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 January 7th, 2008 25

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

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

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

1 TABLE OF CONTENTS Page No. 2 3 WILLIAM JOHN LUCAS, Sworn 4 ALBERT EDWARD LAUWERS, Sworn 5 JAMES NORMAN EDWARDS, Sworn 6 7 Examination-In-Chief by Mr. Mark Sandler 6 8 9 10 Certificate of transcript 301 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon commencing at 9:32 a.m. 2 3 THE REGISTRAR: All Rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Good 6 morning, welcome back. I hope you all, having a good 7 holiday and come back invigorated. 8 Mr. Centa...? 9 MR. ROBERT CENTA: Thank you, 10 Commissioner. This morning we are joined by Dr. Lauwers, 11 Dr. Lucas, and Dr. Edwards from the Office of the Chief 12 Coroner of Ontario. It is a panel of three regional 13 coroners, and they are scheduled to be with us for the 14 next two days. 15 I will conclude my examination of this 16 panel of witnesses today. 17 18 WILLIAM JOHN LUCAS, Sworn 19 ALBERT EDWARD LAUWERS, Sworn 20 JAMES NORMAN EDWARDS, Sworn 21 22 EXAMINATION-IN-CHIEF BY MR. ROBERT CENTA: 23 MR. ROBERT CENTA: Good morning. 24 Doctors, I'd like to begin by taking each of you briefly 25 through your CV just so the Commissioner has a sense of

1 your backgrounds. And we'll begin with you Dr. Lauwers. 2 Dr. Lauwers, you received your MD from 3 the University of Toronto in 1982? 4 DR. ALBERT LAUWERS: Yes. 5 MR. ROBERT CENTA: And you were first 6 appointed a coroner in 1985? 7 DR. ALBERT LUCAS: Yes. 8 MR. ROBERT CENTA: And where did you -- 9 where did you work? 10 DR. ALBERT LAUWERS: I worked primarily 11 in the city of Kawartha Lakes formally, the county of 12 Victoria. 13 MR. ROBERT CENTA: You were subsequently 14 appointed an inquest coroner? 15 DR. ALBERT LAUWERS: That's correct, in 16 1993. 17 MR. ROBERT CENTA: Thank you. And when 18 we organized this panel, you were the Regional Coroner -- 19 Supervising Regional Coroner for Metropolitan Toronto 20 West? 21 DR. ALBERT LAUWERS: That's correct. 22 MR. ROBERT CENTA: And when were you 23 appointed to that position? 24 DR. ALBERT LAUWERS: June of 2006. 25 MR. ROBERT CENTA: And subsequent to

1 that, you've been appointed to a new position. And could 2 you tell us about that? 3 DR. ALBERT LAUWERS: I've -- myself and 4 Dr. Lucas have been appointed to the position of acting 5 Deputy Chief Coroners. 6 MR. ROBERT CENTA: And when was that 7 appointment effective? 8 DR. ALBERT LAUWERS: Effective January 9 the 1st. 10 MR. ROBERT CENTA: As acting Deputy Chief 11 Coroner, do you have -- have you had specific 12 responsibilities assigned to you at that point? 13 DR. ALBERT LAUWERS: The format for the 14 Deputy Chief Coroners previously was 1) was designated to 15 be the Deputy Chief Coroner in charge of inquests; the 16 other, the Deputy Chief Coroner in charge of 17 investigations. 18 Currently what's happened is that Dr. 19 Lucas and I are mutually sharing those responsibilities. 20 MR. ROBERT CENTA: And currently do you 21 chair any of the expert committees at the Office of the 22 Chief Coroner? 23 DR. ALBERT LAUWERS: I do, I chair the 24 Paediatric Death Review Committee and the Death Under 25 Five Committee.

1 MR. ROBERT CENTA: And we will return to 2 talk about those in some detail. Now as a -- before you 3 became a regional supervising coroner, you were the -- 4 you were involved in the Ontario Coroner's Association? 5 DR. ALBERT LAUWERS: I was. 6 MR. ROBERT CENTA: And you were the 7 President of the Coroner's Association? 8 DR. ALBERT LAUWERS: Between 2002 and 9 2004. 10 MR. ROBERT CENTA: Prior to that you'd 11 served on its Executive Committee? 12 DR. ALBERT LAUWERS: For approximately 13 eight (8) years. 14 MR. ROBERT CENTA: Can you describe the 15 purpose of the Ontario Coroner's Association? 16 DR. ALBERT LAUWERS: Well, really the 17 purpose of it is to advance the functioning of the group 18 of coroners in the Province of Ontario, the three hundred 19 and thirty (330) or -- or so physicians; not all of whom 20 are members of the Ontario Coroners' Association, but 21 certainly all of whom receive the benefits of that 22 organization. 23 So it -- it is principally a -- a group of 24 -- in part that exchanges fellowship, but also that tries 25 to advance the death investigation scenario and works

1 cooperatively with the Office of Chief Coroner to do so. 2 In addition to that, it's involved in education of 3 coroners and, in fact, puts on an annual spring 4 educational meeting for that purpose, as well. 5 The memb -- membership is involved in such 6 aspects as the development of -- of criteria, and we're 7 intimately involved in the development of The -- The 8 Death Investigation Manual for Coroners in 2003, as part 9 of the quality assurance process and continue to be 10 active in that committee at the current time. 11 MR. ROBERT CENTA: Is membership in the 12 association voluntary? 13 DR. ALBERT LAUWERS: It's voluntary. 14 MR. ROBERT CENTA: I see from your resume 15 that at -- you were chair of the Negotiations Committee? 16 DR. ALBERT LAUWERS: I was. 17 MR. ROBERT CENTA: And with whom did you 18 negotiate? And over what? 19 DR. ALBERT LAUWERS: Well, I was chair of 20 the Negotiations Committee -- the Negotiation Committee 21 started -- we started our negotiations actually with Dr. 22 McLellan and Dr. Young. I think Dr. McLellan, at the 23 time, was in the acting capacity as the Chief Coroner 24 and, at the time, Dr. Young, as I recall, was the 25 Commissioner of Public Safety.

1 We began negotiations and we met with 2 various parties. As that proceeded, Dr. Young dropped 3 off that panel, and I eventually met with the Minister 4 who was Minister Quinter, and a Deputy Minister, and his 5 name I believe was Mr. Michael Finn. 6 MR. ROBERT CENTA: And did -- what were 7 negotiating over? What was the subject matter? 8 DR. ALBERT LAUWERS: The subject matter 9 was remuneration of coroners for their fee-for-service 10 activities. 11 MR. ROBERT CENTA: And were you able to 12 reach an agreement? 13 DR. ALBERT LAUWERS: We were able to 14 reach an agreement. 15 MR. ROBERT CENTA: Now, as Regional 16 Coroner for Metropolitan Toronto West, how many -- how 17 many coroners do you supervise? 18 DR. ALBERT LAUWERS: I have the smallest 19 number of coroners in the Province. I have ten (10) 20 under my jurisdiction. Some of my coroners are -- well, 21 they do a large number and volume of cases each. 22 MR. ROBERT CENTA: How many cases would 23 you be involved in in -- in your region, each year? 24 DR. ALBERT LAUWERS: All of them. 25 MR. ROBERT CENTA: Sorry, and how many

1 would that be? 2 DR. ALBERT LAUWERS: That would be 3 approximately two thousand (2,000). 4 MR. ROBERT CENTA: So two thousand 5 (2,000) cases divided among the coroners that you 6 supervise? 7 DR. ALBERT LAUWERS: Correct. Now, some 8 of them may do as few as a hundred (100) cases a year, 9 and some of them may do as many as four (4) or five 10 hundred (500) cases a year. 11 MR. ROBERT CENTA: And are some of the 12 coroners -- is there a difference between full-time and 13 part-time in the Toronto West Region? 14 DR. ALBERT LAUWERS: In the Toronto West 15 -- rest -- West Region, I'm not aware that any of the 16 coroners don't actually have other jobs that they do as 17 well, but certainly their coroner's activity would be a 18 substantial component of their income that they earn as 19 physicians. 20 MR. ROBERT CENTA: I understand that you 21 have been involved in promoting quality and quality 22 assurance among the work of coroners in your role as 23 Regional Supervising Coroner? 24 DR. ALBERT LAUWERS: That's correct. 25 MR. ROBERT CENTA: And we will return to

1 that, Commissioner, in some detail because it's a matter 2 of -- of interest to the Commission. 3 But for now you helped to create an audit 4 tool for the use in the Office of the Chief Coroner? 5 DR. ALBERT LAUWERS: I did. 6 MR. ROBERT CENTA: And also a performance 7 evaluation tool that is now used? 8 DR. ALBERT LAUWERS: That's correct. 9 MR. ROBERT CENTA: As a -- if you'll -- 10 turning to page 5 of your CV, you list a number of 11 inquests that you have been involved in. 12 And this is, Commissioner, in Volume I, 13 Tab 1, PFP302398 at page 5. 14 And twenty-two (22) inquests are listed 15 there? 16 DR. ALBERT LAUWERS: Yes. 17 MR. ROBERT CENTA: You'll notice that 18 seven (7) of them are indicated as being discretionary? 19 DR. ALBERT LAUWERS: Yes. 20 MR. ROBERT CENTA: So seven (7) of 21 twenty-two (22). The other fifteen (15) are mandatory 22 inquests? 23 DR. ALBERT LAUWERS: That's correct. 24 MR. ROBERT CENTA: And mandatory 25 triggered by the provisions of the Coroner's Act?

1 DR. ALBERT LAUWERS: Section 10 2 primarily, yes. 3 MR. ROBERT CENTA: Is that a -- would 4 that experience be shared among other inquest coroners, 5 that roughly a third of the inquests they would preside 6 over would be discretionary? 7 DR. ALBERT LAUWERS: No, I think that the 8 discretionary inquests are the inquests that are -- they 9 have larger public safety issues at play. And generally 10 those types of inquests are done by regional supervising 11 coroners or coroners of significant inquest experience. 12 MR. ROBERT CENTA: Across the Province to 13 you have a sense of how of -- of the breakdown between -- 14 of the inquests that are performed each year, how many 15 would be discretionary and how many would be mandatory? 16 DR. ALBERT LAUWERS: It varies from year 17 to year; some years it's as little as 10 percent of the 18 inquests are discretionary, but I -- I -- we -- I guess 19 the format we generally thought is about one-third (1/3) 20 and two-thirds (2/3s). 21 However, increasingly the -- the body of 22 inquests that we do are of the mandatory type, and in 23 fact because of the volume, they -- they can preclude our 24 ability to de -- to do the discretionary inquests. 25 MR. ROBERT CENTA: And how -- how do they

1 preclude your ability to do the discretionary inquests? 2 DR. ALBERT LAUWERS: You know, it's a 3 matter of resources, really; the -- do we have the 4 coroners to do the -- the inquests of the nature that we 5 might choose to -- choose or want to do in the public 6 interest. 7 MR. ROBERT CENTA: And do you have a view 8 on whether or -- it would be desirable for the coroners 9 to be able to conduct more discretionary inquests? 10 DR. ALBERT LAUWERS: I think it would be 11 highly desirable for coroners to do many more 12 discretionary inquests. 13 MR. ROBERT CENTA: And why would that be? 14 DR. ALBERT LAUWERS: Because the 15 mandatory inquests are of a like variety; they're a 16 largely custody related deaths, mining deaths, or 17 construction related deaths. And, Mr. Centa, there is 18 only so many issues that can ever arise in a custody 19 related death or a construction related death where 20 perhaps an individual falls from a roof. 21 MR. ROBERT CENTA: Would -- in your 22 opinion, would the promotion of public safety in Ontario 23 be enhanced by the Coroner's Office being able to shift 24 the balance between discretionary and mandatory inquests? 25 DR. ALBERT LAUWERS: De -- I think that's

1 the case. 2 MR. ROBERT CENTA: But that would require 3 a legislative change to the inquests that are currently 4 mandated. 5 DR. ALBERT LAUWERS: That's correct. 6 COMMISSIONER STEPHEN GOUDGE: Explain 7 that, Dr. Lauwers. That means removing some that are now 8 mandatory? 9 DR. ALBERT LAUWERS: That -- that's 10 correct, Mr. Commissioner. Currently the body of our 11 inquests are custody related deaths, whether they occur 12 in institutions and a good number of them are natural 13 causes deaths. 14 In other words, as the inmate population 15 ages and -- and becomes increasingly more ill, they may 16 die in a correctional facility of natural causes, like 17 heart disease. We're required to do an -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. ALBERT LAUWERS: -- inquest -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. ALBERT LAUWERS: -- on those 22 particular deaths. 23 COMMISSIONER STEPHEN GOUDGE: And was it 24 accident that you picked that as opposed to the 25 construction/mining accident, mandatory death --

1 DR. ALBERT LAUWERS: Well, I -- I chose 2 it in particular because it's probably the largest 3 volume. The custody related deaths are the largest 4 volume of deaths. 5 COMMISSIONER STEPHEN GOUDGE: And does 6 that have -- and I suppose the demography of the 7 custodial population increases that as it ages. 8 DR. ALBERT LAUWERS: That's correct. 9 COMMISSIONER STEPHEN GOUDGE: Yes. 10 Thanks, Mr. Centa. 11 12 CONTINUED BY MR. ROBERT CENTA: 13 MR. ROBERT CENTA: Thank you. Thank you, 14 Dr. Lauwers. We'll return to elements of your CV as we 15 proceed through the examination today. 16 And, Dr. Lucas, your CV is found in Volume 17 I, Tab 2, PFP302419. 18 You received your MD at the University of 19 Toronto in 1976? 20 DR. WILLIAM LUCAS: That's correct. 21 MR. ROBERT CENTA: And you were appointed 22 a coroner in 1991? 23 DR. WILLIAM LUCAS: That's also correct. 24 MR. ROBERT CENTA: Subsequently you were 25 appointed an inquest coroner in March of 1993?

1 DR. WILLIAM LUCAS: That was at a time 2 that the Coroner's Office developed a new category of 3 inquest coroners up until 1993. When that new category 4 was established, any coroner in the Province of Ontario, 5 in accordance with the Coroner's Act, could call in 6 inquest into an investigation that they were involved 7 with. 8 In 1993 the Coroner's Office realised that 9 as inquests were becoming more complex, as issues were 10 being challenged by various parties withstanding, we 11 needed a group of coroners that had a higher level of 12 sophistication and more specific training in how to 13 conduct inquests, and a select group was -- was put 14 forward at that point in time. 15 MR. ROBERT CENTA: And in your opinion, 16 the creation of the inquest coroner designation, has that 17 assisted with the conduct of inquests in Ontario? 18 DR. WILLIAM LUCAS: We think it's helped 19 immeasurably, yes. You know, as Dr. Lauwers indicated, a 20 lot of the inquests that we do are, if I could use the 21 word "fairly perfunctory", in the sense that it's 22 mandated by statute, the issues are often -- or the 23 themes are often repetitive from one (1) type of -- of 24 case to another. 25 That isn't to say that we -- we don't

1 follow due process and make sure that the circumstances 2 are aired in a -- in a full and open forum, but there 3 doesn't tend to -- it doesn't need to be that complicated 4 for most inquest coroners to -- to preside over those. 5 The ones that tend to be the discretionary inquests are 6 ones where they're perhaps much more complex, they're 7 anticipated to be much longer, usually attract interest 8 of intervenor groups and so on, so that we believe the 9 inquest coroner needs a greater level of sophistication 10 to be able to, in essence, cope with -- with the stresses 11 that are put forward in those situations. 12 MR. ROBERT CENTA: And have inquest 13 coroners been provided with specific training or other 14 opportunities to learn about how best to conduct quasi- 15 judicial processes? 16 MR. WILLIAM LUCAS: Yes. At the time, in 17 '93, that this new category of coroners was delineated, a 18 training course was put on that was about three (3) days 19 in duration. And the Deputy Chief Coroner responsible 20 for inquests has seen that that course is repeated every 21 two (2) years since that time. And it's mandatory for 22 inquest coroners to attend that if they want to continue 23 to preside over inquests. 24 MR. ROBERT CENTA: You were appointed a 25 regional supervising coroner first in 1996?

1 MR. WILLIAM LUCAS: Yes. 2 MR. ROBERT CENTA: And you have served as 3 a regional supervising coroner from that point until 4 today -- 5 MR. WILLIAM LUCAS: Correct. 6 MR. ROBERT CENTA: -- in a number of 7 different regions? 8 MR. WILLIAM LUCAS: Yes. 9 MR. ROBERT CENTA: Can you walk us 10 through the various regions where you exercised that -- 11 or held that office since 1996? 12 MR. WILLIAM LUCAS: Certainly. In 1996 13 the existing Regional Supervising Coroner for Niagara, 14 Dr. Bonita Porter, was appointed as a Deputy Chief 15 Coroner responsible for inquests. So that left a vacancy 16 in that area. 17 I was asked to apply for the position and 18 was the successful candidate. I fulfilled that role from 19 the Fall of approximately the 29th, I believe, of 20 September, from that point until early in the year 2000 - 21 - no -- 22 COMMISSIONER STEPHEN GOUDGE: '98. 23 MR. WILLIAM LUCAS: -- 1998, sorry. 24 COMMISSIONER STEPHEN GOUDGE: I am just 25 reading your CV.

1 MR. WILLIAM LUCAS: That's right. That's 2 right. In the summer of 1997 the Regional Supervising 3 Coroner for, as it was called, Metropolitan Toronto at 4 the time decided he was going to leave the Coroner's 5 Office and go back to Newfoundland and -- and go back 6 into medical practice. 7 I was asked to come down on a part-time 8 basis to fill in for him while the Chief Coroner's Office 9 went through the process of recruiting a new regional 10 coroner for the area and ended up staying there for 11 almost five (5) years as the Regional Coroner for Metro 12 Toronto, then Toronto. Its name got changed. 13 And then ultimately we had some geographic 14 redistribution to try and balance the caseload amongst 15 regional coroners. And at that time a new administrative 16 area -- two (2) new administrative areas were created, 17 what we refer to as GTA East and GTA West. 18 And at that time, Toronto was physically 19 divided down the middle at Yonge Street, with GTA West 20 comprising the Regional Municipality of Peel and Toronto 21 west of Yonge Street. GTA East was Toronto east of Yonge 22 Street along with York and Durham Regions. 23 At that point, two (2) regional coroners 24 were appointed to -- one (1) for each of those areas. 25 And a short time after that, we had some

1 further redistribution of boundaries so that a new area 2 that we refer to as Central Region -- which was Peel, 3 York and Durham, the Golden Horseshoe surrounding Toronto 4 -- was severed off as a new area. And I was assigned to 5 take on that new area. 6 7 CONTINUED BY MR. ROBERT CENTA: 8 MR. ROBERT CENTA: And that's known as 9 the Central Region? 10 MR. WILLIAM LUCAS: Yes. And that 11 remained in effect until January 1st of this year, and 12 it's changed yet again. 13 MR. ROBERT CENTA: And what is it now? 14 MR. WILLIAM LUCAS: We -- we've responded 15 to a requirement of the provincial government to change 16 administrative boundaries, as I understand it, into four 17 (4) discrete areas for the Province: North, Central, 18 West, and East. 19 And the Central Region, as government has 20 laid it out, includes the City of Toronto, Halton, Peel, 21 Simcoe, Muskoka, Durham, and York. So that is our new 22 Central Region. 23 And we have decided, based on the volume 24 of cases that are in that area, that we will be working 25 towards recruiting or having four (4) regional

1 supervising coroners assigned to those -- to that Central 2 area. The two (2), as currently exist for Toronto East 3 and West, and then the remainder of that Central Region 4 will be divided up amongst two (2). 5 Currently, I am overseeing the rest of 6 Central Region until we are able to recruit a new 7 individual. 8 MR. ROBERT CENTA: So just before the 9 most recent reorganization, when you were the Regional 10 Coroner for the Central Region, how many coroners did you 11 supervise? 12 MR. WILLIAM LUCAS: It was in excess of 13 thirty (30), about thirty-two (32). 14 MR. ROBERT CENTA: And how many cases 15 would be dealt with by your region in a -- in a year? 16 MR. WILLIAM LUCAS: It varied, but for 17 the last couple of years it was in the neighbourhood of 18 about twenty-four (24) to twenty-five hundred (2,500) 19 cases. It's a little higher now, because the area has 20 been expanded. 21 MR. ROBERT CENTA: Right. 22 MR. WILLIAM LUCAS: As Dr. Lauwers 23 indicated, you've recently been appointed to a new 24 position? 25 MR. WILLIAM LUCAS: Yes.

1 MR. ROBERT CENTA: And what position is 2 that? 3 DR. WILLIAM LUCAS: As one (1) of the 4 acting Deputy Chief Coroners. 5 MR. ROBERT CENTA: Do you continue to act 6 as a regional supervising coroner? 7 DR. WILLIAM LUCAS: At the present time, 8 yes. 9 MR. ROBERT CENTA: Is that expected to 10 change in going forward, or...? 11 DR. WILLIAM LUCAS: Our hope is yes. 12 We're actively recruiting a fourth Regional Supervising 13 Coroner for the Central Region that I just described. 14 That process, in terms of invitations for people that are 15 interested in the position, will close at the, I believe, 16 then end of this week, and we hope that we will then go 17 through a process of interviewing candidates, reviewing 18 their -- their CVs, checking their references and so on, 19 and ultimately making a recommendation to government for 20 an order in council appointment. 21 And as soon as that individual can be up 22 and running we expect that -- that we will have the -- 23 the compliment of people for that Central Region that we 24 require. We also have one (1) Regional Supervising 25 Coroner, Dr. David Evans who in essence retired because

1 he reached the mandatory retirement age, but has been 2 back on contract for the last couple of years assisting 3 us because we -- we have some vacancies within some of 4 the positions. 5 So he's been moving around the Province 6 and filling in various areas. 7 COMMISSIONER STEPHEN GOUDGE: What's the 8 mandatory retirement age? 9 DR. WILLIAM LUCAS: For us it was 65. 10 COMMISSIONER STEPHEN GOUDGE: And is that 11 because of your provincial employee status? 12 DR. WILLIAM LUCAS: Yes, yes. Now 13 that's -- 14 COMMISSIONER STEPHEN GOUDGE: And then 15 did -- 16 DR. WILLIAM LUCAS: -- been changed with 17 the change in legislation, but unfortunately Dr. Evans, 18 his birthday I think actually occurred before the -- the 19 change in law -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. WILLIAM LUCAS: -- became effective. 22 COMMISSIONER STEPHEN GOUDGE: Right. And 23 what's Dr. Cairns role now, is he retired fully? I've 24 forgotten -- 25 DR. WILLIAM LUCAS: I believe he's

1 retired as of the end of this week, sir. 2 COMMISSIONER STEPHEN GOUDGE: Yes, that's 3 what I thought. So the two of you, the way Dr. Lauwers 4 described it, are at the moment sharing investigations 5 and inquests? 6 DR. WILLIAM LUCAS: Yes, that's correct. 7 COMMISSIONER STEPHEN GOUDGE: Longer term 8 do you envisage that sharing continuing or are you going 9 to divide it up? 10 DR. WILLIAM LUCAS: I think our 11 expectation, sir, is that once a new Chief Coroner is 12 appointed in permanence, that that Chief Coroner will 13 oversee recruitment of two (2) individuals to -- to take 14 the two (2) roles predominantly that have existed for the 15 last several years. 16 It's important to understand that even 17 though there -- there may be designations in name, Deputy 18 Chief or Inquest Deputy Chief for investigations, there's 19 a considerable amount of overlap in -- in the fact that 20 they do -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. WILLIAM LUCAS: -- quite a bit of job 23 sharing. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 Thank you.

1 2 CONTINUED BY MR. ROBERT CENTA: 3 MR. ROBERT CENTA: Dr. Lucas, on page 6 4 of your resume, it lists a number of committees that 5 you've been involved with in your capacity as a -- as a 6 regional coroner. I can see under the heading "Office of 7 Chief Coroner" the Senior Management Group Committee. 8 DR. WILLIAM LUCAS: Yes. 9 MR. ROBERT CENTA: The Core Business 10 Committee? 11 DR. WILLIAM LUCAS: Correct. 12 MR. ROBERT CENTA: And two (2) of the 13 expert committees. 14 We'll return to those later on, but -- but 15 while we're here, the Senior Management Committee, who 16 sat on that Committee? 17 DR. WILLIAM LUCAS: Basically that's a 18 monthly meeting of all the senior managers within the 19 Coroner's Office. So the Chief Coroner, the two (2) 20 Deputy Chief Coroners, all the Regional Supervisors and 21 then senior support staff. 22 And over the years there's been generally 23 attendance of the Chief Forensic Pathologist, but that 24 has varied depending on who was in the position and -- 25 and their availability to attend the meetings.

1 MR. ROBERT CENTA: And what -- what is 2 the purpose of the Core Business Committee? 3 DR. WILLIAM LUCAS: The Core Business 4 Committee was established at the end of 2001 to look at 5 the operational issues that pertained to the -- the 6 Coroner's Office; so that we were looking at -- at 7 operational issues relating to investigations, to our 8 ability to make recommendations under the Coroner's Act, 9 and to look at the systems that we had in place to manage 10 the information and the data that we were collecting as 11 part of our investigations. 12 MR. ROBERT CENTA: Thank you. And, Dr. 13 Edwards, your CV is found at Tab 53 of Volume Number I, 14 and it's PFP302432. 15 You earned your MD in 1979? 16 DR. JAMES EDWARDS: That's correct. 17 MR. ROBERT CENTA: From the University of 18 Western Ontario? 19 DR. JAMES EDWARDS: That's correct. 20 MR. ROBERT CENTA: You were first 21 appointed a coroner in 1991? 22 DR. JAMES EDWARDS: That's correct. 23 MR. ROBERT CENTA: And where did you act 24 as a coroner? 25 DR. JAMES EDWARDS: Initially I was a

1 coroner in Hastings county, in the Belleville area, from 2 1991 until 1996. 3 MR. ROBERT CENTA: And during that time, 4 how many cases would you have been involved in on an 5 annual basis? 6 DR. JAMES EDWARDS: We didn't have a high 7 volume of coroner's cases in that region at that time, so 8 I would have done approximately fifty-five (55) to sixty 9 (60) cases per year. 10 MR. ROBERT CENTA: And in 1996 you -- you 11 left Canada briefly? 12 DR. JAMES EDWARDS: I did, yes. 13 MR. ROBERT CENTA: And where did you go? 14 DR. JAMES EDWARDS: I went to join my -- 15 my brother and -- and his family in -- in Kansas for a 16 couple of years. 17 MR. ROBERT CENTA: When -- you returned 18 to Canada in 1998? 19 DR. JAMES EDWARDS: That's correct. 20 MR. ROBERT CENTA: Did you continue to -- 21 or did you reapply to be a coroner? 22 DR. JAMES EDWARDS: Yes, I did. 23 MR. ROBERT CENTA: And where did you find 24 yourself placed? 25 DR. JAMES EDWARDS: I was assigned to be

1 a coroner in Toronto, in Toronto East, although I did 2 cases across -- across Toronto and, in fact, would do 3 cases beyond the boundaries of Toronto if they couldn't 4 find a coroner to -- to respond to cases in a timely 5 manner. 6 MR. ROBERT CENTA: And upon your 7 appointment in Metropolitan Toronto, roughly how many 8 cases would you be doing in a year? 9 DR. JAMES EDWARDS: I was -- I was very 10 busy. I was doing approximately -- eventually I got up 11 to doing approximately eight hundred (800) cases a year. 12 MR. ROBERT CENTA: As compared to fifty- 13 five (55) or sixty (60) from -- in -- when you were 14 acting as a coroner in Hastings County? 15 DR. JAMES EDWARDS: That's correct. 16 MR. ROBERT CENTA: A very different job 17 experience? 18 DR. JAMES EDWARDS: Yeah, I really -- I 19 really enjoyed doing coroner's work, and when the 20 opportunity became available to do more -- more of it I 21 just -- I jumped at it. 22 MR. ROBERT CENTA: Would you have been 23 one (1) of the busiest coroners in Metropolitan Toronto 24 doing approximately eight hundred (800) cases a year? 25 DR. JAMES EDWARDS: I -- I was. I was

1 one (1) -- one (1) of the busiest, if not the busiest. 2 MR. ROBERT CENTA: And was that because 3 you were willing to take on work that you might not 4 otherwise be primarily scheduled for? 5 DR. JAMES EDWARDS: I made myself 6 available to do -- to do calls. So the -- the dispatch 7 unit knew that if I wasn't doing an emerg shift or doing 8 something else that I would -- that I would respond to 9 calls, so they tended to call me. 10 MR. ROBERT CENTA: Your CV indicates that 11 you are enucleating physician for the Eye Bank of Canada. 12 Is that correct? 13 DR. JAMES EDWARDS: That -- that's 14 correct. 15 MR. ROBERT CENTA: Can you explain that? 16 DR. JAMES EDWARDS: When I returned to -- 17 to Canada in 1998, I became a coroner. I got in touch 18 with the Eye Bank and indicated to them that I'd be 19 willing to do enucleations for them and got that -- got 20 that process started. And I did -- I did a large volume 21 of enucleations. 22 MR. ROBERT CENTA: And what is an 23 enucleation? 24 DR. JAMES EDWARDS: Enucleation is -- 25 refers to removing a person's -- or people's eyes after

1 death for purposes of research and transplantation. The 2 -- the most common use that their put for -- used for is 3 corneal transplant. 4 MR. ROBERT CENTA: And in Ontario, how 5 many enucleations procedures would be performed in a 6 year? 7 DR. JAMES EDWARDS: I -- I wouldn't have 8 the numbers across the Province. When I was doing a 9 large volume of them, I would be doing approximately a 10 hundred (100) -- a hundred (100) a year. I was doing -- 11 I was doing a lot of enucleations. 12 MR. ROBERT CENTA: And how important is 13 that enucleation pro -- program for research and 14 healthcare in Ontario? 15 DR. JAMES EDWARDS: It's extremely 16 important from -- in -- in regard to corneal transplants, 17 one (1) -- one (1) enucleation, which would result in two 18 (2) eyes will enable two (2) -- two (2) people who 19 couldn't otherwise see to see, to have their sight 20 restored. That's obviously a tremendous -- a tremendous 21 benefit to them. 22 MR. ROBERT CENTA: In 2001, you were 23 appointed a regional supervising coroner for Toronto 24 East? 25 DR. JAMES EDWARDS: That's correct.

1 MR. ROBERT CENTA: And you hold that 2 position today? 3 DR. JAMES EDWARDS: That's correct. 4 MR. ROBERT CENTA: Have you been promoted 5 in the last week? 6 DR. JAMES EDWARDS: No. No, I haven't, 7 no. 8 MR. ROBERT CENTA: Okay. How many 9 coroners do you supervise in Toronto East? 10 DR. JAMES EDWARDS: Thirteen (13). 11 MR. ROBERT CENTA: And roughly how many 12 cases would be -- come through Toronto East in a year? 13 DR. JAMES EDWARDS: Approximately 14 thirteen (13). I should just mention in -- in that 15 regard that Dr. Lauwers and I cooperate and -- and work 16 together, and for practical purposes we often will share 17 supervisory responsibilities for our coroners. 18 MR. ROBERT CENTA: And your thirteen (13) 19 -- and the thirteen (13) coroners that you supervise, how 20 many cases would they investigate per year in total? 21 DR. JAMES EDWARDS: Two thousand (2,000). 22 MR. ROBERT CENTA: Two thousand (2,000)? 23 DR. JAMES EDWARDS: Yeah. 24 MR. ROBERT CENTA: Dr. Edwards, the 25 Regional Coroners -- who supervises Regional Coroners?

1 DR. JAMES EDWARDS: We report to the -- 2 the coroner -- the Office of the Chief Coroner is a 3 hierarchical structure, we report to the -- to the Chief 4 Coroner and between us and the Chief Coroner there are 5 Deputy Chief -- two (2) Deputy Chief Coroners. 6 MR. ROBERT CENTA: And at the moment, 7 they're filled by Dr. Lucas and Dr. Lauwers? 8 DR. JAMES EDWARDS: That's correct. 9 MR. ROBERT CENTA: Okay. I take it one 10 (1) of the most important roles of the Regional Coroner, 11 Dr. Edwards, is to supervise the conduct of death 12 investigations in the Province of Ontario? 13 DR. JAMES EDWARDS: That's probably our 14 most important role. 15 MR. ROBERT CENTA: Can I ask you to turn 16 to the OCCO Institutional Report, which is PFP149431 at 17 page 12. Paragraphs 24 and 25 describe the regional 18 supervising coroner role. And it states: 19 "As specified in Section -- Subsection 20 (51) of the Act, the Lieutenant 21 Governor in Council also appoints 22 regional coroners, also referred to as 23 regional supervising coroners. 24 Regional supervising coroners are 25 responsible for assisting the CCO in

1 the performance of his or her duties in 2 the region and for performing such 3 other duties as are assigned. 4 Direct communication between an 5 investigating coroner and the regional 6 supervising coroner about a case does 7 not necessarily occur unless the case 8 is particularly complex or considered 9 to be high profile. 10 Though in the past there were varied 11 practice between regional supervising 12 coroners, it is now the routine 13 practice that the regional supervising 14 coroner reads and reviews each case 15 before the case is closed." 16 Do you agree that's a fair description of 17 the duties? 18 DR. JAMES EDWARDS: I agree. The only 19 addition I would make is that new coroners are instructed 20 to contact us for -- for all cases they investigate. 21 MR. ROBERT CENTA: Dr. Lauwers, in 22 general how would you describe the key responsibilities 23 of a regional corner? 24 DR. ALBERT LAUWERS: Perhaps I'll just 25 defer that question to Dr. Edwards.

1 MR. ROBERT CENTA: Dr. Edwards, how would 2 you describe the key responsibilities for a regional 3 coroner? 4 DR. JAMES EDWARDS: Well, a regional 5 coroner, as we mentioned, the most important 6 responsibility is to ensure high quality death 7 investigations in the region which he or she supervises. 8 So that would entail recruiting and 9 educating coroners, having a call schedule so that we 10 have a timely response of coroners to death 11 investigations, being available to coroners for 12 consultation regarding deaths. 13 And one (1) of us is always available 24/7 14 to -- to consult with coroners. If it's 2:00 in the 15 morning, or anytime, we're always available to consult 16 with -- consult with our coroners and also to consult 17 with coroners in other regions if for some reason that 18 coroner -- a regional coroner is not available. 19 We monitor the coroners' work. We review 20 all of their autopsy warrants, review all of their 21 coroner's investigation statements, and provide them with 22 feedback on a -- on an ongoing basis. 23 We deal with any performance issues that 24 we identify regarding our coroners, and we follow up with 25 complex death investigations. And as a part of all of

1 that there's -- as you might imagine, there's a lot of 2 interaction with families. 3 MR. ROBERT CENTA: And I will take you 4 through each of those areas in turn, but let's start with 5 the role of the regional coroner in death investigations. 6 Just to set the table, if you could turn 7 to page 24 in the Coroner's -- in the OCCO Institutional 8 Report, paragraph 64. And Dr. Edwards, I'm looking at 9 the numbers at the very top of the page. You'll see it 10 says "PFP149431/24" is the page I'm looking for. 11 DR. JAMES EDWARDS: Yeah. 12 MR. ROBERT CENTA: And out of approx -- 13 paragraph 64 reads: 14 "Out of approximately eighty thousand 15 (80,000) deaths that occur each year in 16 Ontario, coroners investigate 17 approximately twenty thousand (20,000) 18 deaths annually." 19 So about one (1) in four (4)? 20 DR. JAMES EDWARDS: That's correct. 21 MR. ROBERT CENTA: 22 "Of the twenty thousand (20,000) 23 coroner investigations, approximately 24 seven thousand (7,000) autopsies are 25 warranted and conducted; approximately

1 two hundred (200) to two hundred and 2 fifty (250) cases annually are deemed 3 to be criminally suspicious or 4 homicide; and of those five (5) to 5 fifteen (15) are criminally suspicious 6 or homicide cases involving deaths of 7 children under the age of five (5)." 8 DR. JAMES EDWARDS: That's correct. Most 9 -- most coroner's investigations do not result in an 10 autopsy. Most of the deaths that we investigate are 11 natural deaths. 12 MR. ROBERT CENTA: And we're going to 13 spend most of our time looking at the investigation of 14 criminally suspicious -- 15 DR. JAMES EDWARDS: Yes. 16 MR. ROBERT CENTA: -- and homicide cases 17 today. But you wanted to emphasize that that is only a 18 small portion of the work of coroners in Ontario? 19 DR. JAMES EDWARDS: Yeah. Approximately 20 75 percent of the deaths that we investigate are -- are 21 natural deaths; about 15 percent would be accidental 22 deaths; 5, 6, 7 percent would be suicides; and the 23 remainder are either criminally suspicious or homicides. 24 MR. ROBERT CENTA: Okay. Dr. Lucas, do 25 regional coroners have any role in appointing the coroner

1 -- the investigating coroner that will be responsible for 2 a death investigation? 3 DR. WILLIAM LUCAS: They can be, although 4 in the majority of cases -- particularly in urban centres 5 where there is a sufficient volume of cases and 6 sufficient coroners to warrant it -- we -- we tend to set 7 up call rosters so that coroners will be assigned on a 8 daily basis to be the go-to person for that particular 9 day for any cases that occur. 10 And our expectation is that through the 11 training that we give them, through the support that we 12 provide to them through the regional supervising coroner, 13 that any coroner should be capable of dealing with -- 14 with any case, no matter how simple or complex. 15 And one (1) of the things that we drum 16 into them -- particularly with their new coroner training 17 -- as an ongoing sort of mantra, is if and when you have 18 any doubts, if you have any concerns about your ability 19 to deal with the case, pick up the phone and call your 20 regional supervisor, because they hopefully will have the 21 knowledge, the experience, or at least the ability to go 22 somewhere and seek the -- the assistance that's required 23 to advance an investigation properly. 24 MR. ROBERT CENTA: Dr. Lauwers, in 25 Toronto if a coroner is required to investigate a death

1 or someone thinks that a coroner should investigate a 2 death, how does that process work? Who calls who? 3 DR. ALBERT LAUWERS: So generally 4 speaking, in Toronto we have a dispatch system. And the 5 call will be -- will come into the dispatch system. The 6 dispatcher will take the particulars of the death, 7 location, et cetera. 8 There is in Toronto a call system for the 9 days and the evenings. There is one (1) coroner on call 10 during the day, and the evenings there are two (2) 11 coroners on call. And what will happen is the dispatcher 12 will then dispatch the case to the coroner. 13 Our expectation is that the coroner will 14 then call the -- generally it's a police officer. It can 15 sometimes be a member of Emergency Medical Services, such 16 as a paramedic, or it could be a healthcare worker in a 17 hospital. And we'll canvass the issues regarding the 18 applicability of Section 10 of the Coroners Act to 19 determine whether or not the Coroner has jurisdiction to 20 accept the case as a death investigation. 21 MR. ROBERT CENTA: Does the dispatcher 22 enter -- enter the fact that a case has -- that someone 23 has called in, in any kind of computer system? 24 DR. ALBERT LAUWERS: Well, it -- it's 25 interesting you raise the issue. The -- in Toronto Dr.

1 Edwards and I have the ability to monitor our cases on an 2 ongoing basis just because of that fact. 3 The information is sent in, and the 4 dispatcher enters it into the coroner's investigation 5 system immediately. The disadvantage is, though, that 6 the system only exists in the City of Toronto. 7 So in other words, the four thousand 8 (4,000) deaths that occur each year in the City of 9 Toronto, we have the capability of following. The other 10 sixteen thousand (16,000) cases that occur in the 11 remainder of the Province do not get entered into the 12 central system. 13 And so unfortunately, someone like Dr. 14 Lucas doesn't actually know on a day-to-day basis, unless 15 he's made a prearrangement with his coroners to 16 communicate with him directly that -- about the types of 17 cases that are being managed. 18 MR. ROBERT CENTA: Dr. Lucas, if Toronto 19 has access to his computer system, how are cases logged 20 and tracked in your region? 21 DR. WILLIAM LUCAS: Let me start with how 22 they're dispatched. 23 MR. ROBERT CENTA: Thank you. 24 DR. WILLIAM LUCAS: And that varies 25 across the Province. In my area if someone wants a

1 coroner, they call the local hospital, because we've set 2 up an arrangement with them that in terms of providing a 3 community service, they will be our dispatch centres, so 4 that if someone needs a coroner, they call the local 5 hospital switchboard, who in turn looks at the list of 6 who the coroner on call for the day is and contacts that 7 individual. 8 I've set up a process whereby in ideal 9 circumstances I want my coroners to notify me within 10 about twenty-four (24) to thirty-six (36) hours of any 11 case that they initiate an investigation into. 12 I have varying compliance with that. Some 13 coroners are very good and report them immediately. 14 Other coroners seem to forget that that's an important 15 thing for me, to understand what they're involved with. 16 In other areas of the Province coroners 17 may be located through police dispatching units, and -- 18 particularly in urban or rural -- or rural areas, rather, 19 where there are, as you heard from Dr. Evans -- or Dr. 20 Edwards, a relatively sort of low level of cases, and 21 where coroners may be sort of few in numbers. 22 There tends to be a process where you 23 phone and you -- if you can locate a coroner and they're 24 willing or available to attend at a case, they will go. 25 But there is no formal call schedule in those areas.

1 With the cases that a coroner takes, 2 although we hope that the coroner will inform us about a 3 case fairly promptly, sometimes it can be literally days, 4 weeks, or even months before we hear that a coroner has 5 undertaken an investigation, particularly if it's what 6 the coroner would deem to be a relatively low-profile 7 case. 8 For example, we have an understanding that 9 every tenth death that takes place in a nursing home will 10 be reported to and investigated by a coroner. If a 11 relatively elderly person who has a host of medical 12 problems has been in the nursing home for a number of 13 years and has finally succumbed to old age, the coroner 14 will be required to investigate that if it's what we call 15 a threshold case, one (1) of the -- the tenth cases. 16 They may not perceive that as -- as 17 needing immediate notification of the Coroner's Office. 18 And it will be when we eventually receive a report from 19 them that we become aware that that investigation has 20 taken place. 21 MR. ROBERT CENTA: Do you have any way of 22 knowing whether a -- a case has been assigned to one (1) 23 of your coroners until they contact you? 24 DR. WILLIAM LUCAS: There are other ways 25 and means that we can track it -- sort of lost our

1 speaker here. We -- sometimes we'll get a -- an invoice 2 for transportation of a body if a body has been moved 3 from the scene of death to a hospital for an autopsy, so 4 that we'll become aware of it that way. 5 We may receive a police report that they 6 were involved in a 911 call. We may receive a pathology 7 report when the autopsy has been conducted. Or we may 8 receive an inquiry from a family looking for information 9 pertaining to the coroner's investigation, and we then 10 have to track that down and sort out what this status of 11 it is. 12 MR. ROBERT CENTA: And those ways that 13 you just listed, would you agree that those are sub- 14 optimal ways of you being notified? 15 DR. WILLIAM LUCAS: Absolutely. And to 16 come back to Dr. Lauwer's point about in Toronto having 17 the -- the luxury of knowing on a day-to-day basis the 18 cases that are actively being investigated. 19 What that allows us to do when we enter 20 into our computer system that we have a case ongoing, we 21 can also log in that we're expecting a coroner's report, 22 that we're expecting an autopsy report if an autopsy has 23 been warranted, that we're expecting toxicology, and so 24 on. 25 And in the system we can build in

1 parameters that say if a coroner is investigating, we 2 anticipate or would expect a report within, for example, 3 thirty (30) days or an autopsy report within ninety (90) 4 days. And it allows us to track whether we're -- we're 5 getting our cases and our -- our reports turned around 6 with -- in an efficient manner. 7 MR. ROBERT CENTA: And you can't track 8 benchmarks unless you know the case exists? 9 DR. WILLIAM LUCAS: Absolutely true. 10 MR. ROBERT CENTA: Systemically, do you 11 think it would be advantageous for all regions to have 12 access either to the same system that is used in Toronto 13 or a similar system? 14 DR. WILLIAM LUCAS: Absolutely. As a 15 matter of fact, that was an issue that came before the 16 Core Business Committee about three (3) years ago. We 17 looked at the feasibility of having a pilot project that 18 would include my area, Central area, around Toronto. 19 Unfortunately, because of a number of 20 logistical issues and issues pertaining to manpower 21 resources and equipment, that wasn't able to get off the 22 ground. 23 But ultimately, our goal would be to have 24 a centralized system, a 1-800 number, if you will, that - 25 - that would call -- would be called into a central area

1 that would dispatch a coroner to virtually any area in 2 the Province, within reason. 3 One of the things that we've had to 4 consider is whether that would be technically feasible, 5 say from Sudbury South, and maybe not so feasible in the 6 north, just because of the vast geographic area. But 7 that's something that we're certainly willing to look at 8 and work with. 9 COMMISSIONER STEPHEN GOUDGE: So you 10 would have one (1) dispatch area and number for at least 11 much of the Province? 12 DR. WILLIAM LUCAS: Exactly. And -- and 13 it would be probably not dissimilar to what the OPP has 14 now, after hours, where most of their dispatch, as I 15 understand it, comes out of Aurelia. 16 COMMISSIONER STEPHEN GOUDGE: And all 17 that would be required, I take it, is that the dispatcher 18 have the on-call lists of the various regions? 19 DR. WILLIAM LUCAS: Absolutely, 20 absolutely. 21 MR. ROBERT CENTA: Dr. Lauwers...? 22 DR. ALBERT LAUWERS: We, and the Office, 23 Mr. Commissioner, consider this to be a major quality 24 assurance issue, the fact that there are substantive 25 number of cases within the Province that we can't track.

1 Just to elaborate a little bit, I -- I 2 think one of the core issues that -- that I've listened 3 to, in terms of the evidence that's come forward, is the 4 ability also to track the autopsy reports and their 5 timeliness. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. ALBERT LAUWERS: This can all be 8 built into the current system that we have functioning 9 here in the City of Toronto. And there's no reason that 10 it couldn't be -- that -- that system couldn't be 11 promulgated to the rest of the Province. 12 COMMISSIONER STEPHEN GOUDGE: I do not 13 know if you are going to come back to it, Mr. Centa, but 14 something you said earlier, Dr. Lucas, is a question that 15 I would like to ask a little bit about. And that is the 16 general philosophy that any coroner ought to be able to 17 do any case. 18 Do you triage the cases at all as between 19 coroners? Let me, obviously, take the kinds of case that 20 we are focussing on most, criminally suspicious? 21 DR. WILLIAM LUCAS: Sure. We -- we tend 22 to defer to the on-call system most of the time, but 23 there are occasions when a -- a case may come to my 24 attention as the Regional Supervisor often after the 25 fact. It might be a day or two (2) after the death, and

1 all of a sudden we're -- we're hearing concerns expressed 2 by the family about medical care in a particular 3 institution. 4 Certainly in those cases we have the 5 luxury of assigning a coroner that we think has the skill 6 set or has the -- the ability to deal most effectively 7 with that case. 8 But up until this point, we haven't 9 traditionally been triaging cases of the nature that 10 you're discussing, specifically the coroners with that 11 level of expertise. 12 COMMISSIONER STEPHEN GOUDGE: Any reason 13 for that? 14 DR. WILLIAM LUCAS: Just I think more the 15 practical aspect that coroners -- because they have other 16 responsibilities like their medical practices, working at 17 emergency departments, and so on -- it's very disruptive 18 to their -- their scheduling of other things if we're 19 constantly sort of coming back to the same individual -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. WILLIAM LUCAS: -- and trying to pull 22 him away from his other duties. 23 COMMISSIONER STEPHEN GOUDGE: For what 24 are going to inevitably be difficult cases. 25 DR. WILLIAM LUCAS: Exactly. The way,

1 however, that we've attempted to cope with those more 2 complex cases is, as we've alluded to earlier, and that 3 is to make sure the coroners understand that if they feel 4 that they're out of their depth or that there are some -- 5 some issues pertaining to a particular case -- and we've 6 set down guidelines that say, if you have a case that you 7 believe to be criminally suspicious, one (1) of your 8 first obligations as an investigating coroner is to pick 9 up the phone and speak to your Regional Supervisor, so 10 that we're aware of that case right away. 11 We can dialogue with them and -- and sort 12 out what it is that they're doing as part of their 13 initial investigation, give them some coaching or 14 guidance if we feel that they need to do more or may -- 15 COMMISSIONER STEPHEN GOUDGE: Could you 16 re-assign the case? 17 DR. WILLIAM LUCAS: We could. 18 COMMISSIONER STEPHEN GOUDGE: Or take it 19 over yourself? 20 DR. WILLIAM LUCAS: We could. We could. 21 And -- and often we do that. 22 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 23 Lauwers, do you have any comment on -- I mean, it's 24 obviously a -- 25 DR. ALBERT LAUWERS: Yes.

1 COMMISSIONER STEPHEN GOUDGE: -- subject 2 of interest to me. 3 DR. ALBERT LAUWERS: Just -- just one (1) 4 comment, Mr. Commissioner. The -- the system is designed 5 to -- that every member in the system is competent. Now 6 clearly there are people that are more competent than 7 others with regard to certain types of death 8 investigations. 9 For instance, some of our coroners are 10 anaesthetists. Well, they're ideal to put in a hospital 11 situation -- 12 COMMISSIONER STEPHEN GOUDGE: Yes, 13 exactly. 14 DR. ALBERT LAUWERS: -- around a 15 anaesthetic related death. 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. ALBERT LAUWERS: And we would -- we 18 would try to direct the call that way. Having said that, 19 though, you know, we -- as a principle we have to 20 maintain moral in our group, and if someone is on call 21 and they're -- cases are being shunted to other 22 individuals, it could have a negative effect on the 23 moral. 24 COMMISSIONER STEPHEN GOUDGE: Yes. No, I 25 mean I understand the management issue and the

1 desirability of having all coroners as able as possible 2 to do all cases, but obviously there are cases that would 3 profit from specialisation, and finding that balance 4 isn't easy. 5 DR. WILLIAM LUCAS: Sure, yeah. If I 6 may, we -- we have built into system and have had for a 7 number of years the ability to transfer cases, so that if 8 the initial coroner says, in essence, This is out of my 9 depth, I really just don't have the -- the experience or 10 the knowledge base to assess this case properly, we can 11 assign it to a different coroner. 12 Often that will occur if, for example, a - 13 - the circumstances that lead to a death occurs in one 14 (1) local, and then the person is ultimately transferred, 15 say from a tertiary -- a community hospital to a teaching 16 hospital in downtown Toronto, the Toronto coroner may say 17 there are some issues where this person initially 18 received their care or where the incident occurred that 19 need to be investigated, and we will assign that, as 20 well. 21 COMMISSIONER STEPHEN GOUDGE: Okay, 22 thanks. Thanks, Mr. Centa. Sorry for that -- 23 MR. ROBERT CENTA: Not at all. 24 COMMISSIONER STEPHEN GOUDGE: -- 25 diversion.

1 2 CONTINUED BY MR. ROBERT CENTA: 3 MR. ROBERT CENTA: Dr. Lucas, you -- you 4 indicated that -- that early contact from the 5 investigating coroner to the regional coroner is 6 essential in -- in certain specified cases. 7 If you could turn in the OCCO 8 Institutional Report to page 165, which is PFP149431, 9 page 165. 10 These are the guidelines for death 11 investigation that are currently in force in the Province 12 of Ontario? 13 DR. WILLIAM LUCAS: Correct. 14 MR. ROBERT CENTA: You're familiar with 15 these. 16 DR. WILLIAM LUCAS: I am. 17 MR. ROBERT CENTA: If we could turn to 18 page 179 in that document; this is Section 3 relating to 19 communication between the investigating coroner and the 20 regional coroner. And it provides that the investigative 21 coroner should notify the regional supervising coroner as 22 soon as possible of the following types of cases. 23 1. Cases involving the Special 24 Investigations Unit. 25 2. Deaths of children who are under five

1 (5) years of age or who have prior involvement with the 2 Children's Aid Society. 3 3. Homicides for deaths with suspicious 4 circumstances. 5 So the guidelines mandate that 6 investigating coroners contact you as quickly as possible 7 in -- in those specified cases? 8 DR. WILLIAM LUCAS: Exactly. 9 MR. ROBERT CENTA: How would you rate 10 compliance with those -- with that requirement currently? 11 DR. WILLIAM LUCAS: Generally I would say 12 it's very high. There may be some variance in terms of 13 the timing. If the coroner is called to a scene at two 14 o'clock in the morning, if they are a relatively young or 15 inexperienced coroner, they may call us immediately to 16 seek some guidance, if they are a seasoned coroner who 17 feels very confident in what they're doing, and in 18 previous discussions with the regional supervisor we are 19 prepared to give them a little bit of latitude, they may 20 defer the call until a reasonable hour in the morning, 21 but invariably, we get the call on those cases. 22 MR. ROBERT CENTA: As a regional coroner 23 do you want the call at 2:00 in the morning regardless of 24 who the investigating coroner is? 25 DR. WILLIAM LUCAS: I would say it's --

1 it's not critical. If I have an experienced coroner that 2 I know is going to, you know, be considering all the 3 appropriate things, making appropriate judgments and so 4 on, it's not necessary for me to be called at -- at 2:00 5 or 3:00, although we're never adverse to that. If -- if 6 even a seasoned or experienced coroner wants to advise us 7 about a case then we're happy to hear that call. 8 The other issue that comes up for 9 discussion in many of these is whether or not the body 10 needs to be transported to a regional centre such as the 11 Provincial Forensic Pathology Unit at the Office of the 12 Chief Coroner. Coroners understand that they need to seek 13 our approval for transfers of bodies. 14 So it may be that within the City of 15 Toronto, Dr. Edwards or Dr. Lauwers may not get a request 16 for such a transfer but anywhere outside of the Toronto 17 the Regional Coroner would be involved in that decision- 18 making process. So we would tend to get the call earlier 19 as a result of that. 20 MR. ROBERT CENTA: Dr. Edwards...? 21 DR. JAMES EDWARDS: I was just going to 22 add that we really rely on supporting our coroners to get 23 consistent quality death investigations and we're always 24 available; one (1) of the three (3) of us is always 25 available. And also on occasion we'll go out -- if the

1 coroner is at a scene and there are issues that arise, 2 one (1) of us will go to the scene. 3 Like, for example, if we have -- let's 4 just say we have somebody who's -- who's on a railway 5 track, somebody has died on a railway track, and there's 6 issues regarding getting trains moving again and so on, 7 we will go to that scene. Or if there's a case that's 8 really undifferentiated, we're not really sure which 9 direction it's going to go in, we'll -- we'll often go to 10 the scene to assist the coroner. 11 And really, I think that supporting the 12 coroners, usually by telephone advice but occasionally by 13 going to scenes with them, is really how -- how we deal 14 with getting quality -- quality investigations. 15 MR. ROBERT CENTA: In your view is having 16 a coroner attend the scene an important component of a 17 quality death investigation? 18 DR. JAMES EDWARDS: Well, the coroner 19 must attend every scene in -- in Toronto. 20 MR. ROBERT CENTA: In Toronto? 21 DR. JAMES EDWARDS: Yeah. 22 MR. ROBERT CENTA: How -- how does that 23 work in remote communities? How -- how do we best ensure 24 quality death investigations in remote communities, where 25 it may be difficult for a coroner to attend either a

1 primary or a second scene? 2 DR. JAMES EDWARDS: Now the only other 3 place I've worked besides Toronto as a coroner is in 4 Hastings County and the distances there were fairly -- 5 fairly substantial. We would go to every scene there as 6 well but what we would do is we would cover for each 7 other. So if I was in Belleville, if they couldn't get a 8 coroner in Bancroft I'd go to Bancroft, and similarly the 9 Bancroft coroners would come down and cover us and we had 10 -- we would do that. And we were always able to get a 11 coroner to go to the scene. 12 Now when you get to more remote areas like 13 northern Ontario, it really becomes -- I think for 14 practical purposes it often becomes very difficult to get 15 a coroner to go to very remote communities. And the 16 Coroners Act provides for us to be able to ask police 17 officers to assist us with -- with our duties in that 18 type of situation. 19 MR. ROBERT CENTA: Dr. Lauwers -- 20 DR. ALBERT LAUWERS: Section 9(1) of the 21 Coroners Act sets out that the police service that has 22 jurisdiction will provide assistance to the coroner, and 23 Section 16(3) sets out that a coroner may ask a -- other 24 medical practitioner or a police officer to assist them. 25 Now when I was working in the northeast

1 region, which was the City of Kawartha Lakes, certainly 2 as of the -- as of 2003 when the guidelines for death 3 investigations came about I went to every single scene. 4 Prior to that, however, it was clearly 5 evident that it was a natural scene and there would be a 6 series of questions that I would ask the police officer. 7 Particularly if I happened to be in the south end of the 8 City of Kawartha Lakes and the death occurred in the 9 north end of Haliburton County, there could be a couple 10 of hours' drive involved to go one (1) way to that 11 particular scene, I would inquire of the police officer 12 about the particulars of the death and ensure that I'd 13 satisfied myself that the case was actually a natural 14 death. For all other cases, however, it would require a 15 drive to the scene. 16 For more northern communities, I think -- 17 I haven't practised in the far north, but I can say that 18 the system with the current technologies that are 19 available, such as digital imagining which we rely on 20 heavily; the ability to communicate with people; when I 21 began as a coroner in 1985, cell phones didn't exist. 22 You know, all of that technology makes the possibility 23 for death investigation still to be done in a quality 24 way. 25 COMMISSIONER STEPHEN GOUDGE: The

1 discussion I had with Dr. Cairns, Dr. Lauwers, was about 2 in effect providing guidelines where attendance was not 3 possible; guidelines for investigating officers operating 4 under Section 9. 5 You said you had a series of questions 6 that you would ask the officer if you were at the south 7 end to determine whether it was a natural death or not. 8 Could you standardize that sort of 9 guideline so that, you know, if police officers 10 absolutely had to be used for scene investigation, for 11 example, the photography that had to be done, whatever 12 else you thought was essential and would do yourself if 13 you were there? 14 Is that something that is feasible? 15 DR. ALBERT LAUWERS: That is something 16 that is feasible, Mr. Commissioner. 17 COMMISSIONER STEPHEN GOUDGE: Is it worth 18 pursuing? 19 DR. ALBERT LAUWERS: It is worth pursing. 20 COMMISSIONER STEPHEN GOUDGE: Dr. Lucas, 21 do you want to add anything? 22 DR. WILLIAM LUCAS: I guess the only 23 thing that I would add to that is that we -- we can't 24 forget that in the vast majority of circumstances the 25 police services that are assisting us do an excellent

1 job; that they are very capable investigators; that their 2 identification units are seasoned veterans that -- that 3 are used to dealing with -- with crime scenes of a 4 variety of -- of different natures. 5 And we -- our experience in relying on 6 them to provide us with their gut feel, with their -- 7 their sense of whether they're dealing with something 8 that's of concern to them or not, invariably works. Now 9 does it work 100 percent of the time? Probably not. 10 But I think that although guidelines could 11 easily be created, we have to be sensitive to the fact 12 that they -- they do an excellent job as it is, without 13 anybody sort of spelling out, you know, Here's ten (10) 14 questions that you need to ask yourself when you approach 15 the scene. 16 And -- and again, coming back to the 17 comment that Dr. Edwards made at the beginning, 75 18 percent of the cases that we deal with are -- are 19 generally relatively straightforward natural -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. WILLIAM LUCAS: -- deaths and -- and 22 you know, their -- the index of suspicion is usually 23 dropped down to zero fairly quickly when -- when somebody 24 attends the scene. 25 COMMISSIONER STEPHEN GOUDGE: All right.

1 Dr. Edwards...? 2 DR. JAMES EDWARDS: I know I've had, on 3 occasion, calls from police officers in remote 4 communities if the Regional Coroner for that area is not 5 available. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. JAMES EDWARDS: And I certainly found 8 that it's possible to work through the cases very 9 satisfactorily with the police officer; just ask the 10 police officer questions. Usually they have much of the 11 information already available, and if -- if they don't, 12 they'll get it when I -- when I talk to them 13 COMMISSIONER STEPHEN GOUDGE: But I 14 assume when you do that you've got your own sort of 15 mental check list of things -- 16 DR. JAMES EDWARDS: That's -- that's 17 exactly correct, yeah. But I keep coming back to this 18 that, you know, having somebody available to provide 19 support to coroners, to police officers, to whoever, 20 really is what -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. JAMES EDWARDS: -- gives us quality-- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. JAMES EDWARDS: -- investigations. 25 COMMISSIONER STEPHEN GOUDGE: Right.

1 Thanks. Sorry, Mr. Centa. 2 3 CONTINUED BY MR. ROBERT CENTA: 4 MR. ROBERT CENTA: No problem. We know 5 that of the twenty thousand (20,000) coroner 6 investigations annually, only seven thousand (7,000) of 7 them will involve a post-mortem examination, but I'd like 8 to turn now to communications between investigating 9 coroners and forensic pathologists in cases where a post- 10 mortem examination is going to be conducted. 11 If we could stay in the overview report 12 and turn to page 180 in the OCCO Institutional Report, 13 PFP149431. Theirs is a guideline that deals with 14 communication between the investigating coroner and the 15 pathologist. And it deals with communication, two (2) 16 aspects. First, before the post-mortem examinations 17 conducted, and then second, afterwards. 18 I'd like to ask you some questions first 19 about the communication prior to the conduct of the post- 20 mortem examination. 21 And the guideline provides that there is 22 to be written and verbal communication. And for the 23 written guidelines I see the guideline for warrant for 24 post-mortem examination and verbal: 25 "before the post-mortem examination

1 discussion with pathologist is 2 desirable but not mandatory if the 3 warrant is comprehensive." 4 Now the guidelines for the warrant for 5 post-mortem examination are found in the Institutional 6 Report at page 184. And it sets out that: 7 "The investigating coroner is required 8 to complete the warrant for post-mortem 9 examination as soon as the coroner 10 decides to order the post-mortem 11 examination." 12 And that it must be completely filled out. 13 I'm interested in the paragraph that begins, 14 "background". I'm going to read that. 15 "Background details, including past 16 history, reasons for the post-mortem 17 examination and the circumstances of 18 the death, particularly if 19 circumstances are suspicious, should be 20 provided to assist pathologists and 21 toxicologists. This is a medicolegal 22 document, so it should contain factual 23 information and should not contain 24 speculation, rumour or conclusions that 25 will be made at the time of the post-

1 mortem examination. [bracket] (ie.) 2 describing gunshot wounds as exit or 3 entrance wounds." 4 I take it you agree with that guideline, 5 Dr. Lauwers? 6 DR. EDWARD LAUWERS: I do. 7 MR. ROBERT CENTA: And that suggests that 8 the invest -- warrant for post-mortem examination, the 9 coroner -- investigating coroner will provide some 10 information to the pathologist but not necessarily all of 11 the information that the investigating coroner may have 12 been exposed to. 13 Is that correct? 14 DR. ALBERT LAUWERS: That's correct. 15 That's actually, practically what happens, but I'd like 16 to give a contextual framework to that. 17 The pathologist needs as much information 18 as possible, you know, my own view. And my colleagues 19 may have some -- something to add to this as well. But 20 my own view is I look at the pathologist as a consultant 21 to assist my investigation. 22 And I look at that participation similar 23 to the way that I would -- I would view a -- a consultant 24 in a hospital, if I were working in a hospital. I'm -- 25 if I'm working in the emergency department, I need a

1 cardiologist, I -- I actually ask for the cardiology 2 consult. And I provide as much information as I possibly 3 can with respect to the details of the individual's 4 illness to the cardiologist. 5 My view is the same as with regard to our 6 pathologists. The more information we can possibly give 7 them, the better it is for them. And it allows them to 8 have a more fulsome understanding of the possible 9 circumstances of the death. 10 MR. ROBERT CENTA: And would that 11 include, though, things described in this document as -- 12 as speculation or rumour? 13 DR. ALBERT LAUWERS: Speculation and 14 rumour needs to be vetted through the coroner so that 15 it's not part of a -- a document. 16 MR. ROBERT CENTA: In your view, the 17 coroner should filter out that -- 18 DR. ALBERT LAUWERS: That's correct, but 19 having -- 20 MR. ROBERT CENTA: -- type of 21 information? 22 DR. ALBERT LAUWERS: -- said that, you 23 know, sometimes you will hear an item from a police 24 officer that might be relevant. For instance, you know, 25 they may be able to say, This -- this particular family

1 has been known to us in the past. We've had repeated 2 calls regarding domestic violence in this locale. 3 And -- and qualify where you're getting 4 the information from. 5 MR. ROBERT CENTA: Dr. Edwards, did you 6 need to add to that? 7 DR. JAMES EDWARDS: Yeah, the only thing 8 that I would add is that there should be additional 9 information in the autopsy warrant. You know, we want 10 our coroners -- all of our coroners -- for every case to 11 discuss the -- the issue of identification. 12 We want -- we want to make sure we get the 13 identification right all the time. So we want them to 14 state how the body was identified if it was identified, 15 and if it was not identified, what measures may be taken 16 to -- to identify the body in the future. 17 And the other -- the other point I would 18 make is that conversation between the coroner and the 19 pathologist is a -- is a two (2) way conversation. There 20 may be information in that the pathologist wants to get, 21 additional information from the coroner, that for some 22 reason the -- the cor -- the coroner has not thought to 23 provide. 24 So the coroner -- the pathologist may ask, 25 you know, whatever. If it's a body in a bathtub, Was the

1 head beneath the water, or whatever. And the -- if the 2 coroner has not already got that information, the coroner 3 can go and get that information. 4 So it's -- it's a two (2) way 5 communication. You really can't beat, in medical care, 6 good communication. 7 MR. ROBERT CENTA: This guideline, 8 though, relates to information contained in the warrant-- 9 DR. ALBERT LAUWERS: Yeah. 10 MR. ROBERT CENTA: -- for post-mortem 11 examination. The guideline relating to communication 12 with the pathologist does talk about also contemplated 13 verbal communication. 14 DR. ALBERT LAUWERS: Exactly. 15 MR. ROBERT CENTA: I take it you think 16 that that verbal communication is also extremely 17 important? 18 DR. ALBERT LAUWERS: I -- when I was in - 19 - when I was doing investigations I attempted to talk to 20 the pathologist in each and every case they ordered an 21 autopsy. 22 In Toronto it's sometimes difficult, 23 because there's a number of pathologists working there, 24 and you wouldn't necessarily know who was going to be 25 doing the autopsy the next day. But if I knew who -- who

1 the pathologist was, I would talk to them in every case. 2 MR. ROBERT CENTA: Does the restriction 3 that's set out here on -- it should -- that -- that the 4 warrant should not contain speculation or rumour or 5 conclusions that will form part of the report of post- 6 mortem, does that restriction also apply to the verbal 7 communication between the coroner and the pathologist? 8 DR. ALBERT LAUWERS: Well, the -- the 9 coroner needs to communicate more rather than less to the 10 pathologist. 11 MR. ROBERT CENTA: But should the -- 12 DR. ALBERT LAUWERS: But -- but things 13 that are clearly just rumour and gossip are -- are of no 14 value to anybody. 15 But I think that if -- if issues are 16 raised at the -- at the scene that have not been 17 determined to be -- the investigation would be early on 18 at -- at that time and not been confirmed, I think it's 19 fair enough to tell the pathologist, you know, There's 20 information that may indicate whatever. And -- but just 21 make it clear that that's not -- not known definitively. 22 But -- 23 MR. ROBERT CENTA: In term -- 24 DR. ALBERT LAUWERS: -- gossip and 25 hearsay and -- and rumour, they're -- they're of no value

1 to anybody. 2 MR. ROBERT CENTA: In terms of the total 3 package of information that an investigating coroner will 4 convey to a forensic pathologist, what's the breakdown 5 between how much would be provided in writing and how 6 much would be provided verbally, in -- in your sense, Dr. 7 Lauwers? 8 DR. ALBERT LAUWERS: Well, it's -- it's - 9 - at some point I'm going to ask my colleague to comment 10 on it as well, because it's different in the City of 11 Toronto than it is outside of Toronto. 12 What happens in Toronto is because of 13 there being a number of different pathologists and a 14 number of different coroners on-call, invariably they're 15 very reliant on the written document. The pathologists 16 are very reliant on the warrant. And communication might 17 be kept to a minimum of a -- of a verbal nature. 18 However, when I was practising in 19 Northeast Region, there -- my -- my warrants were written 20 in a sparse manner, and I would always communicate with 21 the pathologist. And indeed I might go to the autopsy 22 and communicate with the pal -- pathologist further at 23 that point. 24 So clearly, in the City of Toronto, 25 because of the nature of the way and the volume of cases

1 being done and the numbers of different individuals, what 2 invariably happens is we need a fulsome warrant written - 3 - written properly so that it -- all -- can almost be a 4 standalone document. 5 Although in the criminally suspicious 6 cases there's an expectation that the phone call should 7 happen as well. 8 In the more rural areas of the Province 9 the preferred method of communication is actually verbal, 10 and the warrants tend not to be as full. And that was 11 certainly my practice when I was practising. 12 MR. ROBERT CENTA: Dr. Lucas, is that 13 consistent with your experience? 14 DR. WILLIAM LUCAS: Absolutely. I think 15 that probably in the overwhelming majority of cases in my 16 region the coroners will -- will verbally speak to the 17 pathologist prior to the autopsy and expand on some of 18 the, what I might call, bullet points that they might 19 include in their warrant for post-mortem examination, so 20 that they might allude to the fact that the person has a 21 history of cardiac disease, and then give a more fulsome 22 explanation of how many times they had been hospitalised 23 and what sort of problems and complications they've had 24 over the years, maybe delineate the medications, and so 25 on.

1 But as Dr. Lauwers said, there are some 2 logistical and practical issues that come into play. And 3 it may be that the coroner has been up all night and goes 4 home to bed, and the pathologist is ready to start the 5 autopsy before they've had a chance to communicate. It 6 may be that the pathologist is not known to the coroner 7 at the time that he's writing his warrant for post- 8 mortem, so it's directed to the pathologist on call, so 9 that -- that we -- we hope that they're -- the written 10 communication is sufficient, that the pathologist has an 11 understanding of what he's doing. And if necessary, that 12 can -- the gaps can be filled in at a later time. 13 MR. ROBERT CENTA: In a criminally 14 suspicious or homicide case, should the contents of the 15 verbal communication between the investigating coroner 16 and the forensic pathologist, should that discussion be 17 memorialised or recorded in writing? 18 DR. WILLIAM LUCAS: I believe it should 19 be. Our expectation would be, I think, that the coroner 20 provides to the pathologist as much relevant information 21 as he believes that he can provide based on his 22 examination of the scene and the circumstances as he 23 understands them and his preliminary examination of the 24 body, which in a homicide situation may be relatively 25 limited for fear of going in and contaminating the scene

1 further. 2 But I think it's -- it's probably 3 imperative on the pathologist to have some way of 4 memorialising that information exchange, perhaps with 5 some note taking that ultimately gets transcribed or -- 6 or ends up in the summary of abnormal finding section of 7 their post-mortem report that would indicate, This was 8 the type of information that was -- was relayed to me. 9 COMMISSIONER STEPHEN GOUDGE: Is it more 10 effective to have the pathologist be the recording 11 vehicle rather than the coroner? 12 DR. WILLIAM LUCAS: My sense is yes, it 13 would be. That isn't to say that there couldn't be some 14 contribution by the coroner -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. WILLIAM LUCAS: -- to that, so that 17 with the things that we have available, like emails and 18 so on, if the coroner had the wherewithal or the facility 19 to go and -- and dictate or -- or type something and send 20 it to the pathologist, it would be of assistance. 21 That may not a be a practical issue in 22 some areas of the Province -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. WILLIAM LUCAS: -- as much as others, 25 but...

1 2 CONTINUED BY MR. ROBERT CENTA: 3 MR. ROBERT CENTA: Now, I'll return to 4 this when we look at the -- the audit tools and the 5 evaluations that regional coroners do of investigating 6 coroners. 7 But in assessing the sufficiency of the 8 information that's being provided by the investigating 9 coroner to the pathologist, in making that assessment of 10 whether the investigating coroner is doing that job well 11 or poorly, would it be of assistance to you to -- to have 12 a record of what the investigating -- or that the 13 investigating coroner had conveyed to the pathologist 14 verbally? 15 DR. WILLIAM LUCAS: I think it could be, 16 yes. 17 MR. ROBERT CENTA: How else would you be 18 able to assess, from a quality assurance point of view, 19 the sufficiency of that information that was communicated 20 verbally? 21 DR. WILLIAM LUCAS: I guess my challenge 22 with your question is that -- that probably in the 23 majority of cases a reasonable amount of information is 24 provided to the pathologist so that they know what the 25 context of -- of the death is, they understand what

1 issues are of concern to the coroner, and what the 2 coroner is -- is hoping that the -- the autopsy is going 3 to accomplish for them. 4 In many cases an autopsy will be 5 warranted, because the cause of death is not clear. The 6 cause of death may even lead to an issue about what the 7 manner of death is. Are we dealing with a death that's 8 accidental versus natural versus, perhaps, something 9 criminally suspicious? 10 So it's -- it's difficult to sort of set 11 down some parameters that say the coroner should transmit 12 X, Y, Z pieces of information in each and every case. I 13 think it -- it's dependent upon the circumstances. 14 And in the vast majority of cases I have 15 confidence that the pathologist understands why they have 16 been requested to do this consultation, what information 17 the Coroner is looking for if they're able to achieve 18 that, and in many autopsies at the end of the process, 19 they don't necessarily have the answers. They -- they 20 may have some preliminary findings that suggest that the 21 cause of death is not yet ascertained and they need to do 22 further studies, including toxicology and microscopy and 23 so on in the hopes that, ultimately, they may be able to 24 come up with an answer. 25 And there's a small percentage of cases

1 that at the end of the process, the finding -- or the 2 conclusion is that there is no definitive anatomic or 3 toxicological cause of death; something has happened that 4 we just, with the limitations of our processes, can't 5 explain. 6 DR. ALBERT LAUWERS: Just to be clear and 7 expand on that a little bit. 8 Dr. Lucas was talking about coroners' 9 cases, in general. For criminally suspicious cases or 10 homicides, the practice is a little different. 11 The lead agency is the policing service, 12 and the coroner's involvement in the recording of the 13 information and indeed, in examining the body isn't -- 14 the coroner does not examine the body in homicide cases 15 and so the amount of information that would be relayed to 16 the pathologist is vastly different in those 17 circumstances. 18 MR. ROBERT CENTA: Is that true as a 19 universal rule, that in a case where a homicide is 20 suspected, the coroner would not inspect the body? 21 MR. ALBERTA LAUWERS: That's correct, we 22 do not introduce evidence on to the body; we don't handle 23 the body. 24 MR. ROBERT CENTA: Dr. Edwards...? 25 DR. JAMES EDWARDS: In regard to

1 memorializing information; I think, in general, the world 2 is moving towards more -- a greater emphasis on 3 memorializing information as opposed to just verbal 4 communication. 5 And certainly when we communicate with 6 pathologists, you know, we review medical records for a 7 pathologist or if we get information about a death, you 8 know, maybe a week, two (2) weeks after the autopsy, we 9 will speak to the pathologist, but we will also attempt 10 to send them either an email or a note to file. 11 And I think that's just the way the world 12 is moving, that people want things in writing and -- and 13 then that gives the pathologist the ability to go back 14 and refer to that information when they're completing 15 their autopsy report weeks or months later. 16 COMMISSIONER STEPHEN GOUDGE: I was going 17 to ask a general question at some point, Dr. Edwards, 18 about the degree to which the fulsomeness of information 19 delivered by the coroner to the pathologist has changed 20 over the times you people -- all three (3) of you -- have 21 been in the field as coroners. 22 If you take yourselves back to the early 23 '90s, how would you compare that information exchange 24 with what goes on now? 25 DR. JAMES EDWARDS: It's -- it's

1 completely different. 2 I mean, back -- back then we relied, to a 3 much greater degree, just on verbal -- verbal 4 communications. 5 COMMISSIONER STEPHEN GOUDGE: Warrants 6 would be cryptic to say the -- 7 DR. JAMES EDWARDS: Yeah. 8 COMMISSIONER STEPHEN GOUDGE: -- most. 9 DR. JAMES EDWARDS: And now the 10 pathologists tell us that they really appreciate it when 11 we give them things in -- information in writing. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. JAMES EDWARDS: It gives them an 14 objective -- an objective set of information that they 15 can rely upon and go back and review later. 16 COMMISSIONER STEPHEN GOUDGE: Right. And 17 I took from the head nods that both you, Dr. Lauwers, and 18 you, Dr. Lucas, agree with that. Anything you want to 19 add? 20 DR. ALBERT LAUWERS: That's a -- sorry, 21 go ahead. 22 DR. WILLIAM LUCAS: I think that compared 23 to the early '90s where you might have a warrant that 24 says something along the lines of "apparent blunt-force 25 trauma to the head" and that was the extent of the

1 warrant in those days, now we expect a much more fulsome 2 description of the scene, the relative position of the 3 body, whether there's evidence of blood spatter, all 4 kinds of useful information that will be of assistance to 5 the pathologist which, of course, is then going to be 6 amplified, probably a hundredfold, by the police who will 7 be able to -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. WILLIAM LUCAS: -- provide digital 10 photographs and that sort of thing as well. 11 COMMISSIONER STEPHEN GOUDGE: Dr. 12 Lauwers...? 13 DR. ALBERT LAUWERS: Well, I started in 14 '85 and I recall exactly as you said, Mr. Commissioner, 15 they were cryptic and short and it was often the cause 16 "found dead at home. What's the cause [question mark]?" 17 That kind of performance wouldn't be 18 acceptable today. We have some fairly strong criteria 19 about what we expect with regard to the warrants. 20 COMMISSIONER STEPHEN GOUDGE: How does 21 the graph of change look over that period of time? 22 I mean, my instinct is from what I've 23 learned so far, is that over the course of the last -- 24 since the turn of the century, there has been a 25 significant uptake in the emphasis on this sort of thing.

1 Is that too general or is that modestly 2 accurate? 3 DR. JAMES EDWARDS: I would -- since -- 4 since I started as a regional coroner in 2001, and that - 5 - not my -- not my initiative, but the office is becoming 6 increasingly concerned with quality. And certainly any 7 measures that we take to promote quality, the office -- 8 the office supports us. 9 And I think before that time there may 10 have been less willingness to confront coroners with 11 quality issues. 12 COMMISSIONER STEPHEN GOUDGE: Dr. 13 Lauwers...? Dr. Lucas...? 14 DR. ALBERT LAUWERS: Well, the -- to me, 15 the -- the uptake did occur, as you say, at the turn of 16 the century - that being 2000 - and the -- the issue, I 17 thought, was the general acceptance on the part of the 18 membership, the Ontario Coroners' Association, and the 19 joint initiative regarding the death investigation 20 criteria, which -- which we're holding coroners to now, 21 and they accept. 22 And, you know, the -- the other -- this 23 was generally reflected in healthcare at the same time, 24 Please give us a set of guidelines so we can understand 25 what the expectation is. If you tell us what the

1 expectation is, we'll try to meet it. 2 COMMISSIONER STEPHEN GOUDGE: You 3 describe that, Dr. Lauwers, as if that was -- as if you 4 were still the president of the Coroners' Association. 5 That is the way it comes across to me. I mean, I know 6 that is not precise, but was this something that coroners 7 were asking for back around 2000? 8 DR. ALBERT LAUWERS: The -- the first I 9 heard of the guidelines that were developed was 10 approximately 2001. And it took until about 2003 until 11 they actually became a reality. I can't say that 12 everybody warmed up to the notion of the introduction of 13 guidelines. 14 Some felt that it would be an imposition 15 on their ability to be able to -- to have the freedom to 16 -- to conduct themselves the way they thought best 17 according to the facts related to the case. There is a 18 body of medical literature, though, that suggests -- and 19 -- and is firmly proven, that the development of 20 guidelines actually instructs people. 21 And it -- the beauty is that it allows you 22 not to miss the things that you actually should be paying 23 attention to, and does allow you to have the freedom to - 24 - to be able to express the particulars of the issues or 25 address those particular issues in your investigation

1 moving forward. 2 So to answer your question, Mr. 3 Commissioner, I think, in principle, the -- the OCA, as 4 an organization, might well have been split, but there 5 was a strong contingent within the organization that felt 6 it was the way to go, and we were successful getting it 7 done. 8 COMMISSIONER STEPHEN GOUDGE: Dr. 9 Lucas...? 10 DR. WILLIAM LUCAS: I think Dr. Lauwers 11 has articulated it fairly well. What -- what I -- I have 12 witnessed is, in the time that I've been involved with 13 the Coroner's Office, initially, the concept was that 14 coroners were largely voluntary. 15 They were -- they were fulfilling a role 16 that was meeting a -- a public need, but we were beholden 17 to them in the sense that they -- their primary interest 18 was their practice and in essence, they were devoting a - 19 - a fair amount of time outside of their regular office 20 and practice procedures -- procedure times to -- to this 21 service to the community. 22 But as medicine evolved and the acceptance 23 of taking a critical look at -- at how in medicine we do 24 business and how the needs for guidelines and standards 25 were becoming more common place in the practice of

1 medicine, coroners were -- were much more acceptive of -- 2 of that within our system as well. 3 And so I think, as -- as you highlight, 4 starting in about the year 2000, there was a tremendous 5 acceleration, and it's -- it's gained some momentum and 6 continues to grow. And I think the -- the positive thing 7 from our perspective, is that the coroners, as Dr. 8 Lauwers suggested, are -- are now very accepting of this. 9 And -- and in fact, very appreciative of - 10 - of the fact that they're being given some degree of 11 structure that assists them in doing their job well 12 'cause I think most of them want to do their job well. 13 COMMISSIONER STEPHEN GOUDGE: All right. 14 Thanks. Thanks, Mr. Centa. 15 DR. ALBERT LAUWERS: Just one (1) last 16 comment. There -- there is an article in the -- I 17 believe -- the Annals of Internal Medicine called, Zen 18 and the Art of Physician Autonomy Maintenance that goes 19 to the -- it's an interesting -- an interesting concept, 20 but it goes to the notion of -- or the article spoke of 21 the -- of the reasons that one would actually want to 22 have guidelines. 23 And the notion is by having guidelines, 24 you -- you give up some your freedom, but then you 25 invariably get it back, which is the notion that I can do

1 a better job by having guidelines in place. 2 COMMISSIONER STEPHEN GOUDGE: All right. 3 That is interesting. 4 5 CONTINUED BY MR. ROBERT CENTA: 6 MR. ROBERT CENTA: We had discussed 7 coroner attending the scene of a homicide or criminally 8 suspicious case, and you had indicated that they -- that 9 the coroner has a diminished role at the scene where he 10 or she attends the scene if it's clearly a homicide, is 11 that correct? 12 DR. ALBERT LAUWERS: That's correct. 13 MR. ROBERT CENTA: On scene attendance, 14 do you believe that it is advantageous for forensic 15 pathologists to attend death scenes where there is a 16 suspicion if the case is a homicide or criminally 17 suspicious? Dr. Lucas...? 18 DR. WILLIAM LUCAS: There certainly is 19 some value in some circumstances for the forensic 20 pathologist to attend. Again, we have to look, sort of, 21 at the -- the complimentary role, if you will, that both 22 the coroner and the forensic pathologist play in these 23 sort of cases. 24 And in certain circumstances, part of the 25 -- I'm sure you've heard from Dr. Pollanen that he

1 divides the -- the autopsy into a number of different 2 segments. And the first segment is information retai -- 3 pertaining to the scene and the circumstances of the 4 death, so that if the circumstances are such that we can 5 relay that information to the pathologist adequately and 6 appropriately -- through the coroner's attendance and 7 through the police with appropriate use of technology -- 8 then there may not be a critical need for the pathologist 9 to attend. 10 Whereas in some circumstances there's 11 nothing that can surpass the -- the opportunity to have 12 your own -- or make your own physical observations. 13 MR. ROBERT CENTA: And so I take it then 14 you would agree that that should remain a discretionary 15 decision, as to whether or not a forensic pathologist is 16 requested to attend a scene? 17 DR. WILLIAM LUCAS: Yes. And as a matter 18 of fact, what I would like to see, in terms of moving 19 forward in this, is some kind of process where -- and 20 again, when we compare and contrast the City of Toronto 21 to the rest of the Province, the City of Toronto is 22 relatively compact, so that if an obvious homicide occurs 23 and there are -- would be value added for the pathologist 24 attending, it's relatively easy to orchestrate. 25 If we're talking within my region of a

1 death that occurs in Keswick and we know that we're going 2 to be shipping the body down to Toronto for the autopsy 3 at our Provincial Forensic Centre, it may be a less 4 practical matter to try and get the cor -- the 5 pathologist to the scene in that circumstance. But on 6 the other hand, there may be some very compelling reasons 7 for the person to be there. 8 So what I would like to see us work 9 towards, with the assistance of the Chief Forensic 10 Pathologist and probably a variety of stakeholders, would 11 be some consensus of -- as to the types of circumstances 12 where that's going to be of value; recognize the -- the 13 pros and cons, the strengths and limitations of that; and 14 to develop some guidelines or protocol that -- that can 15 be consistent across the Province as much as possible. 16 MR. ROBERT CENTA: And I take it the -- 17 the difficulties that you outlined for viewing a death 18 scene in Keswick would be significantly increased for a - 19 - for a remote northern community? 20 DR. WILLIAM LUCAS: I would imagine, 21 absolutely. 22 MR. ROBERT CENTA: You raised the -- Dr. 23 Pollanen's report of post-mortem examination. And I take 24 it that is one (1) of the most important ways that a 25 forensic pathologist communicates information back to an

1 investigating coroner? 2 DR. WILLIAM LUCAS: Yes. 3 MR. ROBERT CENTA: Is there currently a 4 standard form for reports of post-mortem examination in 5 the Province of Ontario? 6 DR. WILLIAM LUCAS: In essence, yes. The 7 format, I think, is fairly standard. The amount of 8 information that's recorded in each of the segments of a 9 post-mortem standardized format will vary depending on 10 the complexity of the case. 11 But there's sort of an initiation of 12 demographic data, the name of the decedent if it's known, 13 and who was in attendance at the autopsy. 14 It then starts with external examination, 15 evidence of medical therapy, evidence of trauma, and sort 16 of goes through a whole list of different segments that 17 the pathologist is expected to respond to. And of 18 course, as I say, those will vary depending on the 19 circumstances of the case. 20 MR. ROBERT CENTA: Dr. Lauwers...? 21 DR. ALBERTA LAUWERS: This might be a 22 question that's better addressed to the pathologist. But 23 having said that, my understanding is there has been work 24 that's been advanced in the interests of trying to create 25 a standardized document for the Province.

1 I understand that document has been 2 implemented and used with some success in jurisdictions, 3 but it's not used throughout the Province. 4 MR. ROBERT CENTA: And, Dr. Lauwers, with 5 respect to reports of post-mortem examination in Toronto, 6 are you generally satisfied with the level of detail and 7 clarity of those reports? 8 DR. ALBERT LAUWERS: I -- I -- we think - 9 - Dr. Edwards may have an opinion about this as well. 10 But we think we get incredibly good reports in the City 11 of Toronto. 12 All our autopsies are done by the 13 pathologist, basically, in the Forensic Pathology Unit. 14 And, you know, these are pathologists that are 15 specialized in this particular service. They give us 16 superb reports. 17 MR. ROBERT CENTA: And you have you -- 18 have you noticed a change in the detail or length of 19 reports over time since you were first a -- an 20 investigating coroner? 21 DR. ALBERT LAUWERS: Well, the level of 22 detail that I would receive when I was in Northeast 23 Region, the quality of the reports, could not -- could 24 not match in any way the types of qualities of reports 25 that I'm currently receiving in the City of Toronto.

1 COMMISSIONER STEPHEN GOUDGE: Is that due 2 to specialization, Dr. Lauwers, or is it due to, today, a 3 greater emphasis on thorough reports -- 4 DR. ALBERT LAUWERS: I think it's multi- 5 factorial, Mr. Commissioner. I think that there have 6 been initiatives by Dr. Pollanen, for instance, to 7 produce guidelines for standardization -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. ALBERT LAUWERS: -- of reporting. 10 That helps tremendously. And the fact that our forensic 11 pathologists here in the City of Toronto are highly 12 specialized with regard to the limits of what they do -- 13 they're not also currently involved in hospital-related 14 pathology -- 15 COMMISSIONER STEPHEN GOUDGE: Hospital 16 pathology. 17 DR. ALBERT LAUWERS: -- et cetera -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. ALBERT LAUWERS: -- so that's at 20 least a part of it. And the other part, of course, is 21 that the entire system of death investigation has 22 advanced over the -- over a number of years. 23 And we recognize, and more formally, what 24 is required in a -- in a fulsome autopsy report 25 examination.

1 COMMISSIONER STEPHEN GOUDGE: Dr. 2 Edwards, you -- 3 DR. JAMES EDWARDS: I was just going to 4 say, you know, the -- Dr. McLellan really -- when he 5 became Chief Coroner really made quality a priority. And 6 that related to -- to coroner's investigations, to our 7 work as Regional Coroners, our expecta -- the 8 expectations of us increase with time, and also 9 pathologists. 10 COMMISSIONER STEPHEN GOUDGE: Right, 11 right. 12 13 CONTINUED BY MR. ROBERT CENTA: 14 MR. ROBERT CENTA: One (1) of the changes 15 that we've heard about is the increasing use of case 16 conferences in criminally suspicious and homicide cases. 17 Is there a role for the Regional 18 Supervising Coroner in those case conferences, Dr. 19 Edwards? 20 DR. JAMES EDWARDS: Yeah, well, actually 21 Dr. Lucas might better answer this question. 22 MR. ROBERT CENTA: Dr. Lucas...? 23 DR. WILLIAM LUCAS: There -- I think 24 they're deferring to me because I probably had a little 25 bit more experience in this area than they have. And

1 that's not because it's -- it's more a geographic issue 2 in the relationship that, particularly in criminally 3 suspicious cases, they have with the Toronto police 4 services and how the Toronto police services manages 5 these types of cases than in other areas. 6 The short answer to your question is, yes, 7 the Regional Supervising Coroner has a critical role to 8 play in that we, in essence, become the coordinator of -- 9 of these types of conferences. 10 The direction that we have from the Chief 11 Coroner which, I think is an excellent one, is that -- 12 that these should be within a reasonable timeframe, 13 usually within a couple of weeks of the autopsy 14 examination wherever possible. 15 And particularly for complex cases where 16 the cause of death is not entirely clear cut, that 17 becomes a critical issue that we have an early meeting so 18 that we can provide police investigators with a sense of 19 the strength or the deficiencies, if you will, of the 20 forensic pathology evidence that we have at that point in 21 time, which can also then assist the -- the police in 22 terms of understanding where they need to go with the 23 direction of their investigation from that point on. 24 COMMISSIONER STEPHEN GOUDGE: You would 25 need the post-mortem report to have a full case

1 conference? 2 DR. WILLIAM LUCAS: We would, although in 3 the vast majority of cases, having a preliminary finding 4 from the pathologist is -- is often sufficient. What 5 I've discovered in the numerous case conferences that 6 I've had over the years is that, in essence, there are 7 two (2) types. 8 There's the ones where the cause of death 9 is not entirely clear, where the pathologist hasn't been 10 able to find something definitive at the time of the 11 gross post-mortem examination and needs to do further 12 studies, toxicology, microscopics and so on. 13 And so that the -- the police have a 14 quandary as to whether we actually know how or why this 15 person died. That's in contrast -- and -- and in those 16 types of circumstances, it's critical that the 17 pathologist is the key participant in those case 18 conferences. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. WILLIAM LUCAS: The majority of case 21 conferences are somewhat different. The cause of death 22 is quite apparent. The person has a gunshot wound, 23 multiple gunshot wounds, stab wounds, or has been -- 24 there's evidence of manual strangulation or something. 25 And the pathologists actually, in those

1 cases, feel that they really have little to contribute to 2 the discussion of -- of how the case should evolve or how 3 the police investigation should move forward. 4 In those situations, the case conference 5 tends to focus more on prioritization of exhibits that 6 are submitted to the Centre of Forensic Sciences for 7 processing. And we spend a lot of time, in those case 8 conferences, discussing and educating police 9 investigators as to the strengths of the science that's 10 available, and whether or not the Centre of Forensic 11 Science is going to be able to assist them with achieving 12 what they're hoping to achieve by submitting a certain 13 piece of -- of evidence for analysis or whether they're 14 not. 15 For example, if someone dies of a gunshot 16 wound in a fairly confined space, someone may ask the 17 question, Well who pulled the trigger? Well, we have 18 discussions about the -- the strengths and the 19 limitations of the science to be able to indicate to the 20 -- to the -- the police officers whether that's going to 21 be possible or not. 22 There may be questions about linking a 23 suspected perpetrator to a scene by blood dec -- DNA 24 contamination, so that they may have sustained an injury 25 in a scuffle, and they want to know whether a -- an

1 article of clothing is going to link the person to the 2 scene, and we'll have some discussions about whether the 3 science is able to do that for them. 4 And on the basis of those type of 5 discussions, ascertain which of the thirty-eight (38) 6 cigarette butts they picked up from the parking lot 7 should be submitted for analysis or not, and this type of 8 -- of thing. 9 MR. ROBERT CENTA: Dr. Edwards...? 10 DR. JAMES EDWARDS: Case conferences can 11 also be of assistance in arranging further testing and 12 I'm thinking of a case that we had back a couple years 13 ago. We had a young child, the child was eleven (11) 14 days old, who died -- died at home with his -- with -- 15 with her mother, and the autopsy didn't show any cause of 16 death. 17 We had a toxicology report and the 18 toxicology report showed that the child had a fatal level 19 of morphine, so where does -- where did the child get the 20 morphine? 21 So we had a case conference into that -- 22 into that. The Deputy Chief Coroner was there, the 23 toxicologist was there, the pathologist was there, there 24 police were there, I was there and we reviewed -- 25 reviewed the -- the child's medical records.

1 We didn't have the mother's medical 2 records; we reviewed the child's medical records, and we 3 saw that the child was being breastfed, and we also saw 4 that the mother was taking Tylenol 3, so the toxicologist 5 was able to tell us that codeine in Tylenol 3 is 6 metabolized to morphine and that's how it causes 7 respiratory depression in death. 8 And so the possibility was raised that 9 perhaps -- although at that time it was just a hypothesis 10 to us, but the possibility that, perhaps, the -- the 11 Tylenol 3 that the mother had been given was being passed 12 to the baby and that had caused the baby's death. 13 So what we did, in that case, was we met 14 with a toxicologist at the Hospital for Sick Children and 15 told him about the circumstances of the death and our 16 hypothesis, and he, under our -- under our jurisdiction, 17 arranged to have further testing done and was able to 18 determine that the mother was a rapid metabolizer of 19 codeine. 20 As a result, she -- her body metabolized 21 codeine very quickly to morphine and the morphine was 22 passed to the baby and that's why the baby died. 23 So, that's just an example of where a 24 case conference and having everybody around the table 25 gives you the -- the ability to set the case in the -- in

1 the right direction and to take the appropriate -- 2 appropriate measures in -- in terms of -- in this case, 3 in terms of determining the cause of the baby's death, 4 but also in terming -- obviously in terms of determining 5 the -- the manner of the baby's death and public safety 6 issues that would arise from that, so case conferences 7 can be very helpful. 8 MR. ROBERT CENTA: Thank you. I need to 9 ask you some questions about the -- the information that 10 the investigating coroner reports back to the Regional 11 Coroner throughout the -- the death investigation. 12 And during the death investigation, what 13 documents will the Regional Coroner expect to receive 14 from the investigating coroner, Dr. -- Dr. Lauwers? 15 DR. ALBERT LAUWERS: Generally speaking, 16 all we see from them is the warrant for post-mortem 17 examination, which is the subject of -- of actually 18 scrutiny and inquiry in the morning, that may initiate a 19 telephone call to the coroner for clarification of any 20 issues arising from that. 21 Subsequent to that, the coroner will file 22 a -- either a preliminary or final Form 3 document and 23 the preliminary -- the preliminary report will not 24 usually give a manner and cause of death, but rather 25 might have a discussion about the potential

1 considerations at that time, and at a later date, a final 2 Form 3 document might arrive and give us the definitive 3 manner and cause of death. 4 MR. ROBERT CENTA: Form 3 documents are 5 also known as coroner investigation statements? 6 DR. ALBERT LAUWERS: Coroner's 7 investigation statements. I'm trying to stay away from 8 that because I know the system is also called coroner's 9 investigation system, CIS, and the form itself is called 10 the coroner's investigation statement, CIS, so. 11 MR. ROBERT CENTA: Thank you. And in a 12 case of a death of a child, let's say under -- under five 13 (5), there would normally be a determination by the 14 Regional Coroner of whether or not any death needs to go 15 to inquest or to go to an ec -- for -- further review at 16 an expert -- one (1) of the expert committees established 17 by the Chief Coroner's Office, is that correct? 18 DR. ALBERT LAUWERS: Well, the -- the 19 deaths of children under five (5) years of age 20 mandatorily go to the Death Under Five Committee, and 21 depending on the findings of the Death Under Five 22 Committee, if there are medical issues, that death might 23 be referred to the Paediatric Death Review Committee. 24 MR. ROBERT CENTA: And, Dr. Lauwers, you 25 currently chair the Paediatric Death Review Committee?

1 DR. ALBERT LAUWERS: I am. 2 MR. ROBERT CENTA: And first with the -- 3 the Death Under Five Committee, you also chair that 4 committee? 5 DR. ALBERT LAUWERS: I do. 6 MR. ROBERT CENTA: And the -- the mandate 7 of that committee is to look at all deaths of every -- of 8 every child under five (5) in the Province of Ontario, is 9 that correct? 10 DR. ALBERT LAUWERS: That's correct. 11 MR. ROBERT CENTA: And it is the 12 committee that determines the cause of death and the 13 manner of death in those cases? 14 DR. ALBERT LAUWERS: That's correct. It 15 -- it's really a quality assurance process trying to nail 16 down, definitively, the manner and cause of death; it has 17 -- it has many different players at the table. 18 There's policing services representative - 19 - represented at the table, and the function of the 20 policing service is to corroborate what we know to be the 21 history with regard to the circumstances surrounding the 22 death. There's a pathologist -- there's several 23 pathologists on the committee and their duty is to do a 24 paper review of the autopsy report of another 25 pathologist. And if they have any questions from time to

1 time, they will request that the slides be provided as 2 well. And they do a more detailed review of that 3 particular death. 4 What happens is basically if there were 5 thirty (30) cases under review in the Death Under Five in 6 any given meeting, the pathologist that had the 7 responsibility for doing those death reviews would 8 present the cases. 9 So we'd hear from the police first. We'd 10 hear from the pathologist next. And then we would 11 collectively, on a consensus, position develop a -- a 12 disposition with regard to the manner and cause of death. 13 And in our system that particular manner 14 and cause of death is designed to -- to be the definitive 15 answer. 16 MR. ROBERT CENTA: If you could turn to 17 Volume II, Tab 44, which is PFP057188. 18 19 (BRIEF PAUSE) 20 21 MR. ROBERT CENTA: That's the report of 22 the PDRC and the Death Under Five Committee from June of 23 2007. And if you could turn to page 29 of that document. 24 25

1 (BRIEF PAUSE) 2 3 DR. ALBERT LAUWERS: Are you looking at 4 committee membership? 5 MR. ROBERT CENTA: Committee membership. 6 DR. ALBERT LAUWERS: Thank you. 7 MR. ROBERT CENTA: And on the left-hand 8 column there's the membership of the Pediatric Death 9 Review Committee, on the right the Death Under Five 10 Review Committee. 11 Can you explain the -- the difference -- 12 what is the difference in the mandate between the 13 Pediatric Death Review Committee and the Death Under Five 14 Committee? 15 DR. ALBERT LAUWERS: The Death Under Five 16 Committee has a very limited mandate. Its mandate is 17 just to find a manner and cause of death. 18 The Pediatric Death Review Committee has 19 an extensive mandate. It -- it relates to issues such as 20 assisting -- well -- well, firstly, there are two (2) 21 wings to the Paediatric Death Review Committee. The one 22 (1) wing is the child welfare expert wing, and the other 23 wing is the -- the medical expert wing. 24 For the child welfare expert wing, what 25 happens is in each death in which a child dies and was

1 under the jurisdiction or Children's Aid were involved 2 with them in the preceding year, then generally -- not 3 generally -- in each and every case the investigating 4 Children's Aid Society is required to file a report. 5 Now, just to be clear about that, it's a 6 little -- little bit -- can be a bit ambiguous in the 7 sense that if a child dies, often that initiates a report 8 to CAS. So what happens is there's a mandate that they 9 have to supply a -- they have to issue a serious 10 occurrence report that's followed by, within fourteen 11 (14) days, a report to our office with regard to the 12 circumstances of the death. 13 And then it's expected that within ninety 14 (90) days they'll do a mull -- more fulsome review of the 15 involvement of -- of their agency with the death. 16 What can happen though is that our child 17 welfare expert may review the circumstances and say, 18 well, you know, clearly if a child dies in a motor 19 vehicle accident on the Gardner Expressway, it's not 20 necessary for the -- the CAS Society to do a fulsome 21 report of their involvement with the child. 22 Now, the medical arm of the Pediatric 23 Death Review Committee, many, many child deaths are 24 complicated medical deaths. And it's -- we will receive 25 a package and -- with the understanding of the

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1 circumstances of the death aren't really understood. 2 And one (1) of the expert members of the 3 Pediatric Death Review Committee will be asked to review 4 the medical circumstances surrounding the death. 5 MR. ROBERT CENTA: Now, you're the chair 6 of both committees? 7 DR. ALBERT LAUWERS: I am. 8 MR. ROBERT CENTA: And there is some 9 shared memberships, some cross-appointments, from the 10 Death Under Five Committee to the Pediatric Death Review 11 Committee? 12 DR. ALBERT LAUWERS: Yes. 13 MR. ROBERT CENTA: Is there -- in your 14 opinion, should the -- should the two (2) committees 15 remain separate? Or could a combined committee perform 16 both roles for the OCCO? 17 DR. ALBERT LAUWERS: I think the 18 committees should remain separate, because respecting the 19 Death Under Five Committee is primarily a committee 20 driven around the pathology issues. It's an iss -- it's 21 a committee that specifically looks at the proper 22 assignation of a cause of death in a pediatric case. So 23 that's the function of that committee. And it should be, 24 in my view, completely isolated from the PDRC. 25 Having said that, they can sometimes exist

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1 in a continuum. For instance, if -- if we look at the 2 pathology report and the circumstances -- if -- if -- 3 pardon me -- if the post-mortem report examination and 4 the circumstances are troubling and we can't reconcile 5 them at the Death Under Five Committee, we may well send 6 them on to the PDRC and ask for review of the death at 7 that level. 8 COMMISSIONER STEPHEN GOUDGE: The report 9 that comes out of the Death Under Five Committee, is that 10 signed by the chair of the committee in the place of the 11 investigating coroner? Who does the Form 3 there? 12 DR. ALBERT LAUWERS: What happens, Mr. 13 Commissioner, is the chair of the committee signs off. 14 We list only two (2) items. The cau -- the medical -- 15 COMMISSIONER STEPHEN GOUDGE: Manner and 16 cause. 17 DR. ALBERT LAUWERS: -- cause -- cause of 18 death and manner of death. 19 COMMISSIONER STEPHEN GOUDGE: Yes. 20 DR. ALBERT LAUWERS: And the chair of the 21 committee signs off on that and sends it to the 22 supervising regional coroner. 23 It's the duty of the supervising regional 24 coroner to inform the investigating coroner and ensure 25 that the final Form 3 of the coroner's investigation

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  1  statement is actually correct.
  2                 COMMISSIONER STEPHEN GOUDGE:   I see,
  3  okay.
  4  
  5  CONTINUED BY MR. ROBERT CENTA:
  6                 MR. ROBERT CENTA:   Just before we leave
  7  the death investigation process, I ask you for -- any of
  8  you can answer this question -- in your view, how
  9  important is it to a successful completion or discharge
 10  of the coroner's function -- and also the regional
 11  coroner's function -- that you are medical doctors?  
 12                 How important is that as a factor in -- in
 13  successful discharge of your duties?
 14                 DR. ALBERT LAUWERS:   Can I just start
 15  with this one?  I'm sorry, Dr. Edwards.  He actually
 16  described a case that I thought was one of the most
 17  important cases I've heard of.  And it had to do with, of
 18  course, the mother breastfeeding her child and taking
 19  Tylenol 3s at the same time.
 20                 Now the child has a toxicology report that
 21  says it has morphine in its system.  There's only --
 22  there's virtually one (1) way an eleven (11) day old baby
 23  is going to get that.  Now it's either an accident or
 24  it's not.  
 25                 And this was the advantage of the coroner

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1 system. I thought it demonstrated it so clearly. Dr. 2 Edwards did the review of the chart, noticed the mother 3 was taking Tylenol 3, posed the question to the 4 toxicologist -- the toxicologist gave the answer, Yes, 5 codeine is broken down into morphine -- and then had the 6 wherewithal to go to the Hospital for Sick Children. 7 And through the expertise that was made 8 available to us there, including the availability of a 9 geneticist and a toxicologist -- and not just any 10 geneticist and toxicologist but, you know, a world-class 11 individual -- we were able to actually sort out and 12 provide to the family the -- the exact answer with regard 13 to how their child died. And furthermore, it had 14 preventative issues with regard to any future children 15 that mother might have. 16 And furthermore, it was published in The 17 Lancet, which is a very reputa -- reputable medical 18 journal. And the purposes of that, of course, is to 19 inform the population of physicians in the world that you 20 need to start thinking about these types of things when 21 you're prescribing narcotics to mother -- to mothers for 22 post-delivery-type pain. 23 So that's a case, to me, where it would 24 not have ever got sorted out in the absence of having a 25 medical -- medical coroner system.

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1 MR. JAMES EDWARDS: I agree. Yeah, 2 there's -- we've -- there's many cases that -- that the 3 Coroner's Office has been involved with similar to that, 4 you know, that -- where because -- because we're 5 physicians, we're able to pick up on issues quickly and 6 deal with them, public health issues. 7 I'm thinking of another case. We had a 8 case, a young girl died -- died suddenly and comes in, 9 has an autopsy. And the pathologist couldn't find a 10 cause of death at the gross autopsy and came up and 11 discussed the case with me. 12 And so we got the -- the decedent's 13 medical records. And she -- turns out she had had a 14 fainting spell a week beforehand and been in the 15 hospital. So we got those medical records, examined 16 those medical records, and she had a heart arrhythmia, a 17 Prolonged QT Syndrome, that had caused her to faint on 18 that occasion. 19 And -- and we thought at that time it 20 likely caused her -- or possibly caused her death. So we 21 were able to initiate measures at that time before we had 22 the final autopsy report. 23 It turned out this -- this girl had a -- 24 she was a teenager. She had a twin sister. And we were 25 able to get in touch with her -- with her mother and then

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1 arranged for her to see a cardiologist. 2 The cardiologist got in touch with us, and 3 we relayed the concerns to the cardiologist. And it 4 turned out the sister had the same lethal -- or 5 potentially lethal disorder that had caused the death of 6 our case. And she ended up having an implantable 7 defibrillator. 8 So we're able to deal with things early 9 on, because -- because we're physicians, because we -- we 10 have a sense of how people's bodies operate, why they get 11 symptoms, why they die suddenly. 12 And the other thing being physicians is of 13 assistance to us is in dealing with hospitals. We often 14 have to deal with hospitals in regard to quality of care 15 issues. And having a physician who understands -- I mean 16 we're not neurosurgeons and cardiovascular surgeons and 17 so on, but we have a sense of -- of how these -- of 18 hospital care. And we just have a lot more credibility 19 in dealing with hospitals. 20 MR. WILLIAM LUCAS: There's a couple of 21 points that I would add to what already has been said. 22 And often, I -- I sort of cite the line with new coroners 23 that I am dealing with in my jurisdiction, is that 90 24 percent of what they know or need to know to be effective 25 death investigators come from their medical background

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1 and training. Because once again, if you look at our 2 stats, three-quarters (3/4s) of our cases are -- are due 3 to natural causes. 4 And I think an important measure of cost 5 effectiveness that flows from that, if you look at our 6 statistics as well, that we -- we have roughly one-third 7 (1/3) of our cases end up going to autopsy, because in 8 two thirds (2/3s) of the cases the physician coroner can 9 use their medical knowledge, skill and judgment to make a 10 determination as to the cause of death. 11 The contrast that, for example, I think 12 there's a -- a statistic listed in some of the literature 13 that's been presented to this Commission about the -- the 14 system in Australia, in Melbourne, the Victoria 15 Institute, where there autopsy rate, as I read it, was 16 somewhere in the neighbourhood of 75 percent of cases. 17 Because they're dealing with a legal coroner's system 18 rather than a medical coroner's system, the coroners 19 involved don't understand the -- the medical issues and 20 have to rely on a pathologist to give them that sort of 21 information. 22 If you -- if our autopsy rate was 75 23 percent, we'd probably add another 9/10 million dollars 24 to our annual budget just to do those autopsies in -- in 25 the current system. So I think it's -- it's very cost

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1 effective. 2 I can also think of at least two (2) cases 3 in my jurisdiction over the years where a homicide has 4 been committed and the -- and the perpetrator was in fact 5 a physician and -- and therefore they used their medical 6 knowledge and skill to -- to cause the homicide by 7 medical means, using drugs including insulin, and without 8 a physician to sort of pick up some subtleties related to 9 the case, we -- we pot -- potentially would have missed 10 those cases. 11 So I think there's a lot of merit to 12 having the medical component. 13 MR. ROBERT CENTA: Commissioner, this 14 would be a -- 15 COMMISSIONER STEPHEN GOUDGE: Are you 16 going to move away from death investigation after the 17 break? 18 MR. ROBERT CENTA: I was going to. 19 COMMISSIONER STEPHEN GOUDGE: Then sorry, 20 let me just postpone the break for a couple of minutes 21 and just ask a question that is of some interest to me at 22 least, and that has to do with the way in which, in any 23 particular autopsy situation, the pathologist comes into 24 play. 25 Who selects the pathologist? Does the

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1 investigating coroner select the pathologist? The 2 Regional Supervising Coroner? Is it pursuant to an on- 3 call system for pathologists that exists? 4 What's the practice across the Province? 5 DR. JAMES EDWARDS: I guess in Toronto we 6 have a fairly -- fairly structured system. Adult 7 autopsies are sent into our building, to the coroner's 8 building -- 9 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 10 DR. JAMES EDWARDS: -- on Granville 11 Street. Children who die at the Hospital for Sick 12 Children are autopsied at the Hospital for Sick Children. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. JAMES EDWARDS: Natural -- apparently 15 natural deaths of children at home are autopsied at the 16 Hospital for Sick Children and traumatic deaths in 17 children, there's some discretion there. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. JAMES EDWARDS: But we don't really 20 have much role in -- in selecting a particular 21 pathologist -- 22 COMMISSIONER STEPHEN GOUDGE: That all 23 happens under the aegis of the Chief Forensic Pathologist 24 at the OCCO? 25 DR. JAMES EDWARDS: Yeah. And -- and --

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1 COMMISSIONER STEPHEN GOUDGE: What about 2 elsewhere in the Province? I mean, to take where you 3 were first practising as a coroner -- 4 DR. ALBERT LAUWERS: In the North East 5 Region, Mr. Commissioner, what would typically happen is, 6 if the case looked to be a standard case, in other words, 7 not criminally suspicious -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. ALBERT LAUWERS: -- I would probably 10 just take it upon myself to direct the autopsy to 11 wherever I could get the service provided. And believe 12 me, there's a -- there's a derth of the availability of 13 autopsy -- 14 COMMISSIONER STEPHEN GOUDGE: Did you 15 have a roster of available pathologists in hospitals in 16 your region that you would go to? 17 DR. ALBERT LAUWERS: Well there was -- 18 there was at one time the availability of -- of autopsy 19 services at -- at one (1) of the hospitals, at 20 Peterborough Regional Health Centre, and the other was at 21 Ross Memorial Hospital, but by the time I had left my -- 22 my investigating coroner's practice, the Peterborough 23 Regional Health Services were no longer doing coroner's 24 autopsies, so it really was just the availability of the 25 pathologists at the Ross Memorial Hospital.

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1 Having said that, Oshawa was in a position 2 to help from time to time, and indeed they did. And as I 3 said, the criminally suspicious and pediatric cases were 4 all sent to Toronto. 5 COMMISSIONER STEPHEN GOUDGE: Out of your 6 region? 7 DR. ALBERT LAUWERS: With the exception - 8 - there's a forensic patho -- forensically trained 9 pathologist working at the Oshawa General Hospital, or I 10 guess it's now called the Lake Ridge, at Lake Ridge 11 Hospital, and he will do cases that are perhaps in the 12 suspicious range, but would be very low in terms of the 13 possibility that there was anything meaningfully going 14 on, and these would -- might be vetted through him, and 15 asked if he would accept them as a case. Otherwise 16 though the case would usually come to the city of 17 Toronto. 18 COMMISSIONER STEPHEN GOUDGE: Okay. And, 19 Dr. Lucas, your experience around the region as you've 20 been the Regional Supervising Coroner? 21 DR. WILLIAM LUCAS: My -- my answer to 22 your question would be that there is a bit of a hybrid 23 system. Let me start by emphasising that all 24 pathologists in the Province that conduct autopsies under 25 a coroner's warrant, no matter how straightforward to the

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1 most complex are credentialed -- 2 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 3 DR. WILLIAM LUCAS: -- by the Office of 4 the Chief Coroner. And we have a process to assure 5 ourselves that they have a skill level that would allow 6 them to conduct autopsies on our behalf. 7 Having said that, there -- there are some 8 circumstances where if the case appears to be very 9 straightforward, if we're dealing with someone who has 10 not a -- an extensively documented medical history -- who 11 dies in their sleep and the coroner has no sense as to 12 what the cause of death is, we may go to any pathologist, 13 in a community hospital locally, that has been 14 credentialed by the Office of the Chief Coroner, to 15 conduct an autopsy. 16 COMMISSIONER STEPHEN GOUDGE: "We" being 17 the investigating -- 18 DR. WILLIAM LUCAS: The investigating -- 19 COMMISSIONER STEPHEN GOUDGE: -- coroner 20 or the Regional Senior? 21 DR. WILLIAM LUCAS: The -- usually the 22 investigating coroner in those types of circumstances. 23 COMMISSIONER STEPHEN GOUDGE: Okay. 24 DR. WILLIAM LUCAS: And -- and he will be 25 satisfied that any one of the pathologists on staff at

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1 the hospital that have been credentialed by our office is 2 competent to do that -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. WILLIAM LUCAS: -- procedure. 5 If there's any question that, perhaps, the 6 case is a little bit more complex or there are some 7 issues or elements to the case that gives the 8 investigating coroner some discomfort with the skill 9 level of the pathologist at his local hospital, he will 10 consult with the Regional Supervisor. 11 And as you've heard, there -- there are 12 some hospitals where there are varying levels of 13 expertise amongst the pathologists on staff, we may 14 select that a case be designated to go to the person who 15 we believe has the experience level or the skill level to 16 do that. 17 In my community we may, in fact, triage 18 cases so that they will go to a particular institution 19 for the autopsy rather than another institution where we 20 feel that the level of skill of the pathologist is, 21 perhaps, not what's required for the complexities of that 22 particular case. And then we always have the ability to 23 -- to bypass the local community hospitals and go to our 24 Centre of Excellence in Toronto for the cases that we 25 feel need that added level of skill and experience.

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1 COMMISSIONER STEPHEN GOUDGE: And how 2 often did you do that? 3 DR. WILLIAM LUCAS: Quite regularly. 4 COMMISSIONER STEPHEN GOUDGE: At least 5 with the criminally suspicious cases? 6 DR. WILLIAM LUCAS: Yes, absolutely. And 7 we have criteria that say certain types of cases will go 8 automatically to the Centre in Toronto. 9 COMMISSIONER STEPHEN GOUDGE: What about 10 pediatric criminally suspicious? 11 DR. WILLIAM LUCAS: As well. As a matter 12 of fact, we basically send all pediatric deaths that 13 require an autopsy to the Pediatric Centre in Toronto if 14 that's the -- the centre that's closest. 15 The only pediatric cases that perhaps 16 would not have an autopsy carried out would be those 17 where, for example, it's a child with numerous congenital 18 problems -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. WILLIAM LUCAS: -- with an expected-- 21 COMMISSIONER STEPHEN GOUDGE: Yes, I was 22 really thinking of the pediatric cases where -- 23 DR. WILLIAM LUCAS: Yes. 24 COMMISSIONER STEPHEN GOUDGE: -- there 25 was criminal suspicion.

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1 DR. WILLIAM LUCAS: Always to our Centre 2 of Excellence -- 3 COMMISSIONER STEPHEN GOUDGE: Was that 4 your practice when you were in the Lake District? 5 DR. ALBERT LAUWERS: Yes, exactly. 6 COMMISSIONER STEPHEN GOUDGE: And is it 7 the practice -- how widely -- I mean, how widely 8 available is that practice throughout Ontario, given its 9 geographical spread? I mean, it... 10 DR. WILLIAM LUCAS: Readily available. 11 We -- we acknowledge that because of the 12 physical vastness of the Province there are cases where 13 we're going to have to absorb considerable transportation 14 expenses to have that case transferred and done at the 15 appropriate centre -- 16 COMMISSIONER STEPHEN GOUDGE: So in 17 Timmins, for example, or Sudbury or Sault Ste. Marie. 18 DR. WILLIAM LUCAS: No -- no question. 19 COMMISSIONER STEPHEN GOUDGE: That a 20 pediatric criminally suspicious death would be autopsied 21 at the OCCO? 22 DR. WILLIAM LUCAS: Correct. 23 DR. ALBERT LAUWERS: That is correct. 24 There are -- I'm sure you've heard this already but there 25 are --

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1 COMMISSIONER STEPHEN GOUDGE: Or at Sick 2 Kids, I -- 3 DR. WILLIAM LUCAS: Yes. 4 COMMISSIONER STEPHEN GOUDGE: -- yes, 5 that is what I meant. 6 DR. ALBERT LAUWERS: There are other 7 centres in the Province. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. ALBERT LAUWERS: And those centres 10 are London, Hamilton. And -- 11 COMMISSIONER STEPHEN GOUDGE: And Ottawa. 12 DR. ALBERT LAUWERS: -- Ottawa -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. ALBERT LAUWERS: -- currently I think 15 isn't doing cases but shall be in the near future. 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. ALBERT LAUWERS: And sometimes the 18 cases from the far north are also -- also go to -- 19 COMMISSIONER STEPHEN GOUDGE: To 20 Winnipeg, we have heard, yes. 21 In this triaging about what cases would be 22 required or would be better served by, for example, Sick 23 Kids or the OCCO, is there a role for the Chief Forensic 24 Pathologist in making that decision? 25 DR. JAMES EDWARDS: We -- we would

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1 normally speak with the pathologist. 2 COMMISSIONER STEPHEN GOUDGE: So it would 3 be a consultative process between perhaps the 4 investigating coroner, the Regional Supervising Coroner 5 and the Chief Forensic Pathologist? 6 Is that the way you would envisage the 7 system working best? 8 DR. JAMES EDWARDS: That's -- that's the 9 way it works presently. We would speak, perhaps not with 10 the Chief Forensic Pathologist, but with a pathologist 11 and consult with the pathologist. 12 COMMISSIONER STEPHEN GOUDGE: Where, at 13 the -- like your -- in Toronto it would be somebody at -- 14 DR. JAMES EDWARDS: At Sick Kids. 15 So I had a case, you know, a month ago. A 16 child -- a young infant died suddenly at home and I 17 thought the autopsy could be done at Sick Kids and I 18 phoned up and I talked to the pathologist on call. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. JAMES EDWARDS: And if he starts the 21 autopsy -- and this was a pediatric pathologist -- if he 22 starts the autopsy and unexpectedly the child turns out 23 to have injuries or turns out to be more criminally 24 suspicious than we had envisioned at the time, then he'll 25 -- he will get a -- a forensic pathologist to assist him.

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1 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 2 Lauwers, any comment on that? 3 DR. ALBERT LAUWERS: Well, just that -- 4 exactly along the same lines. My practice has been where 5 there's been a concerning pediatric death, I generally 6 will actually, physically walk down to Dr. Pollanen's 7 office or meet him and say, I'd like to discuss this case 8 with you. 9 And -- and he will -- he will listen to 10 the circumstances around the death and make a disposition 11 -- make a decision regarding the disposition of where the 12 autopsy would best be done. 13 COMMISSIONER STEPHEN GOUDGE: And by 14 whom? 15 DR. ALBERT LAUWERS: And by whom, that's 16 correct. 17 COMMISSIONER STEPHEN GOUDGE: Dr. 18 Lucas...? 19 DR. WILLIAM LUCAS: Certainly, my 20 experience as our processes have evolved, it's -- it's 21 quite clear to us as regional supervising coroners what 22 types of cases need to go where and who should be doing 23 them, so that it isn't as critical in each and every case 24 that we consult with, say, the Chief Forensic Pathologist 25 to discuss the merits --

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. WILLIAM LUCAS: -- of where it should 3 go, because I think by now we're all on the same page, 4 and we understand those issues. It may be the -- the 5 difficult ones that we need to consult -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. WILLIAM LUCAS: -- with him. But 8 clearly, as -- as you've heard, part of our process is to 9 speak to the pathologist that we anticipate is going to 10 be doing the cases so that we can give them whatever 11 information we have. 12 If there are issues that need to be 13 discussed -- in terms of are they comfortable with doing 14 this, should it be done by a forensic pathologist as 15 compared to a pediatric pathologist -- then we will have 16 those discussions, at that time. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 Thanks. Thanks, Mr. Centa. So we will break now? 19 MR. ROBERT CENTA: Yes, please. 20 COMMISSIONER STEPHEN GOUDGE: Come back 21 at quarter to 12:00. 22 23 --- Upon recessing at 11:28 a.m. 24 --- Upon resuming at 11:46 a.m. 25

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1 THE REGISTRAR: All rise. Please be 2 seated. 3 COMMISSIONER STEPHEN GOUDGE: Mr. 4 Centa...? 5 6 CONTINUED BY MR. ROBERT CENTA: 7 MR. ROBERT CENTA: Thank you, 8 Commissioner. Dr. Lucas, I'd like to ask you some 9 questions about the -- the Regional Coroner's Review. 10 I understand that a regional coroner 11 review is sometimes used in place of holding an inquest? 12 DR. WILLIAM LUCAS: That's correct. 13 MR. ROBERT CENTA: And when -- in what 14 circumstances would you consider it appropriate to 15 consider using the mechanism of a regional coroner 16 review? 17 DR. WILLIAM LUCAS: Okay, maybe I'll 18 start my answer by referring back to the Coroners Act. 19 And when we look at the section that deals with inquests, 20 the jury at an inquest has the ability to make 21 recommendations designed to prevent deaths in similar 22 circumstances in the future. 23 And we interpret the Act as giving 24 coroners at any stage during an investigation -- from the 25 simple investigation that's launched and conducted by an

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1 investigating coroner, right through to the inquest 2 process -- as giving us the ability to make 3 recommendations along the way. 4 And it's not uncommon that a coroner, 5 during the course of an investigation, might discover 6 something that he feels strongly would perhaps prevent a 7 death in the future and for him to make a recommendation 8 to, say, a department of a hospital or whatever. 9 And if that effects change, that's 10 basically where the process would stop, from our 11 perspective. There are occasions when there may be 12 perceived to be larger, more systemic issues, or perhaps 13 even a sense that there's maybe a reluctance to 14 acknowledge that change needs to be effected, say for an 15 institution. 16 And that's the -- the kind of circumstance 17 where the regional supervising coroner, a little bit 18 higher up in the hierarchy in the Coroner's Office, will 19 become involved. 20 Or there may be cases where because of the 21 complex nature of a case, we've referred it to one (1) of 22 death review committees for an opinion. And as part of 23 their assessment of the case and -- and their 24 conclusions, they may feel that there have been some, for 25 example, deficiencies in care that need to be addressed.

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1 We will take that report back to the -- 2 the institution, arrange to convene a regional coroner's 3 review, which is essence an opportunity to sit down with 4 the -- with the powers that be -- with the individuals in 5 responsible positions within the hospital that are able 6 and capable of effecting change, along with the players 7 that were involved in the actual care -- to first review 8 the case that has been, in essence, a paper review by our 9 expert committee or -- or by our office to ascertain that 10 we've got our facts right. 11 And if there are issues that they want to 12 dispute, in terms of our understanding of the facts, to 13 get those corrected -- because again, the -- the quality 14 of the information is as good as -- as what we can find 15 in the hospital record. 16 We know as physicians that hospital 17 records are often far from perfect in terms of their 18 content. And there may be aspects to the case that we 19 just don't understand, because it wasn't documented. 20 But once we've got that sorted out, what 21 we tend to do is broker with the -- usually the 22 institution, like a hospital, some recommendations for 23 change that they will acknowledge. We then exchange 24 information, in terms of a letter that formalises the 25 process.

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1 And we expect that at the end of -- of 2 their process they will re -- reply to us by saying, We 3 acknowledge those recommendations; this is what we've 4 done in terms of an action plan. 5 The advantages of doing it that way are, I 6 think, significant, because many of these case reviews 7 involve very complex medical issues that, to be frank -- 8 and Dr. Lauwers alluded to this, I think, a little 9 earlier -- to -- to bring those kind of cases before a 10 group of laypeople in a -- in a coroner's jury is 11 extremely difficult to give them a sense of the nuances 12 of -- of what was -- was going on. 13 And the inquest, as much as it's not 14 supposed to, tends to be somewhat of an adversarial 15 process, because you've got parties withstanding that are 16 defending their reputation and their actions and so on, 17 so that sometimes some of the subtleties can -- can get 18 lost in the mix. 19 It's -- it's an opportunity to have a 20 very, very constructive dialogue with the institution, 21 because, in a way, it's a private situation that isn't 22 subjected to the scrutiny of the media and headlines that 23 may appear in the -- you know, in the daily papers that 24 would be of an embarrassing nature to the institution. 25 It's an opportunity for them to be very

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1 frank and open with us in the discussions. And our -- 2 our end result is that we often find that it's -- it's 3 much more constructive in achieving the -- the goals in 4 the end that we want to see. 5 MR. ROBERT CENTA: Now, you've described 6 it as a -- as a partially private process to facilitate 7 open and frank communication. 8 In the event that you come to conclusions 9 or recommendations that you think would be of assistance 10 more broadly then to the specific institution that was 11 involved, how are those shared? 12 DR. WILLIAM LUCAS: We have the -- the 13 ability through the Chief Coroner to disseminate that 14 type of information more broadly so that it wouldn't be 15 uncommon if it was felt that there were lessons to be 16 learned that would -- could be shared, for example, with 17 other hospitals across the Province, for the Chief 18 Coroner to alert the Ontario Hospital Association through 19 some kind of a memo or a -- or a letter expressing the 20 concerns. 21 MR. ROBERT CENTA: In the event the 22 Regional Coroner Review is not satisfactory from the 23 perspective of the regional coroner, what other tools 24 remain at -- at your disposal? 25 DR. WILLIAM LUCAS: We always have the

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1 option to call an inquest. And I think perhaps one of 2 the reasons why the process is so successful is -- and -- 3 and I can say this speaking from experience, having been 4 a chief of staff at an institution where during my tenure 5 there were at least four (4) inquests involving some 6 concerns with -- with some of the cases that were managed 7 within my hospital. 8 Hospitals generally do not like the 9 concept of going to inquests. And so if they can -- can 10 show that they're willing to do a critical analysis, to 11 accept some critique and to move forward, my experience 12 has been that most of them are very cooperative in that 13 process. 14 MR. ROBERT CENTA: The Regional Coroner 15 Review process, though, is not simply limited to 16 hospitals? 17 DR. WILLIAM LUCAS: No. 18 MR. ROBERT CENTA: It's available in any 19 circumstance where you could otherwise call an inquest? 20 DR. WILLIAM LUCAS: Exactly, so that we 21 might be meeting with police services if we think that 22 they -- they need to address how they do business. We 23 meet with industry, a variety of different areas. 24 MR. ROBERT CENTA: I'd like to ask you 25 some questions now about the issue of delayed reports of

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1 post-mortem examination and some of the causes and some 2 of the systemic solutions that we might look to, to 3 accelerate the production of those reports. 4 First, Dr. Lucas, as we talked -- or as we 5 discussed earlier, you've been a member of the Senior 6 Management Group Committee since 1996? 7 DR. WILLIAM LUCAS: Correct. 8 MR. ROBERT CENTA: And as I -- as I -- as 9 we've discussed, during those meetings there would -- you 10 recall some general discussion from time to time that -- 11 of concern relating to the delays in Dr. Smith's reports? 12 DR. WILLIAM LUCAS: Yes. 13 MR. ROBERT CENTA: But you don't have any 14 specific recollection of those discussions? 15 DR. WILLIAM LUCAS: No, I don't. 16 MR. ROBERT CENTA: Okay. And was that a 17 problem unique to Dr. Smith? 18 DR. WILLIAM LUCAS: Unfortunately, no. 19 It's -- it's a problem that we encounter with a number of 20 our pathologists, both our forensic pathologists that are 21 our staff, salaried people, as well as physicians in -- 22 or pathologists in the communities that are doing 23 autopsies for us. 24 And I think there's a variety of reasons 25 that explain why we have those delays, but it's -- it's

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1 problematic. 2 MR. ROBERT CENTA: And those delays 3 continue to today? 4 DR. WILLIAM LUCAS: They do, 5 unfortunately, yes. 6 MR. ROBERT CENTA: And what do you think 7 some of the reasons are? 8 DR. WILLIAM LUCAS: Some of the reasons 9 would include, Number 1, the individual pathologist's 10 setting of priorities. Many of the pathologists -- both 11 our staff pathologists and hospital pathologists -- that 12 are doing what I'll call the more routine autopsies for 13 us invariably have a variety of different tasks that are 14 before them that they have to juggle. 15 And often, getting the paperwork completed 16 is -- is something that is relatively lower on their 17 priority scale than -- than actually doing the autopsies 18 themselves. 19 There are other factors that come into 20 play, such as ancillary testing, so that if we were 21 needing to have a toxicology report, they will not 22 complete their final post-mortem report until after they 23 have received that piece of information. 24 If they need to do -- and in many cases 25 there'll be anywhere from a small amount to an extensive

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1 amount of microscopy. In some institutions it takes a 2 while for those tissues to be put in the appropriate 3 format, that they can do their microscopic examinations. 4 And there may be some issues with 5 secretarial support. Many of the hospitals regard the 6 coroners' autopsies as separate and distinct from what 7 the secretarial staff within the Department of Laboratory 8 Medicine is paid to do so that the pathologist will have 9 to figure out and cope with that administrative side of 10 things on their own. 11 So a host of different factors; my 12 colleagues might have some other thoughts that I can't 13 think of right at the moment. 14 MR. ROBERT CENTA: Well, I'd like to -- 15 I'd like to turn to the question of toxicology reports, 16 Dr. Lauwers. 17 Do you have something else other than that 18 you'd like to add? 19 DR. ALBERT LAUWERS: Well, I'm happy to 20 speak to you about toxicology. But before doing that, 21 I'd like to just address one of the issues for the 22 pathologists clearly is the volume of work, you know. 23 And I'm -- I actually think this question would best be 24 addressed to them, but you're wanting the coroner's 25 perspective.

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1 Having said that, you know, if we as a 2 coroner system could scrutinize and be clear about the 3 need for an autopsy in a particular case, it -- it will 4 diminish the volume of cases that are unnecessarily done. 5 And again, this is the luxury that we have 6 in the City of Toronto. But every morning, as part of 7 our rounds with Dr. Pollanen, other pathologists, the 8 Chief Coroner and myself and Dr. Edwards, we go through 9 the autopsies that are scheduled for the day, scrutinize 10 the warrants, review them, read them, and cancel 11 autopsies that we think are clearly not indicated. 12 So there is a -- there's a volume issue at 13 the top coming in. 14 With regard to the toxicology issue -- 15 COMMISSIONER STEPHEN GOUDGE: Before you 16 -- sorry, Dr. Lauwers. Before you go to toxicology, what 17 tools does the coroner side of the death investigation 18 system have to get compliance with the timeliness of 19 post-mortem reports? 20 DR. ALBERT LAUWERS: The tools for the 21 timeliness of post-mortem reports? Well, I -- to the 22 best of my knowledge, the only thing we've ever done is 23 publish guidelines or -- or sort of benchmarks. 24 But the problem, Mr. Commissioner, is that 25 we have external partners to the process --

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. ALBERT LAUWERS: -- who we have no 3 control over. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. ALBERT LAUWERS: And one of those 6 partners is toxicology, for instance. 7 COMMISSIONER STEPHEN GOUDGE: Right. But 8 just in terms of the first point Dr. Lucas turned to -- 9 which is paperwork is harder than autopsies, than doing 10 autopsies -- how does the coronial system deal with that 11 when the pathologists are very often in effect employees 12 of hospitals across the Province? 13 DR. ALBERT LAUWERS: Difficult. 14 DR. JAMES EDWARDS: We'll -- if we're 15 aware of cases that are -- autopsy reports that are long 16 -- long overdue, we will sometimes contact the 17 pathologist ourselves. You know, families are getting in 18 touch with us. They're concerned. Where's the autopsy 19 report? 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. JAMES EDWARDS: But that's -- 22 COMMISSIONER STEPHEN GOUDGE: And 23 obviously we are coming at it from the perspective of 24 those that are criminally suspicious -- 25 DR. JAMES EDWARDS: Sure.

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1 COMMISSIONER STEPHEN GOUDGE: -- where 2 there is a whole dimension of added importance -- 3 DR. JAMES EDWARDS: Yeah. 4 COMMISSIONER STEPHEN GOUDGE: -- in 5 addition to the understandable concern of the families. 6 DR. ALBERT LAUWERS: Unfortunately, in 7 Ontario there isn't a competitive market. I mean there 8 are very few people doing autopsy reports for us. And 9 the bottom line is that if -- if there are limited people 10 doing the service, the ability for us to exert an 11 influence over positive behaviours is somewhat limited as 12 well. 13 COMMISSIONER STEPHEN GOUDGE: What if the 14 hospitals viewed it as an important part of the task of 15 their staff pathologists to provide this service in a 16 timely way? 17 DR. JAMES EDWARDS: There's a -- there's 18 actually -- I'm sorry. I didn't mean to cut you off. 19 COMMISSIONER STEPHEN GOUDGE: No. 20 DR. JAMES EDWARDS: That's actually an 21 issue that we've been del -- dealing with, as Dr. Lauwers 22 mentioned. We were in Toronto. And again, in Toronto we 23 have the luxury, every morning we discuss every autopsy 24 that's going to be done that day. 25 COMMISSIONER STEPHEN GOUDGE: Well, those

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1 pathologists work for you. 2 DR. JAMES EDWARDS: But we were noticing 3 was that there were many hospital deaths, national 4 hospital deaths, that were being sent in for autopsy in 5 the coroner's building. 6 And we really felt that those autopsies 7 would be best done in the hospital for two reasons. 8 First of all, it would decrease unnecessary workload on 9 our pathologists. And also it would assist the -- the 10 pathologist or the -- I'm sorry, the hospitals to do 11 their quality control -- their quality control procedures 12 if they could -- autopsy is central to that. 13 So we initiated a process that lasted 14 probably a year or so. And we would -- if we had a case 15 coming in to our office for -- that we thought could be 16 done in the hospitals, we would either try to send it 17 back to the hospital or we would get in touch with the 18 coroner who had ordered that autopsy and say, you now, 19 Something in the future, don't send those cases in here; 20 send them to the hospital. 21 And now if they -- if the coroners want to 22 send in a clearly natural death from a hospital to our 23 facility, we get them to send them to the hos -- the 24 hospital instead. 25 And we've really decreased the workload on

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1 -- on our pathologists. And also it's of assistance to 2 the hospitals in doing their quality-control processes. 3 They have a shortage of pathologists as well, to be fair 4 to them. 5 DR. JAMES EDWARDS: It had the effect of 6 decreasing, as I recall, the figures year over year. We 7 dropped the number of autopsies by about 13 percent. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. JAMES EDWARDS: And that's one of the 10 -- one of the luxuries we have in Toronto, you know. And 11 I think that throughout the Province, if some kind of 12 similar process could occur where the regional coroners 13 were involved with pathologists before the autopsies 14 occurred, that's the type of quality control -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. JAMES EDWARDS: -- mechanism that you 17 could have in place. 18 COMMISSIONER STEPHEN GOUDGE: Okay. 19 Sorry. Back to toxicology. 20 MR. ROBERT CENTA: Well, just -- just -- 21 COMMISSIONER STEPHEN GOUDGE: Sorry, Dr. 22 Lucas. 23 DR. WILLIAM LUCAS: There just maybe one 24 (1) comment, because your question, Commissioner, is an 25 excellent one (1) in terms of how would we motivate the

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1 hospitals to see that this is -- 2 COMMISSIONER STEPHEN GOUDGE: Well it is 3 something that -- 4 DR. WILLIAM LUCAS: -- an important 5 public service. 6 COMMISSIONER STEPHEN GOUDGE: -- deals 7 with this sort of two (2) masters thing that a -- 8 DR. WILLIAM LUCAS: Exactly. 9 COMMISSIONER STEPHEN GOUDGE: -- 10 pathologist experiences doing an autopsy. 11 DR. WILLIAM LUCAS: And -- and the 12 reality is that in many of the community hospitals, if 13 we're dealing with the non-criminally suspicious cases, 14 the pathologist is already burdened with a heavy 15 workload. 16 The hospital has expectations, in terms of 17 how quickly they will turn around their work product -- 18 COMMISSIONER STEPHEN GOUDGE: Their 19 hospital pathology -- 20 DR. WILLIAM LUCAS: -- their hospital 21 pathology, and so that many of them are in essence coming 22 in early to do their autopsies outside of normal business 23 hours so that it doesn't interfere with that. 24 And if it does, the hos -- if it does 25 interfere, the hospital sort of takes a dim view of that.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. WILLIAM LUCAS: So -- and then the 3 other dilemma that we have in our system, as Dr. Lauwers 4 has indicated, there's not a huge volume of pathologists 5 out there that are doing the work for us. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. WILLIAM LUCAS: So we have to walk a 8 fine line between sort of pushing them as much as we feel 9 we can to get the work done in a timely fashion and do 10 quality work, but not pushing them too hard that they 11 say, You know what, I don't need -- 12 COMMISSIONER STEPHEN GOUDGE: I don't 13 need this hassle. 14 DR. WILLIAM LUCAS: -- the stress, yeah. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. WILLIAM LUCAS: And so I think part 17 of the motivation that has been useful in that sense is 18 that over the last five (5) or six (6) years the amount 19 of compensation that we pay pathologists for doing fee- 20 for-service autopsies has improved considerably. Whether 21 or not it meets a benchmark that they were perceive as 22 adequate yet is a different issue. 23 But certainly I think if -- if we're 24 paying them at a rate that they feel that this is worth 25 their while to be involved, particularly if it's

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1 perceived to be extracurricular-type of activity, not 2 only does it provide some motivation but it also gives us 3 a bit of a handle that we can say, Well, you know, we 4 expect certain things in return -- 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. WILLIAM LUCAS: -- quality and 7 timeliness. 8 COMMISSIONER STEPHEN GOUDGE: And they 9 are not paid until the report is done. 10 DR. WILLIAM LUCAS: Exactly. And also, 11 if you're not doing it in a timely fashion, we may have 12 to re-think whether we want to keep sending business to 13 you, in essence. 14 COMMISSIONER STEPHEN GOUDGE: Okay. 15 MR. ALBERT LAUWERS: There is one other 16 scenario, and it's a bit of stretch. But, you know, not 17 sacrificing anything in the interest of quality, it's to 18 create a differential fee schedule when the pathology 19 report is late. 20 In other words, you get 100 percent if you 21 reach the benchmark. Now that's -- there's obviously 22 going to be extraneous factors that are associated with 23 that. 24 COMMISSIONER STEPHEN GOUDGE: Is that 25 something you have discussed?

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1 DR. ALBERT LAUWERS: Yes. 2 DR. WILLIAM LUCAS: Well, we discussed it 3 around coroners' death investigations and timely receipt 4 of those. 5 COMMISSIONER STEPHEN GOUDGE: Yes. 6 DR. WILLIAM LUCAS: It's not something 7 we've discussed with our pathologists. 8 COMMISSIONER STEPHEN GOUDGE: Yes, 9 because there is an issue about quality compromise at 10 that point, I guess. 11 DR. WILLIAM LUCAS: Right. That's 12 something you can't compromise on really. 13 COMMISSIONER STEPHEN GOUDGE: Well, none 14 of these choices are easy, Doctor. 15 DR. WILLIAM LUCAS: No. 16 17 CONTINUED BY MR. ROBERT CENTA: 18 MR. ROBERT CENTA: Just on -- before we 19 return to toxicology, the question of ensuring timely 20 completion of reports of post-mortem examination, am I 21 correct that you perceive the primary responsibility for 22 that would lie with the Chief Forensic Pathologist in 23 Ontario? 24 DR. ALBERT LAUWERS: Yeah, I think if you 25 look at the current job description of the Chief Forensic

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1 Pathologist, Item 4 on his job description says he's 2 responsible for all -- all autopsies. 3 Now I have to say that I -- you know, Dr. 4 Pollanen works very, very hard. And he -- even if we 5 provided him with the fiscal resources to do it, I'm not 6 sure that he has the personnel to be able to do it or... 7 But I do know that he's envisioning some 8 structure for that type of review in the future. But 9 having said that, you know, his job description is clear 10 about that matter. 11 MR. ROBERT CENTA: And that's set out in 12 the Institutional Report, PFP149431, at page 110, point 13 number 4. 14 And for all the reasons we've discussed 15 previously, you -- you agree that the Chief Forensic 16 Pathologist lacks a robust -- a robust set of tools to 17 ensure compliance with timely production of reports? 18 DR. ALBERT LAUWERS: Absolutely. 19 MR. ROBERT CENTA: Okay. Returning then 20 to -- to the question of toxicology, I understand, Dr. 21 Lauwers, you've continued to look at the issue of the 22 role of the CFS, if any, in contributing to the delay in 23 the production of reports of post-mortem examination? 24 DR. ALBERT LAUWERS: We're just 25 endeavouring. It's -- it's actually the one (1) issue

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1 that comes up at the senior management meeting, because 2 toxicology issues are a regular issue before that 3 committee. And we communicated -- I've been with the 4 office since -- for eighteen (18) months, and it's a 5 recurrent theme. 6 And the Centre of Forensic Sciences 7 Toxicology division are aware of that. They've engaged 8 us in the last -- it's just the last month, as it turns 9 out. And we're trying to look at different ways of 10 improving the service. 11 The turnaround time for -- the most common 12 test they would probably do for us would be an alcohol 13 level. And the turnaround times for a simple test like 14 that are relatively good. But for the complex deaths, 15 including the pediatric criminally suspicious cases, 16 where a -- a full toxicology report is required, the 17 turnaround times are -- could be fairly substantial. 18 MR. ROBERT CENTA: And in your view, what 19 are the contributing factors to those substantial 20 turnaround times? 21 DR. ALBERT LAUWERS: We've -- we haven't 22 actually itemized them. But to be frank with you, we're 23 aware of -- of certain cases in which the materials are 24 drawn by the police or the blood is turned over to the 25 police, and the police don't turn the blood over to the

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1 Centre of Forensic Sciences within a reasonable length of 2 time. 3 Another issue might be the ordering of 4 toxicology samples by coroners. Are they really 5 necessary in the case? Are they going to really affect 6 the -- the assignation of manner and cause of death? Is 7 that really germane to the discussion? So the 8 appropriateness of ordering of toxicology samples. 9 MR. ROBERT CENTA: The point there being 10 that if you could reduce the number of samples being 11 processed, you would expect a reduced a turnaround time, 12 much like the reduction in the number of autopsies in 13 Toronto would lead to quicker reports? 14 DR. ALBERT LAUWERS: Exactly. Another 15 issue that's -- is -- is the way they perform their 16 duties. A toxicologist, my -- my understanding, 17 currently will take the group of values and might do a 18 literature search with respect to that particular set of 19 values and provide a report at the back that says, In 20 three (3) out of four (4) cases, the -- the toxic level 21 was found to be... 22 And in our preliminary discussions with 23 the -- with the toxicology war -- pardon me -- the 24 toxicology service, we've talked about a set of 25 standardized reports which would -- which would detract

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1 from the centre's requirement of each toxicologist 2 looking at each individual case and -- and thereby having 3 to do the research for that individual case. 4 I hope I'm being clear on that. So, you 5 know, if you have ten (10) cocaine-related deaths, what's 6 happening is a toxicologist is individually searching out 7 the literature for those particular deaths, rather than 8 being a standardized form for the entire year for 9 cocaine-related deaths to be updated on a -- on a regular 10 basis. 11 MR. ROBERT CENTA: Is that a question of 12 knowledge management internal to the CFS then, to not 13 lose the results of the prior research that's been 14 undertaken? 15 DR. ALBERT LAUWERS: That's part of it. 16 I -- I think our convention would probably be that we 17 would like just see a -- a yearly standardized set of 18 documents which are given to us on a repeated basis. 19 MR. ROBERT CENTA: Dr. Edwards...? 20 DR. JAMES EDWARDS: Yeah, I'm just going 21 to add one thing. The -- the CFS, when they do 22 toxicology, they do all of the tests to a very high 23 standard, using all the checks and balances and double 24 testing and so on that would be required in a -- in a 25 criminal case.

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1 And we're not sure that that level of 2 testing, with all the time and expense and -- that it 3 would take, is necessary for all of our investigations. 4 You know, we have a -- a pedestrian that's struck by a 5 vehicle. We don't -- we don't need, you know, all the 6 bells and whistles and the -- and the checks and balance 7 and the repeated testing and so on. 8 You know, we could get -- there may be 9 some way to have the testing that's done for our non- 10 criminally suspicious cases to be done on a more 11 expedited basis and not to the same level as testing 12 that's done for criminally suspicious cases. And that 13 might potentially -- and in fact would reduce their 14 workload. 15 DR. ALBERT LAUWERS: There -- 16 MR. ROBERT CENTA: Go ahead. 17 DR. ALBERT LAUWERS: Sorry, I was just 18 going to raise another issue. The other issue is 19 benchmarking. By that, I mean twofold. Are they 20 actually benchmarking their own processes against other 21 like laboratories which run a successful program perhaps 22 in other provinces and states? And how is it that those 23 particular organizations are able to get a reasonable 24 turnaround and still have an accredited lab? 25 And the other is for their individual

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1 employees. There was concern raised about -- they have 2 approximately twenty (20) toxicologists and twenty (20) 3 technicians dedicated at the Centre to toxicology. 4 But, you know, one (1) of the questions 5 that we were interested in was examining, well, how many 6 cases would each do? By that, I mean, a pathologist 7 doing surgical pathology in a hospital, the general rule 8 of thumb, I understand, is about thirty-five hundred 9 (3,500) cases per pathologist. 10 Well, equally, how many -- how many cases 11 would a technician be responsible for a toxicologist? 12 It's -- it's the issue of setting benchmarks so that you 13 know who's performing and who -- who isn't and how that 14 could best be addressed. 15 MR. ROBERT CENTA: Am I correct that the 16 Office of the Chief Coroner is currently engaged in 17 discussions with the CFS around identifying these issues 18 and attempting to determine whether or not solutions can 19 be found? 20 DR. ALBERT LAUWERS: Yes, and -- and to 21 just splash this out in -- in summary, the issue isn't 22 entirely there, as we certainly recognize that the issue 23 -- we significantly contribute to the issue -- and 24 wherever we could assist with providing a solution, we 25 think it should be done with all stakeholders identifying

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1 the potential solutions. 2 MR. ROBERT CENTA: I'd like to now turn 3 to the question -- or the area of the region -- role of 4 the Regional Coroner in reviewing the work of the 5 investigating coroner and promoting quality assurance in 6 the system. 7 And, Dr. Lauwers, you told us earlier that 8 you will, in a case, review the Form 3, the re -- report 9 of post-mortem examination and the warrant for post- 10 mortem examination. 11 I understand you've also been specifically 12 involved in the development of quality assurance tools 13 for the Office of the Chief Coroner? 14 DR. ALBERT LAUWERS: That's correct. 15 MR. ROBERT CENTA: And if you could turn 16 in Volume II to Tab 55, which is PFP032488. 17 DR. ALBERT LAUWERS: Yes. 18 MR. ROBERT CENTA: This is a memorandum 19 dated February 28th, 2007; you're familiar with this? 20 DR. ALBERT LAUWERS: I am. 21 MR. ROBERT CENTA: And this is the memo 22 that circulated the audit tool that you developed, am I 23 correct? 24 DR. ALBERT LAUWERS: That's correct. 25 MR. ROBERT CENTA: Can you describe

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1 briefly the -- the process that led you to create these 2 instruments? 3 DR. ALBERT LAUWERS: One (1) of the 4 things that I found interesting when I came to Toronto 5 was I have a number, only ten (10) coroners who are all 6 very skilled, very knowledgeable individuals. But I was 7 fascinated by the fact that they're narrative statements; 8 the description of the investigation of death was 9 different for each one (1) of them, and it struck me that 10 there had never actually been a narrative template 11 developed in which the coroners had been given 12 instruction as to what it is exactly that we want you to 13 be able to -- to tell us in the narrative. 14 With that in mind, what I did is I -- I 15 took out all of the issues that are -- are related to the 16 standards for death investigation -- the guidelines for 17 death investigation 2003, plus any other lectures that 18 we've given, and I developed a list of approximately fift 19 -- fifty-five (55) or so items. 20 Those items were -- 21 MR. ROBERT CENTA: Okay, just while we're 22 -- while we're trying to sort that out -- 23 COMMISSIONER STEPHEN GOUDGE: Don't 24 anybody breathe. 25

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1 CONTINUED BY MR. ROBERT CENTA: 2 MR. ROBERT CENTA: -- Registrar, could we 3 have PFP032490, and that was -- is found in -- also in 4 Tab 55, Dr. Lauwers. It's the second document just over 5 the page, heading "A Template of Narrative Elements Which 6 Must Be Included". 7 DR. ALBERT LAUWERS: Yes. 8 MR. ROBERT CENTA: And is this the list 9 that you were describing having generated? 10 DR. ALBERT LAUWERS: This was the list of 11 the twenty (20) most important items that the Chief -- 12 the Regional Supervising Coroners all ranked. They were 13 asked to look at about fifty (50) items in total, and 14 then what happened was we ranked the individual items in 15 terms of importance, and we included the twenty (20) most 16 important list... 17 18 (BRIEF PAUSE) 19 20 MR. ROBERT CENTA: And paragraph 2 of the 21 introduction, just above the numbered list, is: 22 "It is imperative that the narrative is 23 complete, avoids irrelevant content, is 24 free of spelling and grammatical 25 errors, has no prejudicial content or

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1 makes findings of law or liability. 2 The narrative should be a professional, 3 understandable documentation of a 4 thorough and competent investigation." 5 And that was the goal of -- around 6 developing this -- this list, is that -- 7 DR. ALBERT LAUWERS: That -- that was the 8 goal. 9 MR. ROBERT CENTA: Okay. And if I could 10 have PFP032491 which is the third page in that tab. This 11 is an audit form? 12 DR. ALBERT LAUWERS: Yes. 13 MR. ROBERT CENTA: And you were involved 14 in designing this? 15 DR. ALBERT LAUWERS: I designed it. 16 MR. ROBERT CENTA: And for what purpose? 17 DR. ALBERT LAUWERS: For the -- the 18 purpose of taking individual coroner's cases and 19 reviewing them with this audit form, and then providing 20 the coroner feedback, and specifically identifying all 21 the issues that were lacking so that the coroner could 22 then include them in their -- their Form 3 narrative in 23 the future. 24 MR. ROBERT CENTA: Is this now 25 implemented for every case in Ontario, or on a occasional

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1 basis? 2 DR. ALBERT LAUWERS: Okay, so, the -- the 3 way it works is that the coroner's -- what I did is I 4 took ten (10) coroner's cases, applied this document to 5 them, gave them a score out of a hundred (100). 6 If the coroner already achieved a score 7 greater than ninety (90), I put the -- I basically put 8 the document on the shelf for the submission of the cases 9 for the rest of the year, but gave the coroner the 10 individual feedback about the issues that were lacking in 11 the document. 12 And then the -- my -- my own plan then is 13 to do this once a year for each of my coroners. Now you 14 know, respecting the fact that I have ten (10) coroners, 15 and there may be regions were there are sixty (60), it 16 can be very difficult for the Regional Supervising 17 Coroner to be able to do this with every coroner. 18 But the -- the improvement in the -- the 19 coroner's Form 3 narratives has been incredibly good. 20 What happens is that -- that the document -- the audit 21 tool is so detailed that I can actually -- I actually 22 came to know who was going to leave out a postal code in 23 the Form 3 document or who -- who didn't regularly report 24 that they'd examined the body. 25 And, you know, by giving coroners that

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1 type of feedback, very often I found that, indeed, they'd 2 been doing it; they just hadn't been recording it on 3 their -- on their Form 3 narrative. 4 MR. ROBERT CENTA: Dr. Lucas, is this 5 form being used outside of Toronto? 6 DR. WILLIAM LUCAS: Yes, and just if I 7 could digress for a minute and -- and give a little bit 8 of historic perspective to demonstrate how effective this 9 tool is, many of the coroners that have been in the 10 system for a long period time -- I'm talking about 11 vintage like Dr. Lauwers that go back to the mid '80's or 12 even earlier. 13 When we started the educational process of 14 -- of trying to upgrade the -- the level and the quality 15 of their reports, many of them said, Well, historically, 16 I was told by a regional coroner in the past that brief 17 is better. 18 And that was their explanation for why 19 some of their reports were -- were so short. But 20 invariably when you talk to them, they would have notes 21 that they had taken during the course of their 22 investigation where a lot of this information in detail 23 was there, they just didn't understand that it was -- 24 that we wanted it incorporated into their report that 25 they submitted.

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1 So the combination of -- of educating them 2 as to the types of material that should be there and 3 providing them with the kind of feedback that Dr. Lauwers 4 has explained, I found is working extremely, extremely 5 well, and most of them are very, very receptive to this 6 kind of feedback. 7 So that the quality is -- is improving. I 8 won't say we're quite there yet in terms of perfection, 9 but we're certainly -- we've come a long way just in -- 10 within the last couple of years. 11 COMMISSIONER STEPHEN GOUDGE: Was there 12 any rationale for the brief is better, or briefer is 13 better philosophy of prior times? 14 DR. WILLIAM LUCAS: I don't know. I 15 think that means -- 16 COMMISSIONER STEPHEN GOUDGE: I mean we 17 were told with post-mortem reports, for example, that 18 briefer was better because you do the report and then 19 expand when evidence was given. 20 DR. WILLIAM LUCAS: Mm-hm. 21 COMMISSIONER STEPHEN GOUDGE: Is there 22 anything like that for investigation of death reports? 23 DR. WILLIAM LUCAS: Generally -- I must 24 say, I'm not in a position to answer that, because I was 25 never told that.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. WILLIAM LUCAS: I became a coroner in 3 '91. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. WILLIAM LUCAS: I've suspected it may 6 have been partly in response to getting, you know, if it 7 was brief, the coroners were more likely to complete them 8 and get them in rather than expecting them to do a fairly 9 lengthy narrative. 10 But beyond that -- do you have any 11 recollection of being told that? 12 DR. ALBERT LAUWERS: Well, I can tell you 13 that I've submitted cases in the past, and I was told 14 that they were rather lengthy. That being said, I 15 continued my pattern of practice. 16 COMMISSIONER STEPHEN GOUDGE: Thanks, Dr. 17 Lauwers. 18 19 CONTINUED BY MR. ROBERT CENTA: 20 MR. ROBERT CENTA: In addition to the 21 audit tool, Dr. Lauwers, you were involved in creating a 22 method of evaluating the per -- the performance of 23 investigating coroners on an annual basis? 24 DR. ALBERT LAUWERS: The performance 25 evaluation for investigating coroners.

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1 MR. ROBERT CENTA: Registrar, if we could 2 turn in the OCCO Institutional Report, PFP149431 to page 3 200, please. And this is Appendix P to the Institutional 4 Report. Is this the Performance Evaluation Form that has 5 been created? 6 DR. ALBERT LAUWERS: It is. 7 MR. ROBERT CENTA: And who administers 8 this form? 9 DR. ALBERT LAUWERS: The Regional 10 Supervising Coroner administers the form when -- when the 11 Regional Supervising Coroner does an annual performance 12 evaluation with the coroner. 13 MR. ROBERT CENTA: And is the -- is the 14 evaluation shared with the investigating coroner? 15 DR. ALBERT LAUWERS: Yes, in fact they're 16 part of the process. 17 MR. ROBERT CENTA: And who else receives 18 a copy of the form? 19 DR. ALBERT LAUWERS: No one, just the 20 regional supervising coroner -- it goes in the coroner's 21 file -- and the coroner himself. 22 MR. ROBERT CENTA: How successful -- when 23 was this first implemented? 24 DR. ALBERT LAUWERS: I can't give you the 25 exact date, but I think it was some time in the year

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1 2007. And the principle behind it being developed was 2 because it became apparent that there -- became apparent 3 to myself and Dr. Edwards, who assisted me with the 4 development of the form, that there were certain issues 5 with regard to performance that are integral to 6 developing a good teamwork atmosphere and that some 7 persons don't necessarily embrace that. 8 And so perhaps by the development of a 9 performance evaluation form, we could -- we could 10 engender behaviour in coroners that would be -- would 11 result in a better overall product for death 12 investigation. 13 COMMISSIONER STEPHEN GOUDGE: Was there 14 anything like this before it? 15 DR. ALBERT LAUWERS: No, not to my 16 knowledge. 17 18 CONTINUED BY MR. ROBERT CENTA: 19 MR. ROBERT CENTA: I note that the third 20 section on -- on the first page deals with communication 21 with the pathologist. 22 "As the coroner seeks to evolve a 23 professional relationship with 24 pathologists conducting medicolegal 25 autopsies, the coroner will always

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1 speak to the pathologist both before 2 and after the autopsy in all homicides, 3 suspicious deaths, deaths proceeding to 4 mandatory inquests, and pediatric 5 deaths." 6 DR. ALBERT LAUWERS: Yes. 7 MR. ROBERT CENTA: And the coroners are 8 evaluated against that? 9 DR. ALBERT LAUWERS: They are. 10 MR. ROBERT CENTA: Is there any component 11 in there that deals with the documentation of 12 communication with the forensic pathologist? 13 DR. ALBERT LAUWERS: There isn't. 14 However, if you look at -- under warrants for post- 15 mortem, there's a fairly extensive list of items that we 16 would like communicated on the warrant for post-mortem. 17 MR. ROBERT CENTA: And to the extent that 18 certain information is provided verbally as opposed to in 19 writing in the -- in the warrant for post-mortem 20 examination, is that captured anywhere in -- in the 21 current evaluation? 22 DR. ALBERT LAUWERS: Well, just -- I'm 23 sorry. Could I get you to repeat that question? 24 MR. ROBERT CENTA: Certainly. The -- 25 there's a section that deals with the content of the

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1 warrant for post-mortem examination. And as we discussed 2 earlier, a significant amount of information may also be 3 provided by the coroner to the forensic pathologist 4 verbally. 5 Is whether or not the -- the coroner 6 documents those conversations, is that captured anywhere 7 on this form? 8 DR. ALBERT LAUWERS: It's not, no. 9 MR. ROBERT CENTA: I'd like to turn now 10 to another area, unless there's anything, Dr. Lauwers, 11 that you wish to add to the -- what we've talked about in 12 terms of the development of -- of quality assurance and - 13 - and audit and evaluation tools for -- for coroners? 14 DR. ALBERT LAUWERS: No, there's nothing 15 else that I'd like to add. Perhaps Dr. Edwards would 16 like to make some comments though? 17 DR. JAMES EDWARDS: I don't know how much 18 you want -- we could talk about this subject for quite 19 some time, but I'll just summarize briefly. 20 We've -- we've really tried to take -- 21 we've really taken measures to improve the quality of 22 death investigations in -- in Toronto. And that's the 23 only region I can speak to. 24 But we've increase the pool of applicants 25 that are applying to be coroners through various

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1 measures, through advertising in journals and so on and 2 so forth, to the level now that we have between four (4) 3 and five (5) applicants for every -- for every coroner -- 4 coroner's position in Toronto. 5 And we have, of the twenty-three (23) 6 coroners in Toronto, thirteen (13) have been appointed 7 since -- since I started. So we have a large pool of 8 applicants. 9 We have a formalized procedure for 10 evaluating the applicants. We have an interview process. 11 Two (2) regional coroners participate in the -- in the 12 interview. We contact references, and we have structured 13 questions that we ask the references. We do a criminal 14 record check for all of them. We do a college check, 15 obviously, for all of them. 16 So we've -- probably the -- the biggest 17 element in -- in any -- in any quality situation in any 18 organization is getting the best people in the 19 organization. And certainly we're very pleased with the 20 coroners that we've appointed. 21 Just for example, we have two (2) coroners 22 that are starting on January 1st of this year. And one 23 (1) is Dr. Susan Belo. She's an anaesthetist at 24 Sunnybrook Hospital. She's got a PhD in pharmacology. 25 She teaches at the University of Toronto.

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1 And the other is Dr. Dan Cass. He's the 2 Head of Emergency at St. Michael's Hospital, or was Head 3 of Emergency, and continues to be an emergency doctor at 4 St. Mike's. 5 So we've really been very pleased with the 6 -- with the coroners we've recruited. And... 7 COMMISSIONER STEPHEN GOUDGE: How have 8 you enhanced the supply? 9 DR. JAMES EDWARDS: Well, what we've done 10 -- what -- it's -- it's much easier for us in Toronto, 11 because we can -- we can offer -- we can offer coroners a 12 large volume. And also they have death investigations. 13 And also they have a large volume of other income they 14 can make from the Coroner's Office completing cremation 15 certificates, and shipment certificates, and so on. So 16 that's -- that's the -- the -- 17 COMMISSIONER STEPHEN GOUDGE: For most of 18 them, would it be the largest part of their professional 19 activity? 20 DR. JAMES EDWARDS: No, I would say no. 21 No. For most of -- 22 COMMISSIONER STEPHEN GOUDGE: What is a 23 normative proportion? 24 DR. JAMES EDWARDS: I would -- 25 COMMISSIONER STEPHEN GOUDGE: Half their

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1 time? 2 DR. JAMES EDWARDS: Maybe -- maybe a 3 quarter. 4 COMMISSIONER STEPHEN GOUDGE: A quarter 5 of their time? 6 DR. JAMES EDWARDS: Yeah. The -- so the 7 -- so -- and -- and -- so having an -- an attractive 8 situation for them to -- to come to. And the coroners 9 tell us that they appreciate the -- the support. I mean, 10 like I mentioned, we're -- we're always -- 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. JAMES EDWARDS: -- available to speak 13 with them. So that encourages them to -- to remain. 14 Increasing the pool; we -- we advertised in the Ontario 15 Medical Association Journal. We got in touch with all 16 the hospitals in Toronto -- the Chief of Staff of all the 17 hospitals -- and asked them to put up notices regarding 18 possibility of work in the Coroner's Office. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. JAMES EDWARDS: Whenever we give 21 talks to hospitals, we -- we mention that possibility 22 that maybe the -- some of the medical staff might be 23 interested in -- in joining our office. So things like 24 that. 25 COMMISSIONER STEPHEN GOUDGE: Okay. What

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1 about elsewhere, Dr. Lucas. I could tell -- 2 DR. WILLIAM LUCAS: Dr. -- Dr. Edwards 3 has painted a very rosy picture for Toronto that 4 unfortunately doesn't apply across the rest of the 5 Province. 6 One (1) of the downsides, if you will, of 7 having a Medical Coroner System is that we have to have 8 doctors that are willing to do the job, and particularly 9 the -- in the -- the more rural communities, the further 10 away from the big urban centres you get, there is a 11 chronic problem with physician shortages in this 12 province. 13 And to go to a community where the 14 physician feels that he's -- you know, he or she is 15 working seventy five (75) or eighty (80) hours a week, 16 has involvement with their clinical practice, working 17 emerg shifts, perhaps being the physician responsible for 18 a long-term care facility and so on, to ask them to take 19 on additional responsibilities sometimes is a real 20 challenge. 21 For many coroners -- Dr. Lauwers can 22 probably help me with -- with the -- the stats on this, 23 but my understanding would be that probably the average 24 coroner in the Province would have somewhere in the 25 neighbourhood of sixty (60) cases a year, like Dr.

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1 Edwards described when he was in Belleville, as compared 2 to the busy Toronto coroners that will have in excess of 3 two (2), or three (3), or four hundred (400). 4 So that for that coroner that's doing 5 thirty (30), forty (40), fifty (50) cases a year, this 6 actually makes up a very, very small portion of their -- 7 their income, although the time that they have to be 8 available to be potentially called for cases may be much 9 more significant than that. And so recruitment is a 10 real challenge for us. 11 COMMISSIONER STEPHEN GOUDGE: How much 12 does the negotiated fee play a part in this, Dr. Lauwers, 13 as the past President of the Association? 14 DR. ALBERT LAUWERS: Yeah, it -- it has 15 to play part of it. The com -- we're competing against - 16 - we're the Ministry of Community Safety and Correctional 17 Services, and we're competing with another ministry, the 18 Ministry of Health and Long-term Care for the same pool 19 of individuals. 20 And as long as we don't -- we don't 21 recognize that discrepancy, as long as we continue to -- 22 you know, continue to hire coroners and ask them to do 23 cases at their financial peril -- peril, we're always 24 going to be in -- in problem -- in a problem state. 25 COMMISSIONER STEPHEN GOUDGE: What's the

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1 current rate? 2 DR. ALBERT LAUWERS: Per case? 3 COMMISSIONER STEPHEN GOUDGE: Yes. 4 DR. ALBERT LAUWERS: That's fee-for- 5 service, and it's three hundred dollars ($300) a case. 6 COMMISSIONER STEPHEN GOUDGE: And what is 7 that -- how is that been -- what is the experience over 8 the last ten (10) years in that fee? 9 DR. WILLIAM LUCAS: It's improved 10 considerably. The problem is that compensation -- 11 COMMISSIONER STEPHEN GOUDGE: Give me 12 some order of magnitude. 13 DR. WILLIAM LUCAS: Well, when -- when I 14 started as a coroner in 1991, I recall that the fee-per- 15 case was ninety-four dollars ($94). 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. WILLIAM LUCAS: So in -- in that 18 period of time, it's -- it's more than tripled. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. WILLIAM LUCAS: The problem is that 21 if you compare -- the average case might take a coroner 22 two (2) or three (3) hours to -- to -- from start to 23 finish -- 24 COMMISSIONER STEPHEN GOUDGE: Yes. 25 DR. WILLIAM LUCAS: And there will be

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1 some cases that will drag on for days and necessitate 2 meeting with families and all that sort of thing, but I 3 would say two (2) to three (3) hours is a reasonable 4 average. If you look at what a physician can generate 5 working in the emergency department or working in their 6 office seeing patients, it pales in comparison. 7 The other challenge that we have that is a 8 recurrent theme in the negotiations and has been for a 9 number of years are issues like an on-call stipend. If 10 I'm going to set myself aside to be available for a 11 weekend, will -- will I get any compensation for that? 12 And our traditional response has been no; 13 unfortunately, that's not the reality of -- of dealing 14 with government in the way we finance the coroner system. 15 In the last several years, the Ministry of Health has had 16 a total change in attitude as it pertains to on-call 17 stipends and many, many physicians will receive some kind 18 of a stipend for being on call for emergency department 19 to do night shifts, to be on call to -- to come in and 20 assist with surgeries at odd hours and this sort of 21 thing, and so physicians are more and more expecting it 22 if the Ministry of Health acknowledges that that's an 23 important way to do business with them -- 24 COMMISSIONER STEPHEN GOUDGE: So why -- 25 DR. WILLIAM LUCAS: -- the Coroner's

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1 Office, yes. 2 COMMISSIONER STEPHEN GOUDGE: Yeah, 3 thanks. Sorry, Mr. Centa. 4 MR. ROBERT CENTA: And, Commissioner, 5 there's a -- in the OCCO institutional report at pages 6 123 to 132, there's a series of charts setting out 7 coroner's fees historically -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 MR. ROBERT CENTA: And in their current 10 form. 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 Thanks, that's helpful. 13 DR. ALBERT LAUWERS: Just a couple of 14 points to clarify, if I could. 15 16 CONTINUED BY MR. ROBERT CENTA: 17 MR. ROBERT CENTA: Mm-hm. 18 DR. ALBERT LAUWERS: With respect to what 19 Dr. Lucas said, the -- the vast majority of coroners in 20 Ontario are doing small numbers of cases; that's the last 21 time we looked at it. In fact, the majority are doing 22 less than fifty (50) cases per year. 23 MR. ROBERT CENTA: So the heavy workload 24 is really a phenomenon in -- in the Toronto region. 25 DR. ALBERT LAUWERS: And large urban

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1 areas. There was -- 2 MR. ROBERT CENTA: Dr. -- 3 DR. ALBERT LAUWERS: I'm sorry, there was 4 a lot -- I'm sorry to do this to you. There is one (1) 5 other issue for clarification that I think is important 6 with regard to quality assurance. 7 One of the things that Dr. Edwards and I 8 do together is, where we have performance issues with a 9 coroner, we have a well-developed and established system 10 for dealing with that. 11 We'll ask the individual to come to a 12 meeting. We'll sit down and we'll -- the three of us 13 will mutually discuss the performance issues. We'll 14 develop a plan for improvement. And we'll commit to a 15 three (3) month review of the particular issues with 16 regard to performance and actually send them a letter 17 which sets out the contents of our conversation, and if - 18 - if the performance doesn't improve, then we're quite 19 prepared to ask the coroner to not be as busy. 20 In other words, what we're prepared to do 21 is cut back on their workload. 22 MR. ROBERT CENTA: How do you respond to 23 complaints from members of the public or third parties 24 about the work of one (1) of the coroners that you 25 supervise?

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1 DR. JAMES EDWARDS: We would -- we would 2 get in touch with the coroner, advise him of the 3 complaint, and ask for a response. And depending upon 4 the complaint and the -- and how it fits in with the 5 coroner's overall performance, we may -- we would likely 6 sit down and meet with the coroner. 7 For example, if we have complaints from 8 families that a coroner is rude -- they're not -- not 9 talking, not getting back to them, not spending enough 10 time with them -- we can't tolerate that. 11 And, you know, if it happens once, well, 12 it happens once, but if we have -- and we'd -- we -- in - 13 - in that case, we would still deal with the coroner, but 14 if it's happening on a repeated basis, we would sit down 15 and deal with the coroner and we would say that's -- 16 that's not tolerable. 17 Or if we get complaints from police 18 officers that they're waiting too long at the scene for 19 coroners, we would -- we would deal with that. So -- 20 some complaints, I imagine there's complaints in any 21 workplace; some complaints are more -- more concerning 22 than others, but -- but we -- we deal with them, and 23 actually we're -- we're government, we -- we have to deal 24 with them, you know. 25 MR. ROBERT CENTA: I'd now like to ask

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1 some questions about organ harvesting in criminally 2 suspicious and homicide cases, and -- and Drs., I'll ask 3 you some questions about this, but first, this arises out 4 of some testimony that we heard from Dr. Saukko and Dr. 5 Whitwell when they were testifying, Commissioner. 6 And on December 13th, 2007, Mr. Ortved was 7 asking questions of Dr. Whitwell, and at page 239 of the 8 transcript, the question was as follows: 9 "MR. ORTVED: And then you..." 10 This is to Dr. Whitwell. 11 "Dr. Saukko made reference yesterday to 12 the fact that there were organs 13 harvested in the Kenneth case and made 14 reference to the fact that he 15 considered that highly inappropriate in 16 a suspicious and potentially homicide 17 case, correct?" 18 Dr. Whitwell responded, 19 "Correct. 20 MR. ORTVED: Do you agree with that? 21 DR. WHITWELL: I do." 22 And: 23 MR. ORTVED: "And similarly Dr. 24 Ouchterlony in the Amber case also 25 authorized organ harvesting as you're

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1 aware." 2 And Dr. Whitwell said: 3 "Correct. 4 MR. ORTVED: Which should not have 5 taken place. 6 DR. WHITWELL: That's correct." 7 Dr. Edwards, do you agree with the 8 positions expressed by Dr. Whitwell and Dr. Saukko? 9 DR. JAMES EDWARDS: Now, I don't know 10 that particular case. I -- I'd -- I can't -- I don't 11 have enough information about that particular case to 12 comment on -- on -- 13 MR. ROBERT CENTA: Dr. -- Dr. Saukko went 14 on to say, in response to a question from Ms. Ritacca, 15 that they -- that in Finland they do not allow or -- 16 harvesting of organs if it's a suspicious death. 17 So in any circumstances where there's a 18 suspicious death in Finland, they cannot harvest the 19 organs, do you agree with -- with that position put at 20 its highest? 21 DR. JAMES EDWARDS: I absolutely agree -- 22 disagree with that -- with that comment, and my 23 colleagues also disagree. 24 MR. ROBERT CENTA: Okay. If we could 25 turn in Volume II to Tab 42. It is PFP302416. This is

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1 in Volume II of your binder, Tab 42. These are the -- 2 the guidelines for organ donation in -- in children's 3 homicide and suspicious death cases. And these are the - 4 - these are the current guidelines, Dr. Edwards? 5 DR. JAMES EDWARDS: That's correct. 6 MR. ROBERT CENTA: Okay. And can you 7 explain why these guidelines were put into place? 8 DR. JAMES EDWARDS: There was a case in 9 2002 that brought the whole issue to a head. And this 10 case, I'm not really familiar with the details of the 11 particular case, but I'm familiar with the process that - 12 - that arose from it. 13 But it was a child at the Hospital for 14 Sick Children who had died as a result of a -- a homicide 15 and was in -- was in -- in the hospital on life support, 16 and the family had indicated a willingness to have the 17 organs donated. 18 And due to poor communication, and 19 basically not -- not very good time management by all 20 parties involved, including the Coroner's Office, those 21 organs were not harvested. 22 And it was felt that this was just a 23 terrible waste, and that we wanted to develop a process 24 that would enable organ -- maximal organ retrieval in 25 every case including criminally suspicious case -- cases

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1 as long as it wouldn't interfere with the -- with the 2 autopsy. 3 And -- and that's the rationale for -- for 4 our process. 5 MR. ROBERT CENTA: And so please explain 6 how these guidelines apply in circumstances where there's 7 a situation where organs may be able to be harvested. 8 What happens? 9 DR. JAMES EDWARDS: So the -- the first 10 phase is usually -- usually somebody gets in touch with - 11 - with either Dr. Lauwers or Dr. Lucas or myself, or in 12 the rest of the Province, with the Regional Supervising 13 Coroner. 14 And that person is usually, in my 15 experience, somebody from the Trillium Gift of Life 16 Foundation. So they'll -- 17 MR. ROBERT CENTA: Just before -- 18 Registrar, we -- could I have document PFP157761? This 19 is found as the last page of Tab 42 in your binder, Dr. 20 Edwards. 21 DR. JAMES EDWARDS: Yep. 22 MR. ROBERT CENTA: 1 -- PFP157761. And 23 this is a -- this is a flowchart that sets out what 24 happens? 25 DR. JAMES EDWARDS: Yes, this is the

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1 flowchart that Dr. Lauwers and I developed subs -- 2 subsequently that puts the -- that puts the process in -- 3 in the -- in the form of a flowchart. 4 MR. ROBERT CENTA: Okay. So at the top 5 of the chart it says: 6 "Where there's an anticipated brain 7 death, there -- someone is to contact 8 the Regional Coroner or Deputy Chief 9 Coroner." 10 DR. JAMES EDWARDS: That's correct. 11 MR. ROBERT CENTA: Okay. And can you 12 walk us through what happens from there? 13 DR. JAMES EDWARDS: Well, the -- the fir 14 -- the first process is an information gathering process. 15 So what we would do is we would -- we would have a -- a 16 coroner proceed to the scene, or to the -- and this would 17 be to the hospital. 18 Or we would go to the hospital our self. 19 The important thing is that a coroner goes to the 20 hospital and examines the medical recor -- medical 21 records, speaks with the attending physician, speaks with 22 the SCAN Team if there's a SCAN Team involved, and 23 gathers information about the medical -- medical 24 condition of the deceased person. 25 MR. ROBERT CENTA: And what is the

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1 purpose of collecting that information? 2 DR. JAMES EDWARDS: To determine where -- 3 where injuries are basically. And -- and the -- and the 4 likely cause of the person being in such a poor 5 condition. 6 MR. ROBERT CENTA: Is it to determine 7 whether organs could be harvested, or to determine 8 whether or not the circumstances are such that it could 9 permit harvesting? 10 DR. JAMES EDWARDS: We don't make a 11 determination about whether organs are fit -- fit for 12 transfer -- for transplant. That's a -- that's a 13 decision that's made by the people. What we do is we 14 make a determination about whether we -- whether 15 harvesting of organs would interfere with the -- with the 16 death investigation. 17 MR. ROBERT CENTA: And I understand that 18 that in -- does that process proceed or involve a case 19 conference among interested persons? 20 DR. JAMES EDWARDS: It's -- there's a 21 case conference. Often -- in -- in many cases, there's a 22 case conference, and many cases will have, sort of, 23 sequential meetings and telephone conversations. 24 MR. ROBERT CENTA: And who's involved in 25 that case conferencing or discussion around the

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1 appropriateness of the harvesting? 2 DR. JAMES EDWARDS: So the Regional 3 Supervising Coroner, the Investigating Coroner, the 4 police, the pathologist, the attending physicians in 5 hospital, the SCAN Team if -- if there -- if the SCAN 6 Team is being involved. 7 And poss -- we may get information from 8 other -- other individuals such as CAS, or previous 9 physicians or -- or so on, but -- but basically those 10 would be the people who would be involved. 11 MR. ROBERT CENTA: And what is the 12 purpose of having that case conference? 13 DR. JAMES EDWARDS: The initial purpose 14 is to -- is to gain information. We want to gain as much 15 information as possible about -- about that individual 16 and about the injuries that they've sustained. 17 MR. ROBERT CENTA: And what factors are 18 taken into account in determining whether or not the 19 circumstances are such that harvesting can proceed? 20 DR. JAMES EDWARDS: The general rule is 21 that we can't permit harvesting if it would interfere 22 with the autopsy. 23 MR. ROBERT CENTA: Sorry, go ahead. 24 DR. JAMES EDWARDS: Yeah, I was going to 25 say, so as part of that case conference, we may initiate

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1 further investigations. We may ask -- the hospitals -- 2 the investigations they had done in working up the 3 patient may be suitable for their purposes. But we may 4 need additional information for us to make our -- our 5 determination about whether we're going to permit organ 6 harvesting. 7 So, for example, we would commonly order - 8 - or not order. We would request that the attending 9 physician do a CAT scan of the chest and abdomen, for 10 example, in the case of head injuries, because we would 11 want to make sure that there's no occult injuries that 12 haven't been detected. 13 And also in that -- in that sort of stage 14 of it, we've had cases where -- we had a couple of cases 15 where people have gone into hospital, you know, young 16 adults have gone to hospital with fever and a high white 17 blood count -- which would indicate that they had 18 infection -- deteriorate to very poor condition. And -- 19 and the question of organ retrieval was being considered, 20 and they didn't have a diagnosis. 21 So in the two (2) cases that I'm thinking 22 about what we did is we asked the -- asked the attending 23 physicians if they would consider doing a lumbar 24 puncture, a spinal tap, because it sounded to us like it 25 could potentially be a case of meningitis. And the two

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1 (2) cases that I'm thinking about, it did turn out to be 2 meningitis. 3 And then the attending physicians 4 initiated -- initiated treatment and were able to -- 5 people still did poorly, but to eradicate the organism 6 that was causing the meningitis from the person's body. 7 And then the body -- the organs were fit for transplant. 8 MR. ROBERT CENTA: And -- 9 DR. JAMES EDWARDS: So there's -- it's an 10 interactive -- it's an interactive process. 11 MR. ROBERT CENTA: Is the Chief Forensic 12 Pathologist or a designate involved in these discussions? 13 DR. JAMES EDWARDS: Always. The 14 pathologist is always involved, because the pathologist 15 is the one (1) at the end of the day who has got to get 16 up in court and testify. 17 And the pathologists were involved in -- 18 in the development of the -- of the protocol, and the 19 pathologists are always -- are also involved in the 20 individual decisions. 21 MR. ROBERT CENTA: And assuming a case 22 conference reaches a conclusion that this is a situation 23 where some harvesting can take place, what happens from 24 that point forward? 25 DR. JAMES EDWARDS: So what would happen

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1 would be it may be a situation where we can permit all 2 organs to be harvested. And often, in other situations, 3 we can only permit certain organs to be harvested. 4 So, for example, if the injuries are 5 restricted to the head and neck, we may be able to permit 6 harvesting of organs from the chest and abdomen, but not 7 eyes and not bones or -- bones or skin. 8 MR. ROBERT CENTA: One of the concerns 9 expressed by Dr. Saukko and Dr. Whitwell is that in a 10 situation where there -- it appears that the child is 11 suffering from a significant head injury ,that there may 12 be other injuries in the body that will not be revealed 13 if those organs that are injured are harvested. 14 How does the case conference and the 15 process that -- that the OCCO has established respond to 16 that? 17 DR. JAMES EDWARDS: Well, we try to -- 18 well, we do take every measure to determine whether there 19 are injuries. So we talk to the police. 20 If somebody was -- if there's -- let's 21 just say take an extreme case, where somebody is -- an 22 innocent victim is shot in the head once, and you have 23 multiple witnesses. There's no physical interaction 24 between the assailant and the -- and the person that's a 25 potential organ donor, then we're pretty -- that's pretty

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1 good evidence that the injuries will be restricted to the 2 -- to the head. 3 We also go through the medical records. 4 We order -- as I said, we order additional testing. 5 Either one of us or the investigating coroner examines 6 the body, and we do everything that we can reasonably do 7 to rule out injuries besides what we know about. 8 And at the organ retrieval itself, if 9 we've permitted the organ retrieval to go ahead, the 10 pathologist would have the option of going if they so 11 desire. 12 MR. ROBERT CENTA: Right -- 13 DR. JAMES EDWARDS: But we -- 14 MR. ROBERT CENTA: -- the guideline -- 15 the chart you've set up here is -- indicates that the 16 coroner and/or foren -- pediatric forensic pathologists 17 can attend at the organ retrieval. 18 And I take it that's so that if something 19 has been missed and something unexpected emerges during 20 the harvesting procedure, the -- the forensic 21 pathologist, if there, would be in a position to respond 22 to it? 23 DR. JAMES EDWARDS: That's correct. And 24 -- and in all cases, the -- the police identification 25 officer attends at the organ harvesting and will take

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1 pictures of anything abnormal that's found. 2 MR. ROBERT CENTA: Can you provide us 3 with a sense of how often in 2007 a coroner's case would 4 have lead to or been involved in organ harvesting? 5 DR. JAMES EDWARDS: Just, certainly if -- 6 if you don't mind, I'd just like to make a comment just 7 to follow up on what you just asked. The -- we're not 8 aware of any cases in which us permitting organ 9 harvesting has interfered with the criminal 10 investigation, not one (1). 11 MR. ROBERT CENTA: I'll -- I'll come back 12 and ask you about that in some detail. 13 DR. JAMES EDWARDS: Right. 14 MR. ROBERT CENTA: So -- so if we just 15 turn to the statistics for a moment. In 2007, I'm 16 wondering about how often this situation emerges? 17 DR. JAMES EDWARDS: So I -- I made some 18 phone calls to Trillium Gift of Life, because I wanted to 19 be able to provide with that information here today. And 20 I phoned them on December 21st of 2007. 21 And they gave me figures which would 22 indicate the minimum number of coroner's case in which 23 we'd authorized organ retrieval. Now, there -- there 24 could be more than that number of cases, because they 25 don't quote -- quote things according to whether they're

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1 coroner's cases or not. 2 So there were at least -- in -- in Toronto 3 there were at least twenty-one (21) case in which we 4 permitted organ retrieval up until that date, up until 5 December 21st of 2007. 6 MR. ROBERT CENTA: And of those twenty- 7 one (21) cases, how many would involve children? 8 DR. JAMES EDWARDS: Nine (9). 9 MR. ROBERT CENTA: Nine (9)? 10 DR. JAMES EDWARDS: Nine (9), yeah. 11 And -- 12 MR. ROBERT CENTA: And did the twenty-one 13 (21) cases -- how many transplanted organ would those 14 twenty-one (21) cases have generated? 15 DR. JAMES EDWARDS: They generated 16 eighty-one (81) organs, forty (40) of which came from 17 children. 18 MR. ROBERT CENTA: Where there any -- 19 where there any circumstances where, as a result of the 20 case conference or other decisions made at the Chief 21 Coroner's Office, there could be no organ donation? 22 DR. JAMES EDWARDS: There were -- there 23 were five (5) cases in which we could not permit organ 24 donation. 25 MR. ROBERT CENTA: And can you just --

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1 without revealing any confidential information or talking 2 the specifics of any case, in what circumstances would 3 the OCCO have concluded that it was inappropriate to 4 harvest any organs in those -- those types of five (5) 5 cases? 6 DR. JAMES EDWARDS: Well, for example, I 7 was involved in a case and -- and I should involve -- I 8 should mention also that in all of these cases we have 9 two (2) -- two (2) regional supervising coroners involved 10 in the decision. 11 But I was involved in a case in which a 12 woman was brought to hospital with multiple blunt force 13 injuries. She -- it appeared that she'd been beaten. 14 And there were injuries sort of all -- all over her body. 15 We didn't have any, you know, any explanation for them. 16 Like we didn't have witness statements or anything else. 17 And we really just thought that there's just no way we 18 can permit organ retrieval to go -- to proceed in that 19 case. 20 So it's unusual. Like I say, there's -- 21 there's five (5) case in which that happened, which we 22 had to decline organ retrieval altogether, and twenty-one 23 (21) in which we were able to permit at least some organ 24 retrieval to go ahead, so... 25 MR. ROBERT CENTA: And when were there

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1 guidelines implemented? Did you say 2003? 2 DR. JAMES EDWARDS: Well, it was 3 initially started in 2002. 4 MR. ROBERT CENTA: And since the 5 inception in 2002, have there been any complaints by any 6 of the participants in the criminal justice system that, 7 with the application of the guidelines, that the -- the 8 guidelines have impaired any criminal investigations or 9 criminal proceedings? 10 DR. JAMES EDWARDS: No one, not one (1). 11 MR. ROBERT CENTA: No -- including both 12 the Crown and the defence? 13 DR. JAMES EDWARDS: Yeah. No -- nobody 14 has raised concerns. And in reading the literature from 15 the United States, they've had a similar -- a similar 16 experience. They don't use the precise guidelines that 17 we use, but if cases are properly screened, they -- it 18 does not interfere with criminal -- criminal proceedings. 19 MR. ROBERT CENTA: And in your opinion, 20 these guidelines are robust enough to prevent the 21 interference with ongoing criminal proceedings? 22 DR. JAMES EDWARDS: That's correct. And 23 also we have a -- it's a -- it's an evolutionary process. 24 The last -- and -- and we make adjustments as -- as time 25 goes on. These guidelines aren't written in stone.

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1 We had a case not too long ago where we 2 had a -- where we permitted organ retrieval on a young 3 person who had sustained injuries to the neck. And when 4 they did the organ retrieval, the midline incision went 5 high -- high in the neck. The pathologist told us this 6 when she did the autopsy. It wasn't high enough to 7 interfere with her findings in that case, but you know, 8 we were concerned that, you know, potentially in -- in 9 future cases it might interfere with -- with the autopsy. 10 So what we decided to do in future cases 11 is that in all cases one (1) of -- one (1) of -- three 12 (3) of us in -- in Toronto will communicate with the 13 harvesting surgeon and say, you know, Don't go -- don't 14 go any higher up than need be for the purpose of your 15 organ retrieval. 16 So it's -- it's a work in progress as 17 well. 18 MR. ROBERT CENTA: In your opinion how 19 beneficial is having these guidelines and the 20 discretionary ability to permit organ harvesting in these 21 kinds of cases where appropriate? 22 DR. JAMES EDWARDS: It's huge. You know, 23 the -- the case that I just told you about, just for 24 example, the -- we permitted retrieval of all the organs 25 from the chest and abdomen.

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1 The -- the heart was not suitable, for 2 medical reasons, for transplant, although the heart 3 valves were. 4 But the two (2) lungs went to a young 5 person who had cystic fibrosis. Well, that's somebody 6 who, you know, that would have died without the 7 transplant. 8 The liver went to a young person who had 9 Wilson's disease, which is of the kid -- of the liver. 10 It's when you get copper deposited in the liver. But 11 that person would have died. 12 And the two (2) kidneys went to adults who 13 were on dialysis for renal failure. So hopefully, if 14 things go as they should, these people will not have to 15 go for their dialysis sessions for several hours three 16 (3) times a week. 17 So the benefits are huge. You know, I 18 just -- I'll just give you one (1) more. The process 19 I've told you about does not apply to eyes. But also the 20 benefits with eyes, as I told you about, are great, and 21 we also have a process around that. 22 And I can recall a conversation. I was 23 teaching one of our -- our coroners how to do 24 enucleations. And she happens to be an anaesthetist at 25 Sunnybrook. And -- so she was in, and I was showing her

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1 to -- how to do this enucleation. 2 And she was telling me about her 3 experience in providing anaesthesia to people who 4 received these corneas. And she was saying these people 5 are just beside themselves with joy, you know, when 6 they're going to be getting a -- getting this transplant, 7 because they'll be able to see again. 8 I mean, the benefit is huge. 9 MR. ROBERT CENTA: Are these guidelines 10 in place only in Toronto, or are they -- are they in 11 place across the Province? 12 DR. JAMES EDWARDS: No, I can tell you 13 that our guidelines have been shared with other regional 14 coroners across the Province. I actually -- I don't know 15 what the experience is across the Province. 16 MR. ROBERT CENTA: We're just about out 17 of time before the break. But Dr. Lauwers or Dr. Lucas, 18 do you have anything to -- oh, sorry, Dr. Edwards. 19 DR. JAMES EDWARDS: I just -- if I could 20 just add -- add one -- 21 MR. ROBERT CENTA: Yes. 22 DR. JAMES EDWARDS: -- thing to that? In 23 -- I think the benefits for organ retrieval are just so 24 great, and I think the process is so valuable. 25 I would personally think that we might

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1 want to have a system in Ontario similar to the system in 2 some US jurisdictions, where if -- if the medical 3 examiner in the states or the coroner in Toronto were to 4 refuse organ retrieval for some reason and -- that we 5 should have to justify that; we should have to explain 6 that. 7 And I know they have a statute, for 8 example, in Texas, where the medical examiner has to 9 explain in writing whenever they refuse organ retrieval. 10 And that explanation has to be given to the appropriate 11 organ procurement agency, which would in Ontario be the 12 Trillium Gift of Life, and also to the family who have 13 authorized the retrieval in the first place. 14 Because, you know, if we're not going to 15 permit it, there should be a good reason, and we should - 16 - we should have to provide that reason to people. 17 MR. ROBERT CENTA: Dr. Lucas, Dr. 18 Lauwers, anything to add to what Dr. Edwards has said on 19 the subject of organ harvesting? 20 DR. WILLIAM LUCAS: It's clear that Dr. 21 Edwards is passionate about this issue. But I guess the 22 only comment that I would make, with all deference to Dr. 23 Saukko from Finland, I would be interested to know what 24 their organ donation rates from the general population 25 are.

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1 It is my understanding, and I don't 2 profess to have this sort of down cold, but I have a 3 recollection that the Scandinavian countries have 4 relatively high organ donations, particularly in Sweden 5 for example, where I think the King of Sweden has been 6 very passionate about this -- this concept. 7 And -- and so he may be in a situation 8 where if the general organ donation rate is much higher 9 than this country, he has the luxury of saying, Well, I 10 don't want to jeopardize a criminal case. 11 We, unfortunately, have very, very low 12 rates of organ donation generally. So I think, as Dr. 13 Edwards suggests, we want to capitalize on any case that 14 we can without sacrificing the quality of the autopsy and 15 the quality of the information that's available to the 16 criminal justice system. 17 In terms of the rest of the Province, I 18 think most of us make every effort that we can in 19 appropriate cases to see that organs are harvested. The 20 dilemma is more of a medical one in that if you're a 21 remote community, they may not have the resources that 22 they have in the City of Toronto to capitalize on those 23 situations. 24 MR. JAMES EDWARDS: I have just one (1) 25 more statistic for you. The organ donations in Toronto,

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1 24 percent come from coroners' cases. So... 2 MR. ROBERT CENTA: Twenty-four (24) 3 percent of all organ donations -- 4 DR. JAMES EDWARDS: Well for -- 5 MR. ROBERT CENTA: -- in Toronto? 6 DR. JAMES EDWARDS: -- 2007. Yeah. 7 MR. ROBERT CENTA: For 2007 came -- arose 8 from coroners' cases? 9 DR. JAMES EDWARDS: Yeah, correct, organ 10 retrievals. 11 DR. ALBERT LAUWERS: I do -- and I know 12 you're aware of the situation that we had in 2006, which 13 was a case that was exactly the same case as Amber, 14 eighteen (18) years later. 15 You might recall some of that, and I 16 wondered if that would be a story worthy of sharing. 17 MR. ROBERT CENTA: And by that, you mean 18 it -- this was a child who was reported to have fallen 19 down a short flight of carpeted stairs, was suffering a 20 head injury, and was antici -- the -- brain death was 21 anticipated. 22 Is that...? 23 DR. ALBERT LAUWERS: That's correct, and 24 the SCAN Team was involved and organ harvesting 25 proceeded. It went on to case conferencing and was

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1 ultimately found to -- at the cor -- during the course, 2 the case conferencing with neuropathology and a full 3 group of individuals there, was found to have -- the 4 manner of death was found to be accident, and the cause 5 of death was blunt force head injury. 6 MR. ROBERT CENTA: And that was a case 7 where it was not certain at the beginning of the case 8 that the child had suffered -- was -- had been harmed in 9 any way? 10 It was a suspicious case? 11 DR. ALBERT LAUWERS: It was treated as 12 suspicious from the outset. And even at the time of the 13 organ donation it was considered to be a suspicious case. 14 And in fact, really the only time it got moved off that, 15 from that particular designation, was at the time of the 16 case conference, which occurred substantively after the 17 organ donation. 18 DR. JAMES EDWARDS: I just -- just one 19 more thing I'd like to mention is that I've discussed 20 this actually with the pathologist at Sick Kids at -- 21 just on Friday at their rounds and with pathologists in 22 our office. 23 And they have no concerns about this 24 process. They're all for it. They think we should be 25 doing more if we can, although, what more we can do, I

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1 can't -- I can't imagine. 2 MR. ROBERT CENTA: This might be a 3 convenient time to break, Commissioner. 4 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 5 Centa. We will be back then at ten (10) past 2:00. 6 7 --- Upon recessing at 12:55 p.m. 8 --- Upon resuming at 2:11 p.m. 9 10 THE REGISTRAR: All rise. Please be 11 seated. 12 COMMISSIONER STEPHEN GOUDGE: Mr. 13 Centa...? Mr. Centa...? 14 15 CONTINUED BY MR. ROBERT CENTA: 16 MR. ROBERT CENTA: Thank you. This 17 afternoon, I would like to begin by asking you some 18 questions about communications with next of kin. And if 19 you look at the Institutional Report, which is PFP149431, 20 page 181. This is a section of the guidelines for death 21 investigation that's set out guidelines for investigative 22 coroner's communications with next of kin. And the 23 preamble states that: 24 "Next of kin are an important source of 25 information concerning the deceased in

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1 a death investigation. They have an 2 important and unique interest in the 3 results of the investigation. 4 In most cases the investigative coroner 5 will gather information regarding a 6 deceased person from the next of kin at 7 a very early stage in the investigation 8 and should be prepared to inform the 9 next of kin of the results of the 10 investigation as it progresses and when 11 it is concluded." 12 And then dropping down to the bottom of 13 that page, it provides that: 14 "In criminal cases, the investigative 15 coroner should consult the regional 16 supervising coroner before releasing 17 any information or documents to the 18 next of kin." 19 Dr. Lucas, I ask you this question: How 20 much contact would an investigative coroner normally have 21 with the family of deceased children in a homicide or 22 criminally suspicious case? 23 DR. WILLIAM LUCAS: Very little, very 24 little. 25 MR. ROBERT CENTA: And why is that?

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1 DR. WILLIAM LUCAS: There again, I think 2 the -- the issue is that we're sensitive to the fact that 3 when it's a criminal investigation, the police are the 4 lead agency. 5 We're basically there in a supportive 6 capacity to assist in whatever way we can to provide 7 forensic evidence pertaining to the body; the cause of 8 death, perhaps if it's in any way questioned; the manner 9 of death; and to support that whole process. 10 And we understand and respect the fact 11 that police have investigative techniques that they will 12 utilize as they work through their investigations, some 13 of which may include information that they chose not to 14 release, either to the media or in general terms. And so 15 we, in essence, defer to them. 16 Now, I should also clarify that there -- 17 we make a huge distinction between those situations where 18 a child has died and the cause of -- or the manner of 19 death appears to be homicide and the police through their 20 investigation indicate that the -- the family or a family 21 member may be a prime suspect, versus a situation where 22 the family members are entirely innocent of that and are 23 as victimized as -- as the -- the child that's died, 24 because they've -- they've sustained that loss. 25 We would probably be much more open and

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1 forthright with -- with that family, clearly, than if the 2 family was being investigated. 3 MR. ROBERT CENTA: So in a -- in a 4 criminal case, if an investigative coroner were to 5 contact you regarding releasing information or documents 6 to the next of kin in a case where family members may 7 still be under some suspicion, what would you normally 8 tell that investigative coroner to do? 9 DR. WILLIAM LUCAS: Generally, any 10 request for information, whatever that nature of the 11 case, our policy now is that all those requests are -- 12 are directed to the regional supervising coroner's 13 office. So in essence, the -- the coroners really are 14 not releasing anything, post-mortem reports or -- or 15 whatever, whereas in the past, it was commonplace for 16 them to do that, particularly in uncomplicated cases. 17 But that comes back to our quality review 18 process that we were talking about this morning. We want 19 to make sure that the -- the work product that goes out 20 has been reviewed and vetted and it is deemed to be at an 21 appropriate level. So that's why we are responsible for 22 that process now. 23 But in a situation like you described, 24 they would probably be directed, as with other cases, to 25 refer to the person on to my office or the regional

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1 supervising coroner's office. 2 And then before any information was shared 3 with them, we would be in touch with the police and/or 4 the Crown's office to see if they had any release 5 concerns about any information. 6 MR. ROBERT CENTA: And decisions to 7 release information then are made on a case-by-case 8 basis, taking into account all the circumstances as 9 understood by the police, the investigating coroner, and 10 you? 11 DR. WILLIAM LUCAS: Yes 12 MR. ROBERT CENTA: Okay. Can we just 13 look at one example? In Tamara's case -- and we'll 14 eventually turn up in your binder, Volume II, Tab 26. 15 But Commissioner, as to provide a little 16 bit of context in Tamara's case drawing from the overview 17 report, which we don't need to turn up, but which is 18 PFP143345. 19 Tamara was born in Scarborough on January 20 18th, 1998. She died a year later in February of '99. 21 On February 11th, 1999, three (3) days after her death, 22 the local Children's Aid Society initiated proceedings in 23 respect of Tamara's two (2) sisters. 24 Ultimately, Tamara's father was charged 25 with second-degree murder arising from her death. And

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1 the criminal proceedings concluded on August 30th, 2001, 2 when he pleaded guilty to manslaughter in the death of 3 Tamara. 4 Now at Tab 26, which is PFP052209, this is 5 a letter that was originally sent to Dr. Porter. But as 6 I think we'll see in the next tab, Dr. Lucas, you 7 provided a response to this letter. And this is dated 8 March 24, 1999. And the letter reads: 9 "I have been retained by the mother of 10 the late Tamara in a child welfare 11 matter. The Children's Aid Society 12 lawyer has indicated that the Coroner's 13 Office is preparing a report. 14 There is a return date before Judge 15 Katarynych scheduled for April 14, 16 1999, and the Coroner's Office will be 17 an important piece of information -- 18 coroner's report [sorry] will be an 19 important piece of information for all 20 concerned." 21 And then at Tab 27 of your binder, 22 PFP052207, you write in response to that letter and state 23 that, in the second paragraph: 24 "I am unable to respond at this time to 25 your request for a copy of the

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1 coroner's report, since our 2 investigation has not been completed 3 and the report finalized. 4 As you are well aware, this death is 5 the subject of a police investigation, 6 and our office is not prepared to 7 disclose any information that may 8 potentially jeopardize that criminal 9 investigation." 10 And I take it from what you told me that 11 that would be a fairly typical response in a situation 12 where a close family member is -- is a suspect in the 13 case? 14 DR. WILLIAM LUCAS: Yes. And I think 15 just to clarify a couple of the points that are in that 16 letter dated April 1st, 1999, under the Coroners Act, 17 Section 18(2), family is entitled to information that is 18 the result of fruits of the coroner's investigation. 19 But the Act is very specific in that that 20 information will be released if and when a decision that 21 an inquest is not necessary has been made, so that in 22 many of these cases we have not made that determination 23 yet. So it would be contrary to the Coroners Act to 24 release that information. So that's -- that's our legal 25 precedent in the Coroners Act.

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1 The second is that clearly, if the family 2 is the subject of the police investigation, again, we 3 would be sensitive to that and respond to -- to their 4 need to protect the integrity of any information that 5 they wanted to hold back. 6 MR. ROBERT CENTA: I'm going to take it - 7 - I don't even know if we need to turn this up -- but 8 back to the guidelines for death investigation. They do 9 provide that: 10 "The investigating coroner should be 11 prepared to inform the next of kin of 12 the results of the investigation as it 13 progresses and when it is concluded." 14 And I take it that that's more true in 15 cases that are not criminally suspicious or homicide 16 cases, that there be ongoing progress reports? 17 DR. WILLIAM LUCAS: Absolutely. And I 18 think what that speaks to though is that -- that it's 19 important -- and what we emphasize with coroners is to 20 keep the lines of communication open so that if the 21 coroner after the preliminary autopsy has information 22 that they can share with the family, These are what the 23 preliminary show. As long as they emphasize that that's 24 subject to sort of the final conclusions that the 25 pathologist draws, we want them to -- to inform the

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1 family as that progresses. 2 Similarly, if there are any delays with 3 the receipt of that final autopsy report, whether it be 4 due to awaiting toxicology or whatever, it's important 5 that the family be kept informed so that they're not 6 getting frustrated by -- by a lack of no information from 7 the Coroner's Office. 8 MR. ROBERT CENTA: In your letter it says 9 that the office is not disclosing any information that 10 may potentially jeopardize the criminal investigation. I 11 take it that that's -- that's a shared view of the 12 Coroner's Office, that your actions should not jeopardize 13 ongoing police investigations? 14 DR. WILLIAM LUCAS: Yes. 15 MR. ROBERT CENTA: And would you agree 16 that -- that you don't see it as your role to further 17 ongoing police investigations either, because you're not 18 the agents of the police officers for furthering their 19 investigation? 20 DR. WILLIAM LUCAS: No, no. 21 MR. ROBERT CENTA: I'd like to ask you 22 some questions, Dr. Lucas, about another case you were 23 involved in, known as Athena's case. 24 DR. WILLIAM LUCAS: Mm-hm. 25 MR. ROBERT CENTA: And just to help you,

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1 there's a few relevant dates to keep in mind. On March 2 6th, 1998, Athena died at the age of three (3) months. 3 Dr. Smith performed an autopsy on March the 7th, 1998. 4 He completed his autopsy report on October 26th, 1998. 5 And in May of 1999 Athena's father was charged with 6 manslaughter. 7 If I could ask you to turn up in your 8 volume to Tab 31, and this is PFP052142. 9 10 (BRIEF PAUSE) 11 12 MR. ROBERT CENTA: We've looked at this. 13 Now, you recognize this note? This is your handwriting 14 and signature? 15 DR. WILLIAM LUCAS: It is. 16 MR. ROBERT CENTA: Okay. And it's dated 17 October 27th, 1998 and it reads: 18 "Police do not want this released 19 immediately to family." 20 Stopping there, you and I have looked at 21 this note and -- and where it came from in the document 22 database. And we've agreed that when you say "this," 23 you're referring to the report of post-mortem examination 24 prepared by Dr. Smith? 25 DR. WILLIAM LUCAS: That's correct.

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1 MR. ROBERT CENTA: So the police do not 2 want the report of post-mortem examination released 3 immediately to family. 4 "They are attempting to get a wiretap 5 order, and then they will give it to 6 the family who are the primary suspects 7 in the death." 8 And again, when you use "they" in the 9 second part of that note, you're referring to the police? 10 DR. WILLIAM LUCAS: Correct. 11 MR. ROBERT CENTA: Okay. And do you 12 recall making this note? 13 DR. WILLIAM LUCAS: Not specifically, but 14 I don't deny that it's mine. 15 MR. ROBERT CENTA: Do -- do you remember 16 where you received the information that the police were 17 attempting to obtain a wiretap order in this case? 18 DR. WILLIAM LUCAS: I do not have a clear 19 recollection of that. But based on other cases, in the 20 normal course of events, I suspect that this was from the 21 police. Because in a case like this, which would not be 22 atypical, we most likely had on file a request from the 23 family or from counsel representing the family for the 24 post-mortem report. 25 And our process is to have that flagged so

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1 that as soon as the report becomes available, if it's 2 suitable or appropriate, we will release that report to 3 the family that have requested it. 4 But as I stated earlier, we always defer 5 to the police in these types of situations -- or the 6 Crown, more specifically -- to make sure that they're 7 comfortable with the release. 8 And so upon receipt of the post-mortem 9 report, I most likely would have contacted the lead 10 investigator for the police, who would act as the go- 11 between between our office and the Crown's office to see 12 if there were any release concerns. And that information 13 would have been given to me. 14 MR. ROBERT CENTA: At Tab 39 of that same 15 Volume II there's an affidavit from Detective Sargent 16 Crone, who was the lead investigator. That's PFP031376. 17 And this is an affidavit sworn on October 7th, 2002. 18 DR. WILLIAM LUCAS: Mm-hm. 19 MR. ROBERT CENTA: And if you look at 20 page 15 -- 14 and 15, I guess, paragraphs 46 to 49 -- 21 paragraph -- I guess paragraph 47: 22 "On December 16th, 1998, I swore to an 23 updated affidavit in support of a 24 wiretap application. Thereafter, 25 Detective Linton and I attended before

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1 Justice Humphrey and a new wiretap 2 authorisation was signed. 3 I'm advised by Detective Linton that on 4 December 16th, 1998, he spoke to Angela 5 and advised her that he would like to 6 meet with her and Angela's father that 7 evening to discuss the post-mortem 8 report. 9 At 7:10 Detective Linton and -- and 10 myself picked Anthony and Angela up at 11 the Gateway Motel and returned with 12 them to 42 Division, where we had this 13 discussion. Detective Linton and 14 myself returned Angela and Anthony to 15 the Gateway Motel at 8:50 p.m. 16 During our meeting, surveillance 17 equipment was installed in Anthony and 18 Angela's room at the motel. And from 19 December 16th, '98, to January 14th, 20 '99, the police intercepted Anthony and 21 Angela's communications, pursuant to 22 the wiretap authorisation." 23 And, Commissioner, that -- that state of 24 events is also confirmed in an affidavit sworn by Angela, 25 which we don't need to turn up, which is found at

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1 PFP027094. 2 So it appears that, from this affidavit, 3 that is in fact what happened. The police obtained a 4 wiretap authorisation and then provide the copy of the 5 report of post-mortem examination to Athena's parents, 6 with the understanding that their conversations about 7 that report would be potentially intercepted pursuant to 8 the order. 9 DR. WILLIAM LUCAS: It would appear so, 10 yes. 11 MR. ROBERT CENTA: Okay. And returning - 12 - returning to the note, the police are essentially 13 asking you to ensure that the report of post-mortem 14 examination is not released in advance of them obtaining 15 the wiretap order. 16 Is that fair? 17 DR. WILLIAM LUCAS: It would appear that 18 that's the case, yeah. 19 MR. ROBERT CENTA: And do you see 20 anything inappropriate in the police making that request 21 of you? 22 DR. WILLIAM LUCAS: General -- no, 23 generally speaking, my experience is that police do not 24 share that amount of information with us. They may use 25 general terms like, For the purposes of our

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1 investigations we would request that you not share or 2 disclose that at this time, without giving any details at 3 all of what their investigative techniques are. 4 So in that sense, it seems a little bit 5 unusual that I got that amount of detail from them. But 6 I guess given that I was provided that detail, for 7 whatever reason, I felt compelled to put that in the 8 notes so that anyone else that may be requested to 9 respond to a request for information would, at least, 10 understand that there was some rationale to it. 11 MR. ROBERT CENTA: Do you see this as an 12 attempt to enlist you and the Office of the Chief Coroner 13 of Ontario inappropriately in furtherance of a police 14 investigation? 15 DR. WILLIAM LUCAS: I don't, no. 16 MR. ROBERT CENTA: How often have police 17 officers informed you that they had or were trying to 18 obtain an order authorizing the interception of private 19 communication? Has that ever happened before? 20 DR. WILLIAM LUCAS: I can't recall that 21 it's ever happened before. 22 MR. ROBERT CENTA: And has a police 23 officer ever asked you to have a meeting with a family or 24 to discuss a report of post-mortem examination with 25 someone they -- the police viewed as a suspect in

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1 circumstances where the police could intercept that 2 communication? 3 Has that ever happened to you? 4 DR. WILLIAM LUCAS: That's -- that's 5 never happened, and I think if -- if they ever attempted 6 to do that, either with myself or with the coroners that 7 report to me and it was brought to my attention, I think 8 we would be having probably a very serious conversation 9 with the police in terms of the appropriateness of that. 10 Because one of the things that -- that 11 concerns us, on an ongoing basis, is the potential for 12 police to try and utilize the coroner's authority or the 13 coroner's warrant powers under the Coroner's Act to 14 further their investigation. 15 And that's something that the courts have 16 ruled is not appropriate. 17 MR. ROBERT CENTA: And we've talked about 18 communications with the family and that sometimes the 19 amount of information that can be provided to members of 20 the family is affected by whether or not there's an 21 ongoing police investigation. 22 Is that also true of communications with 23 the Children's -- with the local Children's Aid Society, 24 that the amount of information you can share with them 25 might be affected by whether or not there's an ongoing

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1 police investigation? 2 DR. WILLIAM LUCAS: Yes. I have to, sort 3 of, qualify that by saying that back in the late 1990's, 4 I think the clarity that we had in terms of our 5 understanding about what information could or could not 6 be released and under what authority, was not as good as 7 it is today. 8 We would regard something like the 9 Children's Aid Society today as a -- an agency that has 10 investigative powers, an agency that -- that we could 11 share information with under legislation such as the 12 Freedom of Information Protection of Privacy Act, Section 13 42. 14 Whereas, I'll confess, back in the late 15 1990's, I don't think that was quite as -- as apparent or 16 clear to us. 17 MR. ROBERT CENTA: So if you could turn 18 to -- in -- in your Volume II, Tab 29, which is 19 PFP095786. That's a letter to you, Dr. Lucas, from the 20 local Children's Aid Society, again involving Athena's 21 case. 22 And they are writing to you seeking 23 information in respect of a ongoing proceeding involving 24 Athena's sibling. And that was sent to you in August of 25 1998. Your -- your response is found at Tab 30 which is

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1 PFP095784. 2 And you say: 3 "In response to your letter dated 4 August 17th, I regret that I can not 5 provide you with the information 6 requested as Athena's death is 7 currently the subject of an ongoing 8 police investigation." 9 Is this an example of the -- the sort of 10 older approach or more dated approach to dealing with the 11 Children's Aid Society? 12 DR. WILLIAM LUCAS: Yes, I would say it 13 is. 14 MR. ROBERT CENTA: And do you agree that, 15 systemically, it's important that information be shared 16 with the children's aid Societies in res -- that -- that 17 may be in the possession of the OCCO in respect of 18 ongoing -- ongoing children's aid proceedings? 19 DR. WILLIAM LUCAS: Absolutely. And I 20 think just to be clear, the position that we would take 21 is one of not being a roadblock to the -- to the 22 circumstance or to sharing of information, but one of 23 seeking whatever legal authority we have to share 24 information when it's appropriate to do so. 25 Having said that, there would still be the

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1 -- the element of conferring with the Crown's office to 2 make sure that they had no release concerns. And as long 3 as everyone that was involved with the case was on the 4 same page, we would go ahead and release, as long as we - 5 - we could find some appropriate legal authority to do 6 so. 7 MR. ROBERT CENTA: From the perspective 8 of the OCCO, leaving the aside the concerns of the Crown 9 and the police, would it interfere with your operations 10 and the work of the investigative coroner if the legi -- 11 if the legislation were to make clear that you could 12 share that kind of information with Children's Aid 13 Societies? 14 Would that affect your work? 15 DR. WILLIAM LUCAS: Not at all that I 16 could perceive. 17 MR. ROBERT CENTA: There might be 18 concerns from these other entities, -- 19 DR. WILLIAM LUCAS: Correct. 20 MR. ROBERT CENTA: -- but you wouldn't 21 have any concerns -- 22 DR. WILLIAM LUCAS: Exactly, exactly. 23 MR. ROBERT CENTA: -- about that -- that 24 sort of change if that change was necessary? 25 DR. WILLIAM LUCAS: Exactly. I don't

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1 know whether my colleagues have any different views on 2 that. 3 MR. ROBERT CENTA: Dr. Lauwers, Dr. 4 Edwards, do you have any views on that? 5 DR. ALBERT LAUWERS: No comment. 6 DR. JAMES EDWARDS: No. 7 COMMISSIONER STEPHEN GOUDGE: So at the 8 moment, as a matter policy, it strikes me the OCCO 9 position is if it impairs the police investigation, we 10 will not release to anybody. Is that...? 11 DR. WILLIAM LUCAS: If -- if they 12 specifically or through the Crown specifically request us 13 not to, we would -- we would defer to that, yes. 14 COMMISSIONER STEPHEN GOUDGE: Even if the 15 CAS is saying, We need it? 16 DR. WILLIAM LUCAS: Right. Now, there -- 17 there's another avenue, of course, that -- that's always 18 open, and that is the courts. If the courts direct us, 19 then certainly there -- 20 COMMISSIONER STEPHEN GOUDGE: Absolutely. 21 DR. WILLIAM LUCAS: -- would be no 22 hesitation. 23 COMMISSIONER STEPHEN GOUDGE: Yes, yes. 24 How does OCCO come to that balance as between the two (2) 25 agencies? Or do you know?

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1 DR. WILLIAM LUCAS: All I know in 2 response to a question like that is that -- that over the 3 last four (4) to five (5) years, we have agonized over 4 the issue of what information should we release, when, 5 and -- and under what authority. 6 And we've got -- we've got a document that 7 gives us guidance on that that's gone through probably at 8 least four (4) or five (5) revisions over that time span. 9 And we constantly strive to -- to get it right to -- to 10 make sure that we are sharing information whenever we 11 can. 12 COMMISSIONER STEPHEN GOUDGE: It is 13 obviously a tough issue? 14 DR. WILLIAM LUCAS: Yeah, exactly. 15 16 CONTINUED BY MR. ROBERT CENTA: 17 MR. ROBERT CENTA: And in -- in 18 criminally suspicious or homicide cases, the -- is the 19 appropriate point of contact between families and the 20 coronial system the coroner? Or is there a role for the 21 forensic pathologist to meet with family members 22 directly? 23 DR. WILLIAM LUCAS: My view would be that 24 because it's a coronial system and the coroner is the 25 investigator, he should be the contact person, whether

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1 that's the investigating coroner or the regional 2 supervisor. 3 Again, coming back to the comments that 4 Dr. Lauwers made earlier, the -- the pathologist, in -- 5 in our view, is -- is a very important consultant to the 6 process whose -- whose function is to focus basically on 7 the issues of cause of death and perhaps help us in -- in 8 our interpretation of the manner of death as a result of 9 that. 10 And I think for the most part, in my 11 experience, pathologists welcome the fact that someone 12 else is being the interface with -- with families and 13 other members, that -- that they don't have to do that. 14 MR. ROBERT CENTA: Dr. Edwards, you'd 15 like to add something to that or...? 16 DR. JAMES EDWARDS: No. No, I completely 17 agree. 18 MR. ROBERT CENTA: Okay. 19 DR. JAMES EDWARDS: The -- the -- 20 generally, the -- the coroner is the contact between -- 21 with -- with any agency. 22 MR. ROBERT CENTA: Okay. Dr. Lucas, I'm 23 going to ask your colleagues now some questions about the 24 coroner's death investigation that was part of the Dr. 25 Smith Review. And I think you were not involved in this

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1 component, so I'll direct my questions for the next 2 little while to Dr. Lauwers and -- and Dr. Edwards. 3 Dr. Lauwers, am I correct that prior to 4 February 2007, you hadn't been involved in any review of 5 Dr. Smith's work? 6 DR. ALBERT LAUWERS: That's correct. 7 MR. ROBERT CENTA: And that in -- in 8 February 2007, Dr. McLellan approached you to provide 9 some assistance? 10 DR. ALBERT LAUWERS: He did. He -- at 11 our regional supervisor coroner's meeting he asked for 12 some individuals to help with the review. 13 MR. ROBERT CENTA: And what did he ask 14 you to help him with? 15 DR. ALBERT LAUWERS: In his office he 16 specifically wanted a review of the coroner's work and 17 actions with regard to the forty-five (45) cases involved 18 in the Dr. Smith Review. 19 And specifically, the question that he 20 wished to know about was whether any identified concerns 21 which may have been the result of the coroner's work 22 could have impair -- impacted Dr. Smith's conclusions. 23 MR. ROBERT CENTA: Who did Dr. McLellan 24 to take on this task? 25 DR. ALBERT LAUWERS: Myself and Dr.

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1 Edwards. 2 MR. ROBERT CENTA: And after Dr. McLellan 3 asked you to take on this task, how involved was Dr. 4 McLellan with the review after that point? 5 DR. ALBERT LAUWERS: Not at all. 6 MR. ROBERT CENTA: As part of your 7 review, did you have any direct personal contact with the 8 external forensic pathologists that had been retained by 9 the Office of the Chief Coroner to look at the pathology 10 involving Dr. Smith? 11 DR. ALBERT LAUWERS: I had contact with 12 them in the context of them coming into our office and 13 sometimes attending morning rounds, but certainly, we 14 never discussed any of the pathology that they were 15 reviewing. 16 MR. ROBERT CENTA: And as part of your 17 review of the -- of the role of the coroner in the death 18 investigation in those cases, did you speak with or have 19 any direct contact with the five (5) external forensic 20 pathologists? 21 DR. ALBERT LAUWERS: I did not. 22 MR. ROBERT CENTA: Okay. And you were 23 asked to take on this task in February of 2000 -- I 24 understand you completed it in early March 2007. 25 DR. ALBERT LAUWERS: That's about the

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1 timing, yes. 2 MR. ROBERT CENTA: And Dr. Edwards, I'll 3 turn to you now. As I understand it, you and Dr. Lauwers 4 worked collaboratively to sort of scope the review, is 5 that correct? 6 DR. JAMES EDWARDS: That's correct. Dr. 7 McLellan gave us general -- general direction and Dr. 8 Lauwers and I sat down and arrived at a method of -- that 9 we -- through which we would achieve that -- that task. 10 MR. ROBERT CENTA: So if you can look at 11 -- in Volume I at Tab 3, PFP137412. And, Dr. Edwards, 12 this is a document that you prepared in -- in 13 collaboration with Dr. Lauwers? 14 DR. JAMES EDWARDS: That's correct. 15 MR. ROBERT CENTA: And is this -- this 16 describes the review of the coroner's death investigation 17 that the two of you undertook. 18 DR. JAMES EDWARDS: That's correct. 19 MR. ROBERT CENTA: The purpose, as 20 listed, is to review the coroner's death investigation 21 and its possible role on Dr. Smith's examination and 22 conclusions. And then there's a -- there's a footnote to 23 that. It says: 24 "The review of the coroner's 25 involvement over the years involved in

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1 this review will be conducted from the 2 perspective of death investigation 3 expectations which were accepted and 4 prevalent for the time." 5 Can you explain what you meant by that? 6 DR. JAMES EDWARDS: The guidelines for 7 death investigation that -- that have been discussed 8 already at -- earlier today were arrived at in 2003, and 9 in the 1990's there was no -- at least to my knowledge, 10 there was no formalized criteria for coroners to -- to 11 abide by while they were doing their duties so we 12 basically went by our understanding of what would be 13 expected of coroners at that time; recognizing that there 14 were not those formal guidelines that were in place -- 15 put into place in 2003. 16 MR. ROBERT CENTA: So it was an attempt 17 not to impose, retroactively, guidelines that didn't 18 exist at the time at the -- of the death investigations 19 in question. 20 DR. JAMES EDWARDS: That's correct, and - 21 - and we were both coroners in the 1990's, so we were 22 familiar with what we would have expected, at least of 23 our own -- of our own behaviour. 24 MR. ROBERT CENTA: Your char -- the 25 document sets out four (4) goals for the review; first to

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1 determine what information the coroner provided to Dr. 2 Smith; second, whether or not the coroner appropriately 3 integrated Dr. Smith's findings into the final coroner's 4 investigation statement; third, whether any significant 5 concerns about the coroner's actions can be identified; 6 and fourth, whether the identified concerns may have 7 impacted on Dr. Smith's conclusions. 8 Stopping -- going back to the third 9 ground, which is whether any significant concerns about 10 the coroner's actions can be identified. Was that meant 11 to include situations where you had determined, under 12 question one (1), that the coroner had failed to provide 13 sufficient information to Dr. Smith or was that getting 14 at something else? 15 DR. JAMES EDWARDS: They're -- they're 16 independent questions. The -- whether -- as far as 17 question three (3), where there any significant concerns 18 about the coroner's actions could be identified, that was 19 related partly to the information provided to Dr. Smith, 20 but also to other -- other things that we thought the 21 coroner may -- should or should not have done. 22 MR. ROBERT CENTA: There's another -- 23 there's a heading marked "objectives", and beneath that 24 it says: 25 "The team will review the following

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1 items." 2 Stopping there. Who's the team? 3 DR. JAMES EDWARDS: The two of us. 4 MR. ROBERT CENTA: Okay. 5 "And will review the following items; 6 first, the coroner's warrant for 7 autopsy, second, the police report, 8 third, the coroner investigation 9 statement, fourth, Dr. Smith's autopsy 10 report, specifically comments regarding 11 the information provided by the coroner 12 and conclusions regarding the cause of 13 death, and fifth, the conclusions of 14 the independent reviewer." 15 Now, these items that you were going to 16 review, where were they located? 17 DR. JAMES EDWARDS: In -- in the charts 18 that we had. We were provided with charts for each of 19 the forty-five (45) cases, and the charts contained this 20 information. 21 MR. ROBERT CENTA: And were the charts 22 assembled specifically for your review or had they been 23 assembled previously for another purpose? 24 DR. JAMES EDWARDS: They had already been 25 assembled. They were -- they were part of the -- part of

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1 the review, I believe that -- that was taken in regard to 2 Dr. Charles Smith's work. 3 MR. ROBERT CENTA: They -- they were the 4 materials that formed the basis of the review conducted 5 by the five (5) external forensic pathologists? 6 DR. JAMES EDWARDS: Yes, part of -- part 7 of that process. 8 MR. ROBERT CENTA: I'd just like to ask 9 you some questions about the items that are identified. 10 Number 2, the police report, what does that mean? 11 Can you explain what you -- what you would 12 have looked for or looked at when you were looking at the 13 police report? 14 DR. JAMES EDWARDS: Well when we were 15 looking at whether we had any con -- significant coner -- 16 concerns about the coroner's actions, we thought that 17 perhaps the police report could assist us. 18 So for example, the police report may have 19 mentioned whether the coroner had gone to the scene and 20 what -- what information had been provided to the 21 coroner. We just thought it would be an independent way 22 of possibly getting information about the -- about the 23 coroner. 24 MR. ROBERT CENTA: And would you have 25 then reviewed photocopies of police officers' notes as

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1 part of the police report? I'm just wondering what the - 2 - what the document would look like. 3 DR. JAMES EDWARDS: It's a police report. 4 There were -- now not -- you know, I can't -- I can't 5 recall police officers' notes. There were police 6 reports. Now not all of the files contained police 7 reports. 8 MR. ROBERT CENTA: Now the material you 9 reviewed came from the files assembled by the Office of 10 the Chief Coroner, correct? 11 DR. JAMES EDWARDS: That's correct. 12 MR. ROBERT CENTA: And as part of your 13 review, did you interview any of the investigating 14 coroners who were involved in these cases? 15 DR. JAMES EDWARDS: At that time we 16 didn't interview any of the investigating coroners. 17 Subsequently -- subsequently Dr. Lauwers did interview 18 one (1) of the investigating coroners after we learned 19 that that -- that case had been a topic of discussion at 20 this inquiry. 21 MR. ROBERT CENTA: And I understand that 22 that's the local coroner involved in Sharon's case? 23 DR. JAMES EDWARDS: That's correct. 24 MR. ROBERT CENTA: And we'll come back 25 and talk about that later. But leaving that one (1)

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1 instance aside, did you interview any of the local 2 coroners involved? 3 DR. JAMES EDWARDS: No we didn't. 4 MR. ROBERT CENTA: And why not? 5 DR. JAMES EDWARDS: We thought that -- 6 well first of all, some of the -- some of the coroners we 7 knew had -- had deceased. 8 We thought from our own experience that 9 the coroners would not have an independent recollection 10 of the -- of the events, of their conversation with Dr. 11 Smith and that even if they did recall speaking with him, 12 we -- we didn't anticipate that they would recall the 13 specific contents of that conversation. 14 And we wanted to keep the review 15 consistent. 16 MR. ROBERT CENTA: And -- but in 17 attempting to answer your first question, which is what 18 information the coroner provided to Dr. Smith, you have 19 no way of knowing whether the coroner -- the 20 investigating coroner provided any verbal information to 21 Dr. Smith in advance of him completing the post-mortem 22 examination? 23 DR. JAMES EDWARDS: That -- that's 24 correct. 25 MR. ROBERT CENTA: And you wouldn't know

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1 if Dr. Smith had asked the local coroner to provide any 2 additional information or additional medical reports? 3 DR. JAMES EDWARDS: No, that -- that's 4 correct. 5 MR. ROBERT CENTA: And then you wouldn't 6 know whether or not the investigating coroner was able to 7 provide Dr. Smith with what he was looking for or not? 8 DR. JAMES EDWARDS: That -- that's 9 correct. 10 MR. ROBERT CENTA: And as I understood 11 from our conversation earlier today, typically a coroner 12 would have communicated some information to the coroner - 13 - or so the coroner would have communicated some 14 information verbally to the forensic pathologist in 15 advance of the conduct of the post-mortem examination? 16 DR. JAMES EDWARDS: That would -- we 17 would expect that would typically be the case, yes. 18 MR. ROBERT CENTA: In retrospect, would - 19 - do you think that interviewing the investigating 20 coroner would have assisted you to meet your goal of 21 determining what information they had given to Dr. Smith? 22 DR. JAMES EDWARDS: Well as I said, we 23 wanted to make the review consistent. And we really 24 thought that the coroners would not have an independent 25 recall of the information that -- that -- what they --

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1 what they would have spoken to Dr. Smith about. 2 And I'm not sure that that would have been 3 of -- been of assistance to us. I mean, I suppose 4 potentially we could have -- we could have, I mean, but 5 we made the decision to not do that. 6 MR. ROBERT CENTA: Okay. Similarly, did 7 you interview any of the regional supervising coroners 8 involved in any of these cases? 9 DR. JAMES EDWARDS: No, we did not. 10 MR. ROBERT CENTA: And, again, why -- why 11 was that decision taken? 12 DR. JAMES EDWARDS: Again we -- we 13 thought we could determine the information that had been 14 provided to Dr. Smith through the autopsy warrants, by 15 looking -- by reading Dr. Smith's autopsy report. And we 16 didn't think that the regional supervising coroners would 17 have an independent recollection of any conversation they 18 may have had with Dr. Smith. 19 MR. ROBERT CENTA: And, again, unless the 20 -- unless Dr. Smith recorded the information provided to 21 him in his report of post-mortem examination, it wouldn't 22 be possible what, if any, information had been provided 23 to him verbally? 24 DR. JAMES EDWARDS: That's correct, just 25 to be -- just to be complete in that regard.

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1 I suppose it's possible that the coroners 2 may have made notes in their own files, but even having 3 said that, coroners purge their files after ten (10) 4 years. 5 MR. ROBERT CENTA: Did you attempt to 6 locate and review any files maintained by an 7 investigating coroner or Regional Coroner? 8 DR. JAMES EDWARDS: No, we did not. 9 MR. ROBERT CENTA: You simply -- you 10 reviewed the documents that had been collected at the 11 Office of the Chief Coroner? 12 DR. JAMES EDWARDS: And provided to us, 13 that's correct. 14 MR. ROBERT CENTA: Right. 15 And you don't -- you wouldn't then know if 16 any of those files would contain any notes of telephone 17 conversations with Dr. Smith? 18 DR. JAMES EDWARDS: If there's any notes, 19 telephone conversations, we would have seen them in the 20 files, and there weren't. 21 MR. ROBERT CENTA: Only if the local 22 files have been collected and form part of the documents 23 in the OCCO review panels? 24 DR. JAMES EDWARDS: Yeah, that's correct. 25 MR. ROBERT CENTA: Correct? Okay.

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1 DR. JAMES EDWARDS: Yeah. 2 MR. ROBERT CENTA: Did you speak with Dr. 3 Smith as part of your review? 4 DR. JAMES EDWARDS: No, we realized that 5 probably the best person to have answered -- answered 6 this question that was put to us would have been Dr. 7 Smith but we really didn't think it would be at all 8 appropriate given the -- the inquiry that was -- was 9 going to be held -- or was potentially going to be held 10 into this -- into his activities. 11 MR. ROBERT CENTA: And why did you not 12 think it was appropriate to speak to Dr. Smith? 13 DR. JAMES EDWARDS: I'm not sure that he 14 would have spoken to us. 15 MR. ROBERT CENTA: Did you ask? 16 DR. JAMES EDWARDS: No. 17 MR. ROBERT CENTA: So again you wouldn't 18 know whether he recalled being provided any information 19 by an investigating coroner or Regional Coroner verbally? 20 DR. JAMES EDWARDS: No, that -- that's 21 correct. 22 MR. ROBERT CENTA: And you wouldn't know 23 if he felt that he had not been provided with sufficient 24 information to allow him to discharge his duties in a 25 particular case?

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1 DR. JAMES EDWARDS: That's correct. We 2 did recognize -- when we designed this study, we 3 recognized that there were limitations inherent in doing 4 a paper review, and those included the limitations that 5 you're alluding to. It was a paper review. It was a 6 review of information that was provided to us. We didn't 7 speak with the person who would be in the best position 8 to be able to answer the question because we didn't think 9 that would be appropriate. 10 And in some of the -- in some of the 11 files, information was missing. Some didn't -- I can't 12 give you the numbers right off the top of my head but 13 some didn't have police reports and some, and I can't 14 recall how many, the autopsy warrants weren't present as 15 well. 16 MR. ROBERT CENTA: As part of your 17 review, did you review Dr. Smith's handwritten or rough 18 notes from the files? 19 DR. JAMES EDWARDS: I don't -- I don't 20 recall seeing any handwritten notes from Dr. Smith, no. 21 MR. ROBERT CENTA: If they -- do you -- 22 you don't recall seeing any at all? 23 DR. JAMES EDWARDS: I can't recall, no. 24 MR. ROBERT CENTA: Are there any other 25 limitations on the review process -- now you've had a

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1 chance to reflect on it -- that arose from the -- the 2 data source that was selected for your review? 3 Are there additional limitations that that 4 imposed? 5 DR. JAMES EDWARDS: No, we recognized 6 these limitations at the time. These aren't -- these 7 aren't -- you know, this isn't a realization that have 8 come -- have come to us subsequently. 9 No, I mean, we examined a limited amount 10 of material -- written material-- there was no -- with 11 one (1) exception we did not speak to any of the parties 12 involved and -- and that's the steps we took. 13 Having said that, we really thought at the 14 time, and I think we still think, that we were able to 15 make legitimate conclusions. 16 MR. ROBERT CENTA: If you could turn over 17 the page to page 2 of document 137412. 18 Dr. Lauwers, is this the -- this is the 19 audit tool that was used to -- as you went through the -- 20 through the files? 21 DR. ALBERT LAUWERS: It was, Mr. Centa. 22 Could I spend just a minute talking about the limitations 23 of the study? 24 MR. ROBERT CENTA: Yes, of course. 25 MR. ALBERTA LAUWERS: I'll be very brief.

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1 Firstly, you've already pointed out that 2 the identified concerns which may have impacted Dr. 3 Smith's conclusions. We thought Dr. Smith would have 4 been the best person to answer that. And the reason we 5 didn't feel it would be appropriate to inquire of him of 6 that particular discussion was that it would have for an 7 external -- external people looking at it, it may well -- 8 they may have viewed it that it was a biassed report. 9 The second issue was we only had three (3) 10 weeks to do the entire inquiry. 11 The third was we only looked at the 12 investigating coroner's work; we didn't look at the work 13 of the Regional Coroners in the study at all. 14 The fourth is that it's a -- it's best 15 suitably described as a retrospective chart review and 16 the limitations of those types of reviews are that you're 17 limited to what's actually physically in the file and 18 certain pieces, as Dr. Edwards has stated, were not in 19 the file. 20 In addition to that, even when the items 21 that you're looking at are in the file, they may not 22 contain the information that you're hoping to seek, and 23 certainly with regard to police reports they often 24 describe extensively the activities of coroners, but in 25 some of the police reports they didn't discussion it at

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1 all. 2 And again, you're only limited to what 3 items are in the file. The fifth is that we made 4 assumptions about these particular items as being 5 surrogate markers for quality in a coroner's death 6 investigation, and we never validated that. 7 There are others that might think that 8 that's not appropriate, but for our purposes and with our 9 experience we felt it was. 10 The sixth has to do with the specific 11 coroners themself, and you've identified, Mr. Centa, all 12 of those limitations, which include that some of them 13 were, in fact, dead. And some of them we -- we chose not 14 to speak to them principally because we ourselves knew we 15 had very little, if any, recall with regard to speaking 16 to Dr. Smith. We didn't review their personal files 17 principally because they wouldn't -- they get purged 18 after ten (10) years. 19 And the seventh item is that Dr. Edwards' 20 entire career was spent in the city or a large portion of 21 his investigative career was spent in the City of Toronto 22 as an investigating coroner where the expectation is 23 different than the expectation they might have had from 24 myself as a rural coroner. And that's -- is either a 25 strength or a weakness, depending on how you review it.

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1 MR. ROBERT CENTA: Just -- just to follow 2 up on the -- the purging of the files after ten (10) 3 years. That would only affect files that would have been 4 closed in 1997 or earlier, if you conducted this review 5 in 2007? 6 DR. ALBERT LAUWERS: Correct. 7 MR. ROBERT CENTA: So any death that took 8 place in '98, '99, 2000, 2001 would not yet have met the 9 purge test. 10 DR. ALBERT LAUWERS: That's correct. 11 MR. ROBERT CENTA: Second, it's possible 12 that local coroners did not purge their files on the ten 13 (10) year anniversary? 14 DR. ALBERT LAUWERS: Absolutely. 15 MR. ROBERT CENTA: So they could have 16 still maintained files from -- prior to 1997? 17 DR. ALBERT LAUWERS: Yes. 18 DR. JAMES EDWARDS: If I could just -- 19 just add there, Mr. Centa. The -- the problem there 20 would have been, though, that we would not have had a 21 consistent review. You know, some files would have been 22 purged, some wouldn't have been purged and we wanted to 23 have a consistent process for all -- for all forty-five 24 (45) cases. 25 MR. ROBERT CENTA: Thank you. Dr.

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1 Lauwers, returning to -- to page 2 of Document 137412. 2 This is the -- there are sixteen (16) questions listed on 3 this page? 4 DR. ALBERT LAUWERS: Yes. 5 MR. ROBERT CENTA: And those are the 6 questions that you asked of each -- of each death 7 investigation with respect to each file. 8 Is that correct? 9 DR. ALBERT LAUWERS: Yes. 10 MR. ROBERT CENTA: Did each of you 11 complete a form like this for each file or did you split 12 the files up? 13 DR. ALBERT LAUWERS: We split the files. 14 I think Dr. Edwards did twenty-three (23) of them, and I 15 did twenty-two (22) of them. 16 MR. ROBERT CENTA: And did you review 17 each other's work on the files that the other had 18 completed or did you simply let that stand? 19 DR. ALBERT LAUWERS: What happened is on 20 completion of a file there would be a brief discussion 21 about the substance of what -- what we found. And, you 22 know, we would freely test what -- about the concl -- we 23 would freely test the conclusions that each other made. 24 MR. ROBERT CENTA: I'm interested in 25 talking to you briefly about question number 4 under the

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1 heading, "Coroner's Warrant for Autopsies." It says: 2 "Were relevant historical issues 3 identified, i.e., medical history of 4 the decedent, police or CAS involvement 5 with either parent, a history of 6 substance abuse?" 7 Is prior police involvement with either 8 parent by its nature always relevant or would its 9 relevance vary with the circumstances of the case? 10 DR. ALBERT LAUWERS: It would rel -- it 11 would be -- it would vary with the circumstance of the 12 case. 13 MR. ROBERT CENTA: And can you just -- an 14 example of when -- what circumstances it would be 15 relevant? 16 DR. ALBERT LAUWERS: Well, certainly 17 where there was a history of repeated domestic violence 18 in the home, where, you know, one (1) of -- one (1) or 19 both of the partners had suffered physical assault, it 20 certainly would be relevant to the pathologist to have 21 that information during the course of their evaluation of 22 the child. 23 MR. ROBERT CENTA: And with respect to 24 prior CAS involvement with either parent, same question: 25 Is it by its nature always relevant or would that vary

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1 with the circumstances? 2 DR. ALBERT LAUWERS: I -- would vary with 3 the circumstances, but I would have to say that that 4 would be information, in our view, that would be 5 important to report to the pathologist in all 6 circumstances. 7 MR. ROBERT CENTA: Okay. And a prior 8 history of substance abuse, relevant by its very nature 9 or dependant on the circumstances? 10 DR. ALBERT LAUWERS: And the same answer, 11 once more, it -- its rel -- its relevance is dependant on 12 the circumstances. For instance, a child that's killed 13 in a car accident on the Gardner Expressway is not -- not 14 particularly relevant to the -- the question. 15 But mostly, this is the type of 16 information that the pathologist needs to have. 17 MR. ROBERT CENTA: Question 5 in the -- 18 in the surveys: 19 "Was a Death Under Two form completed?" 20 DR. ALBERT LAUWERS: Yes. 21 MR. ROBERT CENTA: And we'll come to the 22 responses to each of the files, but -- but you've had a 23 chance to look at them. 24 Did you find any Death Under Two forms? 25 DR. ALBERT LAUWERS: I didn't find any

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1 Death Under Two forms. 2 MR. ROBERT CENTA: Okay. And am I 3 correct that the current version of the Death Under Two 4 form is actually known as a death under -- Death Under 5 Five form? 6 Is that correct? 7 DR. ALBERT LAUWERS: That's correct, Mr. 8 Centa. 9 MR. ROBERT CENTA: And I think that's 10 found at PFP032477. And is that -- do you recognize 11 that, do I have the correct form? 12 DR. ALBERT LAUWERS: I do, sir. 13 MR. ROBERT CENTA: Okay. And currently, 14 who is to complete this form as part of the death 15 investigation? 16 DR. ALBERT LAUWERS: This form should be 17 completed by the investigating coroner. 18 MR. ROBERT CENTA: And it says -- it 19 indicates at the top that it should be forwarded to the 20 pathologist preferably prior to the post-mortem 21 examination. 22 DR. ALBERT LAUWERS: Yes. 23 MR. ROBERT CENTA: Okay. Is this form, 24 in it's current form, designed with -- with a specific 25 type of death in mind or is it -- is it more neutral than

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1 that? 2 DR. ALBERT LAUWERS: No, it's -- it has a 3 specific type of death in mind. It's actually never used 4 in homicides, and in criminally suspicious cases, it may 5 not be used, but specifically what it's designed to do is 6 to sort out cases of Sudden Infant Death Syndrome, SIDS, 7 versus Sudden Unexpected Death; in other words, the 8 typical case would be a child that were found dead in a 9 crib in a home. 10 MR. ROBERT CENTA: And am I correct that 11 -- that the predecessor to this form, it wasn't mandatory 12 to fill in -- to complete a death under two questionnaire 13 prior to March 31st, 2001? 14 DR. ALBERT LAUWERS: That's not my 15 belief. My belief is that when the form first came in 16 1995, it was to be completed. 17 MR. ROBERT CENTA: So it was mandatory 18 from the date it first appeared, through -- through to 19 today. 20 DR. ALBERT LAUWERS: Correct. 21 MR. ROBERT CENTA: Okay. And does it 22 concern you that none of the cases you looked at 23 contained a death under two for -- a completed death 24 under two form? 25 DR. ALBERT LAUWERS: It doesn't within

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1 this population of -- 2 MR. ROBERT CENTA: And why is that? 3 DR. ALBERT LAUWERS: Well, as I've 4 mentioned earlier, if, for criminally suspicious cases, 5 and particularly for homicides, these forms aren't 6 completed, you know, when you're -- one is examining the 7 circumstances of a child that's -- that is found deceased 8 and there's clear evidence of trauma to the child, we 9 would ask the coroner specifically not to complete the 10 form because the investigation -- the lead agency is 11 primarily the police service. 12 MR. ROBERT CENTA: Okay. And -- 13 DR. ALBERT LAUWERS: There are other 14 reasons, as well. 15 MR. ROBERT CENTA: Please, carry -- 16 continue. 17 DR. ALBERT LAUWERS: Cert -- certainly. 18 The -- the other circumstances are, even if it were 19 completed in a -- the case of a child that were found 20 deceased at home, the form in its -- its current format, 21 would have been provided to the police to give to the 22 pathologist, and it may well still be a component of the 23 pathologist's file, but never have made its way back to 24 the Office of the Chief Coroner's file. 25 MR. ROBERT CENTA: And -- and that's

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1 another aspect, I take it, of what you would say was a 2 significant limitation in your review, is that it was 3 dependent on the infer -- on -- on the documents being in 4 the set of files that you looked at. 5 DR. ALBERT LAUWERS: A retrospective 6 chart review, that's one (1) of the limitations. Having 7 said that, if one (1) of these forms had been completed 8 in any one (1) of these cases, we would have felt that 9 the coroner had done a very thorough job, but again, we 10 would have looked at it and thought whether it would 11 truly indicate, and given the circumstances surrounding 12 the death, if it's a homicide where we really don't want 13 coroners going and using this form for those kinds of 14 cases. 15 MR. ROBERT CENTA: Okay. If we could 16 look at the summary form that is set out on page 3, 17 PFP137412, page 3, and was one (1) of these forms 18 completed for each case? 19 DR. ALBERT LAUWERS: Yes, it was. 20 MR. ROBERT CENTA: And with respect to 21 the conclusions that you would have identified during 22 your review; in any given case, how did you go about 23 determining whether or not sufficient information was 24 provided by the coroner to Dr. Smith? 25 DR. ALBERT LAUWERS: By -- by the

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1 tabulation or review of the specific elements in the 2 previous form we just discussed. 3 MR. ROBERT CENTA: So now, which -- which 4 questions would you have taken into account in answering 5 the -- the summary question number one (1)? 6 DR. ALBERT LAUWERS: Well, in part, all 7 six (6) of them. 8 MR. ROBERT CENTA: Under the heading 9 "Coroner Warrant for Autopsy"? 10 DR. ALBERT LAUWERS: Correct. 11 MR. ROBERT CENTA: And what would a 12 finding in -- in -- under question 1, 13 "Sufficient information was provided by 14 the coroner to Dr. Smith?" 15 There's an option there of -- of not 16 applicable or NA. 17 DR. ALBERT LAUWERS: Right. 18 MR. ROBERT CENTA: What -- what would 19 have triggered that? 20 DR. ALBERT LAUWERS: On whether it was 21 "certain death"; for instance, Amber, in which the child 22 sustained injuries but wasn't known at the time the 23 injuries were sustained to have sustained fatal injuries. 24 And so the child's initial representation 25 to the Health Care System is as a living child that

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1 subsequently goes on to die some days later. That would 2 be not -- not applicable. The -- and principally -- I'm 3 sorry, I should flesh that out a little more. 4 Principally, it's because the history that would have 5 been provided to Dr. Smith, in that circumstance, would 6 have come from the medical records at the hospital. 7 MR. ROBERT CENTA: Okay. And in number 8 2: 9 "A coroner appropriately integrated Dr. 10 Smith's conclusion into the completion 11 of the coroner's investigation 12 statement." 13 How would -- how did you go about 14 answering that question? 15 DR. ALBERT LAUWERS: That's -- that's a 16 difficult one (1) and I'll tell you why because when we 17 designed the study, we designed it before we actually 18 engaged the charts and went through them. 19 What became evident and clear to us is 20 that the coroner -- the practice at the time, including 21 the practice for myself in 1985, would have simply been 22 to take the cause of death off the post-mortem 23 examination report of the pathologist and integrated it 24 directly into the Coroner's Form 3 under "Cause of 25 Death." That was the standard that I would have used at

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1 that time and -- 2 COMMISSIONER STEPHEN GOUDGE: Just sort 3 of one (1) sentence? 4 DR. ALBERT LAUWERS: That's correct. So 5 where the one (1) sentence as to cause of death on a -- 6 on the post-mortem examination -- 7 COMMISSIONER STEPHEN GOUDGE: On the 8 post-mortem. 9 DR. ALBERT LAUWERS: -- report of Dr. 10 Smith, would have simply been transposed in the Coroner's 11 Form 3 under "Cause of Death." That was the standard at 12 the time. 13 Of course, as you know, he was a very 14 respected pathologist and there would have been likely 15 little cause to -- to question his opinions at that time 16 on the basis of the coroner's review of the death. 17 18 CONTINUED BY MR. ROBERT CENTA: 19 MR. ROBERT CENTA: And the third 20 question: Significant concerns about the coroner's 21 actions had been identified. 22 Again, how do you go about determining 23 whether that's a "yes" or a "no"? 24 DR. ALBERT LAUWERS: Well, again, a 25 complicated question given that the fact that guidelines

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1 for death investigation weren't actually created until 2 2003. 3 But there were some consistent elements in 4 our view that necessitated the presence of a coroner with 5 regard to this. For instance, we would have expected the 6 coroner to have gone to the primary and the secondary 7 scene to conduct at a scene examination; to have 8 conducted, where appropriate, an examination of the body, 9 again limited where we know that this is a -- this is a 10 homicide-type investigation. And there were other 11 decision-making processes as well. 12 The case I recall vividly is the case 13 where organ donation was allowed to proceed in the 14 absence of discussion with the Regional Supervising 15 Coroner. That would have been in our area where we would 16 have said the coroner didn't meet what we would have 17 both, conceptionally, thought were necessary elements of 18 the -- his work at that time. 19 MR. ROBERT CENTA: At that time? 20 DR. ALBERT LAUWERS: At that time. 21 MR. ROBERT CENTA: And I think I 22 understood Dr. Edwards' answers that if the answer to 23 summary question 1, "Sufficient information provided by 24 the coroner to Dr. Smith" is no, that doesn't 25 automatically mean that significant -- that's -- that

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1 that is a significant concern? 2 DR. ALBERT LAUWERS: That's correct. 3 MR. ROBERT CENTA: Okay. 4 DR. ALBERT LAUWERS: Mr. Centa, the 5 reason for that is there would be valuable information 6 provided by both the policing service, the hospital 7 records and other sources of information. 8 MR. ROBERT CENTA: Just while we're on 9 this question about the serious concerns regarding a 10 coroner's con -- if you look at Tab 7 in your binder 11 which is PFP137432, and this is a form that was completed 12 in respect of Amber's case. And Dr. Lauwers, is this a 13 form you completed? 14 DR. ALBERT LAUWERS: I completed it. 15 MR. ROBERT CENTA: And see question 3: 16 Significant concerns with the coroner's actions have been 17 identified. You've indicated -- 18 DR. ALBERT LAUWERS: Yes. 19 MR. ROBERT CENTA: -- you've indicated 20 "yes." 21 DR. ALBERT LAUWERS: Yes, I have. 22 MR. ROBERT CENTA: Can you explain on 23 this form what went into that determination? 24 DR. ALBERT LAUWERS: It was an 25 interesting case principally because the coroner, in my

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1 view, had the cause and manner of death correct and Dr. 2 Smith's conclusions were ultimately proven not to be 3 correct, but the coroner still had a series of errors 4 that he made. 5 The errors, I thought, were: He did not 6 contact the Children's Aid Society and report the death 7 to them. He did not -- he allowed the organ donation to 8 proceed in the absence of speaking to the Regional 9 Coroner. He allowed the organ donation to proceed 10 without actually physically examining the body of the 11 child. 12 Those were amongst the errors that 13 occurred. 14 Oh, the other error and the larger one (1) 15 was that he allowed -- after organ donation had been 16 completed, he allowed the body to be interred and -- 17 without doing an autopsy on the remainder of the body. 18 By that I mean the neuropathology studies. 19 MR. ROBERT CENTA: And in thou -- and in 20 the circumstances of this case, as we learned from your 21 file review, an aut -- you -- you felt an autopsy was 22 warranted? 23 DR. ALBERT LAUWERS: Yes, absolutely. 24 MR. ROBERT CENTA: And when you say, doc 25 -- the -- the coroner's conclusions about cause and

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1 manner of death were correct, I -- I take it there you're 2 referring to the -- the trial decision of Justice Dunn, 3 who ultimately acquitted the babysitter who had been 4 charged in respect of Amber's death? 5 DR. ALBERT LAUWERS: That's correct. 6 MR. ROBERT CENTA: Okay. 7 COMMISSIONER STEPHEN GOUDGE: Why would 8 you have said an autopsy should have been identified as 9 necessary from the beginning? 10 DR. ALBERT LAUWERS: Because the child -- 11 COMMISSIONER STEPHEN GOUDGE: My 12 recollection is the coroner came to the conclusion this 13 was an accidental death. 14 DR. ALBERT LAUWERS: We -- we would 15 normally autopsy that case, Mr. Commissioner. 16 COMMISSIONER STEPHEN GOUDGE: Why, 17 because of the age of the child? 18 DR. ALBERT LAUWERS: Because of the age 19 of the child, because of the potential that this -- this 20 could evolve into something other than just an accidental 21 death. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. ALBERT LAUWERS: It is a suspicious 24 death. It was from the outset. 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 Okay. When did the Death Under Two guidelines come in? 2 DR. ALBERT LAUWERS: The Death Under Two 3 form -- 4 COMMISSIONER STEPHEN GOUDGE: Yes. 5 DR. ALBERT LAUWERS: -- 1995 6 COMMISSIONER STEPHEN GOUDGE: Yes. So 7 this is before that? 8 DR. ALBERT LAUWERS: This is seven (7) 9 years before. 10 COMMISSIONER STEPHEN GOUDGE: And even 11 then it would have been a suspicious death from the 12 beginning? 13 DR. ALBERT LAUWERS: Yes, in my -- it's 14 my belief that it would have been. 15 DR. JAMES EDWARDS: Oh, I completely 16 agree with that. You have a -- a child who sustains a 17 head injury and the -- mechanism of that -- of seeing 18 that head -- head injury is not clear. In any -- in any 19 situation like this we would want to do a -- do an 20 autopsy. 21 If you had a clear-cut cause for the head 22 injury -- motor vehicle collision, pedestrian struck by a 23 car, something like that -- you might consider, in some 24 cases, not doing an autopsy. But if you have a child who 25 comes in with head injury and you don't have a really

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1 good explanation for that head injury, we would do an 2 autopsy in any -- 3 COMMISSIONER STEPHEN GOUDGE: A really 4 good explanation, Dr. Edwards, is not satisfied by 5 domestic fall? 6 DR. JAMES EDWARDS: No. No, we would 7 want -- we would want to have an explanation. You know - 8 - no. We -- we would want -- we would want to have 9 some -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. JAMES EDWARDS: -- some corroboration 12 of that. 13 DR. ALBERT LAUWERS: And, Mr. 14 Commissioner, I think that's the key point. If there's 15 an independent witness to -- to the mechanism of the -- 16 the reported fatal injury then -- 17 COMMISSIONER STEPHEN GOUDGE: That might 18 have changed that -- 19 DR. ALBERT LAUWERS: Yes, and certainly 20 in -- in our -- the lexicon of what we currently do, 21 where there's independent witnesses of -- of a 22 significant injury, we will not always autopsy those 23 cases. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. ALBERT LAUWERS: Particularly where

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1 we have a CAT Scan which shows definitely what the 2 injuries are. 3 COMMISSIONER STEPHEN GOUDGE: Right, 4 right. 5 6 CONTINUED BY MR. ROBERT CENTA: 7 MR. ROBERT CENTA: And, Dr. Edwards, just 8 clarify, when you said you might autopsy in a situation 9 where there was not a good explanation, you don't mean an 10 explanation that might ultimately -- found to be credible 11 and in fact true, but simply one that leaves some room 12 for doubt, at -- 13 DR. JAMES EDWARDS: Yeah. 14 MR. ROBERT CENTA: -- the time it's 15 offered? 16 DR. JAMES EDWARDS: At the time -- at the 17 time that a decision to order or not order an autopsy is 18 made. 19 MR. ROBERT CENTA: Okay. 20 DR. JAMES EDWARDS: A good explanation -- 21 I mean, a -- a clear-cut explanation of how the child 22 came to have that -- that head injury. 23 MR. ROBERT CENTA: Okay. Returning to 24 the summary form, which is PFP137412, page 3. 25 Question 4:

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1 "The identified concerns may have 2 impacted on Dr. Smith's conclusions?" 3 And am I correct, Dr. Lauwers, when you 4 say the identified concerns, are those the concerns 5 flagged in question 3? 6 DR. ALBERT LAUWERS: They are. 7 MR. ROBERT CENTA: And only question 3? 8 DR. ALBERT LAUWERS: Yes, largely in 9 question 3. 10 MR. ROBERT CENTA: Okay. So question 4 11 is responsive to question 3. Question 3 is: 12 "Were there significant concerns about 13 the coroner's actions?" 14 Question 4 is: 15 "If so, did they -- may they have 16 affected or impacted on Dr. Smith's 17 conclusions?" 18 DR. ALBERT LAUWERS: Correct. 19 MR. ROBERT CENTA: Okay. And am I 20 correct then that question 4 does not take into account 21 whether sufficient information was provided to Dr. Smith? 22 DR. ALBERT LAUWERS: I'm sort of -- I see 23 this trend here, and I'm sorry I -- I need to clarify 24 this. 25 MR. ROBERT CENTA: Please do.

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1 DR. ALBERT LAUWERS: I'm sorry. No, 1 2 and 4 are related, of course. 3 MR. ROBERT CENTA: Okay. 4 DR. ALBERT LAUWERS: One of the integral 5 parts of this whole exercise was to decide whether there 6 was sufficient information provided to the pathologist by 7 the coroner within the context of death investigation at 8 that time. And so that -- that actually related to 9 question 4 and so does question 3. 10 MR. ROBERT CENTA: Okay. So -- so 11 question 4 relates to both 1 and 3 -- 12 DR. ALBERT LAUWERS: Yes. 13 MR. ROBERT CENTA: -- but not question 2? 14 DR. ALBERT LAUWERS: Yes. And -- 15 correct. That's absolutely correct. 16 MR. ROBERT CENTA: So your review then 17 did assess whether sufficient information -- well, if 18 insufficient information was provided to Dr. Smith, did 19 it impact on his conclusions? 20 DR. ALBERT LAUWERS: That's correct. 21 MR. ROBERT CENTA: Great. 22 DR. ALBERT LAUWERS: And -- and just -- 23 I'm sorry for the misunderstanding. 24 COMMISSIONER STEPHEN GOUDGE: No, it is 25 clear now. Thanks.

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1 2 CONTINUED BY MR. ROBERT CENTA: 3 MR. ROBERT CENTA: If you turn in your 4 binders to Tab 4, which is PFP137410. 5 6 (BRIEF PAUSE) 7 8 MR. ROBERT CENTA: Am I correct, these 9 are -- these are your con -- the conclusions from the 10 review? 11 DR. ALBERT LAUWERS: They are the 12 conclusions to the review, yes. 13 MR. ROBERT CENTA: Now, can you -- I 14 understand you wanted -- you wanted to advise the 15 Commissioner about something about the answer to the 16 fourth question? 17 DR. ALBERT LAUWERS: Correct. The answer 18 to the fourth question, the notes should read fifteen 19 (15), and the not applicable should read thirty (30). 20 MR. ROBERT CENTA: So reading from left 21 to right: 22 "The identified concerns may have 23 impacted on Dr. Smith's conclusions." 24 Yes, should be zero. No, should be 25 fifteen (15). And not applicable should be thirty (30).

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1 DR. ALBERT LAUWERS: That's correct. 2 MR. ROBERT CENTA: Okay. And -- so the 3 chart sets out that in thirty (30) cases you found that 4 sufficient information was provided, and eleven (11) 5 cases that was not true, and in four (4) cases it was not 6 applicable. In thirty-seven (37) cases the coroner 7 appropriately integrated Dr. Smith's conclusions, and in 8 six (6) cases the coroner did not appropriately integrate 9 the conclusions, with two (2) being not applicable. 10 You found significant concerns about the 11 coroner's actions in fifteen (15) cases and not in thirty 12 (30), and the identified concerns may have impacted on 13 Dr. Smith's conclusions in fifteen (15) cases, "no", and 14 in thirty (30), "not applicable". 15 The difficult -- if you can help me again 16 with the relationship of question 3 to question 4 and 17 question 1 to question 4 -- no, never mind, I'll move on. 18 Can you just read your conclusions 19 paragraph to me? 20 DR. ALBERT LAUWERS: Sure. 21 "Forty-five (45) of Dr. Smith's cases 22 were reviewed. In eleven (11) cases 23 the coroner provided insufficient 24 information to Dr. Smith. In six (6) 25 cases the coroner did not appropriately

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1 integrate Dr. Smith's conclusions at 2 the completion of the Coroner's 3 Investigation Statement." 4 MR. ROBERT CENTA: Okay. And you are 5 satisfied, based on the review conducted that in no case 6 an identified concern may have impacted on Dr. Smith's 7 conclusions? 8 DR. ALBERT LAUWERS: That's correct. 9 COMMISSIONER STEPHEN GOUDGE: What does 10 the "not applicable where there were identified concerns" 11 mean? I don't quite understand that yet, Dr. Lauwers? 12 DR. ALBERT LAUWERS: So -- 13 COMMISSIONER STEPHEN GOUDGE: That is in 14 thirty (30) of the cases the identified concerns may have 15 -- that question is not applicable? 16 DR. ALBERT LAUWERS: So, Mr. 17 Commissioner, if you look at number 3 -- 18 COMMISSIONER STEPHEN GOUDGE: Yes. 19 DR. ALBERT LAUWERS: -- significant 20 concerns about the coroner's actions have been 21 identified. If the answer is no, the only answer that 22 follows into 4 then -- 23 COMMISSIONER STEPHEN GOUDGE: Okay. 24 DR. ALBERT LAUWERS: -- has to be not 25 applicable.

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1 COMMISSIONER STEPHEN GOUDGE: Okay. So 2 the fifteen (15) cases where the answer is "no" to 3 question 4 are among the eleven (11) cases in 1 and the 4 fifteen (15) cases in 3? 5 DR. ALBERT LAUWERS: Exactly. 6 COMMISSIONER STEPHEN GOUDGE: Thanks. 7 8 CONTINUED BY MR. ROBERT CENTA: 9 MR. ROBERT CENTA: And the recommendation 10 that emerged from your report is that there should be 11 direct verbal communication before and after the autopsy 12 between the coroner and the pathologist for each and 13 every non-natural and/or suspicious death regarding 14 autopsy? 15 DR. ALBERT LAUWERS: That's correct. 16 MR. ROBERT CENTA: As we've discussed, 17 there's very little way of knowing, based on the -- the 18 review you conducted, whether or not there was verbal 19 communication between the coroner and the pathologist 20 before the report of post-mortem examination. 21 Is that correct? 22 DR. ALBERT LAUWERS: That's correct. 23 MR. ROBERT CENTA: And then can you help 24 me understand how this recommendation then logically 25 flows from the review that you conducted?

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1 DR. ALBERT LAUWERS: Well the sharing -- 2 you're -- you're right, because there are significant 3 limitations with the study which we set out, but what 4 became clear and clearer to us was the importance of 5 communication between the coroner and the pathologist so 6 that the pathologist was best informed about the 7 circumstances of the death. 8 The -- to use the terminology I've learned 9 since this Inquiry, there needs to -- in addition, in our 10 view, a mechanism to memorialize the communications 11 between the coroner and the pathologist. 12 DR. JAMES EDWARDS: And I guess -- if I 13 can just add, Mr. Centa? 14 MR. ROBERT CENTA: Yes. 15 DR. JAMES EDWARDS: This recommendation 16 flows from our own -- from our own experience. You know, 17 we -- this is -- this is what we feel should happen. So 18 this recommendation flows partly from this Review, but it 19 also flows from our -- from our experiences as 20 Investigating Coroners and as Regional Supervising 21 Coroners. And -- 22 COMMISSIONER STEPHEN GOUDGE: And it's 23 reflected in some of the quality assurance discussions -- 24 DR. JAMES EDWARDS: Right. 25 COMMISSIONER STEPHEN GOUDGE: -- we had

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1 this morning. 2 DR. JAMES EDWARDS: Yeah. And in fact in 3 giving with -- with consultants of any nature, there has 4 -- there has to be good -- a good exchange of 5 information. 6 7 CONTINUED BY MR. ROBERT CENTA: 8 MR. ROBERT CENTA: This -- this 9 recommendation just makes sense? 10 DR. JAMES EDWARDS: Yes, exactly. 11 MR. ROBERT CENTA: And it made sense 12 before you started the review, and it made sense at the 13 end of the review? 14 DR. JAMES EDWARDS: Yeah. And I guess 15 the only portion of the review that really sort of 16 directly supports this recommendation is that we didn't 17 find any information in our review that indicated there 18 was verbal communication between the coroner and Dr. 19 Smith in any of the forty-five (45) cases, although we 20 fully recognize that there may well have been in some. 21 MR. ROBERT CENTA: And that -- that 22 finding is subject to all the limitations we talked about 23 before, about attempting to ascertain whether or not 24 there was verbal communication. 25 DR. JAMES EDWARDS: Exactly.

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1 MR. ROBERT CENTA: Would that 2 recommendation address any of the fifteen (15) cases 3 where you identified significant concerns about the 4 coroner's actions that were -- that were not connected to 5 there being sufficient information provided to Dr. Smith? 6 Like this reco -- does this recommendation 7 address, for example, the serious concerns about the 8 coroner's conduct in the Amber -- in Amber's case, Dr. 9 Lauwers? 10 DR. ALBERT LAUWERS: No, it does not. 11 MR. ROBERT CENTA: And did you consider 12 making recommendations that would address those -- 13 serious concerns that you had identified, and if not, why 14 not? 15 DR. ALBERT LAUWERS: I didn't, and 16 principally because the -- all of the errors that -- that 17 were made in the Amber case have been long since 18 corrected by various memorandum, and certainly the 19 guidelines for death investigation 2003. 20 Any of those actions would not occur today 21 and they don't occur today. That type of activity would 22 not be tolerable. 23 MR. ROBERT CENTA: Commissioner, I have - 24 - I have a number of other questions about the -- the 25 coroner's death investigation, but this might be an

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1 appropriate time to take the afternoon break, unless 2 you -- 3 COMMISSIONER STEPHEN GOUDGE: Okay. 4 That's fine. We'll be back then in fifteen (15) minutes. 5 6 --- Upon recessing at 3:17 p.m. 7 --- Upon resuming at 3:32 p.m. 8 9 MR. REGISTRAR: All rise. Please be 10 seated. 11 COMMISSIONER STEPHEN GOUDGE: Mr. 12 Centa...? 13 14 CONTINUED BY MR. ROBERT CENTA: 15 MR. ROBERT CENTA: Thank you. Dr. 16 Edwards, earlier you told us that subsequent to March 17 8th, 2007, when you completed the review, you did follow 18 up with one (1) investigating coroner, and that was in 19 Sharon's case? 20 DR. JAMES EDWARDS: Actually, it was Dr. 21 Lauwers who followed up, but that's correct. 22 MR. ROBERT CENTA: Dr. Lauwers, just 23 before I ask you questions on those, to refresh people's 24 memory, the overview report for Sharon's case is found at 25 PFP144453. And paragraphs 1 to 3 of that report set out

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1 that -- that Sharon was born in Kingston in December 2 1989. She died on June 12th, 1997, at the age of seven 3 and a half (7 1/2) years. 4 On June 26th of 1997, Ms. Reynolds was 5 charged with second-degree murder in the death of Sharon. 6 The preliminary inquiry was conducted from April to 7 November, 1998. And on November the 19th, 1998, Ms. 8 Reynolds was committed to stand trial, remanded without 9 bail from June 6th, 1997, until April 26th, 1999, when 10 she was released with the consent of the Crown on terms 11 and conditions. 12 The Crown withdrew the charge against Ms. 13 Reynolds on January 25, 2001, indicating that it did not 14 have a reasonable prospect of conviction. 15 So with that brief background to -- to 16 Sharon's case, Dr. Lauwers, why did you follow up in that 17 case? 18 DR. ALBERT LAUWERS: Well, the concern 19 arose in both my mind and Dr. Edwards' mind that this was 20 one of the cases where clearly, had the coroner provided 21 certain information to Dr. Smith, it may have influenced 22 his opinions and outcome. And with that in mind I called 23 him up and asked him a couple of questions. 24 MR. ROBERT CENTA: And what did you ask 25 him, and what did he say?

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1 DR. ALBERT LAUWERS: I asked two (2) 2 questions only. The first question was: Did you examine 3 the body of the child? And his answer was, No, I was led 4 to a doorway in the basement, and I saw the chid there, 5 and I did not examine the body of the child. 6 That was the first question and -- 7 MR. ROBERT CENTA: And just staying on 8 the first question for a moment. Did the investigating 9 coroner explain why he didn't investigate -- or didn't 10 inspect the body in that case? 11 DR. ALBERT LAUWERS: Yes. Clearly, it 12 was in the view of the police service involved a 13 homicide, and they didn't wish to have the coroner 14 anywhere near the body. 15 MR. ROBERT CENTA: And why was that? 16 DR. ALBERT LAUWERS: Because it's a 17 criminally suspicious homicide, and coroners do not 18 examine the bodies of the decedents in those 19 circumstances. That is reserved for the forensic 20 pathologist. 21 MR. ROBERT CENTA: And was the -- is the 22 concern that the crime scene can be contaminated by 23 another person approaching and -- and handling the body? 24 DR. ALBERT LAUWERS: That's correct. 25 MR. ROBERT CENTA: Okay. That was the

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1 first question. What was the second question you asked? 2 DR. ALBERT LAUWERS: The second question 3 is: When did -- when did the possibility or when did he 4 learn, if at all, about the dog? And the coroner 5 responded that he didn't learn about the dog until 6 sometime thereafter, so it was not a component of his 7 warrant. He didn't know about the dog at the time that 8 he completed the warrant. 9 MR. ROBERT CENTA: And if we can turn up 10 the Coroner's Investigation Statement, the Form 3, which 11 is found at Volume I, Tab 6, which is PFP055753. And 12 there are a number of documents found at Tab 6. I 13 believe the document we're looking for is the third 14 document in, which is towards the end of the tab. It's 15 the Form 3, coroner's investigation statement. 16 17 (BRIEF PAUSE) 18 19 MR. ROBERT CENTA: Do you have that in 20 front of you, Dr. Lauwers? 21 DR. ALBERT LAUWERS: I do indeed. 22 MR. ROBERT CENTA: And this is dated 23 March 17th, 1999. 24 DR. ALBERT LAUWERS: Yes. 25 MR. ROBERT CENTA: And is there any

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1 reference to a dog in this coroner's investigation 2 statement? 3 DR. ALBERT LAUWERS: There is not. 4 MR. ROBERT CENTA: And if the local 5 coroner had been advised of the presence of the dog, 6 would you have expected that fact to appear somewhere in 7 the coroner's investigation statement? 8 DR. ALBERT LAUWERS: If the possibility 9 was that the dog was a contributing factor to the death, 10 I would have. 11 MR. ROBERT CENTA: And when you spoke 12 with the investigating coroner, did -- did he tell you 13 whether or not at the time he completed the coroner's 14 investigation statement if he knew that there was a 15 possibility that a dog was involved? 16 DR. ALBERT LAUWERS: You'll recall, Mr. 17 Centa, that I asked him two (2) questions. 18 MR. ROBERT CENTA: And the second 19 question -- and you -- the answer to the second question 20 precisely was...? 21 DR. ALBERT LAUWERS: He did -- he -- 22 COMMISSIONER STEPHEN GOUDGE: At the time 23 of the warrant. 24 DR. ALBERT LAUWERS: Pardon me? 25 COMMISSIONER STEPHEN GOUDGE: At the time

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1 of the warrant. 2 DR. ALBERT LAUWERS: Right. He -- he did 3 not know about the dog at the time that the warrant was 4 completed, and the issue of the dog came up some time 5 later. 6 MR. ROBERT CENTA: And you're not able to 7 assist us any further than that with when he would have 8 learned. 9 DR. ALBERT LAUWERS: I cannot. 10 MR. ROBERT CENTA: This -- this coroner's 11 investigations here, the form 3 is -- is stamped April 12 26th, 1999 in the office Dr. Bechard, the Regional 13 Coroner. 14 DR. ALBERT LAUWERS: Yes. 15 MR. ROBERT CENTA: He was the Regional 16 Coroner responsible for this file? 17 DR. ALBERT LAUWERS: He was. 18 MR. ROBERT CENTA: And according to the - 19 - the brief summary of events I -- I provided to you, 20 this coroner's investigation statement, which was 21 completed on March 17th, 1999, was completed after the 22 conclusion of the preliminary hearing in the share -- in 23 Sharon's case. 24 If you could turn on the -- or Mr. -- Mr. 25 Registrar, if you could call up the Sharon overview

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1 report, PFP144453, and go to page 47, at paragraph 109. 2 This is a memorandum from Jenna -- recording or 3 memorandum from Jennifer Ferguson, the apriss -- the 4 Assistant Crown Attorney to Mr. McKenna, dated December 5 10, 1997. Mr. -- Ms. Ferguson spoke to Mr. Rumball on 6 December the 9th, 1997 regarding a number of issues. 7 Ms. Ferguson's notations of their 8 discussion including the following, and under heading 5: 9 "Rumble told me that he is going to 10 retain his own pathologist to look at 11 the photographs. He thinks the 12 injuries are bite marks. He may try to 13 have Sharon's body exhumed. 14 [Bracket](Will he -- will he have the - 15 - have to exhume the dog, too, to 16 compare the dental impressions to the 17 injuries?) [question mark]" 18 And then going down a paragraph: 19 "Dr. Bechard called me this morning to 20 tell us he had spoken to Rumble 21 yesterday. He told me about Rumble's 22 theory re. the dog and advised that Dr. 23 Woods, a forensic dentist, could nip 24 that theory in the bud if we wanted a 25 consultation with him. He would

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1 examine the photos, indicated which 2 injuries were likely to be bite marks, 3 and computerise the images. I told him 4 I would speak with you." 5 Now this conversation takes place in 6 December 1997, long before the coroner's investigation 7 statement is concluded in March 17th of 1999. 8 If Dr. Bechard, as these notes indicate, 9 was aware of the possibility that a dog was involved, 10 because of contact with defence counsel, is that the kind 11 of information that the Regional Coroner should have 12 provided to an investigating coroner for the purposes of 13 his investigation? 14 DR. ALBERT LAUWERS: So, the answer is 15 yes. My nor -- my normal practice in closing a case such 16 as this would have been to put a notation called 17 "regional coroner's note" and dated it and then put the 18 additional information that was known to me, and then 19 close the case and sent a copy of the report to the 20 investigating coroner, so that he was apprised of the 21 additional information that I may have gleamed that he 22 did not have. 23 MR. ROBERT CENTA: And, Registrar, if you 24 could turn to paragraph 113, which is over one (1) or two 25 (2) pages.

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1 On paragraph 114 Dr. Wood completed his 2 forensic odontology examination report dated February 3 22nd, 1998, and in this he -- Dr. Wood indicates that 4 he's examined post-mortem photographs of Sharon and 135 5 slides from two (2) separate fatal dog attacks. 6 And he stated -- over the page, please -- 7 and he sets out his report in which he concludes that the 8 marks found in the photographs were inconsistent with dog 9 bite marks. This report is dated in -- in February of 10 1998. 11 Is this the type of report that should be 12 provided to an investigating coroner if it's completed in 13 the process, during -- during the time that the -- the 14 investigation is ongoing? 15 DR. ALBERT LAUWERS: So my -- my 16 experience with that, Mr. Centa, is it might not 17 necessarily be provided to the investigating coroner, 18 would undoubtedly be provided to the Regional Coroner and 19 should be a component of a discussion between the two (2) 20 of them. 21 MR. ROBERT CENTA: And if it was provided 22 to the Regional Coroner, should it have been memorialized 23 somehow in either a coroner's investigation statement or 24 a regional coroner's note that would be include as part 25 of the file?

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1 DR. ALBERT LAUWERS: Yes. 2 MR. ROBERT CENTA: So that is the -- even 3 if the report itself is not made available to the 4 investigating coroner, the information contained therein 5 should be provided to the investigating coroner to 6 determine whether or not it's relevant for his -- 7 DR. ALBERT LAUWERS: Yes. 8 MR. ROBERT CENTA: -- investigation? 9 DR. ALBERT LAUWERS: Yes. 10 MR. ROBERT CENTA: And in the 11 circumstance of this case, would you have expected a 12 coroner -- one (1) step back -- if the local coroner had 13 received the information from Dr. Bechard, would it have 14 been expected that that information would have been 15 referred to somehow in the coroner's investigation 16 statement? 17 DR. ALBERT LAUWERS: Yes. 18 MR. ROBERT CENTA: Commissioner, I'm 19 about to turn away from the review process itself unless 20 you have -- 21 COMMISSIONER STEPHEN GOUDGE: No, that's 22 fine. Thank you. 23 MR. ROBERT CENTA: -- any follow-up 24 questions. 25

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1 CONTINUED BY MR. ROBERT CENTA: 2 MR. ROBERT CENTA: Dr. Lucas, welcome 3 back. 4 DR. WILLIAM LUCAS: I'll -- I'll zone 5 back in. 6 MR. ROBERT CENTA: You can zone back in. 7 I'd like to turn to some more -- some broader systemic 8 questions. And as a Regional Coroner of some experience, 9 a question for you, in your view, who should have primary 10 responsibility for providing oversight of the work of 11 forensic pathologists in Ontario's death investigation 12 system? 13 DR. WILLIAM LUCAS: I think we're all 14 quite clear that that should be the purview of the Chief 15 Forensic Pathologist because he has the expertise in that 16 particular area. 17 The -- largely, as general practitioners 18 in the coroner's system, although there are some as you 19 heard earlier, people with other areas of expertise don't 20 have that forensic pathology expertise. 21 MR. ROBERT CENTA: And I -- is that -- is 22 that view shared by other members of the panel? 23 DR. ALBERT LAUWERS: Yes, I think that's 24 they way we view it. 25 DR. JAMES EDWARDS: Yeah, I agree as

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1 well. 2 MR. ROBERT CENTA: In your opinion -- and 3 any member of the panel can answer this -- when the 4 Office of the Chief Coroner becomes aware of a complaint 5 about the performance of a forensic pathologist 6 performing work on coroner's warrant, whether that's 7 about timeliness or responsiveness or a complaint about 8 the quality of the work, how should the Office of the 9 Chief Coroner of Ontario best respond to that complaint? 10 DR. JAMES EDWARDS: I guess any complaint 11 about any physician should first be dealt with with that 12 physician. It may -- he may be able to resolve the 13 situation just by -- by speaking with the physician 14 himself or herself. 15 MR. ROBERT CENTA: And who should -- who 16 should address that issue with the pathologist? 17 DR. JAMES EDWARDS: I guess whoever 18 identified the concerns, so normally it would be one of 19 us, one of the Regional Supervising Coroners. 20 If we were unable to resolve it to -- to 21 our mutual satisfaction, and we continue to have the 22 concern, then the logical person to bring it to would be 23 the Chief Forensic Pathologist. 24 MR. ROBERT CENTA: And, Dr. Lauwers, do 25 you agree with that -- that stand -- that approach?

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1 DR. ALBERT LAUWERS: I agree with that 2 approach. I think that, you know, you've heard our -- 3 about our fairly extensive review with regard to when we 4 get complaints about coroner's and their -- and their 5 performance. 6 The same thing goes for the forensic arm 7 of the death investigation team, which as Dr. Lucas has 8 eluded to, should have oversight by the Chief Forensic 9 Pathologist. 10 MR. ROBERT CENTA: On a -- on a case by 11 case basis, is it possible for -- or should Ontario look 12 to coroners to be able to provide quality assurance on 13 the forensic pathology work performed by forensic 14 pathologists? Is that -- is that a reasonable 15 expectation or not? 16 DR. JAMES EDWARDS: No. 17 MR. ROBERT CENTA: And why? 18 DR. JAMES EDWARDS: Because we're not 19 pathologists. The only -- the only people who can 20 oversee the work of pathologists is -- would be 21 pathologists. We're not -- we're not experts in 22 pathology. 23 MR. ROBERT CENTA: You do have sufficient 24 medical background, obviously, to consider the cause of 25 death that's set out on a report of post-mortem

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1 examination. You're not -- you're not obliged to simply 2 adopt a cause of death found by a forensic pathologist. 3 Is that correct, Dr. Lucas? 4 DR. WILLIAM LUCAS: That's correct. 5 MR. ROBERT CENTA: But -- and I guess 6 you're drawing a distinction between that and providing 7 quality assurance over the forensic pathology practice -- 8 DR. WILLIAM LUCAS: Component. And I 9 think the issue here is that we certainly, historically, 10 have worked collaboratively and I think we continue to do 11 so even perhaps to a greater degree in this day and age. 12 Yes, as -- as Regional Supervisors, as -- even as 13 coroners, investigative coroners, we have a certain level 14 of sophistication that we can bring, in terms of 15 assessing the bottom line conclusion that's been drawn by 16 the pathologist. 17 I guess where we would draw distinction is 18 if you go through the report on a line-by-line basis or 19 if you -- if you -- you focus on areas like the 20 microscopic sections; if the pathologist tells us that 21 when he reviewed the cardiac tissue, he found evidence of 22 myocarditis. 23 We're not in a position that we can 24 challenge that. We have to take it face value that -- 25 that he is or she is appropriately trained and competent

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1 to make that kind of assessment when they do that sort of 2 review. Where we might have a -- an opinion or, at 3 least, have a perception as to whether they got it right, 4 if I could use that term, is how the whole package comes 5 together and what their conclusions are. 6 And -- and certainly I don't think any of 7 us would shy away from raising a concern if we thought 8 that, reading through the report, there were things that 9 just didn't seem to add up, and -- and the conclusions 10 didn't support what we were finding elsewhere. 11 Granted we would go back to the forensic 12 pathologist and say, Help us understand whether we've got 13 it right, whether we're interpreting the bottom line 14 correctly or what we need to do to -- to correct this. 15 COMMISSIONER STEPHEN GOUDGE: When you 16 say bottom line, you are really talking about cause of 17 death? 18 DR. WILLIAM LUCAS: Yes. 19 20 CONTINUED BY MR. ROBERT CENTA: 21 MR. ROBERT CENTA: Dr. Lauwers...? 22 DR. ALBERT LAUWERS: I just wanted to 23 introduce another issue. The best practice model for 24 quality assurance and oversight is that the clinical 25 expert who has -- has the knowledge actually administers

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1 the system. However, I think the evidence that I've 2 heard is that the system wasn't particularly robust with 3 partic -- with -- with quality assurance initiatives 4 between 1981 and 1994 when there was indeed a -- a Chief 5 Forensic Pathologist who was a -- an individual who was 6 duly qualified. 7 I actually think -- and I -- of course, 8 I've come from a Health Care System in which I did have 9 administrative oversight for areas in which I wouldn't 10 have been considered an expert. It really has more to do 11 with, in some ways, the individual. 12 Our current Chief Forensic Pathologist, 13 Dr. Pollanen, is -- is reputed; has an excellent 14 reputation. He -- he invigorates others; inspires us to 15 a higher level. He's known for his honesty, and he has 16 vision and intuition about the future. 17 All of those attributes are -- are 18 necessary for that quality assurance piece and that 19 oversight piece. It's not -- it's -- it's -- you know, 20 we work as a team, and I'm not so impressed with the need 21 just as long as the individual who is in that position is 22 -- is duly inspired to do what needs to be done. 23 And -- and I believe we currently have 24 that in place at this time. 25 DR. JAMES EDWARDS: And most of our

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1 interaction with pathologists -- when we don't -- it's 2 not so much necessary that we would disagree with their 3 report but where we would want them to look at it again - 4 - would be in cases where we come across additional 5 information. 6 So, for example, I can think of a case 7 where somebody's found in -- in Toronto Harbour and had 8 features of drowning, and the -- and the pathologist 9 signed out the cause of death as drowning. And 10 subsequently, a family member got in touch with me and 11 said that they were concerned that the deceased person 12 was a cocaine user. 13 And they were concerned that, perhaps, 14 they'd been using cocaine at the time. So in that case, 15 I spoke with the pathologist, and we arranged to have 16 cocaine testing done on blood that was stored. And in 17 fact, the person did have cocaine in their blood and that 18 altered the cause of death. 19 But that's the collaborative sort of 20 approach that we would use -- use with pathologists that 21 really, you know, ninety-nine (99) times out of hundred 22 (100) it works. The other -- the other situation where 23 we might not reach the precise same conclusions about the 24 cause of death is the pathologist would be -- the 25 pathologist may on occasion only be willing to go so far

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1 in their autopsy report and determination of the cause of 2 death. 3 And we may have additional information to 4 make -- that would make us feel comfortable in going 5 further. So for example, if we had -- let's just say we 6 had a -- an adult male; body was found decomposed, and 7 there was empty bottles of Demerol at the -- at the 8 scene. 9 And the pathologist does the autopsy. He 10 cannot find the definitive cause of death, but can't rule 11 out a natural cause of death due to the decomposition of 12 the body; do toxicology, we can't get a level of the -- 13 of the drug, but the drug is found in the body. 14 So, you know, did the Demerol cause the 15 death? Well, the pathologist may elect to write -- to 16 certify the cause of death as undetermined. But we may 17 be willing to take the coincidental and the 18 circumstantial information we have about the scene and 19 make a determination of the cause of death as Demerol 20 toxicity. 21 And that's not really, you know, a 22 confrontation or a disagreement with the pathologist, 23 this is -- we have different roles, different information 24 that we consider, and different, I think, levels of -- 25 levels of certainty in making our conclusions.

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1 DR. ALBERT LAUWERS: Just one (1) -- one 2 (1) last comment. You know, we all have a responsibility 3 for quality and when autopsy reports come to us I 4 actually review the cause of death on the autopsy report 5 and ensure that it makes sense with regard to the -- the 6 clinical history, and if that doesn't work, then I let 7 the pathologist know. 8 The American Society of Quality talks 9 about the principles of quality and they include a client 10 focus, participation and teamwork, a process focus, 11 continuous improvement and learning; those are the so- 12 called three (3) principles. And for us, the teamwork 13 part is the integral part. 14 We work with our pathologists together. 15 And we would like them to know when they have concerns 16 about our work and they -- and they should actually let 17 us know as well. And we'll cooperate in whichever way we 18 can to get the best product out there. 19 COMMISSIONER STEPHEN GOUDGE: And I take 20 it, Dr. Lauwers, from what the three (3) of you say, that 21 at least in today's world it would be the very, very rare 22 case where the investigating coroner and the pathologist 23 would, at the end of the day, have different views on the 24 ultimate cause of death question. 25 DR. ALBERT LAUWERS: It's -- it's a very

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1 uncommon circumstance indeed. 2 COMMISSIONER STEPHEN GOUDGE: Does the 3 system need to provide for some kind of tie-breaker in 4 that very, very rare case or what would happen in the 5 hypothetical, recognizing that it is a very rare case? 6 Is there scope for consultation amongst a 7 wider group of informed professionals? How does the 8 Office deal with that? 9 DR. JAMES EDWARDS: I know on occasion we 10 may consult with experts outside the Province to get 11 another -- to get another viewpoint. And the other thing 12 to keep in mind is that our conclusions are not 13 necessarily reached for the same purposes as the 14 pathologist's conclusions. 15 You know, I'm thinking of a -- of a case 16 where we had a fellow who was -- sustained homicidal head 17 trauma, assaultive head trauma, and was in a very poor 18 state and died some weeks later in a rehabilitation 19 hospital, and the immediate cause of death was heart 20 attack. And the issue that came up in -- in regard to 21 completing insurance papers was: Was the heart attack 22 related to the head injury? 23 So the pathologist thought they were 24 likely not related. But for our purposes for determining 25 that a death is natural, in other words, due to the heart

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1 attack, it has to be all natural. So that's the 2 convention in the Ontario Coroner's Office. 3 And we would -- determined that the cause 4 of death is not natural in that case, which does not 5 completely agree with the pathologist, but it's not 6 really inconsistent with the pathologist either because 7 we're reaching our conclusions for a different purpose. 8 DR. ALBERT LAUWERS: Internally, Mr. 9 Commissioner, there is the opportunity to use the expert 10 committees. Certainly for Death Under Five, for 11 instance, it's con -- 12 COMMISSIONER STEPHEN GOUDGE: That would 13 always go to the Committee in a case like the 14 hypothetical I put to the three (3) of you? 15 DR. ALBERT LAUWERS: Correct. 16 COMMISSIONER STEPHEN GOUDGE: And the 17 ultimate objective would be to develop the best 18 collective view the organization could come up with. 19 DR. ALBERT LAUWERS: And the other answer 20 is case conferencing the case. I mean -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. ALBERT LAUWERS: -- if there's a 23 dispute about it, get all the players to the table and 24 have a fulsome discussion about it and try to arrive at 25 the best conclusion.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 3 CONTINUED BY MR. ROBERT CENTA: 4 MR. ROBERT CENTA: And that kind of case 5 conference can take place before formal pronouncements 6 are made on cause of death and manner of death? 7 It needn't be -- it needn't be seen as 8 error correcting but as rather a process of deliberation? 9 DR. ALBERT LAUWERS: Yes. 10 DR. WILLIAM LUCAS: And as a matter of 11 fact, I think in reality that's likely what would happen. 12 If a -- if a case is giving us that much pause for 13 concern and it's -- and we're having difficulty trying 14 to resolve it, I'm sure that that would be done far 15 before any ultimate conclusions were drawn. 16 And that isn't to say that in our system 17 the pathologists can't render an opinion and then with 18 new information revisit and revise his report. We've -- 19 we've seen that on occasion as well. 20 MR. ROBERT CENTA: And it is appropriate 21 for pathologists and for coroners to have access to other 22 experts, clinicians or otherwise, to inform their views 23 on the matter? 24 DR. WILLIAM LUCAS: Yes. 25 DR. ALBERT LAUWERS: Indeed it is. One

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1 (1) of the advantages that we have with working with the 2 Hospital for Sick Children are having the pediatric unit 3 at the Hospital for Sick Children. 4 MR. ROBERT CENTA: You've anticipated my 5 next question, which was I'm interested in your thoughts 6 on whether Ontario -- your views on whether Ontario 7 should have an institutional setting dedicated to 8 pediatric forensic pathology or should all pediatric 9 services be delivered within a strictly forensic 10 pathology institutional setting like the Office of the 11 Chief Coroner? 12 Dr. Edwards...? 13 DR. JAMES EDWARDS: We think there's 14 great benefit in having autopsies done at the Hospital 15 for Sick Children. 16 The Hospital for Sick Children is a 17 tremendous support to -- to the Coroner's Office in terms 18 of doing autopsies, and also in -- in terms of our total 19 death investigations. Their physicians there have 20 tremendous world class expertise and they're willing to 21 assist us with our -- with our investigations. 22 I told you about the case of the -- the 23 breastfeeding mother with the morphine toxicity; that's 24 an excellent example. I can -- I can give you another 25 example. We had a case five (5) years ago now where a

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1 fellow was running; a guy in his earl -- a man -- a man 2 in his early 40s was running and -- and collapsed and 3 died. 4 And the pathologist could not find a cause 5 of death; there was no anatomic cause of death and there 6 was toxicological cause of death. So the issue comes up 7 is, could this be an electric abnormality of the heart 8 that wouldn't show up on -- on an autopsy? 9 So I phoned the -- the fellow's wife and - 10 - and told her -- and told her our findings, and she said 11 that she had four (4) young children and she was 12 concerned about the young children; could this be an 13 electrical problem that would tend to run in the family? 14 So, in that case what we did was we got in 15 touch with Dr. Joel Kirsh, who is a cardiologist at the 16 Hospital for Sick Children. He said, Send the kids to 17 see me. He arranged -- made arrangements for him to 18 assess the four (4) children and -- and to, you know, 19 examine them as to the possibility that they may have, 20 you know, a dangerous electrical problem in their heart. 21 But this is the kind of support that they 22 give us every day and they are just a tremendous resource 23 to us. And if we didn't have them to assist us in doing 24 our death investigations we would have a real problem, 25 because that expertise is not -- is just not available

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1 elsewhere, and -- even in terms of radiology, in terms of 2 doing skeletal surveys for -- for children who die 3 suddenly. 4 They have -- they have -- first of all, 5 they have the facilities there to be able to do CAT 6 Scans. They have technicians who are trained in doing 7 CAT Scans. They have radiologists who are trained in 8 reading CAT Scans, and having the x-ray -- or the 9 autopsies done in the same facility enables the 10 radiologist to go and consult with the pathologist in 11 regard to what -- what he might look for in term -- in -- 12 in the autopsy. 13 And then, finally, it's also of assistance 14 in terms of the feedback between the hospital and the 15 pathologist, so the -- if we have a patient who dies in 16 hospital, the clinical physicians who are treating the 17 patient can consult with the pathologist and give the 18 pathologist information to help them make their 19 determination. 20 And in addition, the information also goes 21 the other way; the pathologist can tell the clinicians 22 what -- what the findings are, and then assist the 23 clinicians in their quality of care review of the case, 24 so it's -- the Hospital for Sick Children is a tremendous 25 benefit to us, and I don't see how any independent

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1 standing facility could re -- replace that expertise. 2 MR. ROBERT CENTA: Dr. Lauwers, how would 3 you explain what -- what you see the OCCO is gaining from 4 the institutional relationship with the OPFPU and the 5 Hospital for Sick Children? 6 DR. ALBERT LAUWERS: Well, I can -- I'll 7 echo some of the other things that -- I'll echo some of 8 the things that Dr. Edwards said, but add to that by 9 saying, I really enjoy the culture at the Hospital for 10 Sick Children. 11 It's a world class leader in terms of 12 research and education, and they have that -- that 13 notion. Now, when you go in there -- I came from the 14 healthcare sector, the Emergency Department, where there 15 was lots of conflict all the time. 16 It was the most pleasing experience when I 17 joined the organization in June of 2006 to be able to 18 have such an inviting relationship. They have great 19 leadership with regard to both David -- Dr. David 20 Chiasson in the Forensic Pathology Unit, the Pediatric 21 Forensic Pathology Unit, and Dr. Glenn Taylor. 22 They have a great best practice model for 23 how they conduct their pediatric autopsies, and Dr. 24 Edwards alluded to that, but the principle being, you 25 have pediatric radiologists; you have -- you have CAT

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1 Scan technology which they're now using. 2 You have pathology assistants who are used 3 to doing pediatric cases, and in fact, one (1) of them, I 4 think, Dr. Don Perrin, has a PhD and is renowned for his 5 knowledge of anatomy. They have infinite capacity to 6 draw in from the resources of the organization 7 consultants to assist them with the individual cases, but 8 the best part is actually the way they present their 9 cases in the consultative manner they do that. 10 What they do is they'll take -- for non- 11 criminally suspicious cases, they'll present the 12 particular case of the child's death, including a history 13 of the clinical review, the slides of the -- the gross 14 pictures of the anatomy, the pathology review. There'll 15 -- there'll be a full discussion about it, and it's a 16 very -- you'll have neuropathologists there, you'll have 17 other pathologists there, you'll have clinical people 18 there. 19 And each of them will add as called upon, 20 or if not, particular issues into the -- into the -- the 21 whole scenario that's being pre -- presented. And it 22 will allow the pathologists presenting the case the 23 opportunity to reflect upon its considerations and form 24 his opinion or enhance his opinion. 25 And the last thing that I find

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1 particularly pleasing is they'll always refer to the 2 literature as they finish. They'll say, Here's a couple 3 of articles on this, and they'll discuss in brief. 4 So it's just a tremendous best-practice 5 model, and it's one (1) if we weren't doing fourteen 6 hundred (1400) cases in the Provincial Forensic Pathology 7 Unit, it would be a wonderful thing to be able to do that 8 but -- but we simply can't because of the volume. 9 So I agree with Dr. Edwards, I think the 10 Hospital for Sick Children is a tremendous resource to 11 us, and it would be hard for me to envision us moving 12 forward without them. 13 COMMISSIONER STEPHEN GOUDGE: What about 14 that small number of cases, Dr. Lauwers, that are 15 criminally suspicious pediatric deaths? 16 DR. ALBERT LAUWERS: I think the -- what 17 I've heard and what I believe is that the co-case 18 management of those types of death are -- should be the 19 presence of a forensic pathologist such as a Dr. Chiasson 20 or a Dr. Pollanen with the pediatric expertise that they 21 can draw upon at that institution. 22 Having said that, Mr. Commissioner, I know 23 that sometimes purely homicidal pediatric cases are done 24 in the Office of the Chief Coroner, and I have no 25 objection with that either.

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1 COMMISSIONER STEPHEN GOUDGE: If what 2 seems to be at stake is less medical and more forensic, 3 if I can put it that way. 4 DR. ALBERT LAUWERS: Exactly. It's for 5 the purely forensic case where there's been clear 6 homicide. 7 There's no benefit really in my view -- or 8 very limited benefit. There actually continues to be 9 that x-ray facility that they have which is so good, but 10 there's limited benefits to doing that at the Hospital 11 for Sick Children entirely. I think those clearly 12 forensic cases, there's a place for that to come to us. 13 But again, when you have a forensic 14 pathologist trained like Dr. Chiasson doing those cases, 15 you know, we still have all of that plus the pediatric -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. ALBERT LAUWERS: -- piece as well. 18 DR. JAMES EDWARDS: And certainly the 19 forensic cases that are admitted to hospital -- to the 20 Hospital for Sick Children and are hospitalized for some 21 time, generally those are done by a forensic pathologist 22 at the Hospital for Sick Children because they have the 23 benefit of access to the treating physicians and also the 24 medical records. 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 Thanks, Dr. Edwards. 2 DR. JAMES EDWARDS: The other thing -- I 3 just add one (1) more thing about Sick Kids, is they have 4 the same values as we do; you know, the -- in terms of 5 organ retrieval, in terms of promoting public safety for 6 families and in getting it right, you know. 7 COMMISSIONER STEPHEN GOUDGE: You put 8 those in your order of importance -- 9 DR. JAMES EDWARDS: It's just, they're 10 very important -- 11 COMMISSIONER STEPHEN GOUDGE: I know, I'm 12 just -- 13 DR. JAMES EDWARDS: I was at Sick Kids on 14 Friday and the pathologist I was talking to them about 15 organ retrieval, he come up today and they're all for it, 16 you know -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. JAMES EDWARDS: -- they're great. 19 20 CONTINUED BY MR. ROBERT CENTA: 21 MR. ROBERT CENTA: Dr. Lauwers, Dr. 22 Edwards, both of you spoke about the x-ray and MRI 23 equipment that was at Sick Children -- Sick Kids. I take 24 it that it -- in referring to that you were referring 25 both to the physical plant -- the actual capital

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1 investment -- but also the -- the professionals that 2 analyse the data that emerges from them. 3 Is that -- do I have that right? 4 DR. ALBERT LAUWERS: That's correct. You 5 know, to properly interpret a pediatric film is no small 6 feat. 7 MR. ROBERT CENTA: And in your opinion, 8 would it make sense to attempt to replicate the capital 9 infrastructure that exists at the Hospital for Sick 10 Children in terms of MRIs and x-ray equipment designed 11 for pediatric cases at Grenville? 12 DR. ALBERT LAUWERS: I think -- not at 13 the Grenville site, but I think our ultimate plan is to 14 have a facility with state-of-the-art technology, and I 15 think that's what I've heard from Dr. Pollanen. 16 MR. ROBERT CENTA: And how important is 17 the presence of forensically-trained pathologists on 18 staff at the Hospital for Sick Children to ensuring the 19 relationship that you've spoken so strongly about? 20 Does it give you confidence that there are 21 forensically-trained pathologists like a Dr. Chiasson -- 22 DR. ALBERT LAUWERS: Yeah. 23 MR. ROBERT CENTA: -- at the institution? 24 DR. ALBERT LAUWERS: Yeah, it's very 25 important. I know in the last month there was a case in

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1 which it started out as a case that was thought to be a 2 medically-related death, and by the completion of the x- 3 rays, it became clear that there were other issues at 4 stake. And the original pathologist -- the pediatric 5 pathologist -- abandoned the approach and simply said, I 6 have to have Dr. Chiasson do the case. 7 DR. JAMES EDWARDS: Yes, that's exactly 8 correct. Or alternatively if the pediatric pathologist 9 were to start the autopsy and find injuries that weren't 10 expected, they can have a forensic pathologist do the 11 autopsy. It really enables us to be able to send cases 12 to Sick Kids. 13 We often -- we don't necessarily know at 14 the outset how these cases are going to turn out and 15 without being 100 percent -- if it appears to be medical 16 and -- though we can never be 100 percent sure, we can 17 send the case to Hospital for Sick Children to be 18 autopsied with the knowledge that if it turns out to be a 19 forensic case, it will be treated appropriately. 20 MR. ROBERT CENTA: And leaving aside the 21 particulars of Dr. Chiasson, but systemically, do you 22 think it is important that if the Sick Kids continue to 23 perform its current function that there be a strong 24 forensically-trained presence at the site? 25 DR. ALBERT LAUWERS: Absolutely.

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1 MR. ROBERT CENTA: Dr. Lucas, do you 2 agree with that? 3 DR. WILLIAM LUCAS: I would agree, and I 4 think what we're hearing is that there's a -- a best- 5 practices model there that -- that could be emulated, 6 perhaps not quite to the same level of sophistication, 7 but certainly to an acceptable level of -- of 8 sophistication and quality at other centres around the 9 province. 10 And I think that -- that certainly, to my 11 way of thinking, is the appropriate direction we should 12 be heading. 13 MR. ROBERT CENTA: Given -- given the 14 geographic size on Ontario and remembering that -- that 15 pediatric forensic cases involving criminally suspicious 16 -- or potentially criminally suspicious or potentially 17 homicide cases is a small number in any one (1) year, 18 what are your thoughts on the best way to organize the -- 19 the provision of -- of pediatric forensic pathology 20 across Ontario? 21 How do we -- how would you recommend that 22 that best happen given the need for access -- competing 23 values of accessibility and efficiency, competence in 24 quality control? 25 DR. WILLIAM LUCAS: Once again, I think

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1 it's a good question to put to the forensic pathologists 2 to see what their -- their thoughts on it are. From -- 3 from our perspective, I think there is some value in 4 having three/four (3/4) centres around the province to 5 address those geographic concerns that you raise. 6 At the same time, understanding that there 7 may be, based on the particular circumstances of any one 8 (1) case, a reason to bypass what might be the -- the 9 closest local centre and come down to the -- the centre 10 in Toronto if the -- the nature of the case is 11 particularly perplexing or there's some issues about it 12 where you want the highest level of expertise that's 13 available in the province. 14 And again, considering the relatively 15 small volume, I see no reason why our office would, in 16 anyway, be hesitant to absorb whatever additional expense 17 was required to that to make sure that we were getting 18 the best product at the end of the process. 19 MR. ROBERT CENTA: Dr. Lauwers...? 20 DR. ALBERT LAUWERS: I think the model is 21 for Centres of Excellence. That's the -- what the 22 clinical world has found. You create several locales 23 that are -- are largely representative of the province, 24 and you create Centres of Excellence with all the 25 radiology technicians; you know, pathology assistants

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1 that are accustomed to doing the case. But there has to 2 be sufficient volume in those centres to -- to allow that 3 expertise to be maintained. 4 COMMISSIONER STEPHEN GOUDGE: The 5 additional cost you spoke of, Dr. Lucas, is very largely 6 transportation? 7 DR. WILLIAM LUCAS: Yes. 8 COMMISSIONER STEPHEN GOUDGE: What are we 9 talking about? Order of magnitude -- 10 DR. WILLIAM LUCAS: Transportation -- 11 COMMISSIONER STEPHEN GOUDGE: -- per 12 case? 13 DR. WILLIAM LUCAS: Yeah. It can be 14 measured in terms of thousands of dollars. Certainly, my 15 understanding is -- 16 COMMISSIONER STEPHEN GOUDGE: Like ten 17 (10), three (3)? 18 DR. WILLIAM LUCAS: Yeah. Three (3) to 19 ten (10). My understanding -- 20 COMMISSIONER STEPHEN GOUDGE: I thought I 21 was giving an impossible extremes, Dr. Lucas. 22 DR. WILLIAM LUCAS: It's my understanding 23 that in the far north that sometimes bills in excess of 24 ten thousand dollars ($10,000) can be -- can be obtained 25 for remote communities where you're -- our office is

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1 flying in OPP officers in a -- in a chartered plane, and 2 a body is being -- 3 COMMISSIONER STEPHEN GOUDGE: To pick 4 them up? 5 DR. WILLIAM LUCAS: -- extricated to 6 another community and so on. So they can be appreciable. 7 COMMISSIONER STEPHEN GOUDGE: But given 8 the numbers, these are manageable costs -- 9 DR. WILLIAM LUCAS: Exactly. 10 COMMISSIONER STEPHEN GOUDGE: -- in the 11 overall scheme of things? 12 DR. WILLIAM LUCAS: Exactly. The other 13 cost factors to -- to bear in mind are not directly ours, 14 but they would be absorbed by police services that have 15 to go to the -- you know, the -- travel down to Toronto 16 to be present at the autopsy and that sort of thing. 17 So that there -- there are some issues in 18 terms of cost and inconvenience for them, but I think, as 19 you say, given the small volumes that's probably, you 20 know, something that they would be willing to accept too 21 knowing that the likelihood of -- of success in terms of 22 a good product, a good analysis, a good assessment of the 23 case at the end is -- is going to be there. 24 DR. JAMES EDWARDS: And I guess while -- 25 while Ontario's geographically a very large province,

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1 most of the cases that we have sent into our office -- 2 because most of the population is centered in -- with -- 3 within a reasonable distance of Toronto tends not be -- 4 they tend not to come from a -- a very long distance. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 7 CONTINUED BY MR. ROBERT CENTA: 8 MR. ROBERT CENTA: One (1) of -- speaking 9 of Centres of Excellence and -- and localizing centres, 10 do you have any thoughts on whether there are advantages 11 to having the Regional Coroner located where the forensic 12 pathology is taking place? 13 Dr. Lucas...? 14 DR. WILLIAM LUCAS: The short answer to 15 that is very much so, and I've had the experience of 16 being in Toronto where I was in close proximity to that 17 and being in -- in two (2) centres that you didn't have 18 that luxury. The -- 19 MR. ROBERT CENTA: Can you just describe 20 -- or name those, so we can understand -- 21 DR. WILLIAM LUCAS: Yes, I was in -- I 22 was in St. Catharines for the Niagara region whereas the 23 forensic centre was in Hamilton. Had I stayed in -- in 24 Niagara, we would have relocated the office from St. 25 Catharines to Hamilton so that we would have that

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1 advantage. 2 Then, of course, in Toronto I was -- had 3 the same opportunity that my two (2) colleagues do now on 4 a daily basis to attend and -- and review the cases every 5 morning that have come in to be done, or the ones that 6 were done yesterday. 7 And now I'm back in the periphery in 8 Brampton for -- for my area of Peel, York and Durham that 9 I need to travel downtown if I want to be available to 10 have that sort of discussion, and the -- of course, the - 11 - the disadvantage that I have is that I don't have that 12 immediate quality assurance check that we heard described 13 before the autopsy is done; reviewing the -- the warrant 14 for post-mortem examination to make sure that the 15 information available to the pathologist is as 16 comprehensive as it should be, and so... 17 DR. JAMES EDWARDS: And just -- just by 18 way of to put it into context, the -- we have a Regional 19 Coroner's Office in Peterborough, but not in Ottawa, and 20 Ottawa will be one (1) of our forensic pathology units. 21 We have a Regional Coroner's Office in 22 Thunder Bay and many of the autopsies from the north are 23 done in Sudbury. And then there's the -- the distinction 24 between St. Catharines in Hamilton that Dr. Lucas alluded 25 to, so it isn't the case now that the Regional Coroner's

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1 Offices are in the same city; let alone the same building 2 as the pathology units that -- that serve them. 3 MR. ROBERT CENTA: And systemically, do 4 you think it's important to have at least -- to -- to 5 have them, at least, in the same city? 6 DR. JAMES EDWARDS: I do, yes. 7 MR. ROBERT CENTA: Dr. Lauwers...? 8 DR. ALBERT LAUWERS: I have nothing more 9 to say. I -- I think it's very important. 10 MR. ROBERT CENTA: How -- how much of an 11 advantage is it for the Regional Coroner to be able to 12 attend rounds -- forensic pathology rounds -- pediatric 13 forensic pathology rounds? 14 DR. ALBERT LAUWERS: Oh, it's -- it's an 15 integral part of everything we do. I -- I -- it's a 16 really -- professionally, it's very fulfilling, but in 17 terms of the management of the system, it's -- it's very 18 important. 19 Communication is the key in a death 20 investigation, in my view. And it provides an 21 opportunity for Dr. Pollanen, myself, Dr. Edwards, and 22 the other pathologists and coroners to meet in the 23 morning and discuss the individual management of cases. 24 By that I mean, review of that post-mortem 25 report, the opportunity to discuss any further

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1 information that should be obtained before the autopsy 2 starts. It may even mean either cancelling the autopsy 3 or putting the autopsy off for a day until we have the 4 required information that the -- the pathologist needs to 5 move the -- the whole process forward. 6 To be able to attend those rounds on a 7 daily basis is important, but equally, in my view, it's 8 very important for me to be able to attend the rounds at 9 the Hospital for Sick Children with regard to their 10 processes, and it's the same -- same discussion all over 11 again, you know, where they see issues with regard to 12 care, patient safety, public safety. 13 You know, they -- they'll raise it with me 14 at the table and they'll say, Would -- would you assist 15 us by warranting those records? We'll take a look at 16 them. And the whole process of -- of patient safety is 17 advanced by that particular initiative. 18 I think it's an integral thing. 19 DR. JAMES EDWARDS: And I guess -- and 20 Dr. Lauwers discussed how we interact with pathologists 21 on a daily basis around cases. We also interact with 22 them around policy development. 23 So, for example, we sometimes do external 24 autopsies instead of full autopsies in -- in certain 25 cases, and Dr. Pollanen and us, and -- and the Regional

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1 Coroners did a study around that, is -- is that working, 2 how well is that working, and that type of interaction 3 around policy development is really facilitated by being 4 in the same building. 5 Also, in regards to issues of staff safety 6 and public health safety, it's beneficial to be in the 7 same building, so if we have -- a case -- we've had 8 several cases where the -- they'll be doing an autopsy in 9 our building, and they determine the person has 10 meningitis, so obviously that raises a lot of concerns 11 about -- about the safety of the staff who are doing the 12 autopsy, and also potentially people who were exposed to 13 that person prior to death, family members, people at 14 school, whatever. 15 And those type of issues are really best 16 sorted out by pathologists and coroners acting together. 17 The pathologists can give opinions regarding what 18 organism is likely to be based on their examination of 19 the body, and were in a position to interact with public 20 health and initiate antibiotic prophylactics for our 21 staff who'll require it, and that happens actually quite 22 often. 23 And then, lastly, another area where we 24 interact well together is in education. So in our most 25 recent New Coroners' Course Dr. Pollanen provided a

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1 session to -- to our coroners -- to the new coroners 2 regarding how to examine a body, which is very helpful. 3 And similarly, we've helped -- he has 4 residents coming -- coming in and doing time in our -- in 5 our office and we've instructed them on -- on 6 enucleations so that -- it wor -- it works both ways. 7 So that day-to-day interaction, it just -- 8 it's -- it's good for the people of Ontario. It's -- we 9 just get a better product all around on many different 10 levels. 11 MR. ROBERT CENTA: You raised the -- the 12 New Coroners' Course, and I'm interested in exploring 13 with you how well you think the New Coroners' Course is 14 preparing coroners to deal with complicated pediatric 15 death investigations? 16 DR. ALBERT LAUWERS: Firstly, it's a bit 17 of a loaded question so I'll maybe dissect a little bit. 18 To be clear, there's only two hundred and 19 forty (240) pediatric deaths -- in the province a year, 20 and of those, probably between five (5) and ten (10) and 21 usually about seven (7) to eight (8) are homicides. So a 22 pediatric death may not come to a coroner for a 23 protracted period of time and in some locales, never. 24 To answer the question, the -- the 25 coroners get instruction with regard to -- as Dr. Edwards

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1 suggested -- the examination of the body, so there's a 2 pathology piece. 3 In addition, Dr. Parai does a three (3) 4 hour lecture on forensic pathology to the coroners as 5 well. They get an indoctrination into the relevant 6 legislation, policies, practices which will govern their 7 -- their investigations, the various Death Review 8 Committees, and they get a one (1) hour lecture with 9 regard to management of pediatric cases. 10 And just to put it in perspective. You 11 know the pediatric deaths are two hundred and forty (240) 12 of twenty thousand (20,000), which is 1 percent, and the 13 time that they get dedicated to that at the New Coroners' 14 Course -- in fact, if you take a twelve (12) to fifteen 15 (15) hour course, they get the full hour, plus they get 16 the advantage of the -- the general forensic pathology 17 piece which is relevant to pediatrics as well. 18 DR. JAMES EDWARDS: Sorry, I'm not -- 19 MR. ROBERT CENTA: Dr. Edwards...? 20 DR. JAMES EDWARDS: -- sure how much your 21 question suggests that we should expand the New Coroners' 22 Course. 23 But I don't really see -- personally, I 24 don't see much benefit in it. The coroners first -- the 25 new coroners, before they attend the course, have to read

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1 relevant legislation and they have to write a test before 2 they attend at the course. I actually mark those tests, 3 so I'm familiar with that. 4 They attend the course. They have ongoing 5 support by the -- by the Regional Supervising Coroner, 6 and we have the ability to be able to encourage our new 7 coroners to shadow more experienced coroners. And we 8 also provide them with ongoing education by ourselves. 9 We have quarterly meetings in Toronto with the Toronto 10 coroners, and we have experts come in and speak with 11 coroners. We've had hematologists speak about blood -- 12 blood reactions, had psychiatrists talk about suicides 13 and so on and so forth so it's -- the New Coroners' 14 Course is not the only education the coroners are 15 getting. 16 And then in addition to that, there's the 17 annual Coroners' course that they can attend every two 18 (2) or three (3) years. So I don't personally think 19 there would be -- really it would be a good use of 20 resources to expand the New Coroners' Course in terms of 21 pediatric death investigations or for any other purpose. 22 MR. ROBERT CENTA: And am I right -- 23 COMMISSIONER STEPHEN GOUDGE: Can I just 24 ask a general question and that is on the pathology side 25 of what we have heard. We have clearly heard a number of

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1 people say that the pathology in pediatric death cases is 2 quite distinctly different from the pathology in adult 3 deaths. 4 Is that true for criminal -- for death 5 investigations? 6 That is, would the three (3) of you say 7 that, by and large, the two hundred and forty (240) 8 pediatric death investigations represent more complex 9 investigations generally than the run of the mill -- I 10 should not put it that way -- than the other death 11 investigations you would undertake? 12 Is there a similar kind of correlation 13 between pediatric death investigations and complexity as 14 there is on the pathology side? 15 DR. JAMES EDWARDS: I'd say they're more 16 complex. 17 Initially, most -- most of the 18 investigations we do are, as we said, natural deaths 19 and -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. JAMES EDWARDS: -- it's quite 22 apparent right from the outset. Pediatric deaths are 23 much more complex, they tend to present in an 24 undifferentiated manner. We don't really know what the 25 manner of death is, and it just requires a much more

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1 complex investigation. 2 COMMISSIONER STEPHEN GOUDGE: Now this 3 goes back to a discussion we had a little bit this 4 morning. I mean, does that suggest any, perhaps, merit 5 in considering, sort of, a specialization amongst 6 coroners for death investigations? 7 That is, if there is an expertise that one 8 develops in pediatric death investigations, if they are 9 generally more complex, is there any room for considering 10 that sort of evolution amongst your coroners? 11 DR. JAMES EDWARDS: I guess there are 12 cases where we do tend to -- if we have the option and 13 it's -- and it's sort of practically possible, we will 14 assign appropriate coroners to do -- 15 COMMISSIONER STEPHEN GOUDGE: Yes, and we 16 talked about that -- 17 DR. JAMES EDWARDS: Yeah. 18 COMMISSIONER STEPHEN GOUDGE: -- this 19 morning. 20 And maybe we are just tilling a little 21 ground here, but do any of you -- either -- any of the 22 three (3) of you have any thoughts on that, viewing it 23 from this perspective? 24 DR. ALBERT LAUWERS: I think the Death -- 25 Death Under Five questionnaire was designed to be the

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1 great equalizer. It recognizes the fact that 2 investigating coroners are going to find the pediatric 3 deaths more troublesome and it allows them to follow a 4 pathway to getting all the necessary information and 5 gathering it to -- to be able to provide a fulsome 6 information. 7 And given the -- the breadth or the -- the 8 great expanse of the Province and the few numbers of 9 cases that are really out there, it would be hard, Mr. 10 Commissioner, for me to envision a specialized group of 11 coroners just really looking at -- 12 COMMISSIONER STEPHEN GOUDGE: So it is 13 just kind of impractical, is that it? 14 DR. WILLIAM LUCAS: Mm-hm, yes. 15 COMMISSIONER STEPHEN GOUDGE: Now, all 16 three (3) of you are nodding. 17 DR. WILLIAM LUCAS: It's exactly what I 18 was going to say, that you might have one (1) or two (2) 19 coroners that -- and -- and we do have coroners that -- 20 that have that degree of expertise -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. WILLIAM LUCAS: -- but the practical 23 reality of trying to disperse them around the Province 24 for those relatively few cases that occur -- when we've 25 developed, if you will, a bit of a safety net to --

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1 COMMISSIONER STEPHEN GOUDGE: So that is 2 a distinction between death investigation by an 3 investigating coroner and pathology, in the sense that 4 the coroner goes to the site, the pathologist can have 5 the body brought to the coroner -- to the pathologist? 6 DR. WILLIAM LUCAS: Correct. 7 COMMISSIONER STEPHEN GOUDGE: But is 8 intriguing that there are these two (2) approaches with 9 pediatric pathology -- 10 DR. WILLIAM LUCAS: Mm-hm, yes. 11 COMMISSIONER STEPHEN GOUDGE: -- and 12 obviously we have -- you pride yourselves on being able 13 to access the specialization at Sick Kids. 14 DR. WILLIAM LUCAS: Mm-hm. 15 16 CONTINUED BY MR. ROBERT CENTA: 17 MR. ROBERT CENTA: Commissioner, it's 18 4:25, and I may have one (1) area of very brief 19 examination tomorrow arising out of some questions -- 20 from the answers arising out of the review process, but I 21 need to look at a couple documents this evening. 22 COMMISSIONER STEPHEN GOUDGE: Okay. 23 MR. ROBERT CENTA: It might be an 24 appropriate time to break. And we've canvassed the 25 counsel for the parties, we have every expectation we

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1 will conclude tomorrow with time to spare. 2 COMMISSIONER STEPHEN GOUDGE: Okay. We 3 will rise then until 9:30 tomorrow morning. 4 5 (WITNESSES RETIRE) 6 7 --- Upon adjourning at 4:23 p.m. 8 9 10 Certified correct, 11 12 13 _____________________ 14 Rolanda Lokey, Ms. 15 16 17 18 19 20 21 22 23 24 25