll -- reviewed scenes of 20 -- videotapes of scenes as well prior to autopsies. A 21 lot of times, it's -- that's time consuming because 22 there's a lot of it that is showing items, or parts of 23 the -- the scene that are really not of great interest, 24 or value to the pathologist. 25 You know, having photographs of -- of

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1 selected items -- having a good IDENT officer at -- at 2 the scene is -- is the number 1 thing. 3 If there's an issue, transmit those 4 particular photographs; that -- that can be useful. And 5 that could be done sooner rather than later in select 6 cases. 7 MR. MARK SANDLER: Mr. Sargent, I'm going 8 to turn to you, because you come at this from a very 9 different perspective than anybody else on the panel. 10 So just to get some sense of typically 11 what would work -- what would take place in your 12 jurisdiction if -- if a young child died, could you take 13 us through what interface you might have with either the 14 coroner, or -- or the pathologist's office, or -- or the 15 police in cases that might be suspicious? 16 MR. JAMES SARGENT: Well, generally what 17 happens is we're contacted by our nurse's registry 18 through the coroner's office, or the police. 19 And we're asked to attend the scene where 20 the death has occurred. What we do then is we make our 21 way to the scene, and as -- as been discussed, I mean, 22 the length of time to get there could be hours. It could 23 be minutes, depending on where you have to go. We're 24 looking at a large geographical area -- 25 MR. MARK SANDLER: I think I'll stop you

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1 there for a moment. I'm sorry. Just to be clear. Your 2 funeral home is here in Thunder Bay, but I take, from 3 your last answer, that -- that you may be going to 4 various places within Northern Ontario where -- where 5 people have died. 6 Am I right as to that? 7 MR. JAMES SARGENT: That's correct. We - 8 - we cover a large geographical area. We'll go as far 9 north as Armstrong, Ontario, which is a three (3) hour 10 drive from here. 11 And we can go -- up to probably three (3) 12 hours is probably a fair -- fair number as -- as far as 13 distance, or time and distance that we would travel in a 14 case where we have to attend a death scene. 15 I'll give you an example that deals 16 directly with this last summer, I believe it was. We 17 were asked to attend at a lake. A young child had passed 18 away. And -- and the family was out camping. 19 And we -- we arrived at the scene, and 20 what we basically do, is we're in charge of transporting 21 the deceased back to the hospital, and then making 22 arrangements from there as to what's going to happen with 23 -- with the body afterward. 24 What we do is work in conjunction with the 25 -- in that case, it was the OPP, who do their on-scene

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1 investigation that they have to do. 2 Then the deceased is placed into a secured 3 -- for adults, it's a pouch. For -- for children, it's 4 maybe something different. 5 But the -- the body is -- is sealed, and 6 the OPP places a seal on that so that the body is not 7 contaminated by us, or -- and then what we would do is 8 drive back to the hospital with the OPP, whether 9 someone's in the car, or we're in the vehicle directly in 10 front of them, or behind them. 11 We drive in -- basically, in procession 12 back to the hospital. Place the -- the remains in -- the 13 human remains in the -- in the morgue unit, which is then 14 again sealed by the OPP until -- and then, from there, 15 the local pathologist, I guess, is involved. 16 I -- I can't really speak to that. 17 Following that, we are -- in a coroner's case where 18 you're the ones that attend, generally you're the ones 19 that follow it through to the stage where the body is 20 transported to Toronto for the -- for the forensic 21 examination down there. 22 And, I mean, on a different topic that -- 23 that has a totally different effect on the family than 24 when, you know, you have autopsies done in Thunder Bay, 25 just as far as time, and everything else that's involved.

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1 That's a whole different topic, but -- 2 MR. MARK SANDLER: Actually, it -- it's 3 one (1) of our key topics, so I -- I -- so I actually 4 want you to go to it a little bit. 5 So -- so in the event that we do have a 6 case in which the body is going to be transported to 7 Toronto for autopsy, for example at the Hospital for Sick 8 Children, how is that done logistically because we really 9 haven't heard about that yet? 10 What would your role be in -- in having 11 that deceased transported to Toronto, and how is it done? 12 MR. JAMES SARGENT: Well, basically, what 13 we would do is make -- first of all, we're given 14 direction as to when things need to occur. 15 So just continuing where we were on the 16 last part. We would bring the deceased to the hospital. 17 Then, in that particular case, we were contacted by the 18 Coroner's Office who we speak with directly, whoever the 19 attending coroner is, and they -- they will notify us, 20 Okay, the post-mortem has been scheduled for whatever 21 time and whatever day, and from there, we'll make the 22 arrangements to have the remains shipped to Toronto. 23 Another logistical problem that we have in 24 Thunder Bay now, too, is that Air Canada no longer 25 provides planes large enough to carry full human remains,

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1 so we're limited to West Jet as our only mode of 2 transportation for -- for caskets. For smaller human 3 remains, that -- that's a little different. There is the 4 cargo space available on some of the Air Canada flights, 5 but... 6 So we would make the arrangements to have 7 the body sent to Toronto, and then we would make 8 arrangements with an agent in Toronto, to act on our 9 behalf or on the coroner's behalf, to transport the 10 remains from the airport to Sick Kids or -- or wherever 11 the -- the forensic autopsy is to take place. 12 They will then, in turn, stay in touch 13 with the hospital and try and give us an idea as to when 14 that's all going to be completed, and they can make 15 arrangements to have the remains sent back to Thunder 16 Bay. 17 Generally the process is, you know, if we 18 -- if we send the remains today, for a post-mortem 19 tomorrow, then the preparation work has to be done down 20 there because especially with children, and this is 21 another issue altogether, but what we do -- I guess the 22 best way to do it is put -- put yourself in -- in the 23 family's position: 24 I've lost my baby today. I'm -- I'm being 25 told that now my baby has to be sent to Toronto in order

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1 to have a forensic autopsy done. I want to have a 2 funeral. It's ver -- obviously a very difficult time 3 when you're dealing with young children, and what -- 4 what's going to happen, so you have to explain to them 5 the body's going to be sent to Toronto tomorrow or 6 whatever, then the next day the post-mortem's going to be 7 done. 8 Hopefully, the folks acting on our behalf 9 down there will get the body the next day, and then 10 they'll do the preparation work immediately, because with 11 children, the body hasn't developed yet, so you know, 12 your vessels deteriorate faster after so -- after you've 13 died. These are all the challenges that we face, so 14 these people want to see their baby again. 15 And a lot of times with the time line with 16 going to Toronto and -- and so on, it makes it very 17 difficult for them to see their baby as they would 18 remember them. 19 That's because just the -- the changes in 20 the body start to occur so much faster in -- in children 21 than they do in adults, so in order to do the preparation 22 aspect of our job, the sooner we can do that, the better 23 to -- to best preserve the body and restore the body to - 24 - to what the family would -- would be used to seeing. 25 But then again -- so then the agent will

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1 then act -- or will then send the -- the remains back to 2 Thunder Bay. We'll -- we'll go to the airport and bring 3 them back to our establishment, and -- but the whole time 4 that this is going on, you're never 100 percent sure as 5 to when everything's going to be done, so you can't go 6 ahead and -- and make arrangements for the funeral. 7 So you -- like last -- a few months ago a 8 friend of mine, they lost a baby after eight (8) days and 9 this was the case. The body had to be sent to -- to 10 Toronto. And the baby died on a Sunday, and we weren't 11 able to have the funeral until the following Monday, so 12 basically eight (8) days, these people grieved for their 13 baby and had no closure. 14 So that's a real issue for -- for families 15 in this area just because -- I mean, that process takes 16 three (3) to four (4) days generally, and that's a lot to 17 ask of somebody when they've -- when they -- when they're 18 experiencing what they are experiencing. 19 I mean nine (9) months of looking forward 20 to having a child and then it's all gone and -- and then 21 on top of all that, you know, the time line's pretty -- 22 pretty crazy for them as far as -- 23 MR. MARK SANDLER: One (1) of the things 24 that we've heard, Mr. Sargent, from Dr. Legge, who is the 25 Regional Sup -- Supervising Coroner, as I'm sure you

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1 know, in -- in this Region, for an extended period of 2 time, was certain deficiencies that -- that are 3 acknowledged in -- in communicating to the families about 4 what is going to happen on these cases, and what I heard 5 you say is that part of the role in communicating what's 6 going to happen, and including time line, sometimes falls 7 upon you, is that right? 8 MR. JAMES SARGENT: Most definitely. I 9 mean, we're the ones that are probably having the most 10 contact with the families. 11 As far as more relevant information, as 12 far as what exactly is going on, and -- I mean, I don't 13 have the expertise to give that information. 14 I'll always defer that to the coroner, or 15 when -- when the police are involved, to the police -- 16 tell the families that that's where they have to go to 17 get those answers because I can't provide them for them. 18 But as far as the rest of it, yeah, 19 basically they're talking to us because we're the ones 20 that are looking after the funeral aspect for them, and 21 we're the ones that are making the arrangements as far 22 as, you know, making the -- the flights and -- and all 23 those types of things. 24 Those aren't duties that should fall back 25 on the family. And -- and, so I would say -- have to say

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1 yeah, the -- the majority of the information they're 2 probably getting is -- is from us. 3 And we, in turn, are asking those who know 4 -- those in the know what -- what our time -- what time 5 line are we dealing with and so on. 6 MR. MARK SANDLER: And one (1) last 7 question to you, and -- and then I'm going to go to your 8 fellow panellists. 9 And that is that we've heard that some of 10 the deaths up north are autopsied in -- in Winnipeg, and 11 -- and are you ever involved in those cases, and if so, 12 is the process any different? 13 MR. JAMES SARGENT: For -- for where we 14 are, no. I -- when you look at Northwestern Ontario, 15 it's a large geographic area. 16 And the majority of those cases would come 17 out of, I would think, places like Kenora. Kenora is 18 only, what, about two (2) hours -- an hour and a half to 19 two (2) hour drive from Winnipeg. 20 For us to drive to Winnipeg, it's eight 21 (8) hours. So, no, it's just as easy for us to make 22 arrangements to fly to Toronto as it is to Winnipeg. 23 MR. MARK SANDLER: Dr. McRae, I made 24 reference to Dr. Legge's evidence when he testified 25 before this Inquiry some time ago.

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1 And -- and I -- I said in my question to 2 Dr. -- to Mr. Sargent that -- that Dr. Legge acknowledged 3 that -- that there was much that could be done to improve 4 communication with the families, and one (1) of the 5 focusses of the discussion was with Aboriginal families, 6 and we'll talk about that more tomorrow. 7 Tell us about your experience. Does the 8 Coronial System, in your view, communicate well with 9 families in these cases of sudden and unexpected child 10 deaths, or -- or can that level of communication be 11 improved? 12 DR. SHELAGH MCRAE: Levels of 13 communication can always be improved. I think having 14 local coroners is very useful in terms of having somebody 15 in your community to whom you can talk to. 16 Not only around the time when the body's 17 gone off, wherever it's gone off to, but afterwards when 18 tidying up the loose ends. What did they find at the 19 autopsy? What does all this mean for my family, and what 20 does it mean -- that sort of thing. 21 Having -- having a local coroner there is 22 -- is quite important. It's -- it's tough. I mean, even 23 with the best of communication systems, if you're trying 24 to fly or drive a body out, and there's a snow storm, you 25 don't know when it's going to get there, and you don't

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1 know when it gets there, when they're going to be able to 2 fit it into their -- to their time line. 3 And -- and I've had cases just as he has, 4 where there's a young baby go out, and, you know, 5 families are distraught and, I'm sorry I can't tell you 6 when it's going to be back. We'll try and get it as soon 7 as we can. And -- and, you know, they're trying to fit 8 it into the lineup. 9 And -- and the other thing I would add, I 10 haven't had this with a child, but sometimes just waiting 11 for the IDENT; usually four (4), or five (5) hours where 12 I am, because I'm right between the Sault, and North Bay. 13 If it's the summer, and that body's 14 outside, that body will go from -- when I first saw it, 15 where it could be embalmed, and -- and be at an open 16 wake, which is what a lot of these communities like, to 17 something that is fly blown, smelly, not good for Dr. 18 Queen, and certainly nothing that the family can look at 19 again. 20 And that's very difficult. 21 COMMISSIONER STEPHEN GOUDGE: So, Dr. 22 McRae, do your IDENT officers come either from the Sault, 23 or Sudbury? 24 DR. SHELAGH MCRAE: No. Sudbury doesn't 25 have IDENT. Either from the Sault, or North Bay.

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1 It's four (4) hours, and that's assuming 2 it's on the road system somewhere. If it's off in the 3 bush, and we have to go with an ATV or a boat, or 4 something, it can be even longer. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 7 CONTINUED BY MR. MARK SANDLER: 8 MR. MARK SANDLER: Detective Inspector 9 Olinyk, I'll come back to you. In the memorandum that 10 you prepared that was circulated today, you listed a 11 number of challenges that are unique to the northwest 12 region in -- in addressing pediatric forensic death 13 cases. 14 Could you just take a few moments and 15 outline for the Commissioner, the challenges that you've 16 identified, and then we'll break them down, and -- and 17 talk about them a little bit if we could? 18 19 (BRIEF PAUSE) 20 21 DETECTIVE INSPECTOR DENNIS OLINYK: Yes, 22 these are the -- the challenges that -- that particularly 23 deal with the -- the timeliness of the post-mortem 24 examination, and of course, the timeliness of the post- 25 mortem examination is, by in large, dependent on where

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1 the post-mortem examination is, in fact, conducted. 2 And generally speaking, the more -- the 3 more often the body is moved from one (1) place to 4 another, the more compromise there is. And in -- in 5 certain scenarios, it becomes a challenge to -- to 6 respond to the community, to secure and record the death 7 scene, to have the -- the body removed and transported, 8 of course, with the chain of continuity to the -- to the 9 hospital where the autopsy is conducted so that a time -- 10 a timely autopsy can be conducted and com -- and 11 completed. 12 From our experience the -- the sooner we 13 can -- we can bring the body to the morgue for autopsy is 14 -- is clearly the better for a whole host of reasons. 15 First of all, understanding what has 16 happened here in those cases, and particularly in those 17 cases involving pediatric deaths, they become far more 18 complex. The -- the cause of death is, for -- for the 19 most part, not obvious, and to know the answer to, Well, 20 what is the cause of death or what is the preliminary 21 cause of death, is a very important aspect. 22 And in -- in some of the communities that 23 we respond to, the -- the distance and the accessibility, 24 barring even the weather, is -- is challenging. 25 I -- I identified these challenges in the

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1 context of where the autopsy would be and when it could 2 take place. 3 And the scenario that we were looking at, 4 from a practical point of view, is those cases where the 5 autopsy is done, for example, in Kenora, as opposed to an 6 autopsy being conducted in Toronto, or at some other 7 location, poses a number of issues with respect to, for 8 example, the loss of evidence in -- in those different 9 areas that I -- that I identified in my memo with respect 10 to body fluid, change, DNA, hair fibre. The more a body 11 is moved, the more often it is from place-to-place, the - 12 - the more compromise there is or the potential for 13 compromise there is. 14 COMMISSIONER STEPHEN GOUDGE: Does the 15 compromise depend on how far it's moved or the number of 16 times it's moved? 17 DETECTIVE INSPECTOR DENNIS OLINYK: I 18 think, Commissioner, the number of times -- the number of 19 times. And I -- and I should indicate, too, in -- in 20 those pediatric deaths that we have become invol -- that 21 we have become involved in, even though the autopsy was - 22 - was done in Kenora, for example, in the cases that -- 23 that I've had over the last few years, the -- the 24 forensic pediatric pathology was done in -- in Toronto. 25 And what that entailed was arrangements

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1 that -- that I would make as the Inspector in charge of a 2 case through the Regional Coroner identifying who the 3 pediatric neuropathologist would be and making 4 arrangements to have the forensic IDENT officer deliver, 5 for example, the brain to that particular doctor to -- 6 for him to conduct his -- his examination. 7 COMMISSIONER STEPHEN GOUDGE: Just 8 dealing with the body, I guess what I was curious about 9 was whether if there's a pediatric death in a fly-in 10 reserve, there is additional compromise if one were to 11 attempt to move the body not to Thunder Bay but, let us 12 say, to Toronto or to Sudbury. 13 Does the distance of the move play any 14 part or is it really the moving it a number of times that 15 adds to the compromise? 16 DETECTIVE INSPECTOR DENNIS OLINYK: It's 17 the number of times and if the body is, for example, in 18 Kenora, then to get the body from Kenora to Toronto 19 would, with the exception of chartering an aircraft, 20 would entail taking -- transferring the body from Kenora 21 to Winnipeg and then placing the body on an air carrier 22 in Winnipeg to Toronto. But to Sudbury, my experience is 23 you'd be going through Toronto which complicates it 24 further. 25 And with respect to the -- the -- the

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1 Sudbury Forensic Identification Unit, again, to give it 2 context, the -- the total number of death investigations 3 from the OPP standpoint, there are more in Kenora than in 4 North Bay, Sault Ste. Marie and South Porcupine combined. 5 COMMISSIONER STEPHEN GOUDGE: That's 6 helpful, thanks. 7 8 CONTINUED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: So, Dr. Eden, I'll 10 come back to you because I always keep the hardest 11 questions for you. You've heard what -- what has been 12 said by fellow panellists and much or all of that has 13 probably been known to you. 14 We discussed various alternatives to 15 address some of the logistics and communicative issues in 16 -- in the North region in -- in past roundtables, and one 17 (1) of the issues that was raised is whether or not 18 there's a need to amend the legislation to permit someone 19 other than a police officer to serve as a surrogate for 20 the coroner when the coroner can't attend the scene. And 21 -- and I'm sure you've been reflecting upon that since 22 our last roundtable. 23 And one (1) of the other alternatives that 24 was -- that was discussed and which will undoubtedly be 25 discussed tomorrow, as well, is is the introduction of an

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1 Aboriginal liaison person to assist with some of the 2 communicative issues that arise as between the Coronial 3 Service and -- and affected families. 4 What comments would you like to make about 5 -- about those or other challenges that have been 6 identified by Detective Inspector Olinyk? 7 DR. DAVID EDEN: I'll speak about the -- 8 the sort of investigator who should be attending a scene 9 when the coroner can't personally attend, and something 10 that Dr. Chiasson mentioned which I think is -- I would 11 like to reinforce is that while pictures and videotape of 12 a scene are very helpful, there's information you get 13 simply from being at a scene that you would not get 14 through photographs. 15 And, therefore, it makes sense that the 16 person at the scene, if that person is not a coroner, 17 should be somebody with the coroner's sensibilities in 18 mind; that is, what -- what the coroner is looking for in 19 a -- in a death scene. 20 So in looking at who should assist the 21 coroner, I have thought about this in some more detail. 22 Again, we go back to the -- the goals of the coroner's 23 investigation, under the Act, which are to find the facts 24 surrounding the death and then possibly to make 25 recommendations.

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1 But unlike some death systems in the 2 world, we're not prosecutorial. We're on the public 3 safety side of the administration of justice. And so -- 4 and the other thing is, the coroner's investigation is 5 based on the body. The findings we make are not 6 exclusively from the body but, obviously, the quality of 7 the investigation of the body makes enormous difference 8 to the quality of the -- the final results. 9 So when I thought of what we need in death 10 investigators, the first is investigative skills; people 11 who are used to conducting investigations. 12 Another skill which is necessary is being 13 familiar with the appearance of the human body and being 14 familiar with death. 15 And from a very practical point of view, I 16 can tell you because -- and I -- I think the forensic 17 pathologist may be able to reinforce this -- that the 18 first reaction of many people when viewing an autopsy is 19 to hit the ground. 20 And you -- you need some experience in 21 being around dead bodies if you're going to be a death 22 investigator because the first few are, viscerally and 23 emotionally, very difficult. 24 The other thing, of course, is knowing 25 what a normal human body looks like and knowing what a

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1 body looks like when it has been injured, and knowing the 2 changes that occur after death and with various forms of 3 injury. 4 The ability to conduct oneself 5 professionally and to recognize standards is important. 6 Understanding the law and making decisions under the law 7 that have significant consequences for other people is -- 8 is critical. 9 Doing documentation which is accurate and 10 complete and which may be used in court is another skill 11 that's required. 12 Dealing with very distressed people, the 13 family of people who've had a death are -- are very 14 distressed and there's a specific set of communication 15 skills that -- that are needed to communicate with 16 people, and I -- I mentioned when I testified previously 17 that in my experience the first meeting I had with 18 family, if they remember two (2) or three (3) words of 19 what I said, that is actually a lot. And there are 20 skills that people need to develop. It's a specific 21 professional skill. 22 Multi-disciplinary relations also very 23 important that you work with other disciplines and you 24 must be able to work with them. 25 And finally, as I mentioned before,

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1 adequate volume is important as well. 2 So if we look at what physicians bring to 3 this, we can see that they -- physicians do 4 investigations as part of their core work. They do 5 medical investigations but they have the investigative 6 skill as a core skill. 7 They obviously know the human body in -- 8 in wellness and in disease and the -- and Emergency Room 9 rotations and attendance at autopsies are both core parts 10 of medical education where physicians are exposed to the 11 body after it's been injured, and -- and exposed to death 12 which is another part of medical education. 13 Physicians are required to conduct 14 themselves professionally and impartially, to recognize 15 standards. They're required to be knowledgeable of the 16 law and, for example, physicians under the Mental Health 17 Act as a core skill are required to make decisions which 18 could result in a person being detained by police and 19 moved to a hospital. 20 So these are very important decisions 21 which physicians must administer. So it's not just 22 knowledge of the law, but actually making decisions which 23 have important effects. 24 Liaison with the distressed people, of 25 course physicians have to do that.

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1 Multi-disciplinary relations, we know that 2 physicians work with many other disciplines and that the 3 case volume, of course, is something that has to be taken 4 into account for -- for coroners and now that is nec -- 5 Northern Ontario. 6 So when -- when we take physicians -- we 7 take people with that background and then we're giving 8 them additional skills, understanding the Coroner's Act 9 particularly, how to apply the Coroner's Act, how to 10 perform death investigations, but that's building on an 11 existing basis. 12 With police I would say as well, it's a 13 core skill of police officers to perform investigations, 14 and they frequently attend death scenes, natural, 15 accident, homicide, suicide, they attend all those. 16 They are required to conduct themselves 17 professionally and that's -- that's part of their 18 training and to conduct their investigations impartially. 19 They have to understand the law and make 20 critical decisions which have effects on other people. 21 They have to document to standards and -- 22 for documents that are going to court. 23 They liaise with distressed people on a 24 regular basis and they des -- they deal with other 25 disciplines, physicians, ambulance, firefighters, many

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1 disciplines. 2 And again, what -- what we would like if 3 a police officer was performing work for the coroner is 4 that they have adequate volume. 5 At the -- the last time I testified we 6 talked about lay coroners and I -- I said that I thought 7 that might work, but in -- after reflection, the concerns 8 I have -- if I look at physicians and police officers, 9 these are people who use those core skills on a daily 10 basis. So even when a coroner is not conducting a death 11 investigation today, or a police officer isn't conducting 12 a death investigation today, they are conducting 13 investigative work. 14 They're dealing with distressed families, 15 they are documenting that. They have a whole lot of 16 their core work which they are performing all the time. 17 And that's as opposed to a -- a lay investigator who 18 would be doing this, including making difficult legal 19 decisions and understanding and applying the law perhaps 20 once a year. 21 So that -- that to me is a -- an enormous 22 difference between the two (2). 23 The exposure to the human body in death, 24 disease and wellness of course is not -- mostly people 25 only see the human body when well.

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1 We don't see dead bodies; we don't see 2 injuries very often. 3 Documentation to standards and for court 4 is really a professional skill. It's not something that's 5 generally seen in the population. 6 The requirement to professionally liaise 7 with other disciplines, again, is not something that most 8 people do in their daily life. 9 And again we get back to the volume issue 10 that you have to be seeing enough. 11 So after taking that -- all of that into 12 account, my suggestion would be that we take the core 13 skills of police and say which skills that police have 14 should be augmented or enhanced specifically for 15 coroner's investigations. And I think those can be 16 easily identified. 17 What police don't have that coroner's have 18 by virtue of their medical background is significant 19 depth in their understanding of the appearance of the 20 human body in death and injury. And that is something 21 for which specific training could be given. 22 The other area in which they don't have as 23 much knowledge as the coroner is of course the Coroners 24 Act, and the -- and the policies of the Coroner's 25 Officer. And again that's something that could easily, I

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1 believe, be imparted. There's already processes in place 2 for police officers to receive specialized training. 3 So-called SOCO officers, scene of crime 4 officers, receive specific training that gives them 5 enhanced skills in specific areas. And I would suggest 6 using that model to give to specific police officers who 7 would then be credentialed as coroner's investigators be 8 given that additional depth of education. 9 And then because it wouldn't be all police 10 officers, but just a -- a subset, they would be getting 11 the volume to -- to apply, so they'd be using those 12 skills on a regular basis. 13 COMMISSIONER STEPHEN GOUDGE: How big of 14 subset, Dr. Eden? I guess my sort of question is if it's 15 a small subset they will be located as remotely from many 16 deaths as the coroner is. 17 DR. DAVID EDEN: I -- I couldn't give you 18 a number, Mr. Commissioner. I think what we would need 19 to do is to say what's the minimum number of officers we 20 would train to ensure that there's always going to be 21 availability given how many deaths at one time we may 22 need to investigate, and that's something we'd have to 23 discuss with -- with police. 24 However, I -- I could see it as improving 25 things, because no matter how there are there will be a

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1 number of police officers there who have that enhanced 2 training and can bring it to the death scene. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 5 6 CONTINUED BY MR. MARK SANDLER: 7 MR. MARK SANDLER: Detective Inspector 8 Olinyk, I'm going to inject you into a dialogue that's 9 taken place well before you became involved in the work 10 of this Inquiry, but one (1) of the issues that has come 11 up is that if coroners can't attend a number of the death 12 scenes in Northern Ontario, and -- and indeed issues were 13 raised about whether or not police are the right 14 surrogate for the coroner in those kinds of cases, do you 15 have any thoughts as to whether there's a role as has 16 been seen in, for example, in -- in other provinces for 17 -- for other kinds of investigators to be delegated the 18 role that would otherwise be given to the coroner at a 19 death investigation? 20 DETECTIVE INSPECTOR DENNIS OLINYK: There 21 are many, many death investigations that take place that 22 do not involve the criminal investigation branch. The 23 vast majority of death investigations are conducted at 24 detachment level within the different policing 25 jurisdictions outside of the OPP.

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1 With respect to death investigations, I 2 think it's fair to say that the way business is done 3 today and has been for a number of years, certainly for a 4 good number of years, the forensic identification unit 5 personnel -- and we're blessed with some -- some very 6 good forensic identification officers who are very 7 seasoned and very experienced -- by and large at the 8 gatekeepers, the gatekeepers of these death 9 investigations. 10 Because -- with the exception of motor 11 vehicle fatalities in this region, if there's a death 12 it's policy for the Forensic Identification Unit -- and 13 there are many, many cases that will follow through the 14 Forensic Identification Unit in Kenora, where the unit 15 commander, and in concert with his staff, will on a 16 priority basis determine, and in concert with the local 17 coroner and sometimes the regional coroner, whether or 18 not a forensic identification officer will attend, and/or 19 in his or her absence a scenes of crimes officer who can 20 fulfill certain functions with respect to the recording 21 of a death scene, the collection and the preservation of 22 evidence, and scene security, body security, and those 23 kinds of things. 24 The -- the system that is in place, I 25 think, works well in the sense that even though the

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1 coroner, the local coroner, may not in fact attend the 2 scene, I -- I believe that because the forensic 3 identification personnel are involved in these cases, 4 they make determinations and recommendations as to 5 whether or not a certain death investigation, for 6 example, ought to involve more than detachment personnel, 7 or may be elevated to Regional Crime Unit personnel, or 8 there may be a request for assistance at the Criminal 9 Investigation Branch. 10 In this -- in this process because of the 11 numbers, and because of the volume of deaths, the -- the 12 Forensic Identification Unit commander, and -- and those 13 who work under his command, have maintained an excellent 14 working relationship with the regional coroner. 15 It's been our experience that many of the 16 coroners have practices in the north. They're -- they're 17 practising physicians. They have clinics. They have 18 hospitals to go to. They're very busy people. 19 Although they're involved, the regional 20 coroner is there and is the -- the quarterback, the -- 21 the oversight, the individual who pulls those together, 22 i.e., the forensic identification people, who I think are 23 -- are most well trained in -- in scene examination, body 24 examination, and those kinds of things by -- by their 25 experience, by the number of scenes that they've

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1 attended, the number of dead bodies they've seen. 2 Dr. Eden made comment about -- about the - 3 - the difference between -- the difference between 4 somebody who's not used to this kind of thing, as opposed 5 to somebody as a medical -- as a physician is, and -- and 6 the -- and the differences, and the fallout from that. 7 So I think we have -- I think we have 8 people trained within the Forensic Identification Units. 9 And it seems to me, from my experience, that those -- 10 those are the best qualified to make assessments, whether 11 it be a pediatric death scene, or a non-pediatric death 12 scene, a homicide, or a suspicious death. 13 COMMISSIONER STEPHEN GOUDGE: I guess I 14 have the same question for you that I asked Dr. Eden, 15 Detective, and that is: 16 Implicit in that, I guess, is that it 17 would be the Forensic Identification Units in cor -- in 18 Kenora, and Thunder Bay, that would send out the 19 identification officers to scene investigations where the 20 coroners would not attend? 21 DETECTIVE INSPECTOR DENNIS OLINYK: Oh -- 22 COMMISSIONER STEPHEN GOUDGE: Is that 23 implicit in what you are saying? 24 DETECTIVE INSPECTOR DENNIS OLINYK: In -- 25 in those cases -- in most of the cases, the -- the police

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1 are -- are engaged before perhaps the coroner is. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 Right. But it would be the forensic identification 4 officers that would serve as the on-the-scene presence 5 for the coroner? 6 DETECTIVE INSPECTOR DENNIS OLINYK: 7 That's correct, Commissioner. 8 COMMISSIONER STEPHEN GOUDGE: I guess my 9 question is: There are investigating coroners both in 10 Kenora and Thunder Bay, why wouldn't they go themselves 11 if the forensic identification officers could get there? 12 Is that simply a question of numbers? Or 13 is it -- sorry, Dr. McRae, you look like you have an 14 answer to that. 15 DETECTIVE INSPECTOR DENNIS OLINYK: I -- 16 COMMISSIONER STEPHEN GOUDGE: It is just 17 that I sort of started with the implicit assumption that 18 there were officers in more locales than there were of 19 coroners in locales, and it turns out that on your thesis 20 they are in the same places. 21 DR. SHELAGH MCRAE: My experience has 22 been that when a -- when a body is found, occasionally 23 I'm the first person called, but usually it's the police. 24 The police, in my area any way, notify me fairly soon: 25 We're on the scene, this is what we've got.

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1 And we talk about it over the -- over the 2 telephone -- hopefully a land line, but not always -- and 3 it's: What kind of a scene is it? Are you suspicious? 4 Are you worried? 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. SHELAGH MCRAE: Do you want me there? 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. SHELAGH MCRAE: Do you think we need 9 to call anybody else? 10 Now in -- in very obvious scenes, you 11 know, there's -- there's been violence, Ident's already 12 on the way before they call me -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. SHELAGH MCRAE: -- because sometimes 15 that's a negotiation at that time. 16 Now if I know that Ident is coming and I 17 have confidence in Ident, and I am in the middle of a 18 busy clinic and it's going to be a five (5) hour 19 turnaround time -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. SHELAGH MCRAE: -- my priorities are 22 the -- are the living patients that are waiting for me. 23 COMMISSIONER STEPHEN GOUDGE: So I guess 24 the reality from your perspective is in any criminally 25 suspicious death the Ident officer is going to have to go

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1 anyway -- 2 DR. SHELAGH MCRAE: Right. 3 COMMISSIONER STEPHEN GOUDGE: -- and 4 therefore, why should the coroner go as well if it's a 5 difficult logistical issue. 6 DR. SHELAGH MCRAE: And the other issue 7 that hasn't come up yet in this discussion is, chances 8 are if I'm that close to the death scene, I also know 9 some of the participants, either the dead person or -- 10 COMMISSIONER STEPHEN GOUDGE: So there's 11 a conflict or a sort of perception issue -- 12 DR. SHELAGH MCRAE: Exactly. 13 COMMISSIONER STEPHEN GOUDGE: -- as well? 14 DR. SHELAGH MCRAE: Exactly. So often, 15 and again, at this point I'm now calling my regional, I 16 may not have much more contribution to that suspicious 17 death scene than to do up some of the paperwork and make 18 sure all the various parties are -- are involved. 19 COMMISSIONER STEPHEN GOUDGE: All right. 20 Okay. 21 DR. SHELAGH MCRAE: Now, I will also, 22 unless I'm specifically advised, you know, you're really 23 too close to that one, I will be there as a liaison to 24 the family -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. SHELAGH MCRAE: -- at the time and 2 down the road. 3 COMMISSIONER STEPHEN GOUDGE: Yes, 4 because that's clearly an important coronial -- 5 DR. SHELAGH MCRAE: Yeah. 6 COMMISSIONER STEPHEN GOUDGE: -- function. 7 DR. SHELAGH MCRAE: Yeah. Now for some 8 of these farther out places we still have the discussion. 9 The -- the tiny tribal police force that really has very 10 little experience, they often call me first and we'll 11 discuss who all we're going to call in. They -- they 12 appreciate having me come out if I -- I can get there, 13 just to bounce things off. One (1) of -- a recent case 14 we had we did up the press release together; they really 15 weren't that used to doing it, and again, I -- I 16 consulted. 17 But -- but that's part of what it is, all 18 of -- none of us in -- out there in the small 19 communities have enough experience to do this well, but 20 together working on it we can say: Who do we need to 21 call? When is it too much for our experience? How can 22 we get these people here efficiently. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 Thanks. Sorry, Mr. Sandler. 25

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1 CONTINUED BY MR. MARK SANDLER: 2 MR. MARK SANDLER: That's fine. One (1) 3 more question for Detective Inspector Olinyk and them I'm 4 going to bring Dr. Queen into the discussion because I've 5 neglected him. 6 Detective Inspector Olinyk, the north is a 7 very complex matrix of jurisdictions when it comes to 8 policing. We -- we know that you can have municipal 9 police forces in -- in some of the areas, we know that 10 the OPP polices some of the areas, we know that the OPP 11 can -- that some of the areas can be OPP administered 12 with -- with local First Nations constables, though 13 without a First Nation's police service, we know some of 14 these jurisdictions are policed by self-directed First 15 Nations services, that -- that nonetheless draw upon the 16 OPP for additional expertise if -- if needed. 17 So, the question I have is: Looking at 18 that whole matrix two (2) -- two (2) things are raised, 19 the first is: Are you confident that in the north if you 20 have a case of a child's death that's potentially 21 suspicious, a sudden and unexpected death, that -- that 22 if need be an expert Forensic Identification Unit will 23 make its way to that scene, in whichever one (1) of the 24 jurisdictions that I've just described? That's the first 25 question.

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1 Well, I'll let you answer that one and 2 then I'll -- I'll give you the followup. 3 DETECTIVE INSPECTOR DENNIS OLINYK: I 4 think the answer is yes, but -- but again, there are 5 potentially investigations and deaths that perhaps may 6 not come across our -- our desk if it's -- if it's non- 7 OPP related. 8 MR. MARK SANDLER: Right. And the second 9 question is this: We heard from Inspector Keetch of the 10 Sudbury Police Service that he'd like to see some 11 available resourcing that's institutionalized that would 12 enable, for example, police officers that are 13 investigating a complex pediatric forensic death case to 14 be able to call up a specialist at the OPP or a 15 specialist with the Toronto Police service to get some 16 help. 17 Is there anything in place that could be 18 drawn upon to -- to enable him to get the kind of help 19 that he was describing? 20 DETECTIVE INSPECTOR DENNIS OLINYK: Yes. 21 I think -- I don't think it's -- it's formalized; in -- 22 in fact, I -- it -- it is not formalized. But I -- what 23 -- what happens is, is the -- the Forensic Identification 24 Units across the -- across the province are now 25 centralized, whereas before they were within the

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1 jurisdiction of the various OPP regions. They are now 2 centralized and -- and report directly to and are managed 3 out of headquarters out of Orillia. I think our forensic 4 identification people know those who have more experience 5 in some areas than others. 6 I think collectively, as an organization 7 and as a forensic identification community, there is 8 little to no difficulty in being able to go to someone 9 within that community to get the -- to get the advice, 10 and to -- to assist in being given the direction to -- to 11 go where they -- they have to go to. 12 COMMISSIONER STEPHEN GOUDGE: I take it 13 with the OPP that would work with what, the detachment 14 officer on the scene first going through the centralized 15 forensic identification administration you now have, and 16 would be routed to -- 17 DETECTIVE INSPECTOR DENNIS OLINYK: Yeah. 18 Mr. Commissioner, the -- the officer on scene would -- 19 would go to the forensic identification unit for that 20 area. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DETECTIVE INSPECTOR DENNIS OLINYK: And 23 then the -- the forensic identification officer for that 24 area then would -- would connect to his or her superior, 25 supervisor --

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DETECTIVE INSPECTOR DENNIS OLINYK: -- 3 and would be directed to whomever within the organization 4 who might best deal with this. And -- and I think from - 5 - in -- in providing perhaps maybe a more wholesome 6 response, given the experience that we've had and the 7 good experience that we've had within the northwest, the 8 judicial districts of the Thunder Bay, Kenora, and -- and 9 Rainy River, is where we have enjoyed a real good close 10 working relationship with the Regional Coroner, who has 11 come in to help us in -- in directing us to -- to where 12 we may have to go to -- for example, to determine who may 13 be doing the -- certain -- certain pathology work. 14 COMMISSIONER STEPHEN GOUDGE: What about 15 the policing side of it, Detective? I mean, as Mr. 16 Sandler's indicated, we heard, for example, from Metro 17 Toronto policing that there is a specialization available 18 in pediatric death investigation. 19 Does the provincial service have anything 20 like that, that is any people, one (1) or two (2) people, 21 that could be identified, I presume, within the Ident 22 administration that could be seen as provincial resources 23 for investigations going on anywhere in the province that 24 involved a sudden unexpected infant death? 25 DETECTIVE INSPECTOR DENNIS OLINYK: It's

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1 certainly something that could be done. 2 COMMISSIONER STEPHEN GOUDGE: Because we 3 have heard from local policing that this would be an 4 invaluable resource to be able to call on, faced with 5 one's first sudden unexpected infant death? 6 DETECTIVE INSPECTOR DENNIS OLINYK: I -- 7 I would agree. 8 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 9 Sandler. 10 11 CONTINUED BY MR. MARK SANDLER: 12 MR. MARK SANDLER: Dr. Queen, you are 13 dealing as a forensic pathologist in -- in your 14 jurisdiction with a number of police forces, I take it? 15 DR. MARTIN QUEEN: Yes. I'm dealing with 16 quite a few, actually. 17 MR. MARK SANDLER: And -- and can you 18 describe -- is there an uneven level of experience in 19 dealing with forensic pathology on the part of the 20 officers with whom you deal, or are you comfortable with 21 the overall level of expertise that's been demonstrated 22 with the police services, at least with whom you 23 interrelate? 24 DR. MARTIN QUEEN: I would say I've been 25 uniformly, extremely impressed with the work of the

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1 forensic identification officers that I -- I deal with. 2 I'm mostly dealing with the forensic team from the 3 Sudbury City Police. And -- and I deal a lot with the 4 OPP forensic people out of North Bay and The Sioux and 5 South Porcupine. 6 And over the last nine (9) years I've 7 gotten to know pretty well all those officers extremely 8 well. And I think we work really well together and -- 9 and I'm very happy with -- with the help I get from them. 10 There are logistical issues again though 11 with dealing with so many forces and -- and so many 12 different officers that are scattered around. We've been 13 talking about barriers and there's a couple of other 14 barriers that -- that I haven't mentioned. This sort of 15 gives me another opportunity to plug a larger, better 16 staff unit in Sudbury. 17 Because I'm a one (1) one show we don't 18 schedule autopsies on weekends, normally, including long 19 weekends, because I can't work every weekend. And 20 although several times a year, my assistant and myself do 21 come in on our time to do cases on weekends if it's a 22 homicide, or a suspicious case or a SIU case, or some 23 high profile case or something. So some cases do get 24 done, but as a routine they don't. 25 So if somebody passes away on a -- on a --

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1 late on a Friday night and it's a long weekend, we're 2 normally not even going to get to consider doing that 3 autopsy until Tuesday. 4 And quite often on a Tuesday, after a long 5 weekend, there's a bunch of bodies piled up, and some may 6 be from the City of Sudbury, some may be from Timmins, or 7 Cochrane, or North Bay or whatever, and then we have to 8 coordinate with all these different police forces who's 9 coming when. And it can become very difficult. 10 And sometimes I've had times when we had 11 so many bodies piled up on Tuesday that we didn't get to 12 finish them all until -- until the Thursday. So a body 13 that might have been found on Friday night didn't get its 14 autopsy till -- till Thursday. So, you know, there -- 15 there are certain problems when you're a one (1) man 16 show. 17 The other -- the other problem along that 18 same line is, you know, I'm a member of a -- of a ten (1) 19 member pathology group. We're all self-employed. We're 20 -- and we decide amongst ourself, you know, how much 21 vacation time we get, and we decided nine (9) years ago 22 that we were all going to take eight (8) weeks of 23 vacation a year. 24 And when I'm on vacation, there's no 25 forensic services in -- in Sudbury and there's no

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1 forensic services for criminally suspicious cases and 2 homicides in Northeastern Ontario. So for those eight 3 weeks a year, those bodies have to go usually to Toronto. 4 Occasionally the -- the Sioux will take straightforward 5 ones. 6 MR. MARK SANDLER: So you're recommending 7 that you have no vacations and that -- and that you work 8 seven (7) hours -- 9 DR. MARTIN QUEEN: I work -- work every 10 weekend. 11 MR. MARK SANDLER: -- seven (7) days and 12 twenty-four (24) hours a day? 13 DR. MARTIN QUEEN: Well, that is what it 14 would take. So you can see again the advantages of 15 having a -- a second person if we had the critical mass 16 of -- of work. 17 The other interesting thing that's a 18 barrier in the north, and -- and this is a minor thing, 19 but we have bad winters and bodies are often frozen 20 solid. And I had a case just recently where a fellow 21 hung himself in a detached garage, wasn't found for two 22 (2) or three (3) days, was frozen solid, and it took 23 eight (8) days for him to thaw. And this was a case from 24 Kapuskasing. 25 Well, the OPP protected that scene for

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1 those eight (8) days. They had an officer sitting at 2 that scene twenty-four (24) hours a day for eight (8) 3 days before we could finally do that autopsy. 4 So it's just a little aside that -- that 5 we really do have some unique challenges in Canada and 6 particularly in the cold, really cold parts of Canada. 7 MR. MARK SANDLER: I should say that I've 8 completed my questioning. The topic of the pediatric 9 forensic death investigation is going to be revisited 10 tomorrow in the context of it being provided in 11 Aboriginal communities. But I do want to give everyone 12 an opportunity once again, if -- if there's any 13 concluding comments or recommendations that you'd like to 14 make that haven't already been covered. 15 Dr. Queen, is there anything else that 16 you'd like to say? 17 DR. MARTIN QUEEN: Thank you very much. I 18 think I've taken enough of your time. 19 MR. MARK SANDLER: Dr. Chiasson...? 20 DR. DAVID CHIASSON: Yes, if I may, 21 there's -- just as -- remind people, I think there might 22 be a bit of confusion what the status quo is as far as 23 pediatric forensic pathology now, and -- and to 24 acknowledge the important role of -- of -- of Winnipeg 25 and, in particular, Dr. Susan Phillips who is the

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1 pathologist there who works in the Medical Examiner's 2 Office, that does a significant number of cases, of 3 pediatric cases, that are referred from the Kenora 4 region. 5 I think it would be of value -- just as 6 I'm talking about liaisoning with other units, including 7 Martin's unit, which I'm very optimistic now will -- will 8 go forward, with Dr. Phillips, in particular -- pediatric 9 forensic pathology as we know is a very small field of 10 specialty experience and, therefore, we need to start 11 looking and -- and developing liaisons across the 12 country, ultimately, but obviously Winnipeg, because it 13 is doing, in fact, a significant number of pediatric 14 cases for the Ontario Coroners System. Certainly, that's 15 -- that's the first step in that direction. 16 COMMISSIONER STEPHEN GOUDGE: Can I ask 17 you for a bit of detail about that, Dr. Chiasson, because 18 we've heard about it but we haven't had any significant 19 detail. 20 How many pediatric forensic cases would 21 you think might go to Winnipeg each year? I mean, do you 22 have any off the top sense of how many cases that might 23 be? 24 DR. DAVID CHIASSON: I -- I don't have any 25 hard statistics, but I know that we review these cases at

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1 the Death Under Five Committee. And we meet -- 2 invariably, there's at least one (1) or two (2) -- we 3 meet four (4) times a year. So I -- I think we're 4 talking five (5) to ten (10) cases a year that have been 5 done by Dr. -- 6 COMMISSIONER STEPHEN GOUDGE: And do they 7 come from any sort of defined geographical area? You 8 raised Kenora. Is it everywhere from Kenora west or is 9 there any bright line there? 10 DR. DAVID CHIASSON: Detective Inspector 11 Olinyk may -- may clarify this, but as I understand, it's 12 Kenora, and what would be the catchment area of Kenora 13 would -- would go -- 14 COMMISSIONER STEPHEN GOUDGE: Where would 15 that be roughly, if I look at the map here, Detective? 16 DETECTIVE INSPECTOR DENNIS OLINYK: Mr. - 17 - Commissioner, it would be within the judicial district 18 of Kenora, which would include the OPP policing area, 19 along with the area policed by the Nishnawbe-Aski police, 20 and the area policed by the Treaty 3 police. 21 Treaty 3 police are all within the 22 district of Kenora, and Rainy River. 23 COMMISSIONER STEPHEN GOUDGE: Does that 24 go right up to James Bay and Hudson Bay? 25 DETECTIVE INSPECTOR DENNIS OLINYK: No,

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1 that's the east end of the Naps. 2 COMMISSIONER STEPHEN GOUDGE: Okay. 3 DETECTIVE INSPECTOR DENNIS OLINYK: The - 4 - the Treaty 3, for all intents and purposes, is around 5 Kenora. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DETECTIVE INSPECTOR DENNIS OLINYK: And 8 they -- there's a total of twenty-three (23) First 9 Nations communities within Treaty 3. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DETECTIVE INSPECTOR DENNIS OLINYK: 12 They're all drive-to communities. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DETECTIVE INSPECTOR DENNIS OLINYK: And 15 then we have the -- then we have the -- the Nishnas -- Na 16 -- Naski -- Aski police service, and there are twenty 17 (20) communities in the west part of the -- 18 COMMISSIONER STEPHEN GOUDGE: Okay. That 19 is what I was getting at. 20 DETECTIVE INSPECTOR DENNIS OLINYK: -- 21 Naps area. 22 COMMISSIONER STEPHEN GOUDGE: So it's a 23 big, big geographical chunk of the province? 24 DETECTIVE INSPECTOR DENNIS OLINYK: It 25 really is. And there's a total of twenty (20)

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1 communities in the west side of -- of Naps, eighteen (18) 2 of which are fly-in, only two (2) drive-to. 3 COMMISSIONER STEPHEN GOUDGE: And they 4 are all in the Kenora -- 5 DETECTIVE INSPECTOR DENNIS OLINYK: 6 They're all in the Kenora area. All within the 7 jurisdiction of Kenora. 8 COMMISSIONER STEPHEN GOUDGE: I see. 9 DETECTIVE INSPECTOR DENNIS OLINYK: And 10 then we then move over to the James Bay coast -- 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DETECTIVE INSPECTOR DENNIS OLINYK: -- 13 where we have the east side of Naps, and there's a total 14 of, I believe, fifteen (15) communities, nine (9) of 15 which are drive-to, six (6) are fly-in communities -- 16 COMMISSIONER STEPHEN GOUDGE: But do they 17 go through Kenora as well? 18 DETECTIVE INSPECTOR DENNIS OLINYK: No. 19 COMMISSIONER STEPHEN GOUDGE: Yes, that's 20 what I assumed. 21 DETECTIVE INSPECTOR DENNIS OLINYK: No, 22 but I guess the point that I was making, Commissioner, 23 was that with respect to Naps, the lion's share of the 24 work is -- is on the west side of it -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DETECTIVE INSPECTOR DENNIS OLINYK: -- in 2 the Kenora side of it. 3 COMMISSIONER STEPHEN GOUDGE: Okay. That 4 is helpful. 5 Then back to you, Dr. Chiasson. Is the 6 arrangement with Dr. Phillips of longstanding? 7 DR. DAVID CHIASSON: I wouldn't say 8 longstanding. It's -- it's an informal arrangement -- 9 COMMISSIONER STEPHEN GOUDGE: Yes, I was 10 going to get -- 11 DR. DAVID CHIASSON: -- as far as -- 12 COMMISSIONER STEPHEN GOUDGE: -- I mean, 13 does it -- is it personal to her, or is there a protocol, 14 or just how did it originate, and what its status? 15 DR. DAVID CHIASSON: I -- I could be 16 wrong about what I'm going to say, but as I understand, 17 Dr. Phillips used to do pediatric pathology, and then 18 started doing forensic pathology for the medical 19 examiner's office. And certainly she would do cases of a 20 pediatric forensic nature. She's, as I understand it, 21 been doing that for quite a few years. 22 COMMISSIONER STEPHEN GOUDGE: Is she on 23 staff at a hospital, or is she on staff with the Medical 24 Examiner's Office? 25 DR. DAVID CHIASSON: I think -- I think

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1 at the present time her primary appointment is at the 2 medical examiner's office. 3 COMMISSIONER STEPHEN GOUDGE: I see. 4 DR. DAVID CHIASSON: And, so she's 5 certainly been doing cases for quite a few years. She is 6 the only one (1) that we routinely see coming out of 7 Winnipeg. Her -- it's only her reports that were 8 routinely in the sudden unexpected death under five (5). 9 I think she's providing the same -- 10 basically the same service for -- for Manitoba, and -- 11 and has added Kenora as part of -- of her service 12 provision with pediatric forensic work. 13 COMMISSIONER STEPHEN GOUDGE: Does she 14 have any links with a children's hospital in Winnipeg? 15 DR. DAVID CHIASSON: There is a 16 children's hospital in Winnipeg. 17 COMMISSIONER STEPHEN GOUDGE: I know. 18 DR. DAVID CHIASSON: I assume that 19 previously she was -- when she was doing pediatric 20 pathology, she was working there. I assume she's 21 probably maintained some kind of a relationship -- 22 COMMISSIONER STEPHEN GOUDGE: And would 23 the neuropathology in her cases be done there, or do you 24 know? 25 DR. DAVID CHIASSON: The neuropathology -

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1 - and -- and Detective Olinyk made reference in -- in his 2 notes there that Dr. Halliday used to be in Winnipeg. 3 Dr. Halliday, you recall, is -- is the senior pediatric 4 neuropathologist -- 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. DAVID CHIASSON: -- and now works 7 with me at Sick Kids, certainly was doing a lot of these 8 cases when he was in Manitoba, and worked with her. 9 COMMISSIONER STEPHEN GOUDGE: But what 10 would happen today with Dr. Phillips' cases? 11 DR. DAVID CHIASSON: They -- they have 12 other neuropathologists now in Winnipeg who are doing the 13 neuropathology -- 14 COMMISSIONER STEPHEN GOUDGE: Okay. 15 DR. DAVID CHIASSON: -- so she gets a -- 16 she refers the cases -- 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 DR. DAVID CHIASSON: -- for 19 neuropathology. 20 COMMISSIONER STEPHEN GOUDGE: Okay. 21 Thanks. 22 DETECTIVE INSPECTOR DENNIS OLINYK: 23 Commissioner, just a comment and followup on that. 24 Recently, just over the last couple of years, we had a 25 pediatric homicide, and Dr. Phillips did the -- did the -

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1 - the autopsy. 2 And -- and my understanding is that the -- 3 the working relationship with -- between herself and -- 4 and the pathology services in Ontario, that there's a -- 5 there's a connect there. 6 And -- and as well in -- in that 7 particular case, the -- the neuropathology was -- was 8 done by -- by Dr. Halliday in that particular case, 9 because the neuropathologist there didn't want to get 10 involved in a med -- in a -- in a legal medica -- a 11 medicolegal case that would involve -- or potentially 12 involve him travelling out of province to attend court. 13 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 14 Chiasson, when you were in your previous incarnation, if 15 I can put it that way, would you have reviewed Dr. 16 Phillips' reports in the way that you've reviewed any 17 other reports in the Ontario system? Do you remember? 18 DR. DAVID CHIASSON: The majority of the 19 reports would be sudden unexpected death under 5 -- 20 COMMISSIONER STEPHEN GOUDGE: Yes. 21 DR. DAVID CHIASSON: -- so since that 22 committee was initiated -- 23 COMMISSIONER STEPHEN GOUDGE: Yes. 24 DR. DAVID CHIASSON: -- we would have 25 reviewed her reports at that time.

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1 COMMISSIONER STEPHEN GOUDGE: But back 2 when you were the Chief Forensic Pathologist? 3 DR. DAVID CHIASSON: You know, I should 4 have been. I don't recall having done it and whether she 5 did very many criminally suspicious or homicide pediatric 6 cases back in -- in that time period. 7 COMMISSIONER STEPHEN GOUDGE: I guess 8 what I'm getting at is whether there are any issues 9 unique to the fact that this is a pathologist from 10 another province building it into whatever quality 11 assurance process is desirable. 12 DR. DAVID CHIASSON: Well, you -- you 13 raise a very good point and I think part of the liaison 14 that I think we need to be looking at between -- in terms 15 of pediatric matters, between our system and -- and 16 what's going on in the medical examiner system, needs to 17 be examined, and -- and -- 18 COMMISSIONER STEPHEN GOUDGE: But what's 19 your sense of whether there are difficulties lurking 20 there or not? I mean, we've heard very little about this 21 and this is one (1) of the great advantages of coming to 22 the north, frankly, is you hear about things that we 23 haven't heard about in Toronto. 24 DR. DAVID CHIASSON: Yes. So from 25 reviewing her reports personally from the Death Under

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1 Five, she produces excellent pediatric -- 2 COMMISSIONER STEPHEN GOUDGE: Oh, I'm 3 sure she does, but if -- 4 DR. DAVID CHIASSON: -- forensic 5 pathology reports -- 6 COMMISSIONER STEPHEN GOUDGE: -- one were 7 talking about a quality assurance system, how do you make 8 part of it somebody who works in another jurisdiction, I 9 guess is my question? 10 DR. DAVID CHIASSON: Well, it certainly 11 would be very difficult. You don't have any -- any 12 control or any -- any power. I mean, it's -- it's the 13 same problem we have in -- in a lot of ways with the non- 14 salaried pathologist in the province. You -- you have 15 the rather blunt instrument of not sending them any work 16 if -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID CHIASSON: -- you were unhappy 19 with their -- their work. So -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. DAVID CHIASSON: -- but I -- I think 22 there, you know, in a collegial manner there -- there's 23 an opportunity and it should be looked at: let's make 24 sure that we are doing things in a similar fashion. 25 And -- and knowing Dr. Phillips and

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1 knowing the work that she's been doing, I -- I don't see 2 that with those -- you know, with the individual -- that 3 particular individual, I don't see any problem -- 4 COMMISSIONER STEPHEN GOUDGE: Okay, 5 thanks. 6 DR. DAVID CHIASSON: -- with that. 7 8 CONTINUED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: I -- I should say that 10 I -- I believe we do have some evidence at the Inquiry 11 that Dr. Pollanen is now conducting reviews -- does 12 review personally the work from Dr. Phillips in those 13 cases. 14 DR. DAVID CHIASSON: Yes, I -- I expect 15 that should be the way. I -- I -- 16 MR. MARK SANDLER: All right. I believe 17 we've taken you off some of your closing comments, so... 18 DR. DAVID CHIASSON: Sorry. Yeah, if -- 19 if I may just complete my -- my final thought, and -- and 20 that's to recognise we are in Thunder Bay right now and 21 we haven't really talked about pediatric pathology as it 22 related to Thunder Bay, other than to say that things are 23 going to Toronto. 24 And having listened to the poignant 25 discussion of Mr. -- Mr. Savage -- sorry, Mr. Sargent,

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1 that, you know, it's clear, I think there is a need to 2 look at how -- you know, we've got Kenora kind of dealt 3 with, we've got Sudbury going to dealt with, I think -- I 4 think there's -- there's really a hope for the future 5 there that's -- that's a real -- realistic one, it is to 6 look at -- at what to do with the cases of a pediatric 7 nature within -- within Thunder Bay. 8 There are, and this was referred to by Dr. 9 McCreary earlier this morning, there are some experienced 10 pathologists, hospital pathologists, who have been doing 11 forensic work in yeomen service for the Coroner's Office 12 there for -- for many years, colleagues that I -- that I 13 certainly respect. 14 They have not been doing pediatric cases. 15 They are neither pediatric pathologists, nor formally, as 16 I understand it, and I -- I can be -- stand corrected, 17 they are forensic pathologists. 18 But I -- I could see that there needs to 19 be thought given towards thinking of not only having a 20 northeastern forensic pathology unit, but actually a 21 northwestern forensic pathology unit in -- in Thunder Bay 22 and looking at their long term staffing and having 23 somebody with formal forensic pathology training. And I 24 say that as opposed to pediatric pathology training 25 because I -- I don't think that's really a practical

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1 thing. 2 So I think that -- that needs to be 3 thought about in the mix of how to deal with pediatric 4 forensic pathology in the north. 5 MR. MARK SANDLER: Thank you, Dr. 6 Chiasson. 7 Detective Inspector Olinyk...? 8 DETECTIVE INSPECTOR DENNIS OLINYK: Just 9 a few comments with respect to -- to the medicolegal 10 cases, the death investigations within the Northwest 11 Region. There are as many deaths that go through -- or 12 there is many autopsies that go through Kenora as -- as 13 go through Thunder Bay. 14 With respect to homicides, more than 75 15 percent of the homicides are within the judicial district 16 of Kenora. More than 80 percent of the suspicious death 17 investigations that entail a CIB investigation are within 18 the judicial district of Kenora. 19 The -- we have two (2) pathologists in 20 Kenora. We have a forensic identification unit in 21 Kenora. Both are very, very busy units. We've had, I 22 believe, an excellent working relationship with the 23 Forensic Ident. Unit; with the pathologists in Kenora; 24 with the -- with the Regional Coroner in Thunder Bay; and 25 not to diminish in any way a good working relationship

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1 with the -- with the local coroners. 2 One (1) -- one (1) final comment and -- 3 and -- and it -- and it -- I tried to give it some 4 context in -- in the area that dealt with where the 5 autopsy ought to be or logistical issues with respect to 6 where the autopsy is conducted. 7 Because we go to a lot of death scenes, 8 because are we dealt with a lot of challenges that -- 9 that are given because of where we go, it is, in my view, 10 with respect to the -- to completing the -- the most -- 11 the -- the most careful and the most precise 12 investigation that we -- without minimizing the loss of 13 evidence is that it's so important -- it's so important 14 from -- from the investigative perspective that the -- 15 that the pathology work be done sooner than later and at 16 a location where it minimizes the number of moves so not 17 to compromise the loss of evidence. 18 MR. MARK SANDLER: Thank you very much. 19 Dr. Eden...? 20 DR. DAVID EDEN: Thank you. I'll start, 21 as before, by building on the remarks of Dr. Queen and 22 Dr. Chiasson, and that's to briefly reinforce the very 23 important role the Thunder Bay pathology unit plays. And 24 it's very important that that unit remain open. 25 Exactly what is done, whether it's

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1 actually designated as a forensic unit or receive support 2 in some other way in terms of ensuring that it's properly 3 staffed and that succession planning is in place and so 4 on, is -- is important for the communities served by 5 Thunder Bay. And the loss of the unit would be -- would 6 create enormous problems. 7 So we certainly want to ensure the Thunder 8 Bay pathology unit remains open. Not -- not that it's 9 threatened, but I -- I think it's -- it's an issue that's 10 been brought up that we want to -- that -- that's it's an 11 important resource for the Northwest. 12 But they -- the most important area that I 13 spoke to, in my opinion, had to do with what to do when 14 the coroner can't attend the scene. And the principle 15 should be that wherever possible and certainly in 16 homicides and criminally suspicious deaths and deaths of 17 children, the coroner should attend the scene. 18 And the question is: Given that in 19 northwestern Ontario there will be circumstances where 20 the coroner can't attend the scene, how do we manage 21 that? 22 And what I would suggest is that there 23 should be someone on scene who has both the general and 24 the specific skills to conduct that investigation. And, 25 as you know, my submission to you is that -- for a police

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  1  officer with additional training provided, in -- in
  2  coordination with the Coroner's Office, would address
  3  that.  And Detective Inspector Olinyk has made a very
  4  good argument that for the OPP, Forensic Ident. would be
  5  the officers who could have that set of skills.  
  6                 There are many other police organizations,
  7  and without saying exactly who the officer should be, we
  8  leave it up to the poli -- each police organization to
  9  say which of their officers they would designate to
 10  ensure that there would be an officer available to attend
 11  scenes.  
 12                 That -- that would be my recommendation
 13  there.
 14                 MR. MARK SANDLER:   Thank you.  Ms.
 15  McRae...?
 16                 DR. SHELAGH MCRAE:   I -- I'm going to
 17  speak slightly off the topics that have been just in
 18  front, and if I'm off the topic of the Inquiry, you can
 19  let me know.  
 20                 I'm speaking as a coroner from a -- from a
 21  small town in a remote area.  I believe a lot of my
 22  function is really not to be part of the criminal system. 
 23  In fact, that's not my function.  It's to investigate
 24  deaths and to make recommendations to prevent future
 25  deaths.

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1 And many of the scenes I attend were -- 2 were never -- we're never going to call the forensic 3 unit. There's nothing criminally suspicious. There's no 4 legal fall-out that's going to happen. 5 But there are still things that where I'm 6 going to say, You know what, maybe something could have 7 been -- could be done so this doesn't happen again. And 8 an extremely important player in -- in my role, as a 9 coroner, is my Regional Supervising Coroner. 10 He will be the one that will come into the 11 community and -- and -- and go to the -- we've got one 12 now in a nursing home in a First Nation where there are 13 some issues about -- about the care and -- and how they 14 set-up things, and we're going to have a Regional 15 Coroner's review. 16 They need me on the ground to identify it. 17 I need him to come and -- and do it in a professional and 18 objective manner because I know so many of the players, 19 and -- and this is where I really think the strength of 20 the Coronial System is. 21 I can't imagine trying to do the job that 22 David Eden has been handed. When -- when you look at 23 this map and look at all the little yellow diamonds, 24 those are all the coroners he's responsible for. 25 And if he's got to do a good job from my

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1 point of view, he has to show up in my community every 2 now and then and he has to do regional reviews in my 3 community every now and then, and that's just impossible 4 for one person. 5 He also has to know my strengths and 6 weaknesses, and he also has to be somebody I'm 7 comfortable calling when I really don't -- when I think 8 I'm in over my depth. 9 And so I would strongly support some of 10 the things that came out of this morning about having at 11 least two (2) Regional Coroners in the area so that they 12 can be there for their coroners and for the communities 13 for whom something better can be done; some -- something 14 can be learned out of the death that -- that may not be a 15 criminally suspicious death. 16 I want to just echo a little bit from this 17 morning too. Even though I'm in a very small town, I do 18 take medical students. If the opportunity comes, they do 19 come on coroner's calls with me. They do -- when I'm 20 thinking about a coroner's call, I think outloud. 21 We talk about the -- the -- the community 22 ramifications, the ethical ramifications, the preventive 23 aspect when you call a coroner and all that sort of 24 stuff. 25 And again, supporting the -- the coroners

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1 in the small towns well, means that we're passing that 2 onto the next generation and hopefully, getting -- 3 getting interest from them. 4 I had to -- I had a student who worked 5 with me who went back to her father who was an Elder in - 6 - in the First Nation she came from and said, Can I do 7 death investigations? Is that appropriate with our 8 culture? 9 And he said, Of course it is. If it's -- 10 if it's part of making life better for people in our -- 11 in our First Nation, of course you can. 12 Another little thing, and again, stop me 13 if I'm going on. 14 That particular physician did not go back 15 to her home community because she couldn't even go to a 16 baseball game without being asked to -- to do something 17 medical or -- or whatever. 18 And I think we have to be very careful in 19 any small community, be it a -- be it a First Nation or a 20 small town, that -- that if we're in a difficult 21 situation, that impartial people come in. 22 That -- that we're not -- that we're not 23 being put in a position of -- of having to make some of 24 these important decisions when they're our neighbours or 25 our patients, or whatever.

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1 Often I am the spokesperson for the 2 Regional Supervising Coroner, and I call him in early 3 because I say, You know what, I know these players. 4 Thank you. 5 MR. MARK SANDLER: Thank you very much. 6 That's very helpful. 7 Mr. Sargent, any closing comments? 8 MR. JAMES SARGENT: I was just going to 9 concur with what Dr. Chiasson had said earlier. I mean, 10 based on the information that has been brought out this 11 afternoon regarding, you know, the size, geographically, 12 of the area that we're discussing right now, and -- and 13 the different factors, you know; the amount of time 14 things take, quality control, the integrity of the -- the 15 deceased, the remains, with all the transporting to here 16 and there and everywhere, I think utilizing Thunder Bay 17 which for -- for a large geographical area in this area 18 is -- is a centre for a lot of things. 19 A lot of the fly-in stuff will come -- can 20 come directly to here, and it does anyway and then goes 21 to Toronto and so on. 22 I think that's something that should 23 really be considered when you look at all the -- the 24 factors involved. 25 Also ano -- another thing that wasn't

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1 really talked about, and I -- this is more in your court 2 than mine, but I do see it just because we make a lot of 3 the arrangements is the actual cost involved in a lot of 4 these -- these cases where the deceased is being 5 transferred to trial, then back. 6 And -- if -- if something could be done, 7 you know, here -- and I realize the Kenora area is still 8 a fair distance from here. I mean, when you think about 9 it that's a six (6)/seven (7) hour drive from Thunder Bay 10 to Kenora, even though we're all in the same area. 11 Sault St. Marie, going the other way, is a 12 seven (7) hour drive. Sudbury's ten (10), eleven (11) 13 hours, so these are huge distances if you're talking 14 about by car, and those are all along the populated 15 roads. I mean, it goes well north beyond that. 16 But Kenora, at least, has that -- that 17 Winnipeg option which is only two (2) hours away. And I 18 think if -- if it's not a problem, it only makes sense to 19 utilize those resources when to transport human remains 20 to Toronto. That has to be done through Winnipeg anyway, 21 you know, so I mean, that probably brings in other 22 logistical problems for you, but I think that those are 23 things that should be considered. 24 Thank you very much for your time. 25 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr.

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1 Sargent. 2 MR. MARK SANDLER: Thank you very much. 3 We have a few questions from other counsel. I believe 4 Mr. Gover has a question. 5 6 QUESTIONED BY MR. BRIAN GOVER: 7 MR. BRIAN GOVER: My question is for 8 Detective Inspector Olinyk, and it relates to autopsies 9 being performed in Winnipeg. 10 I'd like you to give us some insight into 11 the connection of people in the Kenora area to Winnipeg, 12 given that autopsies are being performed there. 13 DETECTIVE INSPECTOR DENNIS OLINYK: Well, 14 apart from autopsies being performed in -- in Winnipeg 15 from time-to-time, Winnipeg is a big city. It's a big 16 centre. It's -- it's close to Kenora, the -- the west 17 end of the northwest region. 18 There's a -- there's a connection between 19 Winnipeg and the northwest part of the northwest region. 20 And I say that because in cases involving deaths and so 21 on, you may have family who -- of the deceased who may 22 very well live in the -- in the -- the Winnipeg area 23 and/or who may live on First Nations communities within 24 the province of Manitoba. 25 And -- and from time-to-time, these

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1 investigations take us from the Province of Ontario to 2 the Province of Manitoba to -- to further our 3 investigation by way of interviewing, and taking 4 statements, and those kinds of things, so there is a -- 5 there's a connection there. 6 MR. BRIAN GOVER: And does that 7 connection include, for example, obtaining medical care 8 on occasion in Winnipeg? 9 DETECTIVE INSPECTOR DENNIS OLINYK: 10 Absolutely. People who live in the northwest part of the 11 region often, at time -- more often than not, I suspect 12 in some cases, are -- are transported -- taken to -- to 13 other -- St. Boniface Hospital or to the Health Scientist 14 Centre in Winnipeg for specialized treatment. 15 Often referrals are made from Kenora, in 16 fact, likely a lot more to Winnipeg from Kenora as -- as 17 opposed to from Kenora to Thunder Bay. 18 MR. BRIAN GOVER: And finally, we're 19 getting a pretty good sense of driving times from Thunder 20 Bay, for example, east and west and north. 21 I understand it takes three (3) hours to 22 get to Armstrong, for example, but how long would it take 23 to travel from Kenora to Winnipeg? 24 DETECTIVE INSPECTOR DENNIS OLINYK: From 25 the Lake of the Woods District Hospital in Kenora to St.

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1 Boniface Hospital, about three and a half (3 1/2) hours - 2 - or about -- about three (3) hours, about three (3) 3 hours. 4 From the -- from -- from the Ontario 5 border to the Manitoba border -- or to Winnipeg would be 6 about a little over two (2) hours, but from hospital-to- 7 hospital, about two and a half (2 1/2) hours. 8 MR. BRIAN GOVER: Thank you very much. 9 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 10 Gover. 11 MR. MARK SANDLER: Ms. Esmonde...? 12 13 QUESTIONED BY MS. JACKIE ESMONDE: 14 MS. JACKIE ESMONDE: Good afternoon. For 15 those of you who I haven't introduced myself to, my name 16 is Jackie Esmonde. I'm one (1) of the lawyers 17 representing a coalition of Aboriginal legal services of 18 Toronto and Nishnawbe-Aski Nation. 19 And, Dr. Eden, I'd like to begin with you. 20 You were asked by Mr. Sandler about the -- the idea of an 21 Aboriginal liaison officer, and it was at that point that 22 you recommended the coroner's investigator through a 23 police force. 24 I have some questions for you about that 25 recommendation. You listed a number of skills that you

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1 see as important to any investigator conducting a cor -- 2 coronial death investigation; investigative skills, and 3 communication with families, and familiarity with the 4 human body, and so on. 5 I take it you'd agree with me that police 6 officers and coroners -- doctors are not the only 7 professionals that would have skills such as that, and in 8 this room alone, it strikes me that Mr. Sargent is 9 someone who would have many of those skills that you've 10 listed. 11 DR. DAVID EDEN: Yes, there are other 12 disciplines that would have some of those core general 13 skills, yes. 14 And actually if I could clarify, the -- 15 and this came at a earlier testimony that there were two 16 (2) issues. One (1) was about the investigator on the 17 scene and the other was about liaising with family. 18 And my answer to Mr. Sandler was about -- 19 strictly about the on-scene investigator and was not 20 about the liaising with family where -- which, in my 21 mind, would be quite different. 22 MS. JACKIE ESMONDE: I did understand 23 that from your answer. 24 Are you aware, Dr. Eden of the difficult 25 historical relationship between First Nation communities

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1 and the OPP? 2 DR. DAVID EDEN: I'm -- I'm aware of 3 issues; I -- I wouldn't have details on it. I surely 4 wouldn't be able to testify to -- to the history of it, 5 no. 6 MS. JACKIE ESMONDE: Are you aware with 7 respect to NAPS, this is a -- a police force that as 8 recently as last week was raising publically serious 9 problems that that force has with resources and funding; 10 are you aware of that? 11 DR. DAVID EDEN: I'm -- I'm aware of 12 issues. The -- the suggestion I made was not specific to 13 OPP, it was to the police service with jurisdiction. 14 And I can tell you that NAPS has -- I -- 15 I've personally been involved in co-investigations with 16 NAPS and I felt that their approach was very impressive. 17 So I -- I was talking about a police officer not about an 18 OPP Officer. 19 MS. JACKIE ESMONDE: No, I understood 20 that that's why I raised the issue of NAPS. And my -- my 21 question was are you aware that NAPS has publically 22 reported on difficulties it has with resources and 23 funding? 24 DR. DAVID EDEN: I -- I've read reports. 25 I'm not -- I'm not expert in that area.

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1 MS. JACKIE ESMONDE: And can I ask you if 2 prior to making this recommendation about the creation of 3 police officers as coroner's investigators, did you 4 consult with any Aboriginal leaders or political bodies 5 about that recommendation? 6 DR. DAVID EDEN: In -- in developing the 7 recommendation I looked at the Coroners Act and the 8 purpose of the Coroners Act. So what I was doing was 9 looking at how to ensure a complete and accurate 10 investigation. It -- it wasn't -- I wasn't basing it on 11 political considerations, I was basing it on ensuring 12 that the investigation of the death is complete and 13 accurate. 14 MS. JACKIE ESMONDE: I take it then the 15 answer is no? 16 DR. DAVID EDEN: You're asking me if I -- 17 if I consulted political leadership of any sort, not -- 18 not simply Aboriginals, I didn't. No, this was based on 19 investigative considerations and quality of 20 investigations and not on any political advice at all. 21 MS. JACKIE ESMONDE: I -- I just have a 22 few questions for you then, Detective Inspector. 23 I -- I was struck in your answers earlier. 24 You spoke about the cooperation that the -- the 25 relationship of cooperation that the OPP has with the

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1 community in carrying out death investigations in some of 2 the more remote communities? 3 DETECTIVE INSPECTOR DENNIS OLINYK: Yes. 4 MS. JACKIE ESMONDE: And that it's a 5 practice of the force that you work with to liaise with 6 the band council, the chief and council -- 7 DETECTIVE INSPECTOR DENNIS OLINYK: Yes. 8 MS. JACKIE ESMONDE: -- whenever you 9 enter those communities. 10 Is it fair -- is that a -- an informal 11 setup or is there a -- some sort of formal protocol that 12 guides you in doing that? 13 DETECTIVE INSPECTOR DENNIS OLINYK: I 14 would say it -- it's informal; I don't -- I don't know of 15 any formalized protocol. It's something we do and it's 16 something that we've done for a long time. 17 MS. JACKIE ESMONDE: And it's something 18 that works in these communities, I take it, working with 19 the community to conduct the death investigation? 20 DETECTIVE INSPECTOR DENNIS OLINYK: 21 Absolutely. 22 MS. JACKIE ESMONDE: And it is fair to 23 say that you rely on the chief and council to assist in 24 liaising with the community and with family members? 25 DETECTIVE INSPECTOR DENNIS OLINYK: To

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1 facilitate the liaison, yes; and to facilitate a lot of 2 other things that we rely on the community to help us out 3 with. 4 And I -- I've referenced a number of 5 different -- different things that -- that the community 6 has -- has helped us with. 7 MS. JACKIE ESMONDE: And I don't think I 8 have very much more time, but I did want to ask you a 9 little bit about the relationship between NAPS and the 10 OPP. 11 In a number of these cases, you're being 12 called in as a support role for NAPS, is that -- is that 13 right? 14 DETECTIVE INSPECTOR DENNIS OLINYK: 15 That's right. In -- in the case of a -- of a homicide, 16 for example, the Nishnawbe-Aski Police Service from time 17 to time will call. In fact, all of the times that I 18 know, any homicide NAPS will call and request assistance 19 of the OPP. 20 And when that assistance is -- is asked 21 for, it is provided. And a CIB inspector is assigned and 22 the investigation is conducted with the resources that of 23 course includes OPP and resources from within NAPS. 24 MS. JACKIE ESMONDE: And -- and that's 25 because the OPP has some specialized resources that NAPS

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1 does not have in these cases, is that right? 2 DETECTIVE INSPECTOR DENNIS OLINYK: 3 Absolutely. Absolutely. NAPS does not have a Forensic 4 Identification Unit. NAPS does not have the benefit of a 5 forensic identification section in our -- in our 6 headquarters, and -- and a lot of other specialities that 7 the OPP has. 8 So all of those specialit -- all of those 9 specialized services are available then to -- to the 10 investigation, as they would in any other case. 11 MS. JACKIE ESMONDE: Thank you very much. 12 Those are my questions. 13 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 14 Esmonde. 15 MR. MARK SANDLER: Well that completes 16 our questioning for this afternoon, Commissioner. I want 17 to express my appreciation to all of those who were 18 involved in today's panel, and -- and most particularly 19 those who travelled from long distances to be here. 20 We're going to have the benefit of Dr. 21 Eden's views tomorrow, but I want to thank the -- the 22 rest of our panellists very much for your contribution, 23 and wish you a safe journey home. Thank you. 24 COMMISSIONER STEPHEN GOUDGE: And for my 25 part, let me do the same.

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1 We really are very grateful for your 2 wisdom, and what you have been able to tell us. So thank 3 you for coming. 4 So we will adjourn now, Mr. Sandler, until 5 9:30 tomorrow morning? 6 MR. MARK SANDLER: That's right. Thank 7 you. 8 9 (PANEL STANDS DOWN) 10 11 --- Upon adjourning at 2:40 p.m. 12 13 14 Certified Correct, 15 16 17 ___________________ 18 Wendy Warnock, Ms. 19 20 21 22 23 24 25