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 17th, 2008 25

2
  1                        Appearances
  2  Linda Rothstein      (np) )     Commission Counsel
  3  Mark Sandler         (np) )
  4  Robert Centa         (np) )
  5  Jennifer McAleer          )
  6  Johnathan Shime       (np) )
  7  Ava Arbuck           (np) )
  8  Tina Lie                   )
  9  Maryth Yachnin       (np)  )
 10  Robyn Trask          (np)  )
 11  Sara Westreich       (np)  )
 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               )     Criminal Lawyers'
  6  Breese Davies        (np)  )    Association
  7  Joseph Di Luca       (np) )
  8  Jeffery Manishen      (np) )
  9  
 10  James Lockyer        (np) )     William Mullins-Johnson, 
 11  Alison Craig               )    Sherry Sherret-Robinson and
 12  Phillip Campbell     (np) )     seven unnamed persons
 13  Peter Wardle         (np) )     Affected Families Group
 14  Julie Kirkpatrick          )
 15  Daniel Bernstein     (np) )
 16  
 17  Louis Sokolov        (np) )     Association in Defence of
 18  Vanora Simpson            )     the Wrongly Convicted
 19  Elizabeth Widner      (np) )
 20  Paul Copeland         (np) )
 21  
 22  Jackie Esmonde        (np) )     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  Chantelle Blom     (np)    )
 10  
 11  Natasha Egan              )     College of Physicians and 
 12  Carolyn Silver     (np)   )     Surgeons
 13  
 14  Michael Lomer      (np)    )    For Marco Trotta
 15  Jaki Freeman        (np)   )
 16  
 17  Emily R. McKernan   (np)   )    Glenn Paul Taylor
 18  
 19  
 20  
 21  
 22  
 23  
 24  
 25

1 TABLE OF CONTENTS Page No. 2 3 DAVID FRANCIS DEXTER, Sworn 4 CHITRA RAO, Sworn 5 MICHAEL JAMES SHKRUM, Sworn 6 7 Examination-In-Chief by Ms. Jennifer McAleer 6 8 9 10 11 Certificate of transcript 328 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 --- Upon commencing at 9:30 a.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Good 6 morning. 7 Ms. McAleer...? 8 MS. JENNIFER MCALEER: Good morning, Mr. 9 Commissioner. This morning we are joined by three (3) of 10 the directors of the regional forensic pathology units: 11 Dr. Shkrum, Dr. Rao, and Dr. Dexter. I'd ask Mr. 12 Registrar if he'd swear in the witnesses. 13 14 DAVID FRANCIS DEXTER, Sworn 15 CHITRA RAO, Sworn 16 MICHAEL JAMES SHKRUM, Sworn 17 18 EXAMINATION-IN-CHIEF BY MS. JENNIFER MCALEER: 19 MS. JENNIFER MCALEER: Thank you, Mr. 20 Registrar. Good morning, Doctors. 21 DR. DAVID DEXTER: Good morning. 22 DR. MICHAEL SHKRUM: Good morning. 23 DR. CHITRA RAO: Good morning. 24 MS. JENNIFER MCALEER: Before you you 25 should have three (3) volumes of documents. We're going

1 to start by looking at the first volume. So if you could 2 open that up before you. And I'd like to begin by 3 briefly reviewing your backgrounds, and I'd like to start 4 with Dr. Rao. 5 Dr. Rao, you'll see that your resume is at 6 Tab 2 of Volume I. You have that before you? 7 DR. CHITRA RAO: Yes. 8 MS. JENNIFER MCALEER: And you obtained 9 your medical degree in India in 1966? 10 DR. CHITRA RAO: That's correct. 11 MS. JENNIFER MCALEER: And you then 12 proceeded to do a Rotary Housemanship at St. Martha's 13 Hospital in Bangalore, India. 14 What -- what is a Rotary Housemanship? 15 DR. CHITRA RAO: That means you rotate 16 through different departments, the major, the medicine, 17 surgery, gyne and obstetrics, pediatrics. So you do -- 18 MS. JENNIFER MCALEER: And would 19 pathology have been a part of that? 20 DR. CHITRA RAO: No, that's a clinical 21 rotation. 22 MS. JENNIFER MCALEER: I see. And then 23 you proceeded to do a residency in pathology at St. 24 Martha's Hospital in India between 1968 and 1970? 25 DR. CHITRA RAO: That's correct.

1 MS. JENNIFER MCALEER: And as part of 2 your residency in pathology, did you have exposure to 3 forensic pathology? 4 DR. CHITRA RAO: In India? 5 MS. JENNIFER MCALEER: Yes. 6 DR. CHITRA RAO: No. 7 MS. JENNIFER MCALEER: Okay. And you 8 then spent from 1970 to 1971 as a tutor in pathology and 9 microbiology -- and we see that on page 3 of your resume 10 -- at St. John's Medical College, also at the University 11 of Bangalore. 12 And was there any forensic pathology 13 component to that period of time? 14 DR. CHITRA RAO: No. 15 MS. JENNIFER MCALEER: Okay. And then in 16 1971 you immigrated to Canada? 17 DR. CHITRA RAO: That's correct. 18 MS. JENNIFER MCALEER: And between July 19 of 1972 and December of 1972 you had a short period of 20 time practising general medicine in Jamaica? 21 DR. CHITRA RAO: That's correct. 22 MS. JENNIFER MCALEER: And then you 23 returned to Canada in 1973, and between 1973 and 1978 you 24 did a residency in general pathology through the 25 University of Toronto?

1 DR. CHITRA RAO: That's correct. 2 MS. JENNIFER MCALEER: And we see that on 3 page 1 of your resume. And you've listed the duties that 4 were included: surgical pathology, post-mortems, work in 5 clinical pathology. 6 Now, was there forensic pathology involved 7 as part of your residency? 8 DR. CHITRA RAO: Unfortunately, at that 9 time, no. 10 MS. JENNIFER MCALEER: Okay. And going 11 back to medical school just briefly for a moment, were 12 there any courses in forensic medicine or forensic 13 pathology when you were in medical school? 14 DR. CHITRA RAO: We had -- we had a 15 course in jurisprudence, medical jurisprudence. 16 MS. JENNIFER MCALEER: And can you just 17 briefly outline the -- the subject matter of that course? 18 What were you taught? 19 DR. CHITRA RAO: Legal aspect of medical 20 practice. And during that course we were also given 21 lectures by forensic pathologists and on various type of 22 interpretation of injuries and different types of blunt 23 force injuries, sharp force injuries, and difference 24 between manner of death, and what other manners, in 25 general.

1 MS. JENNIFER MCALEER: So you learned all 2 that when you were in medical school? 3 DR. CHITRA RAO: That's correct. 4 MS. JENNIFER MCALEER: And was that a 5 full year course? 6 DR. CHITRA RAO: During the third year of 7 medical course we had -- throughout the year we had 8 lectures maybe every two (2) months we had a lecture. 9 MS. JENNIFER MCALEER: All right. So 10 turning back then to your rotation in -- or sorry, your 11 residency in general pathology through the University of 12 Toronto, over the five (5) years you indicated there -- 13 there really wasn't a forensic component to that, but 14 were you actually doing medicolegal autopsies? 15 DR. CHITRA RAO: No, no. 16 MS. JENNIFER MCALEER: Okay. 17 DR. CHITRA RAO: We were only doing a 18 hospital autopsy. Our chairman at that time, Dr. Silver, 19 Malcolm Silver, wanted us to go and spend some time at 20 the Centre of Forensic Sciences forensic pathology 21 department, but then Dr. Hillsdon Smith was too busy and 22 we were not asked to go. So we did not have that 23 training during pathology training. 24 MS. JENNIFER MCALEER: Okay. And then if 25 we turn to page 2 of your resume, we see that you were

1 actually the senior resident from 1978 to 1980. 2 DR. CHITRA RAO: That's correct. 3 MS. JENNIFER MCALEER: Okay. And then 4 your first appointment was in June of 1980 as a associate 5 pathologist at the Belleville General Hospital. 6 DR. CHITRA RAO: That's correct. 7 MS. JENNIFER MCALEER: And you were there 8 from June of 1980 to September of 1981. 9 DR. CHITRA RAO: That's correct. 10 MS. JENNIFER MCALEER: And did you have 11 occasion to perform medicolegal autopsies at the 12 Belleville General Hospital? 13 DR. CHITRA RAO: I did. 14 MS. JENNIFER MCALEER: So that would have 15 been your first exposure then to the world of medicolegal 16 autopsies? 17 DR. CHITRA RAO: No. When I was doing my 18 residency -- senior residency under Dr. Ferris in 19 Hamilton General Hospital I was exposed to medicolegal 20 cases. 21 MS. JENNIFER MCALEER: All right. So 22 what years did you do your senior residency before Dr. -- 23 with Dr. Ferris? 24 DR. CHITRA RAO: Before accepting the 25 staff position.

1 MS. JENNIFER MCALEER: I see. So was 2 that a -- a full year with Dr. Ferris? 3 DR. CHITRA RAO: No, it's almost two (2) 4 years. 5 MS. JENNIFER MCALEER: Two (2) years, 6 okay. And what exposure did you have to medicolegal 7 autopsies with Dr. Ferris? 8 DR. CHITRA RAO: All cases which came 9 routinely through the department, it can be unnatural, 10 unexpected natural causes, suicide, accidents, all 11 varieties of forensic pathology cases I was exposed to. 12 And I did do autopsies under his direction. 13 MS. JENNIFER MCALEER: So were you doing 14 100 percent medicolegal work then when you were with Dr. 15 Ferris? 16 DR. CHITRA RAO: That's correct. 17 MS. JENNIFER MCALEER: Okay. And were 18 you the only one working with Dr. Ferris at that time? 19 DR. CHITRA RAO: For a short while, and 20 then we had another senior resident coming into the 21 program; Dr. Roy. 22 MS. JENNIFER MCALEER: Okay. And what 23 years was that that you did that residency? 24 DR. CHITRA RAO: '78 to '80. 25 MS. JENNIFER MCALEER: I see. So when

1 its senior resident, Hamilton General Hospital, that's 2 with Dr. Ferris? 3 DR. CHITRA RAO: That's correct. 4 MS. JENNIFER MCALEER: All right. Okay. 5 And then we talked a bit about your time in Belleville, 6 and then you moved on to the Hamilton General Hospital -- 7 sorry, I should say went back to the Hamilton General 8 Hospital. And you were a staff forensic pathologist, 9 part-time, between October of 1981 and March of 1984. 10 DR. CHITRA RAO: That's correct. 11 MS. JENNIFER MCALEER: And can you just 12 give us a brief description of your practice at that 13 point in time? How much medicolegal, how much hospital 14 autop -- 15 DR. CHITRA RAO: Only medicolegal cases I 16 did when I was working as a part-time forensic 17 pathologist. 18 MS. JENNIFER MCALEER: All right. So at 19 the same time you were also working as a part-time staff 20 pathologist at the Hotel Dieu Hospital -- 21 DR. CHITRA RAO: That's correct. 22 MS. JENNIFER MCALEER: -- in St. 23 Catherine's? 24 DR. CHITRA RAO: That's correct. 25 MS. JENNIFER MCALEER: And what work were

1 you doing at Hotel Dieu? 2 DR. CHITRA RAO: We did surgical 3 pathology, cytology, I did a little bit of 4 hematopathology, and autopsies; it could be hospital 5 admitted cases. They -- they had three (3) different 6 categories: hospital admitted coroner's case, and then 7 external coroner's case, and the hospital cases. 8 MS. JENNIFER MCALEER: Okay. So you were 9 getting some exposure to coroner's cases as well? 10 DR. CHITRA RAO: That's correct. 11 MS. JENNIFER MCALEER: And then between 12 April of 1984 and present, you were senior staff at the 13 Regional Forensic Pathology Unit at the Hamilton General 14 Hospital? 15 DR. CHITRA RAO: No. From 1984 till '92, 16 I was associate staff pathologist working with Dr. King, 17 and then I was appointed as the director of the unit in 18 1993 until my retirement in 2005. 19 And now I'm the senior pathologist there 20 on a contract basis and I do have administrative 21 responsibilities, and I'm the Director of the Unit. 22 MS. JENNIFER MCALEER: Right. You've 23 gotten a little ahead of me, but from -- from April of 24 1984 to present you've been with the Hamilton General 25 Hospital.

1 DR. CHITRA RAO: That's correct. 2 MS. JENNIFER MCALEER: And in particular, 3 with the Regional Forensic Pathology Unit that's based 4 out of that hospital. 5 DR. CHITRA RAO: That's correct. 6 MS. JENNIFER MCALEER: Okay. Now, you 7 also, between April and June of 1987, I understand, did a 8 three (3) month leave to the Office of the Chief Medical 9 Examiner in Richmond, Virginia. 10 DR. CHITRA RAO: That's correct. 11 MS. JENNIFER MCALEER: And what was the 12 purpose of taking that three (3) month leave? 13 DR. CHITRA RAO: I wanted more exposure 14 in different types of forensic cases; in particular, I 15 wanted to have more exposure to homicide cases. 16 MS. JENNIFER MCALEER: And did you obtain 17 more exposure to homicide cases when you were in 18 Virginia? 19 DR. CHITRA RAO: Yes, I did about fifty- 20 five (55) homicide cases within that three (3) month 21 period. 22 MS. JENNIFER MCALEER: Fifty-five (55) 23 within three (3) months? 24 DR. CHITRA RAO: Yes. 25 MS. JENNIFER MCALEER: And what level of

1 supervision did you have when you were in Virginia? 2 DR. CHITRA RAO: The first week the Chief 3 Medical Examiner, or Deputy Chief Medical Examiner, went 4 through my findings and later on they were satisfied that 5 I could handle it, and so I did not have direct 6 supervision but when I completed the autopsy report they 7 countersigned because I did not have licence to practice 8 there. 9 MS. JENNIFER MCALEER: All right. So you 10 had direct hands on participation in -- in autopsies, 11 medicolegal autopsies? 12 DR. CHITRA RAO: That's correct. 13 MS. JENNIFER MCALEER: You would author 14 reports and those reports would then be reviewed by your 15 colleagues? 16 DR. CHITRA RAO: That's correct. 17 MS. JENNIFER MCALEER: Okay. And I 18 understand that you also attended a medicolegal seminar 19 while you were in Virginia. 20 DR. CHITRA RAO: That's correct. 21 MS. JENNIFER MCALEER: Okay. And 22 overall, looking back over your career, how valuable was 23 that three (3) months that you spent in Virginia back in 24 1970 -- 1987? 25 DR. CHITRA RAO: That was a good

1 experience because it was a different kind of exposure, 2 that was a medical examiner's system, and so that was the 3 first time I was exposed to medical examiner system. And 4 they had a team who investigated the scene and then every 5 morning we had a roundtable conference around eight 6 o'clock going through the cases for that day, and then we 7 would the scene investigation information on every case. 8 And because I was a visiting pathologist, the Chief 9 Medical Examiner will give me the choice of choosing 10 which case I wanted to do that day, and then we went 11 along. 12 I think that was a very good experience. 13 MS. JENNIFER MCALEER: Now is that 14 something that Dr. Ferris had recommended to you? Had he 15 done something similar, as far as you know? 16 DR. CHITRA RAO: Yes, he did. 17 MS. JENNIFER MCALEER: Okay. And then 18 you came back to Hamilton, you stayed at the Regional 19 Forensic Pathology Unit, you became the Director in 1993? 20 DR. CHITRA RAO: Yes. 21 MS. JENNIFER MCALEER: Although that's 22 not on your resume, but we know that -- that's the year. 23 And then also between January of 1996 and 24 December of 2004 you've been the Pro -- you were the 25 Program Director of the General Pathology Residency

1 Program. 2 DR. CHITRA RAO: That's correct. 3 MS. JENNIFER MCALEER: And what are the 4 duties or responsibilities of that position? 5 DR. CHITRA RAO: I was the Program 6 Director for General Pathology, so I was responsible for 7 the general training aspects of general pathology, and I 8 had close contact with the residents who were doing 9 general pathology training. And I also had contact with 10 the Director of the submission-specialty and made sure 11 that the residents were exposed to all areas of the 12 submission-specialty. 13 And then I was also responsible to 14 evaluate them and -- or get the reports from different 15 supervisor from different areas and go through the 16 evaluation. And then I regularly met with each resident 17 and discuss about their progress, and if they had any 18 problem they'd come to me and then I'd look into that. 19 MS. JENNIFER MCALEER: Their -- their 20 career options? 21 DR. CHITRA RAO: Yes. 22 MS. JENNIFER MCALEER: And what was the 23 submission-specialty in particular that you were dealing 24 with? 25 DR. CHITRA RAO: All aspects of general

1 pathology: microbiology, hematology, and chemistry, 2 biochemistry, and -- and anatomical pathology. 3 MS. JENNIFER MCALEER: Right. And you 4 indicated that you retired in April of 2005, but it's 5 been a rather active retirement, hasn't it? 6 DR. CHITRA RAO: Yes. 7 MS. JENNIFER MCALEER: And -- and why is 8 that, Dr. Rao? 9 DR. CHITRA RAO: We have -- we have 10 advertised many times for positions and we haven't had 11 any successful candidate. Having said that, we have 12 recently interviewed a candidate; we are poss -- hoping 13 that the person will accept the position. 14 MS. JENNIFER MCALEER: All right. And a 15 little bit later we'll talk about some of the challenges 16 about finding people to practise forensic pathology. 17 But fair to say, Dr. Rao, that since April 18 of 2005, despite the fact that you've been officially 19 retired, you have been working full time? 20 DR. CHITRA RAO: That's correct. 21 MS. JENNIFER MCALEER: Okay. All right. 22 And then if we could turn, Dr. Dexter, to your resume, 23 which is at Tab 1 of Volume I. 24 DR. DAVID DEXTER: I have it. 25 MS. JENNIFER MCALEER: Thank you. You

1 obtained your medical degree frm the University of 2 Saskatchewan in 1971? 3 DR. DAVID DEXTER: Yes. 4 MS. JENNIFER MCALEER: And although your 5 residency isn't outlined on your resume, I understand 6 that between 1971 and 1972 you completed an internship 7 program in pathology at Queens University? 8 DR. DAVID DEXTER: Yes, I did. 9 MS. JENNIFER MCALEER: And that was a -- 10 a general pathology program, as I understand it. 11 DR. DAVID DEXTER: It was part of the 12 general path program, yes. 13 MS. JENNIFER MCALEER: And was there any 14 component of forensic pathology involved in that general 15 internship? 16 DR. DAVID DEXTER: Within the internship, 17 you start off doing anatomic pathology, and that usually 18 means you're put straight onto the autopsy service. 19 The autopsy service in Kingston General 20 Hospital and Hotel Dieu Hospital, which are the two (2) 21 hospitals that comprise the training program at Queens, 22 had an intermix of autopsies. So that they had, as Dr. 23 Rao indicated, hospital consented autopsies, hospital 24 based medicolegal autopsies, and medicolegal autopsies. 25 So that was integrated into the training

1 program in anatomic pathology. 2 MS. JENNIFER MCALEER: Okay. And you've 3 distinguished between hospital based medicolegal 4 autopsies and medicolegal autopsies. 5 What -- what is the distinction between 6 the two (2)? 7 DR. DAVID DEXTER: It would be a death 8 occurring in hospital in circumstances that the coroner 9 was informed, and there were concerns in documenting the 10 manner of death, and the cause of death, and so forth. 11 MS. JENNIFER MCALEER: As distinct from 12 hospitals (sic) that occur outside a hospital facility, 13 but are then subject to autopsy, pursuant to coroner's 14 warrant? 15 DR. DAVID DEXTER: Yes. 16 MS. JENNIFER MCALEER: Okay. But then 17 done in the hospital facility? 18 DR. DAVID DEXTER: Yes. 19 MS. JENNIFER MCALEER: All right. And 20 then between 1972 and 1975, you did a residency in 21 general pathology; a little bit distinct from the 22 internship. 23 Is that really just a matter of 24 classification, or did you continue to do the same kind 25 of work?

1 DR. DAVID DEXTER: It was the same kind 2 of work. It was a hierarchical process in which you 3 started off doing an internship. It was an unusual time 4 at which you could actually do straight internships in 5 pathology and then you went through an internship tit -- 6 entitlement, which was your first year after medical 7 school, and then you went -- you were formally called a 8 resident for the remaining four (4) years of the training 9 program in general pathology. 10 MS. JENNIFER MCALEER: And not only did 11 you do a residency in general pathology, but you then 12 proceeded to do a residency in anatomic pathology between 13 1975 and 1976. 14 Is that correct? 15 DR. DAVID DEXTER: I did an -- I did an 16 additional year of training to complete eligibility 17 requirements for anatomic pathology. 18 MS. JENNIFER MCALEER: Okay. And again 19 continued to have the same exposure to medicolegal 20 autopsies during that time period? 21 DR. DAVID DEXTER: Yes. 22 MS. JENNIFER MCALEER: And you heard Dr. 23 Rao indicate that when she went to medical school, there 24 was some component of forensic medicine taught at her 25 University.

1 When you went to medical school, Dr. 2 Dexter, was there any component of forensic medicine as a 3 part of the curriculum? 4 DR. DAVID DEXTER: No. 5 MS. JENNIFER MCALEER: Were there any 6 lectures on forensic medicine, or in particular, forensic 7 pathology? 8 DR. DAVID DEXTER: Not at that time, no. 9 MS. JENNIFER MCALEER: Okay. And then 10 between 1976 and 1977, you completed a fellowship in 11 pathology at Memorial Sloan-Kettering Hospital in New 12 York? 13 DR. DAVID DEXTER: Yes. This was a 14 specialization in cancer pathology. 15 MS. JENNIFER MCALEER: Okay. And did you 16 have any exposure to forensic pathology during that 17 fellowship? 18 DR. DAVID DEXTER: No, I did not. 19 MS. JENNIFER MCALEER: Okay. And then 20 from 19 -- after you came back from New York in 1977, and 21 from 1977 to present I understand you have been part of 22 the attending staff at both the Hotel Dieu, and the 23 Kingston General? 24 DR. DAVID DEXTER: Yes, I have. 25 MS. JENNIFER MCALEER: Okay. And you've

1 also held a number of other staff appointments, and 2 they're listed on page 1 of your resume. You're on staff 3 at the Kingston Clinic. You've been active staff at the 4 Perth and Smiths Falls Community Hospital. Also on staff 5 at the Brockville General, St. Vincent de Paul Hospitals 6 in Brockville. 7 You continue to hold all those staff 8 positions, Dr. Dexter? 9 DR. DAVID DEXTER: I do. 10 MS. JENNIFER MCALEER: And what type of 11 work are you doing at the Kingston Clinic? 12 DR. DAVID DEXTER: I'm a consultant in -- 13 in cancer pathology -- 14 MS. JENNIFER MCALEER: All right. 15 DR. DAVID DEXTER: -- for the cancer 16 clinic. 17 MS. JENNIFER MCALEER: No medicolegal 18 autopsies is -- 19 DR. DAVID DEXTER: No medicolegal 20 autopsies, no. 21 MS. JENNIFER MCALEER: -- with that 22 position? 23 And with respect to the Perth and Smiths 24 Falls Community Hospital, is that again part of your 25 cancer specialty, or are you doing medicolegal work?

1 DR. DAVID DEXTER: Neither of those. I 2 offer general pathology directorship of the laboratory 3 responsibilities to both -- to Perth and Smiths Falls 4 Hospital. 5 MS. JENNIFER MCALEER: So that's primary 6 surgical pathology, is it? 7 DR. DAVID DEXTER: It's actually more 8 clinical pathology. So it's hematology, blood banking, 9 chemistry. 10 MS. JENNIFER MCALEER: All right. And 11 then the staff position with the Brockville General 12 Hospital and the St. Vincent de Paul Hospitals? 13 DR. DAVID DEXTER: That was to provide, 14 principally, anatomic pathology services to that hospital 15 at a time where they only have a single pathologist and 16 there were issues of coverage, and I assisted in 17 providing services while the incumbent was away. 18 MS. JENNIFER MCALEER: All right. Then 19 between September of 1991 and July of 1997 you were the 20 Director of Laboratories and Deputy Chief of Pathology at 21 the Hotel Dieu Hospital? 22 DR. DAVID DEXTER: Yes. 23 MS. JENNIFER MCALEER: Can you briefly 24 describe your responsibilities in that position? 25 DR. DAVID DEXTER: Yes. We had a -- a

1 department -- Hotel Dieu Hospital at that time was an 2 active inpatient facility, and it had four (4) 3 pathologists including myself, a microbiologist, and a 4 biochemist, and a full service laboratory for which I was 5 responsible for all aspects including not only the 6 administration, but the fiscal management of that. 7 Additionally, part of my responsibilities 8 during that time was to redesign the entire laboratory 9 and I participated in that activity as well. During that 10 time, I continued to pull my fair share of duties as an 11 anatomic pathologist performing medicolegal autopsies on 12 a regular rotational basis, sharing those with my 13 colleagues in anatomic pathology. 14 MS. JENNIFER MCALEER: Okay. And then 15 between 2000 and 2001 you assumed the position of Acting 16 Director of the Regional Forensic Pathology Unit in 17 Kingston? Who had preceded you or were you the first 18 acting director? 19 DR. DAVID DEXTER: Dr. Sally Ford 20 preceded me. 21 MS. JENNIFER MCALEER: And what was Dr. 22 Ford's background? 23 DR. DAVID DEXTER: She was primarily an 24 anatomic pathologist with specialization in 25 cardiovascular pathology. She had originally come from a

1 background as a general practitioner and then had taken 2 pathology training at Queen's and additional studies, I 3 believe, in Toronto with perhaps Dr. Silver; I'm not 4 certain on that. 5 And then she had spent some time in the 6 forensic unit. I think more on that nature of perhaps a 7 week of so of working with Dr. Hillsdon Smith at that 8 time. More details of her background, I -- I'm not 9 certain about. 10 MS. JENNIFER MCALEER: Right. And as far 11 as you know, Dr. -- Dr. Dexter, she hadn't had any formal 12 board certification in forensic pathology -- 13 DR. DAVID DEXTER: No, she did not. 14 MS. JENNIFER MCALEER: -- from the 15 States. 16 DR. DAVID DEXTER: No. 17 MS. JENNIFER MCALEER: Okay. And then in 18 2001 you assumed the position of Director of the Unit. 19 And you've held that position until 20 present? 21 DR. DAVID DEXTER: Correct. 22 MS. JENNIFER MCALEER: And you're also 23 currently the Director of Autopsy Services for the 24 Kingston General Hospital? 25 DR. DAVID DEXTER: Correct.

1 MS. JENNIFER MCALEER: And just briefly, 2 Dr. Dexter, what is the current breakdown of your 3 practice? 4 I know -- I should have asked you, Dr. 5 Rao, but you're doing 100 percent medicolegal work, 6 aren't you? 7 DR. CHITRA RAO: That's correct. 8 MS. JENNIFER MCALEER: Okay. And -- and, 9 Dr. Dexter, what is the breakdown of your practice? 10 DR. DAVID DEXTER: Currently, and it's 11 been that way for the past several years, the majority of 12 the autopsy cases we do are medicolegal. The approximate 13 numbers that we've been performing each year is 14 approximately three hundred and ten/three hundred and 15 twenty (310/320) autopsies. 16 MS. JENNIFER MCALEER: Right. And I'll - 17 - I'll -- 18 DR. DAVID DEXTER: Of those -- 19 MS. JENNIFER MCALEER: -- take you to the 20 -- the numbers that we've prepared. But just as a 21 general division of your workload, are you doing 60 22 percent medicolegal, 40 percent hospital general 23 pathology or how would you divide it? 24 DR. DAVID DEXTER: You're talking about 25 my personal workload?

1 MS. JENNIFER MCALEER: Yes. 2 DR. DAVID DEXTER: It -- it's a little 3 complicated to explain because I am on regular rotation 4 for autopsy service at which time I would do all cases, 5 hospital or medicolegal ones or forensic ones. And that 6 rotation is of the order of about once every five (5) to 7 six (6) weeks. 8 Because of my responsibilities, which I 9 share with Dr. Ian Young, who is the head of our 10 department who also forensic pathologist, we're available 11 to do those types of homicide or suspicious cases, 12 basically on a one (1) and two (2) basis. 13 So I could get a case in which I might 14 find myself faced with doing a medicolegal autopsy, but 15 additionally continuing to carry my gastrointestinal 16 biopsy sign-out or my hematology sign-out, all on the 17 same day. It would make a very heavy day. 18 MS. JENNIFER MCALEER: Right. 19 DR. DAVID DEXTER: Does that address the 20 question? 21 MS. JENNIFER MCALEER: I think so. I -- 22 I just -- I'm trying to get a feel for -- in a given year 23 though are you doing -- is half your practice medicolegal 24 autopsy and half of it is hospital and surgical 25 pathology?

1 Is that fair? Or is it a different 2 breakdown? 3 DR. DAVID DEXTER: Just dealing with the 4 split between hospital and medicolegal, it's two thirds 5 (2/3s) medicolegal, one third (1/3) hospital, and so 6 anybody who is on autopsy service would be exposed to 7 that approximate division of labour. 8 From the percentage of -- of work that I'd 9 do, I would say probably somewhere between 20 and 25 10 percent of my time is focussed on the autopsy service. 11 MS. JENNIFER MCALEER: Okay, that helps. 12 Thank you. And I understand that you've done, over the 13 course of your career, in excess of a thousand (1,000) 14 medicolegal autopsies? 15 DR. DAVID DEXTER: Yes. 16 MS. JENNIFER MCALEER: And, Dr. Rao, are 17 you able to give us any kind of estimation as to the -- 18 how many medicolegal autopsies you've done over the 19 course of your career? 20 DR. CHITRA RAO: I've done about seven 21 thousand (7,000) medicolegal cases and about three 22 hundred and fifty (350) cases, mainly homicides and equal 23 number of suspicious deaths. 24 MS. JENNIFER MCALEER: All right. And 25 we've seen -- that's on your resume, isn't it?

1 DR. CHITRA RAO: Yes. 2 MS. JENNIFER MCALEER: You've done seven 3 thousand (7,000) hospital and medicolegal autopsies? 4 DR. CHITRA RAO: Yes. 5 MS. JENNIFER MCALEER: And of that about 6 three hundred and fifty (350) have been homicides? 7 DR. CHITRA RAO: That's correct. 8 MS. JENNIFER MCALEER: And then an equal 9 number of criminally suspicious cases? 10 DR. CHITRA RAO: Equal number or more. 11 MS. JENNIFER MCALEER: Okay. Thank you, 12 Dr. Dexter. If we could now turn to you, Dr. Shkrum. 13 You're resume is at Tab 3 of Volume I. 14 You obtained your medical degree in 1978 15 from the University of London, here in Ontario? 16 DR. MICHAEL SHKRUM: University of 17 Western Ontario in London. 18 MS. JENNIFER MCALEER: University of 19 Western Ontario, sorry, in London. 20 You then completed your residency between 21 1978 and 1984? 22 DR. MICHAEL SHKRUM: No, actually I did 23 my internship from 1978 and then did my residency from 24 1979 to 1984. 25 MS. JENNIFER MCALEER: Correct, sorry, I

1 combined the two (2). So from 1978 to 1979 you did a 2 rotating internship at the Ottawa Civic Hospital? 3 DR. MICHAEL SHKRUM: Yes, I did. 4 MS. JENNIFER MCALEER: And then from 1979 5 to 1984 you did your residency in anatomic pathology? 6 DR. MICHAEL SHKRUM: Yes, I returned back 7 to London to do my residency there. 8 MS. JENNIFER MCALEER: All right. And 9 when you went to medical school, Dr. Shkrum, was there 10 any component of forensic medicine taught? 11 DR. MICHAEL SHKRUM: Yes, in the fourth 12 year medicine -- or year, there was a forensic medicine 13 course offered by Dr. Douglas Mills, M-I-L-L-S, who is a 14 hospital based pathologist who practised forensic 15 pathology in London, and he offered an optional course to 16 fourth year medical students. 17 MS. JENNIFER MCALEER: And -- and you 18 took that course? 19 DR. MICHAEL SHKRUM: Yes, I did. 20 MS. JENNIFER MCALEER: And what did you 21 learn? 22 DR. MICHAEL SHKRUM: Well, I -- I had an 23 interest in doing forensic pathology and his course is an 24 overview of different types of injuries can -- that can 25 occur in a forensic setting. We also learned about the

1 Coroner's Act and interpretation of cause and manner of 2 death. 3 MS. JENNIFER MCALEER: And what was it, 4 Dr. Shkrum, that drew you to forensic pathology that 5 early on, when you were in medical school? 6 DR. MICHAEL SHKRUM: Well, I think there 7 was -- certainly was a tv program at the time called 8 Quincy that was quite interesting, and you know, he had-- 9 MS. JENNIFER MCALEER: You're not the 10 first to mention that. 11 DR. MICHAEL SHKRUM: And, you know, 12 forty-five (45) everything was solved with commercials, 13 but that -- that attracted my interest. But I -- I 14 think, you know, inherently there was a -- you know, the 15 detective work, the trying to solve a puzzle, I think was 16 just inherently interesting. 17 So I became interested in forensic 18 pathology, and by excluding a number of other 19 specialties, I -- I went in that direction. 20 MS. JENNIFER MCALEER: All right. And 21 then when you were doing your residency in anatomical 22 pathology at the University of Western, did you have any 23 exposure to medicolegal work? 24 DR. MICHAEL SHKRUM: Yes. I -- I just 25 want to back track. Actually -- regarding my internship,

1 I did do a month of forensic patho -- or pathology 2 rotation at the Ottawa Civic Hospital, and had the good 3 fortune to meet Dr. David King, who's a colleague of Dr. 4 Rao's, because I had my interest in forensics, he 5 cemented that interest during my time in Ottawa. 6 During my residency there was exposure to 7 coroner's autopsies as part of the regular autopsy 8 service. We did assist -- or the pathologist that -- 9 that trained us. And also through Dr. Malcolm Silver who 10 is our Chair, I arranged to have a month rotation in -- 11 at the Coroner's Office in Toronto under the supervision 12 of Dr. Hillsdon Smith. 13 MS. JENNIFER MCALEER: All right. So 14 that you had exposure to medicolegal cases when you were 15 in Ottawa. 16 Did that include criminally suspicious 17 cases? 18 DR. MICHAEL SHKRUM: I don't recall any 19 specifically at that time. Again, I think it was just 20 luck of the draw. 21 MS. JENNIFER MCALEER: And -- and -- 22 DR. MICHAEL SHKRUM: But I did have some 23 exposure to that. 24 MS. JENNIFER MCALEER: At working with 25 Dr. King?

1 DR. MICHAEL SHKRUM: That's right. 2 MS. JENNIFER MCALEER: And then as part 3 of your residency you had arranged for one (1) month with 4 Dr. Hillsdon Smith in Toronto? 5 DR. MICHAEL SHKRUM: That's correct. 6 MS. JENNIFER MCALEER: Okay. And then 7 you took it a step further in 1984 and you did a 8 fellowship in forensic pathology with the Chief Medical 9 Examiner's Office in Chapel Hill, North Carolina? 10 DR. MICHAEL SHKRUM: Yes, I did. 11 MS. JENNIFER MCALEER: And what prompted 12 your decision to do that, Dr. Shkrum? 13 DR. MICHAEL SHKRUM: Well, just that I 14 had the interest in forensic pathology and -- and I -- 15 there was no real place to train in Canada at the time, 16 so I then looked at places in the states and looked at a 17 number of programs and finally settle -- settled on the 18 program at -- in North Carolina. 19 MS. JENNIFER MCALEER: And what exposure 20 did you have while doing that Fellowship? What kinds of 21 cases were dealing with? 22 DR. MICHAEL SHKRUM: Well, there -- there 23 was a service component which obviously we did 24 medicolegal autopsies. I did approximately two hundred 25 (200) cases in that year, of which about forty (40) were

1 homicides. 2 And I also had an administrative function. 3 I was appointed as an Assistant Chief Medical Examiner, 4 so I had an administrative function to review cases from 5 a defined region in the -- in the state, so in that -- in 6 that capacity, I -- I reviewed about fifteen hundred 7 (1,500) reports generated by the local medical examiners, 8 as well as autopsy reports. 9 And also, I would be responsible for the 10 proper certification of death on those cases. 11 MS. JENNIFER MCALEER: Okay. Now, 12 looking back over the course of your career, how valuable 13 was it to you to have gone and done this Fellowship? 14 DR. MICHAEL SHKRUM: Well, it was -- it 15 was priceless. I mean, it did allow me to subsequently 16 write my American Board of Forensic Pathology so I had a 17 formal certification in that discipline. 18 MS. JENNIFER MCALEER: So if we look at 19 page 2 of your resume, we see that you have a diplomat of 20 American Board of Pathology in forensic pathology and you 21 obtained that in 1986. 22 DR. MICHAEL SHKRUM: That's correct. 23 MS. JENNIFER MCALEER: And that's as a 24 direct result of doing your Fellowship in the states. 25 DR. MICHAEL SHKRUM: That's correct.

1 MS. JENNIFER MCALEER: Okay. You also, I 2 see, have a diplomat of the National Board of Medical 3 Examiners. I understand that's a general license that 4 allows you to practice medi -- medicine in the states. 5 DR. MICHAEL SHKRUM: It's a form of 6 qualifying exam. It would be the equivalent of the -- of 7 the licentiate of the Medical Counsel of Canada, which is 8 listed above that, so the LMCC is a qualifying exam that 9 allows a physician to become licensed in Canada. The 10 same would apply to the National Board of Medical 11 Examiners qualification for the United States. 12 MS. JENNIFER MCALEER: And then you have 13 your Royal College of Physicians and Surgeons 14 Certification in anatomical pathology. 15 DR. MICHAEL SHKRUM: Yes, I do. 16 MS. JENNIFER MCALEER: And then the 17 equivalent from the American Board of Pathology in the 18 US. 19 DR. MICHAEL SHKRUM: Yes. 20 MS. JENNIFER MCALEER: Okay. And from 21 1985 to present, you have been a staff pathologist with 22 the Department of Pathology at the Victoria Hospital, 23 which then became the London Health Sciences Centre. 24 DR. MICHAEL SHKRUM: Yes. 25 MS. JENNIFER MCALEER: Okay. And what is

1 the -- the breakdown of your work, Dr. Shkrum? How much 2 medicolegal work are you doing compared to other 3 responsibilities? 4 DR. MICHAEL SHKRUM: Well, it's actually 5 undergone a radical transition. When I was first hired 6 in 1985 at Victoria Hospital, I was hired as a hospital- 7 based pathologist, so I did surgical pathology; so I 8 looked at surgical biopsies, surgical specimens, examined 9 those specimens under the microscope. 10 I also did cytology so I looked at a lot 11 of Pap smears. And a small component of my practice, 12 probably an estimate of 10 percent of my practice, was 13 devoted to doing coroners autopsies. 14 And the practice was limited to the London 15 -- the immediate area of London. I did not take any 16 cases from outside because of the -- the hospital 17 responsibilities that I had. 18 So I had about 90 percent of a component 19 was non-forensic and about 10 percent of my practice was 20 -- was devoted to coroners autopsies. Over the years, 21 and particularly, in about the last couple of years, out 22 of necessity, my practice has shifted such that I'm 23 probably doing -- almost 95 percent of my practice is now 24 devoted to forensics, and that's not just service, but 25 it's also the teaching, research, and administrative

1 components, and about 5 percent of my practice is devoted 2 still to a small area of surgical pathology. 3 MS. JENNIFER MCALEER: And why the shift, 4 Dr. Shkrum, is that a matter of interest or is that 5 changing hospital configuration? 6 DR. MICHAEL SHKRUM: It's -- it's really 7 out of necessity. I mean, we -- we do have a Regional 8 Forensic Pathology Unit, which I'm -- you're -- you're -- 9 MS. JENNIFER MCALEER: Mm-hm. 10 DR. MICHAEL SHKRUM: -- going to get into 11 shortly, but out of necessity, we now get cases referred 12 to us from all over southwestern Ontario, and that number 13 has increased over the last couple of years, and a number 14 of those cases are complex, and it demands an increasing 15 amount of my time to -- to address those cases. 16 MS. JENNIFER MCALEER: Okay. 17 COMMISSIONER STEPHEN GOUDGE: So it's a 18 rise in the workflow? 19 DR. MICHAEL SHKRUM: Correct. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: All right. And 23 from September of 1987 to present, you've been Consulting 24 Medical Staff, Department of Pathology, at St. Josephs 25 Health Care.

1 DR. MICHAEL SHKRUM: Yes. 2 MS. JENNIFER MCALEER: And also during 3 that time period you've been -- sorry, not during that 4 time period -- ten (10) years later, from 1997 to present 5 -- you're the medical leader of Autopsy Services at the 6 Department of Pathology at London Health Sciences. 7 DR. MICHAEL SHKRUM: Yes, as of 1997. 8 MS. JENNIFER MCALEER: And what is -- 9 what are your duties as the medical leader? 10 DR. MICHAEL SHKRUM: Well, I -- I 11 supervise the Autopsy Service, so this is both the 12 hospital-based autopsies -- these are the hospital 13 consent autopsies -- autopsies that have the consent of 14 next of kin, as well as the medicolegal, or coroner's 15 autopsies. 16 When I took over that role in 1997, it was 17 actually a very exciting time because it really was a 18 time that the three (3) hospitals in London merged: St. 19 Josephs Health Care, Victoria Hospital, and University 20 Hospital. 21 So as part of my responsibilities as 22 medical leader, I -- I was in charge of merging the 23 autopsy services of those three (3) hospitals, and also 24 for the planning and ultimate construction of our 25 renovated autopsy suite.

1 MS. JENNIFER MCALEER: Okay. And at that 2 point, there actually wasn't a Regional Forensic 3 Pathology Unit in London. 4 DR. MICHAEL SHKRUM: No. 5 MS. JENNIFER MCALEER: That didn't come 6 about until 2000/2001? 7 DR. MICHAEL SHKRUM: The facility was 8 built in 2000, and they were formally designated as a 9 Regional Forensic Pathology Unit, with the -- with the 10 funding attached to it, in 2001. 11 MS. JENNIFER MCALEER: All right. So it 12 was at 2001 that you became the Director of the Regional 13 Forensic Pathology Unit, but going back as far as 1997, 14 you were, in fact, carrying out a -- a similar role just 15 with wearing your hat as the medical leader, with respect 16 to pathology services from the London Hospital? 17 DR. MICHAEL SHKRUM: Yes, and I think we 18 were starting to take some cases from outside during that 19 interim period. 20 MS. JENNIFER MCALEER: Okay. Thank you. 21 That's a brief overview of your resumes. 22 I'd like to turn now and talk a little bit 23 more about the particular units that each of you direct. 24 Starting with the -- the Kingston Unit, 25 Dr. Dexter. The Kingston Unit, as I understand it, is

1 actually housed in the Kingston General Hospital. Is 2 that correct? 3 DR. DAVID DEXTER: Yes, it is. 4 MS. JENNIFER MCALEER: Okay. And the 5 Hamilton Unit, Dr. Chow -- Dr. Rao, is in the Hamilton 6 General Hospital. 7 DR. CHITRA RAO: That's correct. 8 MS. JENNIFER MCALEER: Okay. And the 9 London Unit is affiliated with the London Health Sciences 10 Centre. 11 DR. MICHAEL SHKRUM: Yes. University 12 Hospital. 13 MS. JENNIFER MCALEER: All right. So all 14 three (3) of your units are connected to hospitals? 15 DR. DAVID DEXTER: Yeah. 16 DR. MICHAEL SHKRUM: Yes. 17 MS. JENNIFER MCALEER: All right. Now 18 with respect to the Kingston Unit, I understand the 19 formal name is the Southeastern Regional Forensic 20 Pathology Unit. Is that correct, Dr. Dexter? 21 DR. DAVID DEXTER: Yes. 22 MS. JENNIFER MCALEER: We'll simply call 23 it the Kingston Unit though today, if that's fine with 24 you? 25 DR. DAVID DEXTER: Thank you.

1 MS. JENNIFER MCALEER: And it obtained 2 its funding from the Solicitor General in 2000. Is that 3 correct? 4 DR. DAVID DEXTER: Yes. That was the 5 start of the funding. 6 MS. JENNIFER MCALEER: Okay. And the 7 current funding is a hundred and fifty thousand (150,000) 8 a year? 9 DR. DAVID DEXTER: Yes. 10 MS. JENNIFER MCALEER: And on top of the 11 hundred and fifty thousand (150,000) that comes in, you 12 and your colleagues also be -- bill on a fee-for-service 13 basis for the medicolegal autopsies that you perform? 14 DR. DAVID DEXTER: Correct. 15 MS. JENNIFER MCALEER: And I understand 16 that that money doesn't go to you directly, Dr. Dexter, 17 but it comes into a general pot that you share with your 18 colleagues, and then you divvy it all up amongst you. Is 19 that correct? 20 DR. DAVID DEXTER: That's correct, yes. 21 MS. JENNIFER MCALEER: Okay. And Dr. 22 Rao, with respect to Hamilton. Your unit was funded in 23 1991, I understand. 24 DR. CHITRA RAO: That's correct. 25 MS. JENNIFER MCALEER: And originally the

1 funding was a hundred thousand (100,000) a year, but for 2 the last ten (10) years has been two hundred thousand 3 (200,000) a year? 4 DR. CHITRA RAO: That's correct. 5 MS. JENNIFER MCALEER: And the fees that 6 you and your colleagues bill for medicolegal autopsies, 7 as I understand it, are sent to the Hamilton General 8 Hospital. 9 Is that -- 10 DR. CHITRA RAO: Account department. 11 MS. JENNIFER MCALEER: Right. So unlike 12 Dr. Dexter's situation, you -- you don't actually get 13 extra money in pocket at the end of the day. 14 DR. CHITRA RAO: No. 15 MS. JENNIFER MCALEER: It -- it goes into 16 the hospital. 17 DR. CHITRA RAO: That's correct. 18 MS. JENNIFER MCALEER: Okay. And Dr. 19 Shkrum, with respect to London, the funding started in 20 2001, as you indicated? 21 DR. MICHAEL SHKRUM: Yes. 22 MS. JENNIFER MCALEER: And currently 23 funding at a hundred and fifty thousand (150,000) a year? 24 DR. MICHAEL SHKRUM: Yes. 25 MS. JENNIFER MCALEER: And your unit

1 operates like Dr. Dexter's in the sense that the fees for 2 medicolegal autopsies are pooled within the unit and then 3 divided amongst those performing medicolegal autopsies? 4 DR. MICHAEL SHKRUM: Yes. 5 MS. JENNIFER MCALEER: Okay. And with 6 respect to the -- the billing for medicolegal autopsies, 7 I understand that that's -- is it a thousand dollars 8 ($1,000) for straightforward medicolegal autopsies? 9 DR. CHITRA RAO: That's correct. 10 DR. DAVID DEXTER: Yes. 11 DR. MICHAEL SHKRUM: Yes. 12 MS. JENNIFER MCALEER: And what is the 13 number for more complex medicolegal autopsies? 14 DR. MICHAEL SHKRUM: One thousand three 15 hundred and fifty dollars ($1,350). 16 MS. JENNIFER MCALEER: Okay. And who 17 determines -- I mean, what -- what constitutes a more 18 complex medicolegal autopsy? 19 DR. MICHAEL SHKRUM: There are some 20 criteria, or actually certain cases that have been 21 designated as complex, so obviously homicide cases; fire 22 deaths -- 23 DR. CHITRA RAO: Pediatric cases. 24 DR. MICHAEL SHKRUM: -- pediatric cases. 25 Cases like that have already been designated as cases

1 that warrant the extra fee. 2 MS. JENNIFER MCALEER: And that -- that's 3 a designation that's been done by the Office of the Chief 4 Coroner? 5 DR. MICHAEL SHKRUM: Yes. 6 DR. CHITRA RAO: That's correct. 7 MS. JENNIFER MCALEER: I see. So when 8 you render an invoice, and you -- you indicate what kind 9 of case it's been, they simply pay you based on how that 10 fits within the classification. 11 DR. MICHAEL SHKRUM: Yes, and I think 12 it's at the discretion of the Regional Coroner as well, 13 as to the payment, because sometimes we under-bill, and 14 the coroner -- Regional Coroner will elect to give us the 15 extra fee. 16 MS. JENNIFER MCALEER: Okay. 17 DR. DAVID DEXTER: Occasionally also we - 18 - in discussion with the Regional Coroner, because of the 19 complexity of a particular case, it's taken additional 20 detailed examination that may not have been particularly 21 evident when the case came in. We've had a very 22 reasonable discussion, and that's been accepted at a 23 higher bill rate. 24 So there is the possibility to negotiate a 25 higher rate if the case, as we spend our time examining

1 it, justifies it. 2 MS. JENNIFER MCALEER: Okay. And how 3 sufficient is the funding? Is it -- is it covering the 4 costs of performing the medicolegal autopsies? Have you 5 done any internal studies to try and determine how close 6 the funding comes to meeting the need? 7 DR. MICHAEL SHKRUM: Well, we -- we are 8 actually undergoing a case-costing exercise at the 9 present time. And -- so we hope to have some numbers 10 actually in the next few weeks that hopefully would be 11 available to this -- to this Inquiry. 12 But I would say, generally, no, I don't 13 think the -- the hospital is realizing its costs from 14 doing these cases. 15 COMMISSIONER STEPHEN GOUDGE: Was it 16 designed -- was the funding designed originally to cover 17 the cost of doing medicolegal autopsies? 18 DR. MICHAEL SHKRUM: I don't think they 19 cover all the costs, but, you know, in recognition that 20 we are doing this work, it is extra work. 21 COMMISSIONER STEPHEN GOUDGE: Yes. 22 DR. MICHAEL SHKRUM: And that obviously 23 there would be extra costs -- 24 COMMISSIONER STEPHEN GOUDGE: There would 25 be administrative costs that the hospital has to bear in

1 each case associated with it. I understand there's an 2 administrative component to each of the units? 3 DR. MICHAEL SHKRUM: Yes. 4 DR. CHITRA RAO: That's correct. 5 DR. DAVID DEXTER: Yes. 6 COMMISSIONER STEPHEN GOUDGE: You may 7 cover -- and I am sure you are going to cover this, Ms. 8 McAleer, but what about the physical plants that each of 9 the three of you operate in? Could you each tell me a 10 little about them and how they came into being? Yours, I 11 take it, Dr. Shkrum, are new? 12 DR. MICHAEL SHKRUM: Yeah, I -- I would 13 say our -- our physical plant is still state-of-the-art. 14 In fact, we've -- we still have -- 15 COMMISSIONER STEPHEN GOUDGE: Was it 16 constructed in -- on the site of one (1) of the old 17 autopsy services that combined? 18 DR. MICHAEL SHKRUM: Yes, it was 19 constructed at the existing autopsy suite that was at 20 University Hospital. It was completely gutted, and then 21 we actually expanded into neighbouring offices and 22 expanded by one-third (1/3). 23 So it, I think, still remains state-of- 24 the-art facility in the province. It was designed also 25 to address forensic -- forensic needs.

1 COMMISSIONER STEPHEN GOUDGE: Explain 2 that. 3 DR. MICHAEL SHKRUM: Well, -- 4 COMMISSIONER STEPHEN GOUDGE: What was 5 that -- to meet forensic needs? 6 DR. MICHAEL SHKRUM: Well, for example, 7 ventilation, security and controlled access to the 8 facility, lighting, that sort of thing. 9 COMMISSIONER STEPHEN GOUDGE: Okay. When 10 you say state-of-the-art, what do you have in terms of 11 radiology, that kind of stuff? 12 DR. MICHAEL SHKRUM: Well, actually our 13 radiology, we have access to a -- 14 COMMISSIONER STEPHEN GOUDGE: You just 15 use what it is in the -- 16 DR. MICHAEL SHKRUM: Well, in -- in the 17 hospital, we have a -- the radiology department is on the 18 second floor; our -- our unit's on the first floor of the 19 hospital. And we have a portable x-ray machine that 20 comes -- comes down with their techs from the radiology 21 department to take our x-rays. 22 COMMISSIONER STEPHEN GOUDGE: Do you use 23 CAT Scans? 24 DR. MICHAEL SHKRUM: On occasion, CAT 25 Scans have been used, yeah. That -- that opportunity is

1 available to us if we had to use it. 2 COMMISSIONER STEPHEN GOUDGE: Because 3 that facility is in the hospital? 4 DR. MICHAEL SHKRUM: Yes, it is. 5 COMMISSIONER STEPHEN GOUDGE: Yes, okay. 6 DR. MICHAEL SHKRUM: Yeah. And I -- and 7 I -- there certainly -- there is interest in our 8 facility. In fact, we recently got an inquiry from a 9 hospital, in Toronto, that's renovating their -- their 10 unit -- or their sui -- autopsy suite, to come down and 11 take a look at ours. 12 COMMISSIONER STEPHEN GOUDGE: Okay. How 13 much additional work was necessary to add what you would 14 call the forensic dimension of it? I mean, is that -- 15 that is a tough question to answer, but just if you were 16 looking at what percentage, additional cost, to the 17 renovation was accounted for by, what was needed for the 18 forensic dimension of the -- 19 DR. MICHAEL SHKRUM: Well, I think we 20 were fortunate that when -- we were actually the -- I 21 guess the first building project that -- off the ground 22 with the merger of the hospital. 23 COMMISSIONER STEPHEN GOUDGE: I see. 24 DR. MICHAEL SHKRUM: We -- we had 25 actually plans in place because of two (2) failed starts

1 before that. We originally were going to build a unit at 2 the old Victoria Hospital, but it was to be closed -- 3 COMMISSIONER STEPHEN GOUDGE: We 4 being...? 5 DR. MICHAEL SHKRUM: Oh, the -- our -- 6 our department in -- in conjunction with the Victoria 7 Hospital. 8 COMMISSIONER STEPHEN GOUDGE: Okay. 9 DR. MICHAEL SHKRUM: That fell through 10 because the hospital was going to be closed. It's an old 11 hospital. Then the -- the next step was to try to build 12 a unit over at another site, the -- the new Victoria 13 Hospital, but that didn't come through. 14 Nevertheless, we had all this information 15 available to us. So when this third opportunity came 16 along, we had a lot of the information already there. We 17 had visited actually other units in the province. We had 18 visited Hamilton, Ottawa, just to get some idea as to 19 what they were doing. 20 What -- you know, what -- what they had 21 addressed in their facilities and potential drawbacks in 22 their facilities and try to remedy this -- with this new 23 one. 24 COMMISSIONER STEPHEN GOUDGE: Do you do 25 hospital autopsies in the facility as well?

1 DR. MICHAEL SHKRUM: Yes, we do, yes. 2 COMMISSIONER STEPHEN GOUDGE: What 3 percentage of the autopsies done there are hospital 4 autopsies? 5 DR. MICHAEL SHKRUM: Well, actually we -- 6 we have a table that addresses that -- 7 COMMISSIONER STEPHEN GOUDGE: You are 8 going to cover that? 9 DR. MICHAEL SHKRUM: Yeah. 10 MS. JENNIFER MCALEER: I am. 11 DR. MICHAEL SHKRUM: But -- 12 COMMISSIONER STEPHEN GOUDGE: I don't 13 want to -- okay. Let's park that question for the 14 moment. 15 DR. MICHAEL SHKRUM: Okay. 16 COMMISSIONER STEPHEN GOUDGE: What about 17 facilities elsewhere in Kingston and in Hamilton, Dr. 18 Dexter, Dr. Rao? 19 DR. DAVID DEXTER: I'll address the ones 20 in Kingston. The -- the autopsy suite area was renovated 21 approximately three (3) years ago. And at that time, we 22 tried to focus on just the same issues to try and ensure 23 that we adapted it where we could to meet forensic 24 requirements. 25 Now, what we have managed -- it --

1 COMMISSIONER STEPHEN GOUDGE: And it's 2 the same kind of adaptation and ventilation security? 3 DR. DAVID DEXTER: Yeah, we put in -- we 4 actually put in an x-ray unit, so it was lead lining and 5 all of the issues of putting in special power for that. 6 COMMISSIONER STEPHEN GOUDGE: Why would 7 you do that as opposed to use the x-ray facilities in the 8 hospital? 9 DR. DAVID DEXTER: Better quality of 10 the -- 11 COMMISSIONER STEPHEN GOUDGE: Better 12 resolution of pictures? 13 DR. DAVID DEXTER: Better -- better 14 resolution of the images. It also made it very easy for 15 the radiology technologists to come. 16 COMMISSIONER STEPHEN GOUDGE: Just to 17 come down and look at -- 18 DR. DAVID DEXTER: Because instead of 19 trying to free up one (1) of the portable x-ray machines 20 that would be used for clinical services around the 21 hospital -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. DAVID DEXTER: -- they would always 24 have to wait for one (1) to become available; now all 25 they have to do is bring some digital cassettes down

1 and -- 2 COMMISSIONER STEPHEN GOUDGE: Plug them 3 in. 4 DR. DAVID DEXTER: -- plug them in. So 5 that's been a -- 6 COMMISSIONER STEPHEN GOUDGE: That's a 7 luxury? 8 DR. DAVID DEXTER: It's been a great 9 advance. The quality -- 10 COMMISSIONER STEPHEN GOUDGE: Do you like 11 that, Dr. Shkrum? 12 DR. MICHAEL SHKRUM: Well, we -- we had 13 to -- we had actually space -- sorry, we had space 14 constraints in our -- in our facility. 15 COMMISSIONER STEPHEN GOUDGE: So you 16 couldn't do it. 17 DR. MICHAEL SHKRUM: We couldn't do it, 18 no. And there's issues then we -- we had of who's going 19 to take the x-rays; of course the radiology technologist, 20 but -- but it was a space -- it was a space issue. 21 COMMISSIONER STEPHEN GOUDGE: Okay. 22 Sorry, Dr. Dexter. 23 DR. DAVID DEXTER: Yeah. So that was one 24 (1) of the issues we tried to address; the second was the 25 mortuary aspect, which is basically the cold room --

1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID DEXTER: -- where the bodies 3 are stored. And in order -- previously what would happen 4 is, if we had a suspicious case coming in, there would be 5 a policeman on duty outside the morgue door overnight -- 6 COMMISSIONER STEPHEN GOUDGE: Yes. 7 DR. DAVID DEXTER: -- ensuring that there 8 was continuation of evidence and so forth. So what we 9 put in was a lockable cage, within that we extend -- 10 extended the area of the -- of the room. 11 The police can now put their own seals on 12 that door -- 13 COMMISSIONER STEPHEN GOUDGE: Yes. 14 DR. DAVID DEXTER: -- their own locks. 15 And then additionally we put in a freezer unit, a unit 16 that could take the body temperature down further, so 17 that partly decomposed bodies could be handled in a 18 similar way. 19 Again the lighting was dealt with. We 20 have OR type lighting over the autopsy tables; that was 21 designed to deal with that. 22 We dealt with the ventilation issues. We 23 were having a debate as to how many hourly changes of air 24 we had, but ours exceed that of the OR standards, which 25 is I think greater than twenty (20) changes an hour.

1 COMMISSIONER STEPHEN GOUDGE: Why is 2 ventilation a particular issue for a forensic autopsy 3 when it might not be for a -- this may sound like a very 4 simplistic question, but what's the answer to that? 5 DR. DAVID DEXTER: Smell. 6 COMMISSIONER STEPHEN GOUDGE: Yes. No, 7 but I mean, is that because you have bodies decomposing? 8 DR. DAVID DEXTER: Yes. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 DR. MICHAEL SHKRUM: Well, it's smell and 11 also infectious agents. 12 DR. DAVID DEXTER: Infectious diseases. 13 COMMISSIONER STEPHEN GOUDGE: Yes, I 14 wondered about that. 15 DR. DAVID DEXTER: Those -- those two (2) 16 aspects of things. One (1) of -- one (1) of the other 17 issues one looked at also was the level, the biohazard 18 level. 19 COMMISSIONER STEPHEN GOUDGE: Yes. 20 DR. DAVID DEXTER: What -- what type of 21 case should we be handling in the unit? Ours is 22 currently a level 2, which means that we can take most 23 things. 24 I think, just to give you another example 25 of -- of an issue that came up with biohazard levels, is

1 when the SARS outbreak occurred, those cases were not 2 done in the Forensic Unit in Toronto, but they were done 3 in the Toronto General Hospital autopsy facility, because 4 of the better biohazard capability of that location. 5 COMMISSIONER STEPHEN GOUDGE: What are 6 biohazard protections? Is it ventilation again or -- 7 DR. DAVID DEXTER: Again, it's negative 8 pressure ventilation, for example. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. DAVID DEXTER: It's the ability to 11 operate in a -- in a suit type of environment. 12 COMMISSIONER STEPHEN GOUDGE: Yes. 13 DR. DAVID DEXTER: And the ability to 14 totally clean and sterilize the facilities -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. DAVID DEXTER: -- afterwards to 17 ensure that there's no carryover of infectious -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. DAVID DEXTER: -- agents. 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. CHITRA RAO: There's a big hood over 22 the dissecting table. 23 COMMISSIONER STEPHEN GOUDGE: I see. 24 DR. DAVID DEXTER: Yeah. 25 COMMISSIONER STEPHEN GOUDGE: Okay.

1 That's interesting. 2 DR. DAVID DEXTER: And just to complete 3 the -- the approach that we took, the other issue that 4 we approached was the -- the integrity of the forensic 5 specimens that we would take, so we designed a secure 6 area for the samples that we retained post-mortem. 7 And originally it was interesting just to 8 see the relationship of the storage room for hospital 9 autopsies, which we thought was adequate for that, and we 10 designed one (1) for the forensic storage, which is now 11 almost full, and it was of equal size to the hospital 12 one. So it's reflective of -- 13 COMMISSIONER STEPHEN GOUDGE: The 14 additional -- 15 DR. DAVID DEXTER: -- several things: 16 one (1), that we have to retain this material -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID DEXTER: -- and two (2), the 19 length of time for retention for this sort of stock 20 bottle, retention has gone up -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID DEXTER: -- and so we have to 23 retain it for a longer period of time. So those give you 24 an -- an overview of the type of approach that we took. 25 COMMISSIONER STEPHEN GOUDGE: Right.

1 That's interesting. What about Hamilton, Dr. Rao? 2 DR. CHITRA RAO: We were due to have a 3 renovation in 2005 and it hasn't happened as yet. And 4 the funding comes from different sources, but the exact 5 amount and who's involved, I'm not aware because 6 financial aspect of running our department is undertaken 7 by our Laboratory Director. 8 COMMISSIONER STEPHEN GOUDGE: I see. 9 DR. CHITRA RAO: And we are involved in 10 planning stage in the sense we can request what we want, 11 what we need. And in early '80's Dr. Ferris had a big 12 plan for us and the facilities and the amount of space 13 required, but by the time it took over, Dr. King became 14 the director, and what we initially requested, it was cut 15 down to about 50 percent roughly. 16 And the things were done without 17 consultation of pathologists; like the dissecting tables, 18 and the height and details, we were never consulted. And 19 when we -- 20 COMMISSIONER STEPHEN GOUDGE: We being 21 the forensic unit? 22 DR. CHITRA RAO: The forensic 23 pathologists. And on one (1) occasion we were asking -- 24 Dr. King was organizing a meeting with the suppliers, and 25 then we were told that to know that has all been done,

1 and we have ordered it, and that was a surprise for us. 2 And so now the reason one (1) they have 3 involved -- Dr. Fernandes who's my colleague, and myself, 4 we have sat a number of meetings, but the thing is, all 5 the time, we ask what's happening. 6 The renovation was supposed to start at 7 2005, and they always say it's with the Ministry, because 8 every stage they step in, we have to get approval from 9 the Ministry. And what we were told was the person who 10 was taking care of this has left. Somebody else has 11 taken over, so that's going to take some time for them to 12 review. 13 So it's been going on, the battle, so we 14 really don't know when the facility is going to come 15 about. And -- and we also have difficulty in the sense, 16 we take residents regularly, and to what the plan was; we 17 were going to renovate both the forensic aspect of 18 autopsy suite as well as the hospital and that the 19 hospital has had some renovation, and they've got a new 20 table. 21 So when the forensic aspect was going to 22 undergo renovation, we forensic pathologist have to use 23 the hospital autopsy table for our cases. And they only 24 have one (1) table, and that's going to be imposing lots 25 of difficulties because our case load sometimes we can

1 have anywhere from two (2) to five (5) cases a day. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. CHITRA RAO: And in those 4 circumstances we cannot take residents because we have to 5 complete that autopsy quickly. So the program director's 6 now -- they're not pleased about it because residents 7 have to have their training. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. CHITRA RAO: So I -- I really don't 10 know when we are going to have those new facilities. 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 Right. And what you've just described, it sounds as if 13 the autopsy suite is kind of divided, physically, between 14 the autopsy table devoted to hospital autopsies, and the 15 autopsy part of the suite devoted to forensics. 16 Is that right? 17 DR. CHITRA RAO: Yes. We have a corridor 18 opposite to each other. The hospital has one (1) room 19 for the autopsy -- 20 COMMISSIONER STEPHEN GOUDGE: I see. I 21 just assumed there was one (1) autopsy suite? 22 DR. CHITRA RAO: No. 23 COMMISSIONER STEPHEN GOUDGE: Do you have 24 a division? 25 DR. MICHAEL SHKRUM: No, we have a shared

1 facility. 2 COMMISSIONER STEPHEN GOUDGE: So that 3 hospital autopsies might be done on the same table that 4 the day before had -- 5 DR. MICHAEL SHKRUM: That's correct, done 6 concurrently. 7 COMMISSIONER STEPHEN GOUDGE: Yes. 8 DR. CHITRA RAO: No, for us it's not 9 that. 10 DR. DAVID DEXTER: Ours are the same. We 11 have hospital autopsies and forensic in the same tables. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 Right. Why are they divided in Hamilton? 14 DR. CHITRA RAO: Because our workload is 15 more, compared to the hospital side, and sometimes 16 hospital side when they do the autopsies it should -- 17 it's done by the residents under the supervision of a 18 staff. It can take two (2), three (3) or even four (4) 19 hours to complete an autopsy. We don't have the luxury 20 of time because we have to release the body as quickly as 21 quickly as possible when we finish. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 Right. 24 DR. CHITRA RAO: And to -- then we also 25 have a separate room with the improved ventilation.

1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. CHITRA RAO: And sometimes hospital 3 pathologists use that room for infectious cases. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. CHITRA RAO: And they also have 6 separate storage room. So it's opposite to the forensic, 7 same corridor. So we have two (2) rooms to do autopsies, 8 so when we have a fellow or resident we can do side-by- 9 side. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 Okay, thanks. Sorry, Ms. McAleer. 12 MS. JENNIFER MCALEER: No, that's -- 13 that's helpful, Mr. Commissioner. You've crossed off the 14 whole page for me, so we'll -- we'll move on -- 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 17 CONTINUED BY MS. JENNIFER MCALEER: 18 MS. JENNIFER MCALEER: -- to the 19 geographic territories that each of your units encompass; 20 your -- your catchment areas. So, Dr. Dexter starting in 21 Kingston, what is the general catchment area for your 22 forensic unit? 23 DR. DAVID DEXTER: Yeah, cases can be 24 referred in by coroners that are based in Belleville, 25 Brockville, Perth and Smith Falls, Napanee, and of

1 course, Kingston, as the -- as the primary location. For 2 the last little while, we've also been receiving cases 3 from Ottawa of homicide and suspicious cases; a duty 4 shared in part with Toronto. 5 MS. JENNIFER MCALEER: And putting aside 6 the -- the Ottawa situation for a moment, I understand 7 that area you've described to be a population base of 8 about three hundred (300) to six hundred thousand 9 (600,000) people? 10 DR. DAVID DEXTER: It's of that order, 11 yes. 12 MS. JENNIFER MCALEER: All right. And I 13 also understand that Belleville and perhaps, Brockville, 14 have pathologists who do medicolegal autopsies, so you're 15 not doing all the medicolegal autopsies in -- from those 16 towns, but you're doing the criminally suspicious cases? 17 DR. DAVID DEXTER: Yes, that's right. 18 MS. JENNIFER MCALEER: Okay. And, Dr. 19 Rao, with respect to Hamilton, what is the -- the 20 catchment area for your unit? 21 DR. CHITRA RAO: It's about 1.7 to 1.8 22 million and we cover Hamilton/Wentworth Region, Halton, 23 Niagara Region, and Guelph/Kitchener, and Cayuga. 24 MS. JENNIFER MCALEER: And are you doing 25 all of the medicolegal autopsies in that area?

1 DR. CHITRA RAO: No, we get the 2 suspicious and homicide cases from that area. I forgot 3 to include Brantford. 4 MS. JENNIFER MCALEER: Okay. So from the 5 areas you described, like Dr. Dexter, the criminally 6 suspicious cases come into your unit, but then you would 7 also deal with just all of the medicolegal cases in the 8 Hamilton area? 9 DR. CHITRA RAO: That's correct. 10 MS. JENNIFER MCALEER: Okay. 11 DR. CHITRA RAO: And we also do all the 12 pediatric cases from all that area. It's done in 13 Hamilton -- unit. 14 MS. JENNIFER MCALEER: Right. And, Dr. 15 Dexter, this is probably a good place to point out that 16 your unit currently doesn't do any pediatric cases, is 17 that correct?? 18 DR. DAVID DEXTER: That is correct, yes. 19 MS. JENNIFER MCALEER: Okay. And the 20 pediatric cases that arise within that population base, 21 where do they go? 22 DR. DAVID DEXTER: They've gone in 23 different directions over the past period of time to CHEO 24 and now currently to Toronto Sick Kids. 25 MS. JENNIFER MCALEER: Okay. And with

1 respect to London, Dr. Shkrum, what is the population 2 base that you are dealing with? 3 DR. MICHAEL SHKRUM: It's approximately 4 1.5 million. 5 MS. JENNIFER MCALEER: And what is the 6 geographic area? 7 DR. MICHAEL SHKRUM: Using cities or 8 towns as a reference point, so to the east would be 9 Woodstock, to the north, Owen Sound, and to the west, 10 Windsor. 11 MS. JENNIFER MCALEER: Okay. And do you 12 do the cases from Windsor or are -- is there a separate 13 group of pathologists? 14 DR. MICHAEL SHKRUM: No, there are 15 pathologists that do medicolegal autopsies in Windsor. 16 And of course, we would get any homicides, criminally 17 suspicious deaths, and pediatric cases from -- from that 18 -- from that area. 19 MS. JENNIFER MCALEER: All right. Now, 20 if we could turn to Volume III, please, Tab 17. That's 21 PFP302981, but it's not in the database, Mr. Registrar. 22 Now, Doctors, this is a chart that the three (3) of you 23 have put together, with us, to try and summarize your -- 24 the workload at the units. 25 So if we could perhaps start at the top,

1 looking at the total autopsies for Kingston, the Regional 2 Forensic Pathology Unit in 2006. 3 Dr. Dexter, you were doing two hundred and 4 eighteen (218) autopsies? 5 DR. DAVID DEXTER: Yes, those are 6 medicolegal autopsies. 7 MS. JENNIFER MCALEER: Those are all 8 medicolegal? 9 DR. DAVID DEXTER: That's -- that doesn't 10 include the hospital ones. 11 MS. JENNIFER MCALEER: I see. Okay. 12 And, Dr. Rao, with respect to Hamilton, again you're 13 doing all medicolegal autopsies, so you had six hundred 14 and fourteen (614) in 2006 and six hundred and thirty- 15 eight (638) in 2007? 16 DR. CHITRA RAO: That's correct. 17 MS. JENNIFER MCALEER: And, Dr. Shkrum, 18 in London, you -- total autopsies, this is medicolegal 19 and hospital? 20 DR. MICHAEL SHKRUM: Yes, and hospital 21 consent autopsies. 22 MS. JENNIFER MCALEER: Okay. And -- 23 COMMISSIONER STEPHEN GOUDGE: So just a 24 sec. The number there, the two eighteen (218), Dr. 25 Dexter, is medicolegal?

1 DR. DAVID DEXTER: That's pure 2 medicolegal, correct. 3 MS. JENNIFER MCALEER: Right. So you 4 can -- 5 COMMISSIONER STEPHEN GOUDGE: What about 6 your number, Dr. Shkrum? 7 DR. MICHAEL SHKRUM: That's medicolegal 8 and hospital consent autopsies. 9 COMMISSIONER STEPHEN GOUDGE: Okay. And 10 if we wanted to break out the medicolegal out of them to 11 get a ballpark -- 12 DR. MICHAEL SHKRUM: If you look at the 13 third -- the third line, number of medicolegal cases. 14 COMMISSIONER STEPHEN GOUDGE: Okay. I am 15 going -- okay, great. 16 MS. JENNIFER MCALEER: That's fine. 17 COMMISSIONER STEPHEN GOUDGE: Okay. 18 Thank you. 19 20 CONTINUED BY MS. JENNIFER MCALEER: 21 MS. JENNIFER MCALEER: I think the -- the 22 error, Mr. Commissioner, is that under Kingston RFP where 23 it says types of autopsies, medical and hospital, that 24 and hospital should be deleted, that's correct, Dr. 25 Dexter?

1 DR. DAVID DEXTER: Yeah, yes. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 MS. JENNIFER MCALEER: Right. 4 COMMISSIONER STEPHEN GOUDGE: Okay. 5 MS. JENNIFER MCALEER: And -- and then 6 going back to the London unit, if we go down the third 7 row -- 8 COMMISSIONER STEPHEN GOUDGE: Yes. No, 9 that is great. Yes, thanks. 10 MS. JENNIFER MCALEER: -- we see what 11 number are medicolegal. 12 COMMISSIONER STEPHEN GOUDGE: Yes, 13 perfect. Thank you. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: Okay. And of 17 course, your's, Dr. Rao, are all because that's all you 18 do. 19 DR. CHITRA RAO: That's correct. 20 MS. JENNIFER MCALEER: Okay. And -- and 21 then Dr. Dexter has told us that of the medicolegals, the 22 two eighteen (218) are about two-thirds (2/3s) of the 23 general work load, and that's consistent with what you 24 told us earlier -- 25 DR. DAVID DEXTER: Yes.

1 MS. JENNIFER MCALEER: -- today. Then 2 looking at the number of criminally suspicious cases; 3 first of all, how are we defining criminally suspicious? 4 Dr. Shkrum, what -- how would you define 5 criminally suspicious? What fits into that category? 6 DR. MICHAEL SHKRUM: Well, I would say in 7 quotations, "concerns that might be raised" by the 8 investigating coroner, or the police following their 9 investigation, or questioning the witnesses. And this 10 may be a -- a real spectrum. It may be simply something 11 that some -- someone sees on the -- on the body that 12 subsequently turns out to be really of no consequence, or 13 ranges all the way up to homicide cases. 14 MS. JENNIFER MCALEER: Now, would you 15 classify SIDS cases, or unexplained deaths, as criminally 16 suspicious? Would that fall within that 10 percent? 17 DR. MICHAEL SHKRUM: Well, I would 18 include it in the 10 percent in the sense that a case 19 like that, a death under five (5) years of age demands a 20 -- a certain protocol that -- that has to be followed, to 21 rule out any signs of suspicious trauma. 22 MS. JENNIFER MCALEER: All right. So 23 when we see that you have indicated that 10 percent of 24 all of the medicolegal cases are criminally suspicious 25 cases, that would include any death under five (5)?

1 DR. MICHAEL SHKRUM: Well, if -- if -- 2 the protocol has to be followed -- some of the pediatric 3 cases we do under coroner's warrant, or a med -- so 4 called medical cases where children are admitted to 5 hospital and die of a known medical disease, but are done 6 under a coroner's warrant. 7 MS. JENNIFER MCALEER: So those would or 8 would not be included in the ten (10) -- 9 DR. MICHAEL SHKRUM: Would not be 10 included as a criminal suspicious case. 11 MS. JENNIFER MCALEER: I see. 12 DR. MICHAEL SHKRUM: Would -- would not 13 require that the protocol necessarily be followed. 14 COMMISSIONER STEVEN GOUDGE: But a sudden 15 unexpected death under five (5) would be included? 16 DR. MICHAEL SHKRUM: Yes. 17 18 CONTINUED BY MS. JENNIFER MCALEER: 19 MS. JENNIFER MCALEER: And all SIDS 20 deaths outside of a hospital setting would be included? 21 DR. MICHAEL SHKRUM: Yes. 22 MS. JENNIFER MCALEER: Okay. Then 23 working backwards, Dr. Rao, you've indicated that in 2006 24 you've given us an actual number, as opposed to 25 percentage; that forty-four (44) of the cases -- sorry,

1 that fifty (50) to sixty (60) of the cases were 2 criminally suspicious cases. 3 DR. CHITRA RAO: That's correct. 4 MS. JENNIFER MCALEER: And -- sorry, you 5 were going to add something? 6 DR. CHITRA RAO: No. I just wanted to 7 add, under the suspicious category, there are certain 8 cases; young woman found dead in the presence of their 9 spouse, or main partner, we have to undertake a special 10 procedure to do. 11 At the end of the autopsy, it may not be 12 suspicious, or homicide. But then we do -- there is a -- 13 a special guideline for that. 14 MS. JENNIFER MCALEER: So those are 15 potential domestic abuse situations? 16 DR. CHITRA RAO: Correct, yeah. 17 MS. JENNIFER MCALEER: All right. And 18 are -- are you including those then -- 19 DR. CHITRA RAO: Some of them. 20 MS. JENNIFER MCALEER: -- in the fifty 21 (50) to sixty (60)? 22 DR. CHITRA RAO: Some -- if it turned out 23 to be, but then most of it sometimes -- we have answers 24 for cause of death. Maybe toxicology, or something like 25 that.

1 MS. JENNIFER MCALEER: All right. So 2 your numbers are -- results are ans -- we know what 3 happened and we're working backwards? 4 DR. CHITRA RAO: Correct. 5 MS. JENNIFER MCALEER: Is that how you've 6 categorized it as -- as well, Dr. Shkrum? Is that 10 7 percent once the post-mortem is complete, you've 8 determined it's a criminally suspicious or homicide case? 9 DR. MICHAEL SHKRUM: Yes. It either 10 confirms the suspicions that have been raised by 11 investigators, and on rare occasions we actually do 12 discover something criminally suspicious during the 13 course of the autopsy. 14 MS. JENNIFER MCALEER: Okay. 15 COMMISSIONER STEVEN GOUDGE: And it then 16 gets categorized as criminally suspicious? 17 DR. MICHAEL SHKRUM: That's right. And 18 people -- people are notified. 19 20 CONTINUED BY MS. JENNIFER MCALEER: 21 MS. JENNIFER MCALEER: All right. And, 22 Dr. Dexter, you've indicated -- sorry. 23 COMMISSIONER STEVEN GOUDGE: Sorry, Ms. 24 McAleer. I just want to ask a question about the 25 medicolegal that may be done outside each of your units

1 that turn up that way during the course of the autopsy. 2 Is there any capacity to borrow expertise 3 from the units? An autopsy is underway, let us say in 4 Windsor, a medicolegal autopsy is underway in Windsor, it 5 is not criminally suspicious at the beginning, something 6 turns up. 7 DR. MICHAEL SHKRUM: Yeah. The -- there 8 may be -- if that happens, I -- I may receive a phone 9 call from a pathologist at a -- another unit, or sorry, 10 at another facility, and they may be simply answered by 11 questions over the -- answering those questions over the 12 phone. 13 If there's still concerns, and obviously a 14 Regional Coroner now would be involved, the case may then 15 be referred to London. 16 COMMISSIONER STEVEN GOUDGE: So does the 17 body actually then come to London? 18 DR. MICHAEL SHKRUM: It would come to 19 London, or if the autopsy's all ready been done, and then 20 issues come out at a later date -- 21 COMMISSIONER STEVEN GOUDGE: As a result 22 of the toxicology, or histology, or something? 23 DR. MICHAEL SHKRUM: Exactly, or further 24 police investigation. Then there will be a review of the 25 case again, using the Regional Coroner as the -- as a

1 contact person -- 2 COMMISSIONER STEVEN GOUDGE: Right. 3 DR. MICHAEL SHKRUM: -- or a liaison -- 4 COMMISSIONER STEVEN GOUDGE: Right. 5 DR. MICHAEL SHKRUM: -- to review that 6 case. 7 COMMISSIONER STEVEN GOUDGE: Does that 8 happen frequently? 9 DR. CHITRA RAO: Not frequently. We have 10 had instances where -- from St. Catherines, a pathologist 11 has started at the autopsy, and then there's some 12 findings they're not sure -- 13 COMMISSIONER STEVEN GOUDGE: Mm-hm. 14 DR. CHITRA RAO: -- and then what they do 15 is they call the coroner and say I'm not sure, and I'm 16 not comfortable to proceed with this, can I send it to 17 the Regional Forensic Unit, and then they will get the 18 permission. And so they issue another warrant for us to 19 do the second autopsy -- 20 COMMISSIONER STEPHEN GOUDGE: Yes, 21 because the transfer of the body would take another 22 warrant, I guess. 23 DR. CHITRA RAO: Exactly, exactly. 24 COMMISSIONER STEPHEN GOUDGE: Yes. 25 DR. CHITRA RAO: Transfer of the body, as

1 well as performing an additional -- yes. 2 COMMISSIONER STEPHEN GOUDGE: Right, 3 right. 4 DR. CHITRA RAO: And so we have had 5 occasion, not really often. 6 COMMISSIONER STEPHEN GOUDGE: What, a 7 handful of cases each year? 8 DR. CHITRA RAO: Yes, that's what I'd 9 say. And sometimes they may not do the autopsy, they'll 10 go through the history and the warrant and they'll say, I 11 think this is not for me -- 12 COMMISSIONER STEPHEN GOUDGE: Yes. 13 DR. CHITRA RAO: -- to do and then they'd 14 inform the coroner. 15 COMMISSIONER STEPHEN GOUDGE: Yes. 16 DR. CHITRA RAO: If the decision lies on 17 -- if the coroner, local coroner, says, No, I think you 18 can do, and still if the pathologist is not happy, they 19 can go to the Regional Supervising Coroner and request 20 them. 21 And I normally tell them when we meet, 22 anytime you're not happy with it and you're not confident 23 to do it, it's rather you say, no, and then let somebody 24 else do it. And then if they have a problem with the 25 local coroner, they can always contact the Regional

1 Supervising Coroner. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 And, Dr. Dexter...? 4 DR. DAVID DEXTER: It's been a very rare 5 occurrence in our area. I think the Regional Supervising 6 Coroner plays a significant role in -- 7 COMMISSIONER STEPHEN GOUDGE: In 8 streaming the cases to the right places in the first 9 place. 10 DR. DAVID DEXTER: Yes. Yeah. 11 COMMISSIONER STEPHEN GOUDGE: Okay. 12 DR. MICHAEL SHKRUM: I wonder if I could 13 just add one (1) comment -- 14 COMMISSIONER STEPHEN GOUDGE: Sure. 15 DR. MICHAEL SHKRUM: -- regard -- 16 regarding the criminally suspicious. I think because 17 they're Regional Forensic Units, perhaps the index of 18 suspicion is low. If anything, does not look right to 19 the investigating coroner or the police, you know their 20 default position is to consult with the Regional Forensic 21 Pathology Unit and generally send that case there. 22 The implication is, and particularly in -- 23 in Kingston and London, is that if it's criminally -- 24 deemed criminally suspicious, then -- then a forensic 25 trained pathologist, myself or my colleague, Dr. Tweedie,

1 would have to do that case. 2 COMMISSIONER STEPHEN GOUDGE: Yes, I mean 3 that's why I'm asking, obviously, because we've spent -- 4 we've heard a lot of evidence about levels of expertise, 5 and your units represent the best expertise we've got in 6 the Province and, you know. 7 DR. DAVID DEXTER: I agree, to re -- 8 reiterate what Dr. Shkrum said. So the -- the issue of 9 identifying a case as criminally suspicious begins at the 10 beginning; that's certainly my view of these things, 11 because we have to address that and treat it as 12 criminally suspicious, which may mean different 13 approaches, more samples to be taken, a host -- 14 COMMISSIONER STEPHEN GOUDGE: And 15 different skill sets brought to bare on the autopsy. 16 DR. DAVID DEXTER: Absolutely. And so 17 that -- suddenly the ones that are listed here from the 18 Kingston Unit would -- would really follow that type of 19 approach; that this is being brought to the Unit with the 20 heading of suspicion. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID DEXTER: And that would mean 23 that either Dr. Young or myself would be -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. DAVID DEXTER: -- doing that post-

1 mortem. 2 COMMISSIONER STEPHEN GOUDGE: Okay, 3 thanks. Thanks, Ms. McAleer. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: Thank you, Mr. 7 Commissioner. And then just finishing up with respect to 8 the percentage of criminally suspicious cases in the 9 Kingston Unit, you've indicated, Dr. Dexter, it's 10 approximately 10 to 15 percent of all of your medicolegal 11 cases are criminally suspicious cases. 12 DR. DAVID DEXTER: Yes. There's perhaps 13 a point that may be helpful to understand; Kingston is a 14 wonderful place, but it is surrounded by prisons, and as 15 a consequence death in custody, whether it be natural, 16 suspicious, suicide, homicide -- 17 COMMISSIONER STEPHEN GOUDGE: A big part 18 of your work. 19 DR. DAVID DEXTER: -- is a significant 20 part of our work, which is why the number of inquests are 21 -- are so high in the Kingston area dealing with that, 22 whether it be natural or whether it be a suspicious type 23 of thing. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25

1 CONTINUED BY MS. JENNIFER MCALEER: 2 MS. JENNIFER MCALEER: All right. And 3 then you've also been able to break out homicide numbers 4 for us; and, Dr. Dexter, you're looking at four (4) or 5 five (5) in 2006? 6 DR. DAVID DEXTER: Yes, that would be 7 approximately right. 8 MS. JENNIFER MCALEER: And, Dr. Rao, 9 significantly more, you had forty-four (44) in 2006. 10 DR. CHITRA RAO: That's correct. 11 MS. JENNIFER MCALEER: And, Dr, Shkrum, 12 you've had twenty (20). We don't have a 2006 number, but 13 we have a 2005 number. 14 DR. MICHAEL SHKRUM: That's correct. In 15 -- in 2006 actually we rely on the Coroner's Office to 16 give the final manner of death, so those statistics for 17 our Unit are delayed by a year. 18 And if one does the math, if we have 19 twenty (20) homicides, then by doing the math, for 20 example, in 2005 there were four hundred and twenty (420) 21 aut -- twenty-three (23) medicolegal autopsies, so twenty 22 (20) were homicides and twenty (20) would have been 23 considered approximately criminally suspicious. 24 MS. JENNIFER MCALEER: I see. And then 25 with respect to who's doing the criminally suspicious and

1 homicide cases, I take in each of your units you have a 2 number of pathologists who are doing medicolegal cases, 3 but when it comes to doing autopsies in criminally 4 suspicious or homicide cases, that only particular 5 pathologists do those autopsies. 6 Is that correct, generally speaking -- 7 DR. DAVID DEXTER: Yes. Yes. 8 MS. JENNIFER MCALEER: -- for all of you? 9 DR. MICHAEL SHKRUM: Yes, we have a model 10 in our -- in -- in the London Unit where all pathologists 11 participate in the autopsy service and doing coroners 12 autopsies to varying degrees, but there's two (2) of us - 13 - myself and Dr. Tweedie -- who'd do the criminally 14 suspicious and homicide cases. 15 MS. JENNIFER MCALEER: So the -- the 16 practice then at -- or the policy at your hospital is 17 that all the pathologists do medicolegal cases? 18 DR. MICHAEL SHKRUM: Yes. 19 MS. JENNIFER MCALEER: And how many 20 pathologists are we talking about? 21 DR. MICHAEL SHKRUM: We have 22 approximately two (2) dozen pathologists in our 23 department. 24 MS. JENNIFER MCALEER: Twenty-four (24)? 25 DR. MICHAEL SHKRUM: Yes.

1 MS. JENNIFER MCALEER: And of the twenty- 2 four (24), it's only the two (2) of you that do 3 criminally suspicious or homicide cases? 4 DR. MICHAEL SHKRUM: That's correct. 5 MS. JENNIFER MCALEER: Dr. Rao, your unit 6 -- your -- you're housed in the hospital, but your unit 7 has only the three (3) of you in it, is that correct? 8 DR. CHITRA RAO: Yes, two (2) full-time 9 pathologists, Dr. John Fernandes and myself. 10 MS. JENNIFER MCALEER: And -- 11 DR. CHITRA RAO: And then Dr. King helps 12 us one (1) in three (3) or one (1) in four (4) weekends. 13 So when he's on the weekend, he can do all the suspicious 14 case or homicide. We don't have to be second on-call. 15 We have a Fellow in our unit, so when he's 16 on-call, Dr. Fernandes and myself will take turn. One(1) 17 month I'll be second on-call; the following month, Dr. 18 Fernandes will be second on-call. We do allow the Fellow 19 to do either suspicious or homicide case, but one (1) of 20 was would be there from the start till the end. 21 MS. JENNIFER MCALEER: All right. And -- 22 and Dr. King is also retired, is that correct? 23 DR. CHITRA RAO: Yes. 24 MS. JENNIFER MCALEER: But -- but still 25 actively involved in your unit. And is that a matter of

1 need or interest with respect to Dr. King? 2 DR. CHITRA RAO: Definitely a need 3 because we are only three (3) of us and at times, Dr. 4 Fernandes and myself, we end up doing two (2) weekends in 5 a month. And it's quite a load. And sometimes our 6 weekend cases are much more than what we do during the 7 weekdays. 8 And Dr. Fernandes does three (3) days a 9 week, Monday, Wednesday, and Friday, and I'm on service 10 for Tuesday and Thursday. 11 COMMISSIONER STEPHEN GOUDGE: How big is 12 the pathology department at the hospital? 13 DR. CHITRA RAO: Hospital big. And we 14 have four (4) -- we have amalgamated, so under the 15 umbrella of the university, we have four institution. 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. CHITRA RAO: Hamilton General 18 Hospital, Henderson General Hospital, St. Joseph's -- 19 COMMISSIONER STEPHEN GOUDGE: Right. Was 20 the patho -- were the pathology departments combined or 21 the -- 22 DR. CHITRA RAO: Combined in the sense in 23 Henderson Civic -- Hamilton Civic Hospital, under that 24 comes Hamilton General and Henderson. All the surgical 25 pathologies are done by pathologists located at

1 Henderson. In Hamilton General, we have two (2) 2 neuropathologists, two (2) part-time cardiovascular 3 pathologists, and two (2) full-time forensic 4 pathologists. 5 COMMISSIONER STEPHEN GOUDGE: And I guess 6 none of them are interested, -- 7 DR. CHITRA RAO: No. 8 COMMISSIONER STEPHEN GOUDGE: -- except 9 the last two (2), in doing forensic -- 10 DR. CHITRA RAO: That's correct. They're 11 not interested, and -- and they're very busy. In fact, 12 McMaster now lately, most of the hospital has been 13 complimented with more new pathologists. Otherwise, for 14 a long time, we were understaffed in every area. 15 COMMISSIONER STEPHEN GOUDGE: Right, 16 right. Okay. 17 18 CONTINUED BY MS. JENNIFER MCALEER: 19 MS. JENNIFER MCALEER: Dr. Rao, you heard 20 Dr. Shkrum explain that at his hospital, all of the 21 pathologists are doing medicolegal work. At your 22 hospital, though, is it just the three (3) of you plus 23 your Fellow who are doing medicolegal work? 24 DR. CHITRA RAO: Yes, during the week it 25 will be two (2) of us, Dr. Fernandes, myself, and the

1 Fellow. Weekend, once in four (4) weekends, Dr. King 2 does. 3 MS. JENNIFER MCALEER: All right. So the 4 four (4) of you are doing all the medicolegal and all the 5 criminally suspicious with the caveat you indicated with 6 respect to your Fellow? 7 DR. CHITRA RAO: That's correct. 8 MS. JENNIFER MCALEER: Okay. Now, Dr. 9 Dexter, in Kingston, first of all, it's only you and Dr. 10 Young who are doing the criminally suspicious and 11 homicide cases? 12 DR. DAVID DEXTER: Yes. 13 MS. JENNIFER MCALEER: And what about -- 14 are you -- are others doing medicolegal cases? 15 DR. DAVID DEXTER: Yes, there's thirteen 16 (13) other pathologists. And so that they will do -- 17 COMMISSIONER STEPHEN GOUDGE: Do they 18 each take their turn? 19 DR. DAVID DEXTER: They each take their 20 turn, yeah. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: So similar to what 24 Dr. Shkrum explained? 25 DR. DAVID DEXTER: It's a similar model.

1 MS. JENNIFER MCALEER: Okay. 2 COMMISSIONER STEPHEN GOUDGE: Which model 3 is better? 4 DR. DAVID DEXTER: I'll let you answer 5 first. 6 DR. CHITRA RAO: I think the mest -- best 7 model will be a unit run by full-time forensic 8 pathologists. And of course, we should -- if any 9 hospital pathologists are interested in doing medicolegal 10 cases and they're trained, they should be encouraged to 11 do. 12 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 13 Shkrum? 14 DR. MICHAEL SHKRUM: I have an opinion. 15 No, the model we have, because there are other 16 pathologists doing the more routine coroner's cases, it 17 does mean that myself or Dr. Tweedie can concentrate our 18 efforts on the more problematic ones. We do share in the 19 regular autopsy service. 20 COMMISSIONER STEPHEN GOUDGE: Right. You 21 would do the run of the mill, if I can put it that way? 22 DR. MICHAEL SHKRUM: We still do our 23 regular cases, but we -- we knew we have -- we have a 24 safety valve that allows us to concentrate on these cases 25 in the eventuality that other routine cases are there,

1 there are other pathologists available to do them. 2 And -- and we do share a weekend rota. 3 We're on-call one (1) every two (2) weekends. We're 4 there to -- we're available to do these more problematic 5 cases whereas the routine cases on a weekend are done by 6 a pathologist on-call that weekend. Also, -- 7 COMMISSIONER STEPHEN GOUDGE: So on the 8 expertise side of the ledger, expertise would say, Well 9 if you could do them with all forensic pathologists, you 10 do them all that way? 11 DR. MICHAEL SHKRUM: Ideally, that 12 would -- 13 COMMISSIONER STEPHEN GOUDGE: That would 14 be great? 15 DR. MICHAEL SHKRUM: -- if you had enough 16 manpower. 17 COMMISSIONER STEPHEN GOUDGE: But I guess 18 what you addressed, Dr. Shkrum, is that this case load -- 19 the criminally suspicious, the difficult forensic ones -- 20 don't come in a steady stream. They, kind of, in terms 21 of -- they may come in -- 22 DR. MICHAEL SHKRUM: In droves. 23 COMMISSIONER STEPHEN GOUDGE: -- in 24 droves at one (1) point, and then there may be a dry 25 spell?

1 DR. MICHAEL SHKRUM: That's right. And 2 also, another matter, is that it's a question of career 3 choice. I mean, some pathologists may elect to do full 4 time forensic pathology. 5 But remember that forensic pathologists 6 come from a background of either anatomical or general 7 pathology. There is a skill set that they've already 8 been trained to do. A number of pathologists may elect 9 to have, sort of, have a combined practice to still keep 10 up their skill set; what they've been originally trained 11 to do, yet do forensics on the side. 12 So as Dr. Rao said, there has to be -- you 13 know, the opportunity -- if -- if a pathologist wants to 14 continue their surgical pathology practice, that allows 15 them to do that, yet still do the forensics. So there 16 has to be -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. MICHAEL SHKRUM: -- some latitude in 19 the system to allow that to occur. 20 DR. CHITRA RAO: And then also some 21 pathologists may take medicolegal cases because of the 22 extra money, and that shouldn't be the criteria even 23 though it happens now in remote places. 24 And that shouldn't be the criteria. The 25 criteria like he indicated -- a person who's interested,

1 wants to do, but doesn't want to get involved in 2 criminally suspicious or homicide. That person should be 3 given the opportunity to do that. 4 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 5 Dexter...? 6 DR. DAVID DEXTER: I guess I also have an 7 opinion. The -- the issue in our academic centre and 8 unit is a little bit more challenging in that we have to 9 cover off responsibilities that reflect a multitude of 10 tasks: the academic role that we have within the 11 department of pathology, the teaching of medical 12 students, residents in training; all of that aspect of 13 things. 14 We also have a service component to the 15 hospital that is quite substantial. And that service 16 component is spread amongst the various members depending 17 on their skill set. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. DAVID DEXTER: And so that my 20 responsibilities are split between providing forensic 21 expertise, with looking after the service and the unit. 22 Every morning I visit down to see what's on deck, discuss 23 with the pathologists and the residents some of the 24 issues that might be helpful in dealing with approaching 25 that particular problem.

1 So I do that, but the rest of my day may 2 be apportioned between doing hematopathology, GI 3 pathology, bone and soft tissue. And so my mix is 4 different. Whilst I would certainly suggest that having 5 somebody who is full time forensic pathology would be 6 ideal, the other side of the coin would be the workload 7 that is available, for example, in the Kingston Unit. 8 Would it keep that person fully occupied? 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 Right. 11 DR. DAVID DEXTER: And I think that would 12 be -- 13 COMMISSIONER STEPHEN GOUDGE: A 14 challenge? 15 DR. DAVID DEXTER: Yeah, that would be 16 challenged, and quite rightly so, too. On the other 17 hand, having the split of medicolegal cases being done by 18 my capable colleagues on the anatomic side of things, 19 does help as Dr. Shkrum has indicated, for me and Dr. 20 Young to focus on those more problematic -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID DEXTER: -- cases. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 Thanks. 25 DR. DAVID DEXTER: So it's a little bit

1 different in each of the centres. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 That's helpful. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: All right. So 7 just finishing up with the chart then, we're going to 8 talk more specifically about the pediatric cases. So, 9 Dr. Dexter, your unit doesn't do any pediatric cases, and 10 why is that, Dr. Dexter? 11 DR. DAVID DEXTER: Several reasons. One 12 (1) is the number of natural pediatric cases that would 13 come through our hospital. Yes, we do have a department 14 of pediatrics. We do have a pediatric surgeon, but it's 15 a relatively small set-up. 16 And so the competence will not be there. 17 And so there is absolutely no hesitation in supporting 18 the premise that we should not be doing these cases in 19 Kingston. They need to go to centres where people are 20 doing these types of autopsies, whether they be natural 21 deaths within the hospital setting, or medicolegal 22 deaths. 23 They should be done elsewhere where there 24 is volume. We don't have it. 25 MS. JENNIFER MCALEER: All right. Dr.

1 Rao, you are the only person who does pediatric cases at 2 your unit? 3 DR. CHITRA RAO: Yes. For the time being 4 now, any homicide cases in pediatrics I do are 5 suspicious. But there are times when it's not indicative 6 of suspicious or homicide, Dr. John Fernandes can do, but 7 then usually I supervise. 8 And in the past, Dr. King has done 9 homicide, and straightforward case -- pediatric cases. 10 Then we had the fellow, Dr. Ted Tweedie, who did the 11 fellowship under us, he has done pediatric cases, 12 including homicide. 13 But lately now it's been directed that 14 I'll be doing the homicide case. In my absence, the 15 cases go to Toronto. 16 MS. JENNIFER MCALEER: All right. So in 17 the past, when Dr. King was full time, he would do 18 pediatric cases? 19 DR. CHITRA RAO: He has done it. 20 MS. JENNIFER MCALEER: Until recently, 21 the practice was that if it wasn't a criminally 22 suspicious or homicide pediatric case, and you felt 23 comfortable with it, then one (1) of your colleagues 24 would do it, even if it was a medicolegal autopsy, 25 correct?

1 DR. CHITRA RAO: Yes. 2 MS. JENNIFER MCALEER: But that's 3 recently changed, and now you do all medicolegal 4 pediatric cases, criminally suspicious or not. 5 Is that correct? 6 DR. CHITRA RAO: No. Occasionally I've 7 asked Dr. Fernandes to do when I'm there, because I'm not 8 going to be there forever. 9 MS. JENNIFER MCALEER: All right. 10 DR. CHITRA RAO: So if he's going to run 11 the Department after me, he has to start doing pediatric 12 cases. 13 MS. JENNIFER MCALEER: And you supervise 14 him on those cases? 15 DR. CHITRA RAO: Yes. Not maybe full 16 time, but then I go through the goals with him, and then 17 if he has any doubt or something, he'll always call me. 18 And before he signs out, I go through the slides with him 19 and then we'll release the report. 20 MS. JENNIFER MCALEER: All right. And a 21 little bit later we'll talk more about the peer review in 22 your particular unit. 23 COMMISSIONER STEVEN GOUDGE: Can I just 24 ask, Ms. McAleer, very quickly, what is the training of 25 your colleagues who do criminally and suspicious and

1 homicide cases in each case? 2 And starting with you. Dr. Tweedie, 3 what -- 4 DR. MICHAEL SHKRUM: Dr. Tweedie is 5 actually trained in a fellowship program that was offered 6 by Hamilton, and supervised by doctors around King, and 7 he was -- 8 COMMISSIONER STEVEN GOUDGE: Would he be 9 certified as a forensic pathologist? 10 DR. MICHAEL SHKRUM: He's -- he's not 11 certified, but he was trained very well. 12 COMMISSIONER STEVEN GOUDGE: In a 13 fellowship program that would be in addition to the 14 general residency in general pathology, or anatomic 15 pathology? 16 DR. CHITRA RAO: This is an extra one (1) 17 year he did, after he completed four (4) year training in 18 forensic path -- I'm sorry, anatomic pathology, then he 19 did this Royal College fellowship exam, and then he came 20 and did one (1) year fellowship with us in forensic 21 pathology. 22 COMMISSIONER STEVEN GOUDGE: Right. 23 MS. JENNIFER MCALEER: This -- this might 24 be a good time, Mr. Commissioner, just to briefly talk 25 about this very unique fellowship program that's --

1 that's run out of the Hamilton -- 2 COMMISSIONER STEVEN GOUDGE: Okay. 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: -- Unit. As the 6 Commissioner knows, until very recently there's been no 7 certification in Canada available, at least from the 8 Royal College of Physicians and Surgeons, with respect to 9 the sub-specialty of forensic pathology, despite that, 10 Hamilton, as I understand it, Dr. Rao, has for a number 11 of years offered a fellowship program in forensic 12 pathology. 13 Is that correct? 14 DR. CHITRA RAO: That's correct. 15 MS. JENNIFER MCALEER: And when one 16 completes that fellowship, one will not get Board 17 Certified in Canada because it simply isn't possible, 18 until recently, but yet one would still complete a 19 fellowship in forensic pathology at your Unit? 20 DR. CHITRA RAO: That's correct, and the 21 McMaster University gives them a certificate saying that 22 they've completed one (1) year of fellowship. It's not 23 only unique in forensic pathology. 24 There are other speciality in McMaster 25 where the resident, after they have completed their

1 residency program, they can choose to spend one (1) 2 additional year in their choice of sub-specialty. 3 MS. JENNIFER MCALEER: And how long has 4 Hamilton been offering this fellowship in forensic 5 pathology? 6 DR. CHITRA RAO: One (1) of the criteria 7 for the Government to give us extra funding was that part 8 of the funding will be utilized in training a fellow, and 9 in turn the fellow would be employed at an Ni (phonetic) 10 Institution, or elsewhere. 11 MS. JENNIFER MCALEER: I'm sorry. When 12 you say "extra funding", we're back to the money that 13 comes from the Solicitor General's office then? 14 DR. CHITRA RAO: That's correct. 15 MS. JENNIFER MCALEER: Okay. 16 DR. CHITRA RAO: And that was, I think, 17 implemented in '96. 18 MS. JENNIFER MCALEER: I see. 19 COMMISSIONER STEVEN GOUDGE: Have you had 20 a fellow each year? 21 DR. CHITRA RAO: No. Ted -- Dr. Ted 22 Tweedie was the first year, and then we had a gap. Last 23 year we had a foreign student who had completed his 24 residency in Toronto; he was from Saudi Arabia. 25 COMMISSIONER STEVEN GOUDGE: Mm-hm.

1 DR. CHITRA RAO: He completed one (1) 2 year fellowship with us. At the moment, we have another 3 fellow from Sri Lanka is completing. 4 And we were supposed to get a resident 5 from Western University, but we were -- in fact we were 6 going to offer her the fellowship program, and then 7 appoint her as a junior staff in our department, but then 8 unfortunately, Dr. Michael Pollanen got her, so she's 9 starting her fellowship with him this year, 2008, July. 10 COMMISSIONER STEVEN GOUDGE: Right, 11 right. 12 DR. CHITRA RAO: We may get another Sri 13 Lankan fellow next year. 14 COMMISSIONER STEVEN GOUDGE: Right. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: So to go back to 18 Mr. Commissioner's questioning, with respect to Dr. 19 Tweedie, then, after he completed his fellowship with 20 you, Dr. Rao, he then went to work with you, Dr. Shkrum. 21 But he has not lets say gone down to the States and 22 gotten the experience that the two (2) of you have 23 obtained, or taken the step further that you've taken, 24 Dr. Shkrum, which is to write the Boards in the US in 25 forensic pathology.

1 DR. MICHAEL SHKRUM: No, and I -- I don't 2 think his training would be recognized, actually, through 3 -- through the American Board. 4 COMMISSIONER STEPHEN GOUDGE: Yes, that's 5 what I've heard -- 6 MS. JENNIFER MCALEER: Yeah. 7 COMMISSIONER STEPHEN GOUDGE: -- that the 8 Americans have a very sort of -- 9 DR. MICHAEL SHKRUM: That's right. 10 COMMISSIONER STEPHEN GOUDGE: -- narrow 11 view of -- 12 DR. MICHAEL SHKRUM: Now, again, we'll 13 probably discuss this later, but the -- it's envisioned 14 that people that are currently in practice in forensic 15 pathology, there'll be some kind of practice eligibility 16 route -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. MICHAEL SHKRUM: -- route that will 19 allow them to -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. MICHAEL SHKRUM: -- write a -- the 22 certifying exam. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. CHITRA RAO: When I did my three (3) 25 month rotation in Richmond, Virginia, I did inquire about

1 it, and at that time, I contacted Dr. Hersh (phonetic); 2 he was in New York. What he told me was, you've been 3 through my CBN, and then he said, You have done so many 4 cases, so you will be eligible, and so if you want to, 5 you can. 6 And I chose not to; first of all, the 7 cost, and second, I felt enough is enough -- I've done so 8 many exams and, you know. And since Canada didn't 9 request -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. CHITRA RAO: -- there was no 12 requirement you -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. CHITRA RAO: -- have to be Board 15 eligible. It's only a thing after David Chiasson took 16 over as Chief Forensic Pathologist. He preferred 17 forensic pathologists with a Board -- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. CHITRA RAO: -- qualification. 20 MS. JENNIFER MCALEER: So that's why you 21 don't have the Board certification that Dr. Shkrum has. 22 DR. CHITRA RAO: No. 23 COMMISSIONER STEPHEN GOUDGE: And what 24 about Dr. Fernandes and Dr. King? 25 DR. CHITRA RAO: Dr. Fernandes did one

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1 (1) year Fellowship in Richmond, Virginia, and in fact, 2 we sent him -- he was paid by Richmond, Virginia, but 3 then we offered him a position on the condition that he 4 completes his Fellowship, but he didn't do the Boards. 5 And Dr. King has got DMJ from England, but 6 he doesn't have Board qualification, but he's a Fellow of 7 the Royal College of Canada. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 And, Dr. Dexter, what about Dr. Young? 10 DR. DAVID DEXTER: He's similar to 11 myself. I -- I don't have, you know, his full CV, but my 12 understanding is that he's an anatomic pathologist; he 13 does not have his American Boards. 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 But -- 16 DR. DAVID DEXTER: But it's through 17 experience -- 18 COMMISSIONER STEPHEN GOUDGE: Yes, 19 exactly -- 20 DR. DAVID DEXTER: -- the same route, 21 really, that I took. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. DAVID DEXTER: Yeah. 24 25 CONTINUED BY MS. JENNIFER MCALEER:

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1 MS. JENNIFER MCALEER: And is -- is Dr. 2 Young at the beginning of his career or more towards the 3 end of his career? Are we looking at a gap, perhaps, in 4 the next fifteen (15) years in -- in Kingston? 5 COMMISSIONER STEPHEN GOUDGE: Let's call 6 him senior, as a -- 7 MS. JENNIFER MCALEER: I'm trying to ask 8 that question diplomatically. 9 DR. DAVID DEXTER: I think he's about 10 fifty (50), so you can read into that... 11 12 (BRIEF PAUSE) 13 14 CONTINUED BY MS. JENNIFER MCALEER: 15 MS. JENNIFER MCALEER: And what about Dr. 16 Fernandes, Dr. Rao? 17 DR. CHITRA RAO: He -- he's -- his 18 background is very interesting because he was a 19 practising obstetrician for a long time and then he took 20 the government -- there was about a couple -- five (5), 21 six (6) years ago, the government introduced -- 22 physicians in other lines have a reentry program and they 23 can choose other speciality, so then he chose forensic 24 pathology. 25 He wanted -- so he got into a general

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1 pathology residency program in Toronto; he completed 2 that, and then he went for one (1) year of forensic 3 pathology Fellowship in Richmond, Virginia, and then he 4 joined us. 5 MS. JENNIFER MCALEER: Right, so how 6 senior is he? 7 DR. CHITRA RAO: He's the same as -- in 8 his early 50's or mid 50's. I'm not too sure -- 9 MS. JENNIFER MCALEER: All right. So he 10 may be working in his retirement, as well. 11 DR. CHITRA RAO: Yeah. 12 MS. JENNIFER MCALEER: Okay. 13 DR. CHITRA RAO: Oh, no, he has now -- 14 the government has taken out the retirement age, so if he 15 wants to, he can work. 16 MS. JENNIFER MCALEER: And -- and Dr. 17 Tweedie is considerably younger, Dr. Shkrum, is that 18 correct. 19 DR. MICHAEL SHKRUM: Yes, he is. 20 MS. JENNIFER MCALEER: He's just starting 21 his career. Okay. Thank you. I think that covers the - 22 - the chart, Mr. Commissioner, unless you have any more 23 questions about -- 24 COMMISSIONER STEPHEN GOUDGE: Yes, no, 25 that's great.

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1 MS. JENNIFER MCALEER: -- the case 2 distribution. 3 If we could then change topics a little 4 bit. We're going to come back to talk about your units a 5 little bit more later when we talk about the peer review 6 within the units, but now I'd like to talk just a little 7 bit about the autopsy procedures and how autopsies are 8 done and communication issues surrounding autopsies. 9 Let me start by asking -- and you -- you 10 don't need to refer to any particular documents. Let me 11 ask you first, though, about scene attendance. Dr. 12 Dexter, do you ever attend the scene of a death? 13 DR. DAVID DEXTER: When I reflect back 14 over the thirty (30) years that I've been doing this, 15 it's, I think, three (3) times. It's an unusual 16 occurrence for myself. I think looking at the other 17 members of the department that have done forensic 18 pathology, maybe a couple more occasions, but it's very 19 infrequent in the Kingston area to attend the scene. 20 MS. JENNIFER MCALEER: And is that a 21 matter of -- who makes that decision? Is that you and 22 your colleagues or is that something that the 23 investigating coroner or the Regional Coroner dictates? 24 Who -- who decides whether you go to the scene or not? 25 DR. DAVID DEXTER: It's usually the

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1 coroner who has asked or requested that we attend the 2 scene. And often the Regional Coroner but again, number 3 of cases, very small. 4 MS. JENNIFER MCALEER: Dr. Rao, what is 5 your practice? 6 DR. CHITRA RAO: We very often go to the 7 scene, especially in Hamilton. This practice was set by 8 the first forensic pathologist, Dr. Foster, continued by 9 Dr. Ferris and then Dr. King, and all of us go. 10 And this is a learning opportunity in the 11 sense. If we have residents doing their rotation in our 12 unit and we have to go to the scene, we'll take them too. 13 And so we encourage. 14 And normally even though sometimes the 15 police will call us to come to the scene, our first 16 question to the police will be, Have you notified the 17 coroner? Because the coroner has to let us know, and 18 they have to approve, Yes, you can go to the scene. 19 Sometimes the coroner will be at the 20 scene, and then they call the duty pathologist, like me 21 or Dr. Fernandes, and they'll say, I think you should 22 come down here when I'm here, and then we go. 23 MS. JENNIFER MCALEER: So there's a 24 different culture then in the Hamilton area with respect 25 to forensic pathologists going to the scenes of death?

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1 DR. CHITRA RAO: That's correct. 2 MS. JENNIFER MCALEER: And what value 3 does that add in your experience, Dr. Rao? 4 DR. CHITRA RAO: I think it's very 5 valuable in the sense when you go to the scene -- first 6 of all, you can form your own opinion, and that helps us 7 in our final summation of the case. 8 And -- and plus also what happens is so 9 that in court if you're asked, we don't have to say, 10 Hearsay, because I went to the scene, and I noticed this. 11 And second is, at the scene you can plan how you're going 12 to proceed with that case. 13 In a sense, if it is a sharp force injury, 14 we may have to do x-rays. So if we know well in advance, 15 then we can come to the hospital and make arrangements. 16 And also we can inform the police. We are there on an 17 advisory capacity. 18 So we can tell the police, maybe this, you 19 have to bag the hands or you have to bag the head and how 20 do you proceed, transportation, and also times -- we can 21 also help them. 22 They may not be very sure what type of 23 case they are handling. And by looking at the case, at 24 the scene, we may be able to let them know, I think 25 you're dealing with a blunt force, or we're dealing with

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1 a sharp force injury, or if he can say something about 2 the injury and give them advice as to what they should 3 look for. 4 So it varies from cases to cases. 5 MS. JENNIFER MCALEER: So I -- I hear 6 there that there's a preservation of evidence component 7 to it? 8 DR. CHITRA RAO: That's correct. 9 MS. JENNIFER MCALEER: And there's also - 10 - it sounds like you're doing an initial assessment of 11 what you're seeing, and providing some -- I don't know if 12 direction's the right word -- but some feedback to the 13 police that may guide their investigation, is that 14 correct? 15 DR. CHITRA RAO: That's correct. That's 16 correct. 17 MS. JENNIFER MCALEER: Okay. Dr. Shkrum, 18 what has been your experience? 19 DR. MICHAEL SHKRUM: When I first -- 20 first returned to London, I was called to a handful of 21 scenes by the London police department, but over the last 22 approximately fifteen (15)/twenty (20) years, my scene 23 attendance has been rare. 24 I went to one (1) scene recently. My 25 colleague, Dr. Tweedie though has been called to a couple

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1 of scenes in the last few months. 2 MS. JENNIFER MCALEER: And again you -- 3 you used the verb "called", so it's -- it's the local 4 coroner, or the -- 5 DR. MICHAEL SHKRUM: Yes, it's a -- 6 MS. JENNIFER MCALEER: -- Regional 7 Coroner that's asking you? 8 DR. MICHAEL SHKRUM: -- it's usually a 9 decision made by the investigating coroner in conjunction 10 with the -- with the police investigating the case. 11 MS. JENNIFER MCALEER: Okay. 12 DR. MICHAEL SHKRUM: And I should just 13 add, there are all -- alternatives to scene visitation. 14 MS. JENNIFER MCALEER: And what are 15 those, Dr. Shkrum? 16 DR. MICHAEL SHKRUM: Well, in -- in -- 17 because I serve a large area, South Western Ontario, it 18 may not be practical for me to travel all over the 19 countryside looking at -- at scenes. 20 So we do have the benefit that when -- 21 first of all, we have an idea over the phone, when the 22 case is discussed with us, what is going on. But the 23 forensic identification officers attached to various 24 police forces are -- take excellent photography -- 25 excellent digital images.

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1 And those -- those images are reviewed 2 with us prior to the autopsy. So we can get a handle on 3 the scene. Perhaps not as good as actually attending, 4 but I think a -- a reasonable alternative. 5 MS. JENNIFER MCALEER: And, Dr. Dexter? 6 DR. DAVID DEXTER: Yeah, I would 7 reiterate that we -- we've set up an area where we have a 8 conference room where we can review DVDs, videos, CDs, 9 chips, but also have an opportunity to discuss the 10 issues. 11 We have, because of computerization, 12 ability to magnify images, to focus on particular things. 13 And I suppose to put it in a word, it serves as a virtual 14 visit to the -- the scene. 15 And -- and we've found that very useful. 16 The one (1) occasion where I went to a scene most 17 recently, and then followed up with appearing in court in 18 relationship to it, is that, perhaps not surprisingly, 19 I'm viewed as having some skill sets that parallel that 20 of an identification officer, which I had to very quickly 21 say that I'm there to get an overall impression of the 22 scene. Whether an object was 2 inches to the right or 3 23 inches to the left; I -- I don't have that expertise. 24 I was not there to document that type of 25 thing. So it, in fact, caused more issues. It was not

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1 particularly helpful in moving things forward, I did not 2 think. 3 MS. JENNIFER MCALEER: I see. Dr. 4 Rao...? 5 DR. CHITRA RAO: Occasionally, Dr. 6 Fernandes and myself, we have gone to the scene after we 7 have completed the autopsy. There's certain issues -- we 8 thought by going to the scene, it may help us and which 9 indeed, has helped us, so. 10 MS. JENNIFER MCALEER: Okay. So in 11 keeping with this topic of interaction with the police 12 then, Dr. Dexter, what interaction do you have with the 13 police? If you -- if you get a new case, when do you 14 usually first see the police, and how do you communicate 15 with one another? 16 DR. DAVID DEXTER: Because we try and 17 start post-mortem examinations early in the day, we try 18 and ensure that everybody's going to be there. Now, 19 who's everybody? It's the Identification Officers who've 20 -- who've attended the scene; maybe the detectives who 21 are following up on the case. It might be a variety of 22 individuals; fire marshalls. 23 Again, it depends very much on the nature 24 of the case as to what expertise is out there. The 25 discussion with the coroner may be to varying degrees of

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1 detail. So the coroner certainly recognizes there is a 2 case; has some general overview of the complexity of it 3 and the issues. 4 But considerably more information may be 5 forthcoming from the Identification Officers and the 6 detectives through, if not anything else, more 7 investigation in the passage of time. So that would 8 occur before we would consider starting the actual 9 physical autopsy. 10 MS. JENNIFER MCALEER: And how do you -- 11 or do you document the information that you receive from 12 the police? 13 DR. DAVID DEXTER: Well, there would be 14 several forms of documentation. We would ensure that we 15 had a copy of all the images, and that would include any 16 DVDs or movies. That would become part of our record 17 that we could refer back to as with signing the case out. 18 I would take notes of -- of the circumstances and the 19 information I would have received. 20 If there's a medical record, a chart in 21 the hospital records, we would have that available to us. 22 That's the sort of information I -- I would have. 23 MS. JENNIFER MCALEER: Okay. And is that 24 similar for you, Dr. Shkrum? 25 DR. MICHAEL SHKRUM: Yes, it's a similar

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1 procedure that we have a pre-autopsy conference, and we 2 discuss issues. And I may raise issues with the police 3 as well. And again, that would govern how we approach 4 the -- approach the autopsy. 5 MS. JENNIFER MCALEER: And how do you 6 document your communications with the officers? 7 DR. MICHAEL SHKRUM: I -- I -- sometimes 8 I'm provided a synopsis by the -- by the officers. And 9 many times -- or always I write notes on the -- on the 10 worksheets that I'm using, during the course of that 11 discussion. 12 MS. JENNIFER MCALEER: All right. Now, 13 Doctor, I'll come back to you -- 14 DR. DAVID DEXTER: If I can -- 15 MS. JENNIFER MCALEER: Oh, sorry, yes. 16 DR. DAVID DEXTER: -- if I can just 17 clarify that. There -- there are sometimes the -- the 18 scene notes that the police have, and sometimes we get 19 copies of those. That's helpful. That goes into our 20 record. I take notes, but then I also dictate what I 21 understand has happened; what I found at the autopsy, 22 immediately on completing the autopsy. 23 So I transfer it from a annotated form 24 into what the current state of affairs is as I understand 25 it at the time of completion of the physical aspect of

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1 the ana -- of the pathology. 2 MS. JENNIFER MCALEER: Okay. And, Dr. 3 Rao, I understand your practice is similar in that you do 4 meet with the police officers ahead of time, but you 5 actually have a form that you use to document information 6 you received from the police, is that correct? 7 DR. CHITRA RAO: Yes. And they have to 8 fill in the document. We provide the document. It's in 9 the coroner's office where the police will come and 10 record it. 11 MS. JENNIFER MCALEER: All right. And 12 we'll see an example of that form. It's in Volume II, 13 Tab 56. It's PFP152815. And as I understand it, Dr. 14 Rao, this is a -- a document that your unit's generated? 15 DR. CHITRA RAO: That's correct. 16 MS. JENNIFER MCALEER: Okay. And when is 17 this used? How is this used? 18 DR. CHITRA RAO: This was reviewed by Dr. 19 King. Initially, it started with Dr. Foster. He had a 20 very simple form. Then when Dr. Ferris took over, he had 21 a different kind of form. He modified it. And then when 22 Dr. King took over it, he further modified it and now we 23 use that form. 24 MS. JENNIFER MCALEER: And the police 25 fill out this form?

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1 DR. CHITRA RAO: Yes, the police fill 2 out. 3 MS. JENNIFER MCALEER: And see that 4 there's a -- there's a column, "Re: Manner of Death 5 Apparent," so that the police officers are giving you, I 6 guess, an initial assessment at to what the manner of 7 death is? 8 DR. CHITRA RAO: That's correct. 9 MS. JENNIFER MCALEER: Okay. And then do 10 you maintain a copy of this and the police maintain a 11 copy of this? 12 DR. CHITRA RAO: That's correct. 13 MS. JENNIFER MCALEER: Okay. 14 DR. CHITRA RAO: And we also have an 15 incident report from the police. So sometimes we don't 16 get that immediately, because they send that to their 17 Coroner's Office. We have a Coroner's Office in 18 Hamilton, and so they send that copy. And then, if it 19 need be, we can always get a copy of that. 20 MS. JENNIFER MCALEER: All right. And 21 then -- 22 COMMISSIONER STEPHEN GOUDGE: Well, why 23 is the manner of death line there? 24 DR. CHITRA RAO: Manner of death? 25 COMMISSIONER STEPHEN GOUDGE: Yes.

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1 DR. CHITRA RAO: That gives us some 2 indication -- their initial investigation of the case, 3 what ideas they have. Sometimes it's quite obvious. 4 They go to the scene, and they've talked to the family. 5 And they know it's heart disease, this patient is 6 suffering from heart disease or pulmonary disease. So 7 they tick the box, natural. 8 And sometimes they go to your scene of 9 obvious hanging. And there's a suicide note there, and 10 they have the history of depression or he has attempted 11 in the past. So they're quite confident. They may tick 12 the suicide. 13 And then homicide, obvious homicide, they 14 will tick homicide. 15 If they are not sure, then they'll say 16 unknown. 17 COMMISSIONER STEPHEN GOUDGE: Is that 18 helpful? 19 DR. CHITRA RAO: Yeah, sometimes, yes. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: Why is it helpful, 23 Dr. Rao? 24 DR. CHITRA RAO: Helpful in the sense, we 25 get a sense before we do the autopsy what kind of case we

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1 are dealing. Just because they have ticked of natural, 2 or suspicious, or homicide, we don't try to get into that 3 line. We will also see what we find in our autopsy. 4 Sometimes what they have ticked as suicide 5 may not be suicide, or sometimes accident. Of course, 6 most of the time when we say accident, it's a motor 7 vehicle accident. 8 MS. JENNIFER MCALEER: So to what extent, 9 if -- if any, do -- do all of you censor information you 10 receive from the police? I mean this -- this form shows, 11 in particular, some information that you get from the 12 police, Dr. Rao. 13 But I -- I take it, Dr. Shkrum and Dr. 14 Dexter, that it would not be unusual for a police officer 15 to opine to you on what he thinks the manner of death is, 16 as well, even though he's not committing it to writing. 17 So, Dr. Shkrum, in your experience, I 18 mean, do police communicate to you, We think this is a 19 suicide, We think this is a homicide? 20 And -- and what -- of what use of that -- 21 what use is that information to you? 22 DR. MICHAEL SHKRUM: Well, I guess the 23 police -- police business, they're always suspicious of 24 everything. And I think we're there as, you know, I 25 guess, in a sense of triage function.

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1 We're there to filter the information that 2 they are providing us, to treat it with an open mind and 3 in an objective fashion. 4 Obviously, it's important information that 5 will guide how we approach the autopsy, to either address 6 their concerns in a positive or a negative way. And 7 hopefully, at the conclusion of the autopsy, come up with 8 an answer or, in some cases, perhaps a pending kind of 9 situation which will rely on additional testing or 10 studies or investigation that's required. 11 MS. JENNIFER MCALEER: Is -- is there 12 information that officers try to give you and you just 13 don't want to hear it? I mean do you ever stop the 14 conversation? 15 Do you ever say, You know what, I don't 16 really need to know that? 17 DR. MICHAEL SHKRUM: Well, in my 18 experience, I -- I have problems -- and again, I -- I 19 perhaps seek some guidance on this -- but regarding 20 confessions, that sometimes police will have a 21 confession. And there are details in that confession 22 that obviously would influence the -- the autopsy, so I - 23 - I struggle with that. 24 I -- I usually don't try to -- want -- 25 want to hear the -- the details of the confession. But

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1 nevertheless, I do want some guidance as to issues I 2 might have to address during the course of the autopsy in 3 a general way. 4 MS. JENNIFER MCALEER: Can you give us an 5 example? What kind of information that would be in a 6 confession would -- would assist you in your autopsy? 7 DR. MICHAEL SHKRUM: Well, say if, you 8 know, there was an issue of sexual assault and there was 9 details of that sexual assault. You know, it might be 10 better just to say, Doctor, can you address the issue of 11 sexual assault in this case? As -- as opposed to going 12 into the details, maybe that sort of thing. 13 But again, that's something I -- you know, 14 that might -- we might need guidance on in the future. 15 MS. JENNIFER MCALEER: Dr. Dexter, what 16 are your views on the issue of what information you get 17 from the police and whether or not the pathologist should 18 be censoring that information in any way? 19 DR. DAVID DEXTER: I -- I'm not sure I 20 can add very much to what Dr. Shkrum has said, because 21 that's been very much my -- my approach to these things. 22 We -- we do need information. I don't think this 23 something that you can approach with a blank sheet of 24 paper. 25 And so, therefore, you're doing from the

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1 purity of findings. This is sometimes an approach that 2 is taken by surgeons and -- when they give us lumps to 3 diagnose they think that we should do it. De novo, as 4 perhaps an intellectual problem and this is not the right 5 way to do this, and certainly not in relationship to the 6 type of cases we're talking about. 7 So I'm very open to receiving information 8 because it may influence how one might approach the case. 9 In dealing with some of the prison deaths, some of the 10 information as to why they're incarcerated and some of 11 original crimes, may be somewhat irrelevant to how I 12 might approach the autopsy. But otherwise I would be 13 supportive of Dr. Shkrum's comments. 14 MS. JENNIFER MCALEER: Just one (1) last 15 follow up question then, before the break, on this topic. 16 What about prior CAS involvement, if -- if 17 we're dealing in a pediatric case -- and I will limit my 18 questions to you, Dr. Rao and Dr. Shkrum -- is -- is that 19 something that you would want to know? 20 DR. CHITRA RAO: I want to know. 21 MS. JENNIFER MCALEER: And why do you 22 want to know? 23 DR. CHITRA RAO: Well, because sometimes 24 the findings can be subtle in the case we are doing. 25 What I want to know is CAS involvement because of what

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1 nature -- because of another abuse of another child or is 2 it a physical neglect, that kind of issues. And -- but 3 just because I get that information that doesn't mean I'm 4 going to use that information to make it -- yeah, this 5 particular case I'm doing could be that, no. I keep an 6 open mind. 7 I keep an open mind. And I think 8 especially in pediatric case it's desirable to have every 9 information what you have, not only on the child, child's 10 progress, family history, medical history, and ever -- 11 all factors play into coming into the conclusion as to 12 the cause of death. 13 MS. JENNIFER MCALEER: Dr. Shkrum...? 14 DR. MICHAEL SHKRUM: I've routinely asked 15 that question in the past where there's been Children's 16 Aid involvement. And again I would seek guidance on 17 this, but, again, it doesn't alter the approach to the 18 case. 19 I mean, there is a protocol in place that 20 will address whether there are injuries, whether acute or 21 chronic injuries, and regardless of whether there is CAS 22 involvement, the police have usually made that inquiry 23 and they will also bring that information forward and say 24 that this child had suffered some injuries in the past. 25 MS. JENNIFER MCALEER: Okay.

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1 DR. CHITRA RAO: I'm sorry. Can I add to 2 the -- one (1) or two (2) of -- of this Forum? 3 MS. JENNIFER MCALEER: Certainly. 4 DR. CHITRA RAO: The main thing we are 5 interested in this, how -- the position of the body, how 6 we compare, because sometimes there can be -- a 7 positional asphyxia can cause death. But if the person, 8 whoever attended the scene and they're altered, and if 9 you don't have that information, the autopsy may be 10 fairly negative. We may not have a cause of death, or a 11 traumatic asphyxia, something fallen upon, and if they 12 have removed that object then we do not have that 13 information, we'll have a negative autopsy. 14 And another thing is events -- events 15 leading to the death, if we have a case that's a verbal 16 altercation and the person suddenly collapses and if we 17 at autopsy find evidence of artery -- coronary artery 18 disease, then we know, as are patients underlying 19 coronary artery disease if they're subjected to physical 20 or emotional stress, that can induce a cardiac 21 arrhythmia. 22 So it is important for us to know that 23 kind of information. So we stress those are kind of 24 information we need. 25 MS. JENNIFER MCALEER: All right. Thank

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1 you. Mr. Commissioner, perhaps this is a good time to 2 take a break. 3 COMMISSIONER STEPHEN GOUDGE: Sure. We 4 will rise then until twenty-five (25) to 12:00. 5 MS. JENNIFER MCALEER: Thank you. 6 7 --- Upon recessing at 11:19 a.m. 8 --- Upon resuming at 11:39 a.m. 9 10 THE REGISTRAR: All rise. Please be 11 seated. 12 COMMISSIONER STEPHEN GOUDGE: Yes, Ms. 13 McAleer? 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: Doctor, just 17 following up on communications with the police and 18 practices in the autopsy room, do you engage in any 19 practice with respect to police note taking during 20 autopsies? 21 I'll start with you, Dr. Shkrum. Are 22 officers taking notes during autopsies? Do you ever 23 caution them about taking notes? 24 DR. MICHAEL SHKRUM: I do caution them 25 and I also indicate to them that, you know, I -- well

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1 certainly at the end of the autopsy I will summarize my 2 findings for them and watch them take their notes while 3 I'm doing that. I tend to discourage note taking during 4 the course of the autopsy because -- because there's a 5 series of steps, the -- the findings are somewhat 6 preliminary until we complete the autopsy. Only then can 7 I really summarize as to where we're at with the case. 8 Lately, though, we do have a -- a 9 notification form that is sent to the Toronto Forensic 10 Pathology Unit to be vetted by Dr. Pollanen or his 11 delegate, indicating what the nature of the case is 12 about; and this again, in reference to homicides or 13 criminally suspicious case -- cases. 14 And if there are issues that require 15 pending tests, that's indicated on the notification form. 16 So that notification form -- if I remember, I also make a 17 copy for the police. So what I send to the Toronto unit 18 to be vetted and also will be given to the police to take 19 as part of their record. 20 The idea of this notification form is that 21 within twenty-four (24) hours, if there is still a 22 problem as perceived by Dr. Pollanen or his delegate, we 23 will get feedback and -- to address certain issues. So 24 it's -- it's, kind of, being a safety net that we're not 25 going to be missing a potential, you know, avenue of

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1 investigation. 2 MS. JENNIFER MCALEER: All right. So -- 3 sorry. 4 COMMISSIONER STEPHEN GOUDGE: Does it 5 have a preliminary conclusion in it? 6 DR. MICHAEL SHKRUM: It may actually 7 indicate the actual cause of death. And -- and sorry, I 8 didn't actually bring a copy to -- to provide you, but 9 it's very similar, I think, what is used in -- in 10 Hamilton. But it -- it may have an actual conclusion as 11 to what the cause of death is, gunshot wound, stabbing, 12 not quite straightforward. 13 But in other cases, it may be a pending 14 cause -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. MICHAEL SHKRUM: -- where the cause 17 of death is not apparent. It's pending fur -- further, 18 say, neuropathological examination, examination of the 19 brain, pending toxicology -- 20 COMMISSIONER STEPHEN GOUDGE: Or 21 histology or whatever. 22 DR. MICHAEL SHKRUM: Exactly. 23 COMMISSIONER STEPHEN GOUDGE: Yes. 24 25 CONTINUED BY MS. JENNIFER MCALEER:

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1 MS. JENNIFER MCALEER: Why don't we turn 2 up the Hamilton document since that is in the database. 3 It's at Volume II, Tab 57. Volume II, Tab 57, it's 4 PFP157647. Now, Dr. Rao, I understand this is a document 5 that you prepared or that was prepared in your unit. 6 But, Dr. Shkrum, you're indicating that 7 this is similar to the document that you use? 8 DR. MICHAEL SHKRUM: Yes, we have a 9 similar document. It's -- it's somewhat modified, but 10 it's a -- it's a similar -- similar document. 11 MS. JENNIFER MCALEER: And the reason why 12 you both have these -- these documents is because there's 13 now a policy that with criminally suspicious cases, 14 you're going to inform the Chief Forensic Pathologist 15 directly, immediately following your post-mortem 16 examination? 17 DR. MICHAEL SHKRUM: Yes. 18 DR. CHITRA RAO: That's correct. 19 MS. JENNIFER MCALEER: Okay. And, Dr. 20 Dexter, you're familiar with that practice as well? 21 DR. DAVID DEXTER: Yes. We've modified 22 our form. It's -- it was based on the Hamilton one, so 23 it's very similar. Our process is -- is the same as -- 24 MS. JENNIFER MCALEER: All right. So 25 then looking --

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1 COMMISSIONER STEPHEN GOUDGE: Would you 2 give a copy to the police in each case? 3 DR. DAVID DEXTER: We -- in Kingston, we 4 have not. That would be the only difference. 5 COMMISSIONER STEPHEN GOUDGE: Any reason 6 for that? 7 DR. DAVID DEXTER: Because I think our 8 tradition has been one of an oral reporting to the 9 police. This is what we can tell you at this point. And 10 it's a similar communication that we make directly to the 11 case coroner. So when we complete the autopsy, we really 12 have two (2) persons that we connect to. 13 One (1) is the coroner who issued the 14 warrant. The second is the -- the police officer -- also 15 is inquiring of us what our findings are, so we will 16 directly tell him and ensure that what he writes down is 17 what we tell him. With regards to the criminal -- 18 MS. JENNIFER MCALEER: Sorry, can I stop 19 your right there, Dexter -- 20 DR. DAVID DEXTER: Yes. 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: -- Dr. Dexter. 24 When you say we make sure that what he writes down is 25 exactly what we tell him, how do you do that? Do you --

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1 do you look at their notes? Do you sign their notes? 2 DR. DAVID DEXTER: Quite often we have to 3 spell things, but basically, yes, we -- we tell them that 4 the cause of death is heart attack. 5 MS. JENNIFER MCALEER: All right. So 6 there's -- the officer's standing there taking his -- 7 DR. DAVID DEXTER: Yes. 8 MS. JENNIFER MCALEER: -- notes as you 9 are speaking, but you don't sign their notebook or 10 anything like that? 11 DR. DAVID DEXTER: No, I do not sign 12 that. 13 MS. JENNIFER MCALEER: Okay. 14 DR. DAVID DEXTER: That -- that's not 15 been our practice. 16 MS. JENNIFER MCALEER: All right. Sorry, 17 I interrupted you. You were saying there were two (2) 18 people you report to. One (1) -- not report to, but you 19 share information with, and that's the officer and the 20 local coroner. 21 DR. DAVID DEXTER: The case coroner. 22 MS. JENNIFER MCALEER: And I guess -- the 23 third would be the Chief Forensic Pathologist in 24 situations where it's a criminally suspicious case? 25 DR. DAVID DEXTER: And we would use the

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1 same mechanism that's been described. 2 MS. JENNIFER MCALEER: Okay. Dr. Rao, do 3 you -- to answer the Commissioner's question, do you give 4 this form to the police officer? 5 DR. CHITRA RAO: I do. And I make them 6 sign. There's a column you can see; signature of 7 pathologist and signature of investigator. And to -- we 8 also indicate there what is our cause of that 9 preliminary. Or if you know -- like Dr. Shkrum said, if 10 it is a straightforward gunshot wound or stab wound, 11 we'll write. But if you do not have a direct cause of 12 death, we inform -- and we write in this form and say why 13 we are waiting for other ancillary testing, micro, and 14 special consultation cases. 15 So -- so the police will know what we are 16 waiting for. Before this form was sent to us, we had a 17 practice. In our rough sheet autopsy, the last column is 18 cause of death. So in that we write our opinion. And 19 then we showed it to the police, and usually before 20 starting the case, we tell the police we can discuss 21 various options about this case, or differential 22 diagnosis, but we are not taking down anything. 23 At the end of the autopsy, I'll let you 24 know what is my working diagnosis. That's how we are 25 going to write it. I may not inspect exactly what

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1 they're writing -- like he said, sometimes they have 2 spelling problem. 3 So I'll write it on my sheet, and I tell 4 them, This is the present preliminary cause of death. 5 MS. JENNIFER MCALEER: All right. Dr. 6 Dexter, with respect to note taking -- do you provide any 7 instruction to the police with respect to note taking? 8 DR. DAVID DEXTER: Yes, I do. And there 9 are a number of issues here, because as you're going 10 through the case, we will have pathology residents. 11 These are trainees in anatomic pathology that we wish to 12 train in the areas of medicolegal pathology. 13 So the discussion would generally be 14 widely ranging on the types of approaches that are 15 possible to resolve particular challenges or problems; 16 the considerations that one might have to take into 17 account in any given case. 18 So it's widely ranging. In that type of 19 setting, if we have somebody who is obsessive-compulsive 20 in taking notes, it's -- it's going to lead people in the 21 wrong direction, because we're not at the point of making 22 specific conclusions with regards to our findings. 23 So I point out that, Please do not take 24 notes during the procedure. We will discuss our 25 findings, and I will give you direction at the end of the

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1 case. You must understand that we will be talking about 2 a wide range of possibilities, and this is dealing with 3 the educational side of things and indeed, the discussion 4 with the pathology assistant -- 5 MS. JENNIFER MCALEER: Yes. 6 DR. DAVID DEXTER: -- and he knows, Hmm, 7 I wonder what that means. And different issues will come 8 out, many of which may turn out to be completely 9 irrelevant to the final -- 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 DR. DAVID DEXTER: -- findings. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. DAVID DEXTER: So -- discouraged. 14 MS. JENNIFER MCALEER: All right. 15 COMMISSIONER STEPHEN GOUDGE: And would 16 you explicitly tell the police that at the beginning of 17 each medicolegal autopsy? 18 DR. DAVID DEXTER: Yes, I would. Yes, I 19 would. 20 COMMISSIONER STEPHEN GOUDGE: Would each 21 of you do that? 22 DR. MICHAEL SHKRUM: I would go with what 23 Dr. Dexter and say. Yeah, we -- we do train people, and 24 there's a lot of speculation that goes on and questioning 25 of --

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1 COMMISSIONER STEPHEN GOUDGE: Even -- 2 even without residents around it -- 3 DR. MICHAEL SHKRUM: Absolutely, that's 4 right. 5 COMMISSIONER STEPHEN GOUDGE: -- there 6 would be speculation. 7 DR. MICHAEL SHKRUM: Yes. 8 COMMISSIONER STEPHEN GOUDGE: There would 9 be information exchanged by way of hypotheticals and so 10 on. 11 DR. MICHAEL SHKRUM: That's right. 12 COMMISSIONER STEPHEN GOUDGE: It could 13 easily mislead. 14 DR. MICHAEL SHKRUM: Yes. 15 DR. DAVID DEXTER: Yes. 16 17 CONTINUED BY MS. JENNIFER MCALEER: 18 MS. JENNIFER MCALEER: Just to follow up 19 on the Commissioner's question. Do you actually 20 articulate that to the police officer before every 21 autopsy, Dr. Shkrum? 22 DR. MICHAEL SHKRUM: Well, at the -- at 23 the inception of the case when we have our -- our pre- 24 autopsy conference, if -- if the resident is observing 25 the case, I will introduce that individual to the police

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1 as a pathology resident, so they know up front that this 2 is somebody that's training. 3 MS. JENNIFER MCALEER: All right. But -- 4 but do you also then tell them, I don't want you to take 5 notes? 6 DR. MICHAEL SHKRUM: Well, I'll indicate 7 to them that yeah, I will summarize the case to them at 8 the conclusion of the case. Of course they're taking 9 notes in terms of evidence collection, but not to take 10 notes of, sort of, speculation during the course of the 11 autopsy. 12 MS. JENNIFER MCALEER: All right. And, 13 Dr. Rao, you were nodding. Do you also, as Dr. Dexter's 14 explained, provide a little opening comment to the police 15 about note taking? 16 DR. CHITRA RAO: Yes. Every case I do 17 tell them. In fact, I emphasize more in cases of 18 homicide and suspicious cases. 19 MS. JENNIFER MCALEER: All right. And 20 then -- 21 DR. DAVID DEXTER: If I can just raise 22 one (1) circumstance that may obviate that, and that is 23 where you're dealing with a team of investigation 24 officers like the -- the team that is involved with the 25 prison deaths.

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1 This is a -- a pretty standard team, and 2 so that we know each other reasonably well. And some of 3 these rules of engagement are established -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID DEXTER: -- early in our 6 working relationship and remain intact. So that there 7 may be some circumstances where you don't -- 8 COMMISSIONER STEPHEN GOUDGE: Where you 9 don't need to do it to get -- 10 DR. DAVID DEXTER: -- you don't -- you 11 don't reiterate it -- 12 COMMISSIONER STEPHEN GOUDGE: Right, fair 13 enough. 14 DR. DAVID DEXTER: -- in that sort of 15 setting. 16 COMMISSIONER STEPHEN GOUDGE: Fair 17 enough. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: All right. With 21 respect to the collection of exhibits or -- or evidence 22 during an autopsy, Dr. Rao, in Volume II, Tab 58, 23 PFP157648, we have a document called Record of Autopsies 24 Exhibits and Violent Deaths Where Criminal Charges may be 25 Laid.

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1 Is this a document that you created? 2 DR. CHITRA RAO: This was actually 3 created by Dr. King. 4 MS. JENNIFER MCALEER: It originates from 5 your unit though, is that correct? 6 DR. CHITRA RAO: Yes, that's correct. 7 MS. JENNIFER MCALEER: And what is this 8 document and when is it used? 9 DR. CHITRA RAO: We use in every case of 10 sus -- suspicious cases and homicide, or any 11 circumstances where we get a sealed body; I mean the 12 storage locker or body bag seal. And then the police 13 come. 14 So there is a protocol. We don't open the 15 seal -- break the seal after the police are there. 16 So there is column here, Is there a seal? 17 And then if so, what time it was broken, who was present 18 at the time of autopsy. 19 And then we proceed to say how we received 20 the body: with clothing, no clothing, all that. We check 21 the boxes. 22 And then any samples taken, such as 23 fingernail clippings or hair, everything is documented 24 here. 25 And at the end of the autopsy we seal the

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1 specimens until we get signature of the exhibit or 2 identification officer and the pathologist. And then at 3 the end we handover, and then we tell them what time we 4 handed over the specimen. 5 And then we take a photocopy of this, and 6 the original will go the exhibit officer, and I keep the 7 autopsy. And the pathologist will keep the copy of this 8 form, and it goes into the file. 9 MS. JENNIFER MCALEER: So there's a clear 10 record of all samples taken, all exhibits, nail 11 clippings, everything that's on the sheet? 12 DR. CHITRA RAO: Exactly. And then plus 13 if you have taken x-rays, that is also indicated, and we 14 give the name of the x-ray technologist. 15 MS. JENNIFER MCALEER: All right. Dr. 16 Shkrum, do you do something similar in your unit? 17 DR. MICHAEL SHKRUM: Yeah, a little bit 18 more informal, but in my working sheets I do have slots 19 where it indicates evidence collected, x-rays taken, that 20 sort of thing. 21 I'll make notes in my worksheets of what 22 evidence was collected during the course of the autopsy. 23 If I have a memory failure, I will ask the police to 24 provide me an exhibit list ultimately. And sometimes 25 I'll -- I'll avail myself of that opportunity.

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1 MS. JENNIFER MCALEER: So, what's 2 happening then is the police officers are -- are making 3 their own exhibit lists as you are taking samples or -- 4 DR. MICHAEL SHKRUM: Yes. And they -- 5 the record the times that I turn those samples over to 6 them. And as I'm doing that, I'll make a note in my 7 worksheet as to the evidence collected. And -- and as I 8 said, sometimes there's vo -- many items of evidence that 9 are collected. I may miss something. So in that case I 10 may ask for an exhibit list to be provided to me. 11 MS. JENNIFER MCALEER: All right. And, 12 Dr. Dexter, what is your practice? 13 DR. DAVID DEXTER: Ours is similar to Dr. 14 Shkrum's, somewhat less formal. The information is 15 integrated in several areas. 16 One (1), in the medicolegal report in 17 which the -- the annotation of the samples taken. 18 The second place is actually in the 19 submission sheet to, for example, the Forensic Science 20 Centre for Toxicologic Examination. That will indicate 21 seal numbers, the type of specimen, and what was 22 requested. 23 Additionally, we've developed a small 24 Excel computer program in which we indicate what we've 25 retained. For example, We've retained the brain, we've

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1 done x-rays. And it's just a check box type of thing. 2 So in each case we can refer back to that computer 3 program, which has limited access to those that need to 4 know, as -- as to what sort of specialised studies have 5 been done. 6 So it's not quite in this format. 7 MS. JENNIFER MCALEER: Okay, thank you. 8 Now, tying in all this information that we've been 9 talking about and how it is reflected in your post-mortem 10 examination reports. 11 So the information that you get from 12 police officers, do you identify in your post-mortem 13 examination report the information you've obtained from 14 the police, if in fact you were relying on it or it forms 15 a basis of any of your conclusions, Dr. Shkrum? 16 DR. MICHAEL SHKRUM: Yes. And so in 17 addition to my cause of death I make attribution to the 18 information sources that I've -- I've based my cause of 19 death and are relevant to the cause of death or other 20 significant findings during the course of the autopsy. 21 So at the minimum, I will have a coroner's 22 warrant that provides some history of the circumstances 23 of the death. I will usually quote that in verba -- 24 verbatim and make the attribution to the coroner's 25 warrant.

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1 If it's a homicide or criminally 2 suspicious death, then I will summarise the information 3 that's provided to me by the police during that pre- 4 autopsy conference or subsequent information received via 5 case conferences or -- or telephone conversations. 6 If there is information from a hospital 7 chart, whether the person was admitted to hospital, 8 related to the incident or sometime in the past that is 9 relevant to the -- the autopsy report, I will also again 10 summarise that in my report. 11 MS. JENNIFER MCALEER: And has that 12 always been your practice, Dr. Shkrum, or is that 13 something that's developed over time? 14 DR. MICHAEL SHKRUM: I -- that is 15 actually developed over time. Initially I -- I was 16 somewhat of a minimalist. I would just indicate the 17 cause of death. And I think that was sort of tailored by 18 the nature of the report form that was being used in the 19 province. 20 And then in the last number of years I've, 21 at the minimum, put in the coroner's warrant information. 22 And then more recently I've also -- particularly in -- in 23 homicide and criminally suspicious death, I've also 24 indicated my sources of information, as I said, from 25 hospital charts, police, et cetera.

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1 MS. JENNIFER MCALEER: So back in the 2 1990s, then, would it be fair to say, Dr. Shkrum, that 3 that was a period when -- in which you would have been 4 writing more minimalist reports that -- that centred 5 primarily -- simply on the cause of death? 6 DR. MICHAEL SHKRUM: Yes. 7 MS. JENNIFER MCALEER: Okay. And, Dr. 8 Dexter, you were nodding as -- was that your practice as 9 well? 10 DR. DAVID DEXTER: Yes. It -- it 11 reflects an evolution and -- and a more rapid change 12 recently in that the issues of opinion for example, the 13 issues of the case summary, these were not integrated 14 into the old report form. 15 And so if you look at my reports from that 16 sort of time period, there is nothing there. 17 MS. JENNIFER MCALEER: And that's the 18 1990s? 19 DR. DAVID DEXTER: Except cause of death. 20 Yes. 21 COMMISSIONER STEPHEN GOUDGE: Entirely 22 conclusory? 23 DR. DAVID DEXTER: Yes. It's entirely 24 conclusory. So my -- my current reports are -- have been 25 modified to -- to incorporate some of these issues. And

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1 they will continue to be modified as we deal with some of 2 the issues before us. 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: And do you 6 currently attribute information sources the way Dr. 7 Shkrum has explained? 8 DR. DAVID DEXTER: Not as detailed as 9 that. It is largely based on the coroner's warrant type 10 of information. 11 MS. JENNIFER MCALEER: Okay. So you 12 don't ident -- 13 DR. DAVID DEXTER: So my -- my summaries, 14 if you wish, are -- there is one (1). It's relatively 15 short. I can see it in the near future expanding to 16 incorporate some of these issues so that there is 17 attribution to information depending on where it's come 18 from. 19 So again, it's an educative and an 20 evolutionary type of process. 21 MS. JENNIFER MCALEER: All right. Dr. 22 Rao, what is your practice? 23 DR. CHITRA RAO: My practice is when I 24 started training under Dr. Ferris, I was told that I was 25 a forensic pathologist and not a hospital pathologist, so

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1 I shouldn't be giving diagnosis. 2 Instead, I have to give an -- a summary. 3 And it starts with what information you received, either 4 from the police or from the coroner. And then the second 5 paragraph will be what you found at autopsy, gross as 6 well as micro. 7 And the third will be your critical 8 pathological correlation. And then you give your cause 9 of death. 10 And then you also -- initially, for all 11 homicide cases, I did not include toxicological findings, 12 except if it had some role in the person's death, that 13 I'll introduce. Otherwise I felt that was another area 14 of expertise and they'll answer. But only I will say, 15 Please refer to toxicology report, and then give my cause 16 of death. 17 And in cases where I've gone to the scene, 18 the report will start off with information -- I'll say, 19 Post-mortem examination commenced with a visit to the 20 scene. And I'll just, in one (1) or two (2) lines, I 21 will discuss what my impression of the scene was and then 22 continue the rest. 23 MS. JENNIFER MCALEER: So -- so your 24 report writing style, has it changed very much over the 25 last twenty (20) years then?

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1 DR. CHITRA RAO: No. I've been doing 2 from day one (1), from '78 -- 1978 -- up to the time the 3 same. And Dr. King does a summary, and Dr. Fernandes 4 does the same. We all follow the same. 5 COMMISSIONER STEPHEN GOUDGE: If you have 6 a consultation -- for example, with a neuropathologist -- 7 do you include that? 8 DR. CHITRA RAO: I include, definitely. 9 And until then -- 10 COMMISSIONER STEPHEN GOUDGE: All of 11 three (3) of you nod about that? 12 DR. DAVID DEXTER: Yes. 13 DR. MICHAEL SHKRUM: Yes. 14 DR. CHITRA RAO: And one (1) paragraph 15 will say, The brain was examined by the neuropathologist, 16 and his findings indicated, blah, blah. And then if that 17 played a role in my thing, I'll include that. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: All right. And 21 the correlation section that you've spoke of, is that 22 also what we sometimes call the interpretation section of 23 a report? 24 Dr. Shkrum are -- are you -- do you 25 actually articulate in your report your interpretation of

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1 what you're seeing before you actually get to your 2 conclusion? 3 DR. DAVID DEXTER: It depen -- it depends 4 on the complexity of the cause of death. You know, if 5 it's a gunshot wound or stab wound, it may be very 6 simple, that -- you know, The track has passed through a 7 vital area of the body. 8 But if it's a more complex type of case, 9 there may be more interpretation that's -- that's 10 supplied there. And obviously, as Dr. Rao indicates, 11 there may be sources of other information, such as 12 toxicology, that may have to be brought into play in that 13 interpretation. 14 There also may be interpretation -- I 15 sometimes put in certain types of injuries that in 16 themselves have not caused the death, but are of -- of a 17 significant nature. 18 MS. JENNIFER MCALEER: We're going to 19 talk about testifying a little bit later, perhaps after 20 lunch. 21 But I take it that in your experience, 22 even back in the 1990s, when you weren't writing down 23 your interpretation or your document sources, you were 24 asked to testify to those issues in court. 25 Is that true, Dr. Shkrum?

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1 DR. MICHAEL SHKRUM: Yes. 2 MS. JENNIFER MCALEER: And, Dr. 3 Dexter...? 4 DR. DAVID DEXTER: Yes. 5 MS. JENNIFER MCALEER: And, Dr. Rao, 6 different, because you would have actually been writing 7 that out. 8 Is there any effort now to try and have a 9 closer relationship between what you are called to 10 testify upon and what's in your post-mortem examination 11 report. 12 So in other words, are you trying to draft 13 your post-mortem examination reports now to cover the 14 areas that you anticipate one might question you on when 15 you're actually called as a witness? 16 DR. MICHAEL SHKRUM: Yes, I think to try 17 to make the report more transparent and understandable to 18 -- to the -- to the, I guess, the consumer of that 19 report. 20 MS. JENNIFER MCALEER: Dr. Dexter, would 21 you agree? 22 DR. DAVID DEXTER: Yes, I -- I think 23 that's clearly been an initiative in part coming from Dr. 24 Pollanen's effort in -- in regards to quality assurance; 25 and -- and linking what was a list of abnormal findings

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1 with a cause of death. 2 COMMISSIONER STEPHEN GOUDGE: Yes. 3 Outlining the reasoning process that gets you from -- 4 DR. DAVID DEXTER: Yes. 5 COMMISSIONER STEPHEN GOUDGE: -- your 6 findings to your diagnosis? 7 DR. DAVID DEXTER: Yes, yeah. And -- and 8 the problem that one faces is that the -- the degrees of 9 linkage -- the solidarity of your conviction, if you 10 wish, may be quite variable, but it's not visible to 11 those that read the report. And I think quite clearly 12 that's an area of deficiency that is currently being 13 addressed by adding an interpretive opinion -- 14 COMMISSIONER STEPHEN GOUDGE: The more 15 that is there the more that may become apparent, isn't 16 that so? 17 DR. DAVID DEXTER: Yes. 18 COMMISSIONER STEPHEN GOUDGE: That is: 19 The more that is in the report, the more the certainty or 20 lack thereof of the diagnosis -- 21 DR. DAVID DEXTER: Yes. 22 COMMISSIONER STEPHEN GOUDGE: -- may be 23 apparent, -- 24 DR. DAVID DEXTER: Yeah. In other 25 words, --

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1 COMMISSIONER STEPHEN GOUDGE: -- which is 2 a good thing, I take it? 3 DR. DAVID DEXTER: Yeah, it's the premise 4 on which you made your conclusion, -- 5 COMMISSIONER STEPHEN GOUDGE: Yes. 6 DR. DAVID DEXTER: -- you know. How did 7 you reach that conclusion? 8 COMMISSIONER STEPHEN GOUDGE: Yes. 9 DR. DAVID DEXTER: Yeah. 10 COMMISSIONER STEPHEN GOUDGE: Dr. Rao...? 11 DR. CHITRA RAO: Sometimes the coroner 12 goes to the scene, and he sees a body at the bottom of 13 the stairs, and there's definite open wound. And then we 14 do an autopsy. And then it's our duty to say that the 15 injury -- that laceration they saw -- is it related with 16 -- is there an underlying fracture of the skull or is 17 there underlying brain injury? 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. CHITRA RAO: If not, then we have to 20 explain why did this person end up there. So could be 21 he's intoxicated with drug or alcohol or he had natural 22 disease. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. CHITRA RAO: And that initiated -- so 25 it's -- as a part of a consultant, you have to inform --

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1 indicate in your report, and then say, Even though there 2 was an external injury that played no material part in 3 this disease. 4 And it's consistent with him or her having 5 sustained as a result of the final collapse, due to... 6 COMMISSIONER STEPHEN GOUDGE: And I mean, 7 that is a useful comment, Dr. Rao. I mean, I take it all 8 of you would agree that part of a fulsome report -- a 9 transparent report -- to use your word, Dr. Shkrum, would 10 be to explain why you have ruled out certain causes of 11 death -- 12 DR. CHITRA RAO: Exactly. 13 COMMISSIONER STEPHEN GOUDGE: -- that may 14 have apparent facts that tend in that direction, but do 15 not get you there for reasons that you can explain? 16 DR. DAVID DEXTER: That's right, yes. 17 DR. CHITRA RAO: That's correct. 18 DR. MICHAEL SHKRUM: Yes. Just a -- a 19 caveat, though, even thought we try to write the fulsome 20 report, I don't think we can anticipate every issue that 21 may arise. 22 DR. CHITRA RAO: Yes. 23 DR. MICHAEL SHKRUM: So again, just a 24 word of a warning that we just can't anticipate 25 everything.

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1 COMMISSIONER STEPHEN GOUDGE: I think of 2 it this way, having listened to you and several of your 3 colleagues, that it is an effort to put on paper what is 4 going through your head as you reach your conclusion. 5 DR. CHITRA RAO: Exactly. 6 COMMISSIONER STEPHEN GOUDGE: Is that 7 sort of a fair synopsis? 8 DR. MICHAEL SHKRUM: Yes. 9 DR. CHITRA RAO: Yes. 10 COMMISSIONER STEPHEN GOUDGE: Do you 11 agree, Dr. Dexter? 12 DR. DAVID DEXTER: Yes, I do. I -- I 13 think it's a -- a point in time. You've got all the 14 information up to this point in time, and this is your 15 best construct. Now, the caveat -- and I think Dr. 16 Shkrum was indicating -- is that there may be additional 17 information at some -- 18 COMMISSIONER STEPHEN GOUDGE: Absolutely. 19 DR. DAVID DEXTER: -- other time that may 20 allow -- but -- and the issue there is that your record 21 exists as a point in time. And -- and we need to deal 22 with the adjustment that may be necessary -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. DAVID DEXTER: -- as a consequence -- 25 COMMISSIONER STEPHEN GOUDGE: It is a

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1 transparency that I think you all say now is a best 2 practice is for me -- your best shot at -- 3 DR. DAVID DEXTER: Yeah. 4 COMMISSIONER STEPHEN GOUDGE: -- 5 explaining on paper what is -- how your head has got you 6 from the facts to the diagnosis? 7 DR. CHITRA RAO: Yeah. In fact, there 8 have been instances we have brought what our working 9 diagnosis and what we thought and that has happened and 10 later on we have got calls -- you know, you could think 11 that's exactly happened, now we have further information, 12 so that has helped. 13 COMMISSIONER STEPHEN GOUDGE: Okay. I do 14 not know if you are going to get into it, Ms. McAleer, 15 but can I talk a little with each of the three (3) of 16 them about levels of certainty of the diagnosis? 17 MS. JENNIFER MCALEER: Certainly. 18 COMMISSIONER STEPHEN GOUDGE: Or were you 19 going to do that? 20 MS. JENNIFER MCALEER: No, but that's 21 fine. We can do it -- we can do it here, Mr. 22 Commissioner. This is probably a good time. 23 COMMISSIONER STEPHEN GOUDGE: It is 24 clearly one (1) of the issues that is front and centre in 25 best practice report writing is how you experts

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1 articulate the level of certainty with which you have 2 drawn your diagnosis. I mean, how do you address that, 3 Dr. Shkrum? 4 DR. MICHAEL SHKRUM: Well, again, if it's 5 an obvious cause of death, like it's very easy -- 6 COMMISSIONER STEPHEN GOUDGE: Right. It 7 is -- 8 DR. MICHAEL SHKRUM: -- it's 100 9 percent -- 10 COMMISSIONER STEPHEN GOUDGE: -- yes, 11 yes, it is the grey ones -- it's the grey areas that are 12 the tough calls. 13 DR. MICHAEL SHKRUM: And I -- I think 14 that -- I think with the reporting that we're doing now 15 with listing, you know, findings, and I think if it's a 16 complex cause of death or a number of causes of death 17 it's simply outline, Here are the issues. 18 I -- I think it's very difficult to assign 19 a percentage though. You can't say that something is 20 76 percent versus 23 percent. That -- you just can't do 21 that. 22 COMMISSIONER STEPHEN GOUDGE: But some 23 conclusions are more certain in your mind than others. 24 DR. MICHAEL SHKRUM: Well, there may be 25 more objective evidence, more evidence from the autopsy--

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1 COMMISSIONER STEPHEN GOUDGE: That 2 provides the explanation for the conclusion being more or 3 less certain. 4 DR. MICHAEL SHKRUM: That's right. But, 5 however, there may be, you know, a little outlier there 6 that says, Okay, well it raises this possibility, but 7 based on the constellation of findings, it points in this 8 -- in this direction. 9 COMMISSIONER STEPHEN GOUDGE: Okay. But 10 let me put the hypothetical that Dr. Pollanen taxed us 11 with where you had two (2) cases: One, a recently 12 deceased body -- what appears to be a stab wound in the 13 chest cavity, a nick in the heart and a chest cavity full 14 of blood; diagnosis on the basis of those facts, stab 15 wound. 16 DR. MICHAEL SHKRUM: Right. 17 COMMISSIONER STEPHEN GOUDGE: Okay. The 18 second case is nothing but a skeleton where there is a 19 nick in the rib over where the heart was. The diagnosis 20 may be the same, cause of death, stab wound, but held 21 with far less certainty because of the evidentiary base 22 available to the pathologist. 23 DR. MICHAEL SHKRUM: But I think -- I 24 think that can be commented on though. 25 COMMISSIONER STEPHEN GOUDGE: How do you

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1 deal with that though? How do you deal with the level of 2 certainty? Is it to be simply seen, Dr. Shkrum, from the 3 evidence-base, the fact-base from which the conclusion is 4 drawn? Or is it expressly articulated? 5 DR. MICHAEL SHKRUM: Well, again, and my 6 colleagues can comment further, but I think in the case 7 of skeletal remains, I would say, You know, there is this 8 wound on the ribs. Given its location, there is a 9 probability that the heart would have been penetrated, 10 but it cannot be conclusive because of the lack of soft 11 tissue. 12 COMMISSIONER STEPHEN GOUDGE: So you 13 would use the language that would indicate the conclusion 14 of cause of death that was in some sense qualified. 15 DR. MICHAEL SHKRUM: That's right. 16 COMMISSIONER STEPHEN GOUDGE: Whereas in 17 the other case, it would not have been? 18 DR. MICHAEL SHKRUM: No, because again, 19 as a pathologist dealing with a skeleton, you're at a 20 disadvantage. You don't have the soft tissue -- 21 COMMISSIONER STEPHEN GOUDGE: Yes. 22 DR. MICHAEL SHKRUM: -- to -- to assess, 23 so -- 24 COMMISSIONER STEPHEN GOUDGE: But somehow 25 you would find language that articulates in your report

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1 the lesser level of certainty, if I can put it that way, 2 based on the challenge of having only skeletal remains. 3 DR. MICHAEL SHKRUM: Yes. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: And sorry, can I 7 interrupt just for a moment? Am I hearing, Dr. Shkrum, 8 that you indicate that you may not actually even come to 9 a cause of death as stabbing in those circumstances? 10 DR. MICHAEL SHKRUM: Well, I would 11 probably -- I may raise it as simply undetermined. I 12 mean, you could argue that that particular wound may be 13 only superficial, -- 14 COMMISSIONER STEPHEN GOUDGE: Yes. 15 DR. MICHAEL SHKRUM: -- and -- and did 16 not penetrate the -- the heart. So, you know, it could 17 be undetermined but raising the comment that the 18 probability or possibility that the heart was penetrated 19 is raised, and -- and probably just leave it at that. 20 MS. JENNIFER MCALEER: I see. 21 DR. CHITRA RAO: Again, like you said, 22 I'll see that it's a superficial nick or it has gone 23 through and through the bone. If it has gone through and 24 through the bone -- the possibility of the location of it 25 -- then you may say there's a possibility that could have

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1 been a penetrating injury or perforating injury to the 2 lung or the heart. I'd raise the possibility, and then 3 I'll say, In view of the condition of the skeletal 4 remains and no soft tissue, this conclusion can neither 5 be confirmed nor ruled out on examination of the bones 6 alone. 7 And if it's a through and through and the 8 police want to know what kind of weapon, then I'll ask 9 the anthropologist to examine the bones, and I'll 10 incorporate their opinion along with my report. 11 COMMISSIONER STEPHEN GOUDGE: Okay. But 12 depending on, to take the subset that you have put at it, 13 Dr. Rao, if the rib is actually penetrated, you would 14 find language that suggests rather more probability than 15 if it's just a nick in the rib. 16 DR. CHITRA RAO: That's correct. But I 17 won't give a percentage. 18 COMMISSIONER STEPHEN GOUDGE: Okay. Do 19 you have language categories that you are comfortable 20 with: possible, probable, very probable or how do you do 21 it? 22 DR. CHITRA RAO: I usually use the word 23 "suggests" or "raises the possibility". 24 COMMISSIONER STEPHEN GOUDGE: Yes. 25 DR. CHITRA RAO: And then I will leave it

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1 at that. I -- 2 COMMISSIONER STEPHEN GOUDGE: And once 3 you get over the bar of probable, you know -- the rib has 4 been penetrated, does that become probable? 5 DR. CHITRA RAO: I suppose, yes, it does. 6 But I don't know whether I'll put -- 7 COMMISSIONER STEPHEN GOUDGE: Yes. 8 DR. CHITRA RAO: -- that in my report. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 DR. CHITRA RAO: Because if it's only a 11 skeletal remain, I've just got the -- 12 COMMISSIONER STEPHEN GOUDGE: These are 13 huge challenges for -- 14 DR. CHITRA RAO: Exactly. 15 COMMISSIONER STEPHEN GOUDGE: -- the 16 three (3) of you, just as forensic pathologists, let 17 alone... 18 DR. CHITRA RAO: Yeah. 19 COMMISSIONER STEPHEN GOUDGE: But 20 obviously the interest is, the lay listener, the legal 21 system, hears that language and may not be able to 22 capture precisely, if I can use the phrase "the level of 23 certainty" that the expert pathologist has in his or her 24 head. 25 What do you say, Doctor?

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1 DR. DAVID DEXTER: I agree. It is a 2 horribly difficult area, and I've been challenged in just 3 the same way -- what do you mean by possible or probable? 4 What degree of likelihood and so forth is? The other 5 observation I would make is that I'm sure amongst the 6 three (3) of us and the other pathologists that you've -- 7 you've heard in -- in this Commission Hearing that their 8 probable may be different from your probable. 9 DR. MICHAEL SHKRUM: Correct. 10 COMMISSIONER STEPHEN GOUDGE: Fair 11 enough. 12 DR. DAVID DEXTER: And I don't know how 13 that's going to play out in regards to the legal system. 14 I think all I could, you know, identify is the 15 extraordinary difficulty that that sort of -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID DEXTER: -- wording provides. 18 I think it's extremely difficult and very unwise to try 19 and develop some sort of table approach in which these 20 words and -- you know, it's 25 percent, 50 percent, 75 21 percent. 22 COMMISSIONER STEPHEN GOUDGE: The cases 23 are too varied to do that, I suspect, you will say. 24 DR. DAVID DEXTER: I -- I just -- it just 25 can't be done.

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1 COMMISSIONER STEPHEN GOUDGE: Right, 2 right. 3 DR. DAVID DEXTER: And we have other 4 terminology, such as "consistent with" that within -- 5 COMMISSIONER STEPHEN GOUDGE: That is 6 sort of a different problem. 7 DR. DAVID DEXTER: It's a -- 8 COMMISSIONER STEPHEN GOUDGE: That is an 9 ambiguity problem. 10 DR. DAVID DEXTER: -- it's a ang -- 11 ambiguity problem, but in the medical side of things, it 12 is something that is regularly used. 13 COMMISSIONER STEPHEN GOUDGE: Yes, right. 14 DR. DAVID DEXTER: And within the medical 15 community, it has some understanding, but you cross it 16 into the legal community, and it poses problems. 17 COMMISSIONER STEPHEN GOUDGE: Yes, 18 because it may have a very different connotation in the 19 legal system. 20 DR. DAVID DEXTER: Precisely. 21 COMMISSIONER STEPHEN GOUDGE: And that is 22 part of the communication bridge that we have heard a 23 good deal about, and that is a real challenge. 24 DR. DAVID DEXTER: I -- I sometimes use 25 the term "favour" --

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1 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 2 DR. DAVID DEXTER: -- to give an intent, 3 and I use the word "bias" carefully here. But a -- a 4 bias towards a particular mode of -- of -- a particular 5 cause of death. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. DAVID DEXTER: But they are 8 adjectives -- 9 COMMISSIONER STEPHEN GOUDGE: Correct. 10 DR. DAVID DEXTER: -- and there is 11 different weighting of their interpretation, I grant you. 12 COMMISSIONER STEPHEN GOUDGE: Right, 13 right. 14 DR. CHITRA RAO: Then sometimes there are 15 some findings in autopsy, you'll have a differential 16 diagnosis. So you list that to these findings could 17 represent -- 18 DR. DAVID DEXTER: Yes. 19 DR. CHITRA RAO: -- these various 20 conditions. However, in this particular case because of 21 the findings, A, B, C, I favour more the diagnosis of 22 this particular entity. 23 COMMISSIONER STEPHEN GOUDGE: That just 24 pushes the problem back one (1) square on the board 25 though, Dr. Rao. For each of the differential diagnoses,

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1 the same problem arises, does it not? 2 DR. CHITRA RAO: That's -- that's 3 correct. 4 DR. MICHAEL SHKRUM: I think it's 5 incumbent upon us as forensic pathologists in our 6 reports, you know, to put a comment, There are 7 limitations to this examination. 8 DR. CHITRA RAO: Exactly. 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. MICHAEL SHKRUM: It's incumbent upon 11 us to make the Crown aware of that. And certainly, if 12 it's not brought out in our testimony, it's incumbent 13 upon the defence to raise that issue. 14 COMMISSIONER STEPHEN GOUDGE: Right. I 15 mean, it may well come back, Dr. Shkrum, to what you 16 began with, and that is transparency. That is, trying to 17 put on paper as best you can, your own cause of death 18 opinion with all the qualifications or lack thereof that 19 the evidence has provided to you. 20 DR. CHITRA RAO: And plus, if you -- you 21 do not have a cause of death, and -- and if you're not 22 confident of that, mention that in the report. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. CHITRA RAO: The case is such -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. CHITRA RAO: -- we can't come to any 2 definite conclusion. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 Well, that is a helpful discussion. Thank you. 5 6 CONTINUED BY MS. JENNIFER MCALEER: 7 MS. JENNIFER MCALEER: Thank you. Change 8 in topics, completely, for a moment. I want to talk a 9 little bit about interaction with clinicians in the 10 autopsy room. What interaction do you have, and, Dr. 11 Shkrum, how often do have clinicians in your autopsy room 12 and under what circumstances? 13 DR. MICHAEL SHKRUM: I can think of, sort 14 of, three (3) general areas where we've had clinical 15 involvement. One (1) is the orientation of injuries. 16 And -- so for example, if someone is rushed to hospital 17 and has some type of surgical procedure and they make an 18 incision through a wound or they put in the tubes that 19 create wounds, it may not be clear from the medical chart 20 as to what is going on. 21 So at the minimum, I will phone the 22 surgeon or the emergency physician to clarify where these 23 iatrogenic wounds occurred or -- or alteration wounds 24 occurred. And on occasion, the -- the clinician or the 25 surgeon may actually have to come to the autopsy suite.

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1 Sometimes there may be a -- a finding 2 related to a surgical procedure that may require 3 clarification also. The second sphere of, sort of, 4 involvement would be in sexual assault cases that in -- 5 in the past I've used the resources of our -- the 6 director of the Adult Sexual Assault Centre in London, 7 Dr. Susan McNair, to assess injuries that have occurred 8 in homicide cases. 9 And the third sphere is the assessment of 10 -- of pediatric cases. Again, Dr. David Warren, who is 11 in charge of the child abuse team at -- at the Children's 12 Hospital in London -- obviously, he has expertise in this 13 area -- and his services have been called. 14 And one occasion -- not my case actually 15 but a case of my colleague, Dr. Bertha Garcia (phonetic). 16 She's actually the Chief and Chair of our department. In 17 the past she has done forensic cases. She actually had 18 the experience in Alberta where she -- she did 19 medicolegal autopsies. 20 On this particular occasion she had a very 21 problematic pediatric case with multiple trauma. And I 22 was actually away, but I was able to contact her. And I 23 suggested to her that she have Dr. Warren perhaps attend 24 or assess some of these findings with her. And he was 25 kind enough to -- to give her some assistance in that

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1 matter. 2 At the minimum though, we've, in some 3 pediatric cases, we have sought out Dr. Warren's opinions 4 to -- either to assess images that were taken during the 5 autopsy or assess, say, a clinical presentation or 6 clinical outcomes of certain types of cases. 7 MS. JENNIFER MCALEER: All right. What - 8 - what value -- well, first of all, with Dr. Warren, does 9 he actually come in to the autopsy suite? 10 DR. MICHAEL SHKRUM: Not in the cases 11 I've dealt with. But as I said, in this one (1) 12 particular case that my -- my Chief, Dr. Garcia, was 13 involved with, he actually came to the autopsy suite. 14 MS. JENNIFER MCALEER: And what -- what 15 value does he add? What -- what is he able to -- to do 16 that you -- that you can't do or that your colleague 17 can't do? 18 DR. MICHAEL SHKRUM: Well, I think in 19 general terms, clinical -- a person with clinical 20 experience, whether it's sexual assault or a 21 pediatrician, they see a lot more living individuals that 22 we see, say, in the post-mortem setting. 23 I mean, these cases are -- are not common. 24 And if there are certain types of injuries that are 25 there, we may want to want to assess their, you know,

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1 what the significance of those injuries might be. 2 Now whether it's attendance at the autopsy 3 suite or subsequent assessment of digital images, we 4 would rely, sometimes, on these clinical experts to give 5 us some assistance as to what those injuries might mean, 6 because they obviously see a large volume of individuals. 7 We see a very small number of individuals. 8 MS. JENNIFER MCALEER: Is there any 9 concern, though, with respect to post-mortem artifacts 10 and the fact that something may look differently on -- on 11 them when they're dead -- 12 DR. MICHAEL SHKRUM: Yes. And that's -- 13 that's -- 14 MS. JENNIFER MCALEER: -- than when 15 they're alive. 16 DR. MICHAEL SHKRUM: -- that's -- that's 17 the danger, because, you know, simply with changes in the 18 body after death, which could mimic or obscure injuries, 19 you do run into that potential problem. 20 And, again, one has to be very careful 21 before calling in these experts to say, Okay, this is a - 22 - the condition of this body maybe precludes that kind of 23 clinical assessment occurring. 24 So a decomposed body which -- where 25 there's injuries that have been potentially altered, it

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1 may be simply that those injuries or apparent injuries 2 are described in a very descriptive fashion and no 3 further clinical assessment can be done because of the 4 limitations that the clinical expert might have in that 5 situation. 6 MS. JENNIFER MCALEER: Okay. 7 COMMISSIONER STEPHEN GOUDGE: But it is 8 really up to the pathologist to guard against any sort of 9 post-mortem changes skewing what you hear from -- 10 DR. MICHAEL SHKRUM: Yes, I think, yeah, 11 I think so. I mean, you're calling in this expert. And 12 I think -- I think you have to be aware of that person's 13 limitations in that particular setting. 14 COMMISSIONER STEPHEN GOUDGE: All right. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: Right. Dr. Rao, 18 what has been your experience? 19 DR. CHITRA RAO: My experience is 20 somewhat similar to Dr. Shkrum, especially in a trauma 21 case or a homicide case where they have undergone 22 surgical intervention. I want the surgeon to tell me, 23 you know, what they saw before they had the procedure. 24 But sometimes we also have paramedics' 25 report, EMS who have gone to the scene. And they, in my

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1 area they're very good in drawing diagrams and tell us 2 where the injuries were. And then we get the help of the 3 emergency physician or surgeons. 4 But they don't particularly come to see 5 the autopsy. 6 In some cases I have also involved the 7 odontologist in case adult or children, if there is bite 8 mark or something. So I would like the odontologist to 9 come and examine before I do anything else. Of course I 10 take the swab first and then leave it and they'll come, 11 and then they do the photographs, L Scale (phonetic), and 12 all that. 13 And in pediatric cases there are 14 occasionally, I have got the help of the clinician. We 15 have a -- a child abuse team, they're called Child 16 Advocacy and Assessment Program, short term is CAAP. And 17 sometimes if the patient is admitted in the hospital and 18 they think the child is not going to survive, they 19 normally call me and let me know, There's a case we're 20 handling, this is what... 21 And sometimes they'll say, Could you let 22 me know when the autopsy is going to be, because we'd 23 like to be present and then they are. And the reason 24 there is -- they will also, if -- especially if the 25 patient has been in the hospital for a week or ten (10)

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1 days, some of the injuries would have disappeared. We 2 may not be able to see it. 3 And then they are there, they tell 4 exactly, We found this. And there's also a diagram in 5 their chart. And then I can make incision in that area 6 and see whether there was anything underlying. And I can 7 take microscopic sections and say, Yes, there is a 8 healing injury there. And so it helps that way. 9 And sometimes we discuss all -- or they 10 mainly -- they also want to know what they're working 11 diagnosis -- was that correct? Am I finding those, you 12 know, interpretation is proper? 13 So in both way, we'll help each other. 14 MS. JENNIFER MCALEER: Let me ask you 15 both, Dr. Shkrum and Dr. Rao, do you -- do you see those 16 two (2) roles as compatible? The -- the role of the 17 child abuse team, the objectives of the child abuse team, 18 and the objectives of the forensic pathologist? 19 Is -- are they compatible? Do they work 20 well together? What's been your experience? 21 DR. CHITRA RAO: In my experience it -- 22 it has worked well. And then what happens is sometimes 23 on clinical conditions, where the patient has had been to 24 the hospital and remained there for a couple of days and 25 discharged, they may have injuries. And they'll take

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1 photographs of that. 2 And then they'll call me and we set around 3 the table and we discuss what kind of injury -- you know, 4 what is the mechanism, underlying mechanism. So we 5 discuss together. 6 And so I have learned something from them. 7 Like Dr. Shkrum said, we do not have that large numbers 8 of cases coming to autopsy where us clinician has got 9 much more exposure. 10 And so they learn something from us, and 11 we learn something from -- I think it's very good 12 relationship we have in our centre. 13 MS. JENNIFER MCALEER: Dr. Shkrum...? 14 DR. MICHAEL SHKRUM: I think it's 15 ultimately the responsibility of the pathologist to 16 determine the cause of death. But in the realm of 17 injuries, again, clinical input can be invaluable. 18 MS. JENNIFER MCALEER: Okay. And, Dr. 19 Dexter, we've been talking about pediatrics a little bit 20 there. But in your experience, do you have clinicians 21 come in to help assess with burn patterns or sexual 22 assault cases? 23 DR. DAVID DEXTER: There's been very few 24 in the way of sexual assault cases where that's -- that's 25 been necessary.

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1 But I think the first example that Dr. 2 Shkrum gave was that of -- of a trauma type setting, 3 where paramedics may have played a role in putting 4 needles here, there, and everywhere. It might be a drug 5 addict, so one's trying to find out of who put a needle 6 there. Was it a paramedic who did it, or was it part of 7 the IV drug abuse? 8 That actually is quite a challenge 9 sometimes because of the documentation issue on the 10 paramedic sheets. They don't necessarily indicate every 11 hole they've made or that it took three (3) time -- three 12 (3) efforts to get a -- a vein. 13 The situation is often what's happened in 14 the emergency department or in the surgical suite where 15 incisions have been made, chest has been cracked, and so 16 forth. And in a case of multiple stab wounds, things may 17 have been sewed up. All of those sorts of things. 18 So when somebody has ended up in the OR 19 with major surgical procedures as a consequence, it may 20 be complicated, and the simplest thing to understand what 21 went on is to ask the surgeon. 22 So it may be a conversation, but on rare 23 occasions they've actually come down and assisted and 24 pointed out, Yes, this is what we did, and this is how it 25 was.

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1 So it's -- it's helpful in those 2 circumstances. 3 MS. JENNIFER MCALEER: All right. 4 Changing topics completely for a moment, interaction with 5 family members. 6 What role, if any, do you see for the 7 pathologist with respect to communication and interaction 8 with family members of the deceased? 9 Dr. Dexter...? 10 DR. DAVID DEXTER: In our setting there 11 is virtually no direct relationship between the 12 pathologist and the family members. I can hark back on 13 maybe one (1) case where a family member was concerned 14 about ensuring that they had all the tissue blocks 15 returned to them to ensure burial for a relative that had 16 died. 17 I think it was actually many years 18 previously, and we had some direct conversations and -- 19 and were able to satisfy that individual. 20 But it's a very rare occasion, and that's 21 the only example I can think of, actually, at the moment. 22 MS. JENNIFER MCALEER: And so it's not 23 just a recent phenomenon, that that's been your 24 experience through your whole practice, is you -- 25 DR. DAVID DEXTER: Correct.

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1 MS. JENNIFER MCALEER: -- you've had very 2 limited interaction -- 3 DR. DAVID DEXTER: The coroner -- the 4 coroner acts as the interface to the family. 5 MS. JENNIFER MCALEER: All right. Dr. 6 Rao...? 7 DR. CHITRA RAO: We do not have any 8 contact with the family, and our secretaries are very 9 good to screen the telephones. 10 And sometimes the family members may not 11 be able to contact the investigating coroner. And then 12 in those circumstances, my secretary will say, Okay, if 13 you have concern, please contact the regional supervising 14 coroner. And they know who's in that area. They'll give 15 their number. 16 And they go and -- and only in the past, 17 maybe on one (1) or two (2) occasions, they called and 18 they got my extension directly. So I talked to them. 19 And then I don't go into detail. I'll just say, you 20 know, The protocol is you have to get the findings from 21 the coroner, not from me. 22 MS. JENNIFER MCALEER: All right. Dr. 23 Shkrum...? 24 DR. MICHAEL SHKRUM: I would echo Dr. 25 Rao's assessment in that when I worked as a fellow in the

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1 Medical Examiner's Office it was different. There was 2 direct contact with families, but not in the coroner's 3 system. 4 MS. JENNIFER MCALEER: And that's been 5 your experience throughout all of your time -- 6 DR. MICHAEL SHKRUM: Yes. 7 MS. JENNIFER MCALEER: -- in the 8 coroner's system? 9 DR. MICHAEL SHKRUM: Yes. 10 MS. JENNIFER MCALEER: And do you -- 11 COMMISSIONER STEPHEN GOUDGE: Where the 12 contact is by the coroner? 13 DR. MICHAEL SHKRUM: Pardon me? 14 COMMISSIONER STEPHEN GOUDGE: Where the 15 contact is by the coroner? 16 DR. MICHAEL SHKRUM: Yes. But to the -- 17 with the family, yes. 18 19 CONTINUED BY MS. JENNIFER MCALEER: 20 MS. JENNIFER MCALEER: Do you see any 21 role for the pathologist to have contact with the family, 22 Dr. Shkrum. Is there any value to be added? 23 DR. MICHAEL SHKRUM: Well, it may be a 24 redundancy, you know, whether we can add anything to the 25 discussion. We do co -- convey our findings to the

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1 coroner as to cause of death and perhaps other findings 2 that -- of -- of relevance, such as a heart disease. 3 There may be issues about organ retention. 4 And we certainly inform the coroner that we've retained 5 an organ, such as the brain, and we hope that -- that is 6 communicated to the family. 7 So -- so, certainly any concerns or any 8 information from the family, hopefully, is then relayed 9 back to -- to us and -- and then we'll attempt to deal 10 with it. 11 MS. JENNIFER MCALEER: What about just 12 explaining the cause of death, though? 13 DR. MICHAEL SHKRUM: Well, again, we rely 14 on the coroner, you know, whether this would be 15 redundant, that, you know, really the coroner, my -- my 16 understanding of it, he or she is supposed to be 17 explaining that to the family. 18 So, I -- I think in some way it would be 19 redundant from that aspect. 20 MS. JENNIFER MCALEER: And, Dr. Rao, do 21 you agree? 22 DR. CHITRA RAO: Yes, I do agree. 23 Sometimes we have neuropathology consultation, and they 24 may want to know a little more history. We don't go to 25 the family, we go to the coroner and say, Could you

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1 please get the information for us? 2 And -- or like he said, in heart disease, 3 young individual of seventeen (17), eighteen (18) 4 suddenly drop dead. And then they have heart disease, 5 and they should -- the family should undergo genetic 6 studies. So we don't contact the family, but we tell the 7 coroner, Will you please contact the family and let them 8 know? 9 Or if we are suspecting something, we'll 10 say, Could you find out from the family whether this 11 individual had any ECG or what about the other siblings? 12 Any indication as to hereditary disease? 13 So that way, but we never directly contact 14 the family. 15 MS. JENNIFER MCALEER: All right. And, 16 Dr. Dexter, you'd agree with that? 17 DR. DAVID DEXTER: I would. I'd just 18 make the observation that the coroner has a fairly unique 19 role in that they are constantly in contact with the 20 family. They have a much more established linkage, and 21 it's not an area of experience that we have as 22 pathologists. 23 MS. JENNIFER MCALEER: All right. 24 DR. MICHAEL SHKRUM: I guess another 25 thing I'd just add, I mean, we do generate a report where

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1 it will indicate that organs are retained. And the case 2 Dr. Rao used about a young individual dropping dead and a 3 possibility of heart disease, that would be in our 4 conclusion, but realising that report comes out some 5 months later. 6 And so, really, it's incumbent upon that 7 coroner to communicate that information in the immediate 8 setting, and eventually, when that report is completed to 9 the family. 10 The families may not always request a copy 11 of that report, so that information may not be known to 12 them. 13 MS. JENNIFER MCALEER: Changing topics 14 again, can we look at Volume II, Tab 44? I'd like to 15 discuss with you your -- your general approach to cases. 16 So it's Volume II, Tab 44, and it's PFP032278. And this 17 is Memo 631 from April 10th, 1995. 18 You're all familiar with this memo? 19 DR. DAVID DEXTER: Yes. 20 DR. MICHAEL SHKRUM: Yes. 21 DR. CHITRA RAO: Yes. 22 MS. JENNIFER MCALEER: Yes. And you were 23 familiar with it when it was issued, as opposed to just 24 in your preparation for your testimony here today. 25 Is that correct?

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1 DR. DAVID DEXTER: Yes. 2 DR. MICHAEL SHKRUM: Yes. 3 MS. JENNIFER MCALEER: Dr. Rao, you -- 4 you saw this when it first came out in -- 5 DR. CHITRA RAO: Oh, yes. 6 MS. JENNIFER MCALEER: You all did. 7 DR. CHITRA RAO: It was sent to all the 8 regional unit. 9 MS. JENNIFER MCALEER: All right. So 10 this is the memo, as you know, that contains the 11 suggestion on page 4, three quarters (3/4s) of the way 12 down the page: 13 "Unfortunately, in this day and age 14 child abuse is a real issue, and it is 15 extremely important that all members of 16 the investigative team think dirty. 17 They must actively investigate each 18 case as potential child abuse and not 19 come to a premature conclusion 20 regarding the cause and manner of death 21 until the complete investigation is 22 finished and all members of the team 23 are satisfied with the conclusion." 24 Now, starting with you, Dr. Shkrum, when 25 this memo came out in -- in 1995, did you review it?

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1 Were you familiar with it at the time? 2 DR. MICHAEL SHKRUM: Yes. 3 MS. JENNIFER MCALEER: And do you recall 4 that particular clause that I just reviewed with you, the 5 -- the "think dirty" approach? 6 DR. MICHAEL SHKRUM: Yes. 7 MS. JENNIFER MCALEER: And what was your 8 interpretation or impression of that paragraph? 9 DR. MICHAEL SHKRUM: Well, I don't think 10 it really influenced how I -- I approach cases. In fact, 11 this memorandum deals with a protocol. I mean, there's a 12 benefit from this memorandum. And now we have a -- sort 13 of a standardized approach to deal with these cases. 14 I think if, you know, if you'd stop maybe 15 after the first word and simply say, "think" or "think 16 objectively," you know, that -- I think that would have 17 satisfied the same required -- as opposed to "think 18 dirty." I mean, I can understand the rationale. 19 I mean, for example, on the preceding page 20 on item Number 1 near the bottom, it says: 21 "In three (3) of two hundred and four 22 (204) cases reviewed there's no autopsy 23 done." 24 So, I mean, there was obviously gaps in 25 the system that had to be addressed.

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1 MS. JENNIFER MCALEER: So what you're 2 saying, I take, Dr. Shkrum, is that at the time -- before 3 this protocol was issued there was no protocol, and that 4 there was some value in having this protocol issued? 5 DR. MICHAEL SHKRUM: Well, there might 6 have been individual protocols at -- at different 7 facilities. But, no, there was no -- no standardized 8 protocol for approaching these types cases. 9 MS. JENNIFER MCALEER: And the suggestion 10 that one think dirty, did that alter your approach at all 11 to cases with children under two (2)? 12 DR. MICHAEL SHKRUM: No, it did not. 13 MS. JENNIFER MCALEER: Okay. Dr. -- 14 DR. MICHAEL SHKRUM: That's right in a 15 sense that I -- I have now followed a protocol. But it 16 didn't change my sort of, I think, objective approach to 17 those cases. 18 MS. JENNIFER MCALEER: Okay. You didn't 19 see it as a presumption of abuse unless one can prove 20 otherwise? 21 DR. MICHAEL SHKRUM: No, I did not. 22 MS. JENNIFER MCALEER: Dr. Rao, you 23 received this memo at the time. You reviewed it at the 24 time? 25 DR. CHITRA RAO: Yes.

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1 MS. JENNIFER MCALEER: And what was your 2 interpretation of the "think dirty" approach? 3 DR. CHITRA RAO: That didn't influence my 4 work and my coming to a conclusion. And most of the 5 things issued here in the protocol we were following much 6 earlier than 1995. 7 And the only exception is we didn't 8 routinely do total body skeletal in all the children. 9 Only if there was some indication or in my examination I 10 see some swelling or something, then we may do x-ray, but 11 apart from that, we were doing regularly all 12 toxicological screening, bacteriology, virology screening 13 in all babies. 14 And so "think dirty" in the sense, what is 15 says is, Keep all your option open. Start your case with 16 an open mind. Don't come to any conclusion as soon as 17 you see a baby -- baby there, as, Oh, this has to be 18 natural. Don't think that way. Or don't think, Oh, this 19 has to be a homicide, no. 20 Do everything you can for that case and 21 then finally come to your conclusion. So this suggests 22 an open -- keep it open. And I think "think dirty" came 23 from, I think, investigat -- by police. 24 And police are taught when they start 25 their criminal investigation, because they are said,

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1 Always when you go to the scene keep that option so that 2 you absorb everything what is in the scene and you don't 3 develop a tunnel vision. 4 MS. JENNIFER MCALEER: All right. So you 5 -- it didn't alter your approach, and you didn't see it 6 as instruction with respect to a starting presumption of 7 abuse unless you can show otherwise? 8 DR. CHITRA RAO: That's correct. 9 MS. JENNIFER MCALEER: Okay. Now, Dr. 10 Dexter, in 1995 was your unit doing pediatric cases? 11 DR. DAVID DEXTER: We didn't really exist 12 as a unit at that point -- 13 MS. JENNIFER MCALEER: Sorry -- 14 DR. DAVID DEXTER: -- but there were 15 pediatric cases being done, some of which were coming 16 under the potential hedging of query SIDS -- 17 MS. JENNIFER MCALEER: Did you receive 18 this memo? 19 DR. DAVID DEXTER: I -- absolutely. And 20 in fact, what it provided was an approach to these type 21 of cases where we really didn't have a standard approach 22 before. The -- the issue of the "think dirty," although 23 it's capitalized there, really didn't influence my 24 approach to these things. 25 It -- it had to be an objective approach.

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1 In fact, the general approach to things forensic, whether 2 it be pediatric or adult, was always -- 3 COMMISSIONER STEPHEN GOUDGE: Objective. 4 DR. DAVID DEXTER: -- What are the 5 options here? They were objective. I -- I -- 6 COMMISSIONER STEPHEN GOUDGE: Does "think 7 dirty" capture your approach? 8 DR. DAVID DEXTER: No, it does not. 9 DR. CHITRA RAO: No. 10 DR. MICHAEL SHKRUM: No. 11 12 CONTINUED BY MS. JENNIFER MCALEER: 13 MS. JENNIFER MCALEER: Do -- do you see 14 that language as somewhat problematic? 15 DR. DAVID DEXTER: Absolutely. 16 MS. JENNIFER MCALEER: Why is that, Dr. 17 Dexter? 18 DR. DAVID DEXTER: Well, I think it 19 infers a bias, a bias that something bad has happened. 20 And you're starting from that point of view, and the -- 21 the sort of inference is that you've got to create a 22 trail of evidence or logic or somehow, that reflects back 23 on something bad having happened. So it's an issue of -- 24 of bias. It's an issue of tunnel vision. There are a 25 variety of terminologies that could apply to it.

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1 It's the wrong approach. You have to be 2 open to a variety of possibilities. And so objective, 3 open, objective thinking, I think, is the approach, not 4 that. 5 MS. JENNIFER MCALEER: Yet it was not 6 interpreted that way by any of you, if I understand your 7 evidence? 8 DR. CHITRA RAO: Yeah, I didn't think 9 that way. I felt in -- especially in pediatric cases, 10 sometimes -- some cases where we say SIDS, that can be a 11 remote possibility. It could be a cause of smothering. 12 So back of your mind when you're doing, 13 you always have to think, Am I doing everything? Do I 14 have enough findings here to say one way other, what's a 15 cause of death? 16 So that's the way my approach is. The 17 thinking dirty, it never played any role in -- 18 COMMISSIONER STEPHEN GOUDGE: You have 19 all been very clear to say that it did not change the way 20 you approach cases. 21 DR. CHITRA RAO: We practice. 22 COMMISSIONER STEPHEN GOUDGE: And you 23 were all somewhat troubled by the language, I think. Is 24 that a -- 25 DR. DAVID DEXTER: Yes.

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1 DR. CHITRA RAO: Yes. 2 DR. MICHAEL SHKRUM: Yes. 3 4 CONTINUED BY MS. JENNIFER MCALEER: 5 MS. JENNIFER MCALEER: All right. So 6 the -- 7 COMMISSIONER STEPHEN GOUDGE: Can I just 8 ask sort of a little detail question? 9 Did any of you feel at the time that this 10 reflected the view, in effect, at head office -- at the 11 Office of the Chief Coroner -- that there was child abuse 12 going undetected? 13 DR. CHITRA RAO: Yes, I think so. 14 COMMISSIONER STEPHEN GOUDGE: And they 15 wanted to stop that? 16 DR. DAVID DEXTER: Or the potential for 17 child abuse. Again, the statistics on the first page, I 18 mean three (3) of two hundred and four (204) cases, no 19 autopsy done. Well, you know, were these natural deaths? 20 Were they abuse cases? 21 There's ca -- instances where autopsies 22 had no skeletal surveys, so there's no assessment of 23 whether there's any chronic abuse going -- so, yes, I 24 mean I think there was certainly concern that potentially 25 cases were being missed of -- of abuse.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID DEXTER: If I can add to that, 3 I have some recall of a meeting in which these statistics 4 were raised, these Numbers 1 through 6. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. DAVID DEXTER: And what troubled me 7 more than anything about that was that it sort of 8 indicated to me that we weren't doing, or somebody was 9 not doing, all of those things that could and should have 10 been done. 11 For example, the toxicology, you know, the 12 issues of babies being given too much cough medicine, you 13 know -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. DAVID DEXTER: -- something that 16 would suppress their respiratory function and so forth. 17 If -- if you don't do toxicology, you don't find it. So 18 that I found very troubling. I thought is was indicative 19 that these types of cases were perhaps not being 20 investigated as thoroughly as -- as could be from a 21 pathology -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. CHITRA RAO: The only thing, Mr. 24 Commissioner, I wanted to say, because you asked us the 25 question, the "think dirty," whether it concerned us.

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1 For me it wasn't a concern. For me, as a 2 per -- person who is doing pediatric pathologist, I 3 wanted that option to be kept in my mind. 4 Just because I have that option, it 5 doesn't mean I'm going to do the autopsy and I make sure 6 I'll find the findings to say that, no. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 9 CONTINUED BY MS. JENNIFER MCALEER: 10 MS. JENNIFER MCALEER: All right. So 11 moving forward then, if we could turn to Tab 51, please, 12 of Volume II, this is PFP034041. You're all familiar 13 with -- well, perhaps DAC -- Dr. Dexter, you are not. 14 But Dr. Rao and Dr. Shkrum, you're both 15 familiar with the autopsy guidelines for homicidal and 16 criminally suspicious deaths in infants and children? 17 DR. CHITRA RAO: Yes. 18 DR. MICHAEL SHKRUM: Yes. 19 MS. JENNIFER MCALEER: And you would have 20 received and reviewed these guidelines when they came out 21 in April of 2007? 22 DR. CHITRA RAO: Yes. 23 DR. MICHAEL SHKRUM: Yes. 24 MS. JENNIFER MCALEER: And if we look at 25 the second page -- actually, sorry, it's the fourth page

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1 of the document, we see that there are indicators for use 2 of these guidelines. 3 Without reviewing them all orally, you're 4 familiar with these guidelines, Dr. Shkrum? 5 DR. MICHAEL SHKRUM: Yes. 6 MS. JENNIFER MCALEER: Or these 7 indicators, I should say. And you are, as well, Dr. Rao? 8 DR. CHITRA RAO: Yes. 9 MS. JENNIFER MCALEER: And are they 10 helpful? 11 DR. CHITRA RAO: Yes. 12 DR. MICHAEL SHKRUM: Yes. 13 MS. JENNIFER MCALEER: How -- how do you 14 use them in your practice? 15 DR. MICHAEL SHKRUM: Well, I guess if 16 there's a scenario where, you know, there's a -- you 17 know, either there's a scenario or circumstances that 18 would suggest these possibilities, or if we see these 19 findings -- either the coroner sees findings that would 20 suggest some of these problems or we'd see them at 21 autopsy -- then, yes. 22 I mean the guidelines need to be followed. 23 MS. JENNIFER MCALEER: All right. And 24 does this incorporate what you had been doing prior to 25 April of 2007?

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1 DR. CHITRA RAO: Yes. 2 MS. JENNIFER MCALEER: Or is this a new 3 approach? 4 DR. CHITRA RAO: No, we have -- I have 5 used this approach even before seeing the document. 6 MS. JENNIFER MCALEER: All right. And - 7 - and did you, as well, Dr. Shkrum? 8 DR. MICHAEL SHKRUM: Yeah, I think 9 generally on most of these items, yes. 10 MS. JENNIFER MCALEER: All right. And 11 then we see in 2.3: 12 "In general, the pathologist must keep 13 an open mind to the possibilities of 14 quote 'violent death, child abuse, 15 sexual assault, maltreatment, and 16 neglect'. On this basis it is 17 recommended that the forensic 18 pathologist have a low threshold for 19 performing special dissections and 20 collecting biological samples." 21 Now, would you agree that this is a better 22 way of perhaps expressing the idea of keeping an open 23 mind? 24 DR. CHITRA RAO: Correct. 25 DR. MICHAEL SHKRUM: Yes. Yeah, I mean,

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1 it -- it addresses the approach that has to be taken in 2 these cases to either include or exclude the -- these 3 various possibilities. 4 MS. JENNIFER MCALEER: All right. And 5 then if we were to move forward to Tab 53, which is 6 PFP139350, still in Volume II. 7 And I take it all three (3) of you would 8 have received these guidelines in October of 2007, with 9 respect to criminally suspicious cases and homicides? 10 DR. CHITRA RAO: That's correct. 11 DR. MICHAEL SHKRUM: Yes, it is. 12 MS. JENNIFER MCALEER: And if we look at 13 the second page, we actually see that all three (3) of 14 you were consulted with respect to preparing these 15 guidelines. 16 And I think that's true also for the first 17 edition, which is a little bit earlier in the documents 18 at Tab 47, the July 2005 version of this document? 19 DR. MICHAEL SHKRUM: Yes. 20 DR. CHITRA RAO: That was -- I think that 21 was mainly prepared for -- by Michael Shkrum, even though 22 we did have some conversation. 23 DR. MICHAEL SHKRUM: Michael Pollanen. 24 DR. CHITRA RAO: Sorry, Michael Pollanen, 25 not, sorry. Too many Michaels.

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1 Sorry, Michael Pollanen. And then we did 2 have a couple of telephone conversations. And then later 3 on he decided he was going to devise, and he wanted the 4 input from all the other units. 5 MS. JENNIFER MCALEER: All right. So, 6 well maybe if we do flip back then to Tab 47 for a 7 minute, which is PFP03398. 8 DR. CHITRA RAO: Yes. 9 MS. JENNIFER MCALEER: PFP033981, sorry. 10 So we look at the -- about the guidelines -- 11 DR. CHITRA RAO: Yes. 12 MS. JENNIFER MCALEER: -- is a reference 13 to the regional forensic pathology units in the middle of 14 the second paragraph. And it talks about consultation 15 with the units and incorporating comments into the 16 document. 17 Were -- were you all in fact consulted -- 18 DR. MICHAEL SHKRUM: Yes. 19 MS. JENNIFER MCALEER: -- to prepare this 20 document? 21 DR. MICHAEL SHKRUM: Yes. 22 DR. CHITRA RAO: Yes. 23 DR. DAVID DEXTER: Yes. 24 MS. JENNIFER MCALEER: Okay. And then 25 moving forward then to the second edition, which as at

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1 Tab 53, and which then specifically references you. 2 Were you saying, Dr. Rao, that this second 3 version was primarily Dr. Pollanen's work, but with some 4 consultation by you? 5 DR. CHITRA RAO: No. The second -- we 6 had two (2) occasions where we sat and discussed and 7 certain things we wanted to devise for the wording of it. 8 And so we all agreed to -- there was seven (7) of us. 9 And then he brought the final. 10 MS. JENNIFER MCALEER: I see. 11 DR. CHITRA RAO: Yeah. 12 MS. JENNIFER MCALEER: And that's the 13 document we have at Tab -- 14 DR. CHITRA RAO: October 2007. 15 MS. JENNIFER MCALEER: -- 53. 16 DR. CHITRA RAO: Yes. 17 MS. JENNIFER MCALEER: Okay. And these 18 guidelines also include, if you look at the table of 19 contents on page 3, homicidal or criminally suspicious 20 deaths in infancy or childhood in their table of 21 contents. 22 And if we turn to Tab, sorry, page 35... 23 24 (BRIEF PAUSE) 25

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1 MS. JENNIFER MCALEER: We see there that 2 now these general guidelines also specifically deal with 3 -- with children. Correct? 4 DR. CHITRA RAO: Yes. 5 DR. MICHAEL SHKRUM: Yes. 6 MS. JENNIFER MCALEER: Okay. So that 7 means then, if I understand it correctly, currently there 8 are two (2) guidelines that apply. And I'm -- I'm not 9 suggesting they're different from one another. 10 But essentially there are two (2) 11 documents that you have, resort to when you're doing 12 children's cases. There's the document at Tab 51, which 13 is specifically titled "Death in Infant and Children," 14 and then we have the document at Tab 53, which is the 15 general guidelines with a chapter on that topic as well. 16 DR. CHITRA RAO: That's correct. 17 DR. MICHAEL SHKRUM: Well, I think -- I 18 think that document on -- 19 DR. CHITRA RAO: It's at -- 20 DR. MICHAEL SHKRUM: -- Tab 50 -- 21 MS. JENNIFER MCALEER: Three (3)...? 22 DR. MICHAEL SHKRUM: -- the tabs here, 23 51, is probably incorporated as part of -- 24 DR. CHITRA RAO: From there. 25 DR. MICHAEL SHKRUM: -- the general --

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1 the general document. 2 MS. JENNIFER MCALEER: Right. But it -- 3 but they're both still in use, is my understanding -- 4 DR. MICHAEL SHKRUM: Yes. 5 MS. JENNIFER MCALEER: -- is that 6 correct? And -- or do you still use both of them? 7 DR. MICHAEL SHKRUM: Yes. 8 DR. CHITRA RAO: Yes. 9 MS. JENNIFER MCALEER: Okay. 10 DR. CHITRA RAO: And I -- 11 COMMISSIONER STEPHEN GOUDGE: But you 12 really now only need the 2007 document? I mean, I had 13 sort of read the 2007 -- 14 DR. MICHAEL SHKRUM: Right. 15 COMMISSIONER STEPHEN GOUDGE: -- document 16 as incorporating and replacing the 2005 document. 17 DR. MICHAEL SHKRUM: Yes. 18 DR. CHITRA RAO: That's correct. 19 COMMISSIONER STEPHEN GOUDGE: Is that the 20 way you -- 21 DR. CHITRA RAO: Yes. 22 DR. MICHAEL SHKRUM: Yes. 23 COMMISSIONER STEPHEN GOUDGE: -- have 24 applied it in practice? 25 DR. CHITRA RAO: Yes.

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1 DR. MICHAEL SHKRUM: Yes. 2 MS. JENNIFER MCALEER: Okay. 3 DR. CHITRA RAO: And I think I also have 4 to include, when we had the conversation, first the 5 medical directors met. And then he also instructed us to 6 go and discuss with our colleagues and get their opinion 7 too. 8 DR. MICHAEL SHKRUM: Yes. 9 DR. CHITRA RAO: So when the second 10 meeting we -- took place, there were very constructive 11 criticism or more comments on it, so which we brought to 12 the Chief Forensic Pathologist. And that was also 13 incorporated so I want to recognize the input of other 14 colleagues too. 15 MS. JENNIFER MCALEER: Okay. All right. 16 All right. I think that counsel for the Coroner's Office 17 may follow up with a little bit on that topic. 18 But just -- just to be clear though, is it 19 your understanding that you no longer look at the 20 document at Tab 51 because now you only have to look at 21 the document at Tab 53? Or are you still using both of 22 them? 23 DR. CHITRA RAO: You want the truth? 24 MS. JENNIFER MCALEER: I -- there's no 25 right answer. I want to know what -- what your practice

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1 is -- 2 DR. CHITRA RAO: No, no. 3 MS. JENNIFER MCALEER: -- right, and 4 what's your understanding? 5 DR. CHITRA RAO: Yeah. This is a 6 general, and if you ask me, Do you go through this every 7 time you do a pediatric case? No. 8 But I know the general thing, what we are 9 supposed to do. And -- and then if we have any 10 difficulty or something we may go into that, or I will 11 call the pediatric pathologist or Michael Pollanen and 12 say, Hey, I'm in this situation, what else can I do? 13 So, you know, we have the general concept 14 of what it is, but I don't think I refer to that every 15 time I do a case. 16 MS. JENNIFER MCALEER: Dr. Shkrum...? 17 DR. MICHAEL SHKRUM: So I would use the 18 second edition, October 2007 exclusively, which 19 incorporates the guidelines for pediatric deaths. 20 MS. JENNIFER MCALEER: Okay. Thank you. 21 I think this would be a good time to break for lunch. 22 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 23 McAleer. We will rise then until two o'clock. 24 25 --- Upon recessing at 12:46 p.m.

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1 --- Upon resuming at 2:02 p.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Ms. 6 McAleer...? 7 8 CONTINUED BY MS. JENNIFER MCALEER: 9 MS. JENNIFER MCALEER: Thank you, Mr. 10 Commissioner. Doctors, I'd like to turn now to your 11 experience giving testimony. 12 Dr. Dexter, can you give us an overview as 13 to how many times in your career you've had the 14 opportunity to testify? 15 DR. DAVID DEXTER: Because of the 16 Kingston experience with prison deaths, we've had quite a 17 lengthy experience in inquests. And I estimate over the 18 thirty (30) odd years I've been there, about a hundred 19 and fifteen (115) inquests I have given evidence as, from 20 the point of view of trials, preliminary, and -- and so 21 forth, approximately twenty-five (25). 22 MS. JENNIFER MCALEER: Dr. Rao, what's 23 been your experience? 24 DR. CHITRA RAO: I think on the average, 25 twenty (20) to twenty-five (25) times I got called every

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1 year, so if you add my last twenty-five (25) years 2 experience, it would be a couple of hundred (100). 3 That's a modest number. 4 MS. JENNIFER MCALEER: And are you 5 testifying primarily in criminal proceedings or family 6 court matters? Can you give us some kind of idea as the 7 breakdown of the kinds of cases you could accord on? 8 DR. CHITRA RAO: I have given evidence 9 for inquests; family court, very few times, not frequent; 10 and murder trials and preliminaries. And I have attended 11 a couple of civil cases. 12 MS. JENNIFER MCALEER: Dr. Shkrum, what 13 experience have you had testifying? 14 DR. MICHAEL SHKRUM: In the Province of 15 Ontario I've testified over a hundred (100) times at 16 various levels -- inquests, preliminary hearings, and 17 trials by Judge or jury. I've had one (1) family court 18 ser -- experience, or fam -- family-type hearing. I've 19 also testified at a previous public inquiry. 20 During my fellowship I testified probably 21 twelve (12) to fifteen (15) times, either during my 22 fellowship year in North Carolina or subsequent over the 23 next few years after I had left. And this included 24 capital cases. 25 MS. JENNIFER MCALEER: And staying with

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1 you, Dr. Shkrum, what training did you receive or have 2 you received over the course of your career with respect 3 to how to testify as an expert? 4 DR. MICHAEL SHKRUM: During my fellowship 5 year there was training available through the local law 6 school at the University of North Carolina. There was 7 interaction with the law students. 8 But subsequent to that, there was really 9 no formal mechanism to -- to become a, you know, an 10 expert witness in court. Certainly there would be 11 courses offered at various meetings or people would speak 12 at forensic meetings about how to testify in court. But 13 there's no formal training subsequent to my fellowship 14 year. 15 MS. JENNIFER MCALEER: All right. 16 DR. MICHAEL SHKRUM: Now, in the -- since 17 that time -- or sorry, in -- in the more recent past 18 there have been expert witness courses offered through 19 the Office of the Chief Coroner. Chief Forensic 20 Pathologist Dr. Pollanen has organised those. 21 MS. JENNIFER MCALEER: And can you 22 briefly describe that course that the OCCO is now 23 offering to forensic pathologists? 24 DR. MICHAEL SHKRUM: It starts off with a 25 series of lectures or demonstrations as to expert witness

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1 testimony and techniques. And then it's followed by use 2 of sort of mock cases, where there's an examination or 3 cross-examination done by Crown and defence lawyers of 4 the pathologists who are participating in the -- in the 5 workshop. 6 MS. JENNIFER MCALEER: And do you recall 7 how long that seminar has been offered? 8 DR. MICHAEL SHKRUM: Yes, it's been the 9 last coupe of years it's been offered. 10 MS. JENNIFER MCALEER: So two (2) years, 11 or in excess of two (2) years is your best recollection? 12 DR. MICHAEL SHKRUM: I think it's gone on 13 two (2) years now, I think. 14 DR. CHITRA RAO: Two (2) years. 15 DR. MICHAEL SHKRUM: Two (2) years, yeah. 16 MS. JENNIFER MCALEER: Okay. And, Dr. 17 Rao, what training, if any, have you received with 18 respect to how to testify as an expert? 19 DR. CHITRA RAO: I've had no formal 20 training. But when I trained under Dr. Rex Ferris, he 21 gave me some suggestions how to testify. And he took me 22 to court when he was testifying, and then he always used 23 me as a critic. 24 He said, You listen and then you let me 25 know what I should have done, whether I've done okay or

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1 whether any improvement. And so I learned like that. 2 And when I was in Richmond, again, I went 3 with the Chief Medical Examiner or the Deputy Chief 4 Medical Examiner when they -- when they were testifying, 5 I went with them. 6 And now my practise is, I take my 7 residents or fellow, whenever I go to court, they come 8 with me. And you learn on the job. 9 MS. JENNIFER MCALEER: Would Dr. Ferris, 10 when you were -- when you started out, would Dr. Ferris 11 go to court and watch you testify? 12 I -- I understand that he wanted you to 13 come and watch him testify, but would he watch you 14 testify -- 15 DR. CHITRA RAO: He did. 16 MS. JENNIFER MCALEER: -- and give you 17 feedback? 18 DR. CHITRA RAO: He did. And the first 19 two (2) or three (3) occasions he was very critical, 20 because I had used only medical terminology. 21 And for my first experience, I remember I 22 said something about pleural cavity, and the Crown asked 23 me to explain to the jurors what do you mean by pleural 24 cavity. It took me about a couple of minutes to say, 25 What am I going to say? What is pleural cavity? How do

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1 I -- so -- so he was very critical. 2 And so now, I practice in my mind when I'm 3 preparing for the case if any difficult medical 4 terminology is there, I will have -- you know, I'll 5 explain it in a laymen's term. 6 MS. JENNIFER MCALEER: And like Dr. 7 Shkrum, do you also -- have you attended the courses 8 offered by the Office of the Chief Coroner on testifying? 9 DR. CHITRA RAO: Yes, I did attend 2007, 10 and I was a participant in the mock trial. We both were 11 as pathologists. 12 MS. JENNIFER MCALEER: And, Dr. Dexter, 13 what training, if any, have you had with respect to how 14 to testify as an expert? 15 DR. DAVID DEXTER: Similar to Dr. Shkrum, 16 we've not had formal training in how to do this. But at 17 various conferences over the years there's been elements 18 of issues to do with performance in court and how to do 19 it appropriately and how not to do it. 20 The most recently, there's been the 21 significant effort to -- for us to experience the issues 22 in a practical way of expert testimony. And I 23 participated in just the same way as my two (2) 24 colleagues in, if you like, dummy cases with a Crown, a 25 judge, in one (1) of the earlier ones, and a defence

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1 lawyer basically going at you an then critiquing how you 2 have performed. 3 That's been most helpful, because really, 4 as I reflect on it, it's the only assessment of one's 5 ability to give information in a -- in a legal type of 6 setting that I think I've had over the years. And 7 finally -- 8 COMMISSIONER STEPHEN GOUDGE: What is the 9 most valuable about it, Dr. Dexter? I mean, clearly I 10 suspect for all three (3) of you the notion of 11 articulating the medical thoughts you have in terms that 12 laypeople can understand is a critical component. 13 What beyond that? 14 DR. DAVID DEXTER: I think a reflection 15 on the content, the total content, and the way one has 16 constructed one's report in relationship to the 17 preparation for giving evidence, for example. I think 18 all of us spend time, particularly with the Crown 19 attorneys, prior to giving evidence. 20 And that is a time where we spend -- or at 21 least I spend a significant amount of it going over with 22 the Crown, so that the Crown has an understanding of what 23 I can say, what I can't say, and the nature of my -- my 24 conclusions. 25 And so that is -- is part of the

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1 contribution to the performance in court. 2 COMMISSIONER STEPHEN GOUDGE: Sorry, 3 Doctor. If you want to say something, and absolutely I 4 would be delighted in a minute. 5 But on the language question, a question 6 that I had that I did not ask this morning when we were 7 talking about drafting your reports, is it or has it 8 become a practice in drafting the reports to consider 9 that there may be a lay audience in addition to the 10 coroner and to draft accordingly; that is, to diminish 11 the use of medical phrases and substitute phrases that 12 are more easily understood by laypeople? 13 Is that out of all part of what you do? 14 DR. CHITRA RAO: Yes. In fact, I was 15 trained by Dr. Ferris. He said, Your report doesn't go 16 to a medical person. Your report can be review by 17 laypeople like lawyers, police, family, insurance people. 18 So you have to make them understand. 19 And you almost, when you make a summary, 20 should be like a story telling. Like, why do you come to 21 this? What happened? So I got used to doing that way. 22 COMMISSIONER STEPHEN GOUDGE: All right. 23 Dr. Shkrum, do you have any comment on that? 24 DR. MICHAEL SHKRUM: A sort of similar 25 variation. Certainly in the cause of death, in the

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1 summary statement, I'll try to make it as clear as 2 possible to a -- to a layperson. But the -- the body of 3 the report will probably still use the medical jargon. 4 COMMISSIONER STEPHEN GOUDGE: Like the 5 findings, I guess -- 6 DR. MICHAEL SHKRUM: That's -- 7 COMMISSIONER STEPHEN GOUDGE: -- are 8 pretty hard to avoid -- 9 DR. MICHAEL SHKRUM: Well, 10 COMMISSIONER STEPHEN GOUDGE: -- the 11 medical terminology. 12 DR. MICHAEL SHKRUM: -- I guess I look at 13 it, you know, it's probably like legal document. You 14 have a medical document that poten -- potentially another 15 medical expert will be looking at. 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. MICHAEL SHKRUM: The medical terms 18 may be more precise in terms of describing what you're 19 seeing than, say, a lay -- a layperson's terms. So 20 you're -- you're having that exchange with another 21 medical expert, but the bottom line is understandable to 22 both the medical expert and -- and the layperson. 23 It's just like a contract or a legal 24 document. You have another lawyer interpret it for you, 25 but hopefully at the end of the day everybody understands

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1 what's going on, so... 2 COMMISSIONER STEPHEN GOUDGE: Yes. The 3 reasoning process we talked of this morning is something 4 that can be put in lay language. That is how you get 5 from the medical findings to the diagnosis? 6 DR. MICHAEL SHKRUM: And -- and certainly 7 it can be a use of a medical term, and then brackets or, 8 you know, some -- the lay -- layperson's term could be 9 used or some layperson's explanation of it. 10 DR. CHITRA RAO: Yeah, for -- for 11 example, we may say cause of death carpulmina -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. CHITRA RAO: -- so in my summary I'll 14 explain that, what it is -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. CHITRA RAO: -- and basic -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. CHITRA RAO: -- so that, like he 19 said, the medical person will also understand at the same 20 time as the layperson. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. CHITRA RAO: And I think -- can I 23 refer to when she asked about the education? 24 COMMISSIONER STEPHEN GOUDGE: Yes. 25 DR. CHITRA RAO: I also took part in

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1 advocacy program organised by the Association of Crown 2 Attorneys and have attended five (5), six (6) meetings 3 annually. 4 And I've been in a mock trial. And so 5 that helped me, too. And we had a mock trial where there 6 was a Judge, Crown, and defence questioning. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 Before we leave -- sorry, Dr. Shkrum, do you want to add 9 something? 10 DR. MICHAEL SHKRUM: I just want to -- 11 just add to that. When I did my first court case in 12 North Carolina, the Chief Medical Examiner came with me 13 to watch me testify and came a few other times. That was 14 a memorable experience. 15 COMMISSIONER STEPHEN GOUDGE: Was it 16 helpful? 17 DR. MICHAEL SHKRUM: Yes, it was. And, I 18 mean, obviously very nervous doing the very first case. 19 And it was a death penalty case, and so it was -- it was 20 good to have him there -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. MICHAEL SHKRUM: -- providing 23 feedback, so... 24 COMMISSIONER STEPHEN GOUDGE: Right. On 25 the language issue, I meant to ask you this morning, Dr.

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1 Dexter, you've referred to the "consistent with" language 2 as having a particular meaning in the medical community 3 that might well be different from the legal meaning or 4 the meaning that the legal community would take. 5 Give me your sort of dictionary 6 definition, from a medical perspective, of the meaning of 7 "consistent with." 8 DR. DAVID DEXTER: I think we use it 9 quite commonly in -- in surgical pathology and in 10 hematopathology, a whole series of -- of branches where 11 we're looking a complex of morphological changes. And 12 the -- the issue of differential diagnosis is -- is 13 there, and one is using it to say, Well, given all the 14 information we have, this fits. 15 COMMISSIONER STEPHEN GOUDGE: Yes. 16 DR. DAVID DEXTER: There could be other 17 explanations for it, but this fits. And if there's some 18 -- something that's not jiving, then the message back to 19 the clinician is, You may have to look further on this 20 case. There may be some other things you want to 21 investigate. But on what we've got at the moment, it 22 seems to fit. 23 I think that would be the way we would 24 approach it. 25 COMMISSIONER STEPHEN GOUDGE: That's the

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1 way you use "consistent with"? 2 DR. DAVID DEXTER: Yes. 3 COMMISSIONER STEPHEN GOUDGE: That's 4 interesting. Okay, that's helpful. Sorry, Ms. McAleer, 5 I was just going -- we talked then about giving evidence 6 and one dimension of the learning process each of you 7 have gone through about giving evidence being to use 8 language that may be more accessible by laypeople than 9 when you were talking to your medical colleagues. 10 Another dimension we have heard a lot 11 about here is the consciousness of the limits of your 12 expertise, as actors in the system attempt to drive you 13 beyond that. 14 Is that something that has been a part of 15 your learning process about giving evidence? 16 DR. MICHAEL SHKRUM: Yes, on occasion we 17 -- we are asked questions, I think, beyond our level of 18 expertise. 19 I think a common example would be 20 toxicology, that -- we have a toxicologist's report. 21 There is a result. We have appended that report to ours. 22 It may be significant in terms of the cause of death, 23 contributing to the cause of death, or somet -- you know, 24 or contributing to the circumstances surrounding the 25 cause of death.

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1 So we may be asked some general questions. 2 I think, you know, as a doctor we should be able to 3 answer some questions about alcohol. But if it comes to 4 -- to saying, well, How many drinks? What would be the 5 effect on that individual? That's probably up to another 6 expert to -- to delve into. 7 So, I think -- I think we're aware of our 8 -- our limits of our expertise, and we've also obviously 9 deferred to other -- other experts. 10 COMMISSIONER STEPHEN GOUDGE: Either Dr. 11 Shkrum -- Dr. Rao or Dr. Dexter...? 12 DR. CHITRA RAO: For me, again, I agree 13 with him. At the same time, sometimes we go to testify 14 and the lawyer wants to -- wants us to interpret the CT 15 Scan or MRI. And again I'll say -- they'll put the plate 16 on and I'll say, I'm sorry, I can't do that. You'll have 17 to call a radiologist. 18 And so sometimes they'll say, Aren't you a 19 physician and shouldn't you read? Yeah, but then I'm out 20 of that line for long time, so I don't want to. 21 COMMISSIONER STEPHEN GOUDGE: Dr. Dexter, 22 anything you want to add? 23 DR. DAVID DEXTER: Yeah, the -- for 24 example, if we've had a case where I've had to use a 25 consultant, neuropathology --

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. DAVID DEXTER: -- detailed 3 investigation, or cardiac pathology -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID DEXTER: -- detailed 6 investigation. So it's been incorporated in my report 7 and incorporated in my summary of abnormal findings in my 8 conclusion. If one is therefore in a court setting and 9 one is being asked about those particular aspects and the 10 detail contained in that and why that was favoured versus 11 something else, I would -- and I quite readily do this, 12 say that that is not my area of expertise. I would 13 suggest consultation with -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. DAVID DEXTER: -- those -- with that 16 appropriate expertise. 17 COMMISSIONER STEPHEN GOUDGE: Thanks. 18 DR. MICHAEL SHKRUM: The other thing I've 19 noticed sometimes at inquests, the pathologist is 20 considered the multi-purpose witness -- 21 DR. CHITRA RAO: Yes. 22 DR. MICHAEL SHKRUM: -- and we are the -- 23 DR. DAVID DEXTER: For all things 24 medical. 25 DR. MICHAEL SHKRUM: For all things

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1 medical. And that sometimes happens too, so. 2 COMMISSIONER STEPHEN GOUDGE: So it's 3 simply something as part of the giving evidence function, 4 it has to be front and centre in the educating of 5 pathologists prior to appearance? 6 DR. DAVID DEXTER: Yes. 7 DR. MICHAEL SHKRUM: Yes. 8 DR. CHITRA RAO: That's right. And then 9 even when we consult neuropathologists or cardiovascular 10 pathologists, understood they may be called to testify. 11 COMMISSIONER STEPHEN GOUDGE: Right. 12 DR. CHITRA RAO: They know that. 13 COMMISSIONER STEPHEN GOUDGE: In your 14 fellowship program, Dr. Rao, is there any formalized 15 training beyond having your fellow come to watch you? 16 About giving evidence. 17 DR. CHITRA RAO: Yes, I think we follow 18 the Can Med recommended by the Royal College, and what we 19 teach them is you have to be a medical expert, you have 20 to be a scholar, you have to be a communicator. And what 21 we do is during the course every week we may give them -- 22 suppose he has had an interesting case, we'll say, Okay I 23 want to talk -- I want you to talk about this case, lets 24 present it. 25 So they have to research and -- you know.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. CHITRA RAO: And they're present -- 3 at that time we will quiz them, Okay, in case you're 4 going to court and if they ask you this question, how 5 would you respond? 6 COMMISSIONER STEPHEN GOUDGE: I see. 7 DR. CHITRA RAO: That way -- 8 COMMISSIONER STEPHEN GOUDGE: Okay. 9 DR. CHITRA RAO: -- mock thing. 10 COMMISSIONER STEPHEN GOUDGE: Yes, 11 thanks. Ms. McAleer...? 12 13 CONTINUED BY MS. JENNIFER MCALEER: 14 MS. JENNIFER MCALEER: Just following up 15 on your earlier answer, Dr. Dexter, about the dummy 16 exercises that you participated in with a judge and -- 17 and a Crown attorney. Was that through the Office of the 18 Chief Coroner or was that -- 19 DR. DAVID DEXTER: It was. 20 MS. JENNIFER MCALEER: It was? 21 DR. DAVID DEXTER: It was. There was an 22 additional course that we went to a little -- not -- not 23 so very long ago that was put on by the Osgoode Law Group 24 that was on expert testimony, and some of the challenges 25 associated with it.

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1 MS. JENNIFER MCALEER: So going back to 2 the area of training then, what -- what training is 3 currently available to your colleagues who want to do 4 forensic pathology work or who are doing forensic 5 pathology work? 6 So, Dr. Shkrum, in your unit, how do you 7 train your colleagues to do -- to testify in court? 8 DR. MICHAEL SHKRUM: The -- actually the 9 -- the testimony would -- or giving testimony would 10 actually probably be limited to mainly my -- myself and 11 to Dr. Tweedie, because we do the homicides and 12 criminally suspicious deaths. 13 On some occasions a pathologist may attend 14 at an inquest, and at which point I will go over the case 15 with them and try to anticipate what sort of issues -- 16 what issues may arise. On occasions I've actually gone 17 to the inquest on their behalf, because they're simply 18 not available; they might be out of country. 19 So -- so basically the activities are 20 mainly myself, Dr. Tweedie. And of course Dr. Tweedie 21 trained in Hamilton, had experience there in testi -- in 22 giving testimony. 23 MS. JENNIFER MCALEER: Do you think that 24 there is sufficient training currently for forensic 25 pathologists who have to testify? Or are there things

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1 that you would like to see in the future? New programs? 2 DR. MICHAEL SHKRUM: Well I think, you 3 know, with the -- the program we've been going to the 4 last couple years, I think that's a -- that's a very good 5 program. 6 I think also it might be useful in -- in 7 addition to having a program like that, perhaps getting 8 defence lawyers, Crown -- Crown attorneys, forensic 9 pathologists, maybe at least once a year maybe talking 10 about, sort of general issues, or maybe even specific 11 issues that are risen with trials; potential problems or 12 key points to -- to stress that -- that have come out of 13 those particular hearings, because we don't always hear 14 about them -- you know, maybe in a newspaper or by -- you 15 know, by discussion with a colleague. But there's 16 nothing formal set up to -- to let those issues be aired 17 in a -- in a more sort of general way for all the people 18 concerned. 19 MS. JENNIFER MCALEER: Dr. Rao, what are 20 your views? 21 DR. CHITRA RAO: I thinks things have 22 really improved now, since Dr. Michael Pollanen has taken 23 the position of Chief Forensic Pathologist. He -- his -- 24 one (1) of his goal is education and he has organized 25 meetings, and to not only hear what happens as I suppose

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1 some inquiry like such -- like this one which happens 2 outside this country like in England or States, he'll 3 always inform us the outcome. He comes to know and then 4 he sends an email. And it's very good to read about 5 that. 6 And -- and then like Dr. Shkrum said, 7 again, it'll be good if we have more meeting, or more 8 convention with Crown attorneys and defence lawyers, 9 police, and the pathologist, and that'll help. And I 10 think Dr. Michael Pollanen's goal is going in that 11 direction. 12 MS. JENNIFER MCALEER: Dr. Dexter, do you 13 have anything to add? 14 DR. DAVID DEXTER: I think there are two 15 (2) things. One (1) is what do we do for people like us 16 who are forensic pathologists that spend time doing 17 inquests and -- and going into trial type situations? We 18 can always learn. We can always improve. We can always 19 look at better ways of communicating effectively. 20 The second area that I think maybe Dr. 21 Shkrum can address in part, is when we develop this 22 program for educating forensic pathologists through the 23 residency education thing -- so we're taking somebody who 24 is trained as an anatomic pathologist, we're putting 25 through the -- this certification program we've talked

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1 about -- that integrated within that is the opportunity 2 to address some experience and training in how to give 3 evidence and give it appropriately. I -- I don't know 4 the content of -- of that year, but I would think it 5 would be an ideal opportunity to -- to at least address 6 some of those issues in a training mode. 7 MS. JENNIFER MCALEER: And, Dr. Shkrum, 8 perhaps you could speak to that briefly since you are -- 9 why don't you tell us a little bit about your current 10 position with respect to the submission-specialty program 11 that's being developed at the Royal College of Physicians 12 and Surgeons? 13 DR. MICHAEL SHKRUM: Well I'm the Chair 14 of the Specialty Committee for Forensic Pathology for the 15 Royal College of Physicians and Surgeons of Canada. And 16 I assumed that position in -- in July of -- of this -- 17 sorry, 2007. 18 COMMISSIONER STEPHEN GOUDGE: You're the 19 first occupant I take it? 20 DR. MICHAEL SHKRUM: Yes, I'm the first - 21 - there was a working group prior to that that was 22 chaired by Dr. Jean Michaud, whom you've already heard 23 from at this Inquiry and then I took over the role of 24 Chair of the -- of the Specialty Committee. And as part 25 of that Committee we are in charge of developing

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1 documents that allow this specialty to proceed forward in 2 terms of certification process for trainees, as well as 3 accreditation of individual programs. 4 In answer specifically to your question, 5 it deals with the -- one (1) of the objectives of it -- 6 being a communicator, there is a provision there that 7 makes reference to providing courtroom testimony. So 8 there's an expectation that a trainee will develop skills 9 in presenting of their findings in -- in a courtroom 10 setting. 11 We don't have the details of that, because 12 that will be up to the individual programs to develop 13 that -- that particular piece, but there -- that -- that 14 is certainly included there. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: There's an 18 expectation from the College's perspective that the 19 programs that are going to be developed will specifically 20 have training on -- in that particular field? 21 DR. MICHAEL SHKRUM: That's correct. 22 MS. JENNIFER MCALEER: Okay. 23 COMMISSIONER STEPHEN GOUDGE: What's your 24 time table? 25 DR. MICHAEL SHKRUM: Well, it's ironic

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1 that you ask that, because on -- on -- next week on 2 January 22nd we are actually having a teleconference as 3 me as Chair, as well as representatives across the 4 country, and Royal College people in the administration. 5 We're going to discuss the status of the documents. 6 They're -- I think their approval is imminent. We'll 7 discuss the -- how the accreditation process will roll 8 out, and there are some other issues that we'll discuss 9 at -- at that meeting. 10 But we anticipate, and again, being very 11 optimistic that probably in the very near future, the 12 information will be finalized and that will be 13 disseminated on the Royal College website to program -- 14 sorry, to post-graduate deans at all the medical schools 15 across Canada. And then it will be incumbent upon them 16 to interact with their local forensic pathologist, or as 17 a program director -- 18 COMMISSIONER STEPHEN GOUDGE: To create 19 the residency program? 20 DR. MICHAEL SHKRUM: That's -- that's 21 correct. So then they will have to fill out a series of 22 documents outlining their resources, you know in terms of 23 who is going to do the training, what their background 24 is, what kind of cases they offer to -- to the trainee. 25 And then that will be sent back to the

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1 Royal -- Royal College. Our Specialty Committee will 2 have some input as well the -- as the accreditation body 3 at the Royal College. And then we anticipate that -- 4 that the -- the programs and certainly there's an 5 interest in Toronto through Dr. Pollanen, that programs 6 will be up and running in July of 2008. 7 COMMISSIONER STEPHEN GOUDGE: But that 8 puts us -- they'd be four (4) year programs? 9 DR. MICHAEL SHKRUM: No, this would be -- 10 this would be -- 11 COMMISSIONER STEPHEN GOUDGE: This would 12 be one (1) year after -- 13 DR. MICHAEL SHKRUM: No, these -- these 14 would be people that have already been through an 15 anatomical general pathology program. 16 COMMISSIONER STEPHEN GOUDGE: Okay. 17 DR. MICHAEL SHKRUM: So they have that -- 18 that base -- 19 COMMISSIONER STEPHEN GOUDGE: They have 20 that core foundation. 21 DR. MICHAEL SHKRUM: That's right, so 22 they have their -- they would have their five (5) years 23 of post-graduate training -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. MICHAEL SHKRUM: -- following medical

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1 school, and then they would have their one (1) year 2 additional fellowship training. 3 COMMISSIONER STEPHEN GOUDGE: Right. Is 4 there any thought or utility to the thought of an 5 experience based equivalent to obtain the certificate? 6 DR. MICHAEL SHKRUM: Yes, there is a -- 7 and this will probably be the subject of a meeting in the 8 spring time when our Specialty Committee actually meets 9 onsite, likely in Ottawa, that there is a -- what's 10 called a practice eligibility route -- 11 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 12 DR. MICHAEL SHKRUM: -- that will 13 consider that -- people that are currently in practice, 14 how do they qualify to write the certifying exam. My 15 understanding is that one has to be in a practice for at 16 least five (5) years, and there will be some type of 17 assessment, again, the details have to be worked out yet. 18 There will be some type of assessment of 19 the -- that person's practice, and then that'll make 20 them eligible then to write the exam and obviously they 21 have to pass -- 22 COMMISSIONER STEPHEN GOUDGE: In place of 23 the additional year of residency? 24 DR. MICHAEL SHKRUM: Well that's right, 25 because there's obviously many people practising now

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1 without this certification. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. MICHAEL SHKRUM: They can't -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. MICHAEL SHKRUM: -- they can't go 6 back to train, they're -- they're practising physicians. 7 COMMISSIONER STEPHEN GOUDGE: Too old to 8 go back to school. 9 DR. MICHAEL SHKRUM: Well, no, that's -- 10 never old -- too old to learn, but... 11 COMMISSIONER STEPHEN GOUDGE: But 12 that's -- 13 DR. MICHAEL SHKRUM: But -- 14 DR. CHITRA RAO: Yeah, I think at this 15 juncture I have to mention that for the Royal College to 16 recognize forensic pathology as a submission-speciality, 17 that was really initiated by my colleague, Dr. David 18 King. 19 He did quite a lot of work in it, and in 20 fact he contacted various forensic pathology units in 21 Canada, and then he prepared a document, and in fact he 22 presented that practice of forensic pathology in Canada. 23 And then he contacted this group in Ottawa, Dr. Johnston 24 as well as Dr. Bechard, and then they initiated this. 25 And now if you expect me or Dr. King to do

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1 an exam now, then I think that will be the day I'll say, 2 Enough is enough, no more, that's it. 3 COMMISSIONER STEPHEN GOUDGE: Okay. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: All right, coming 7 -- coming back to the topic of testimony for a moment. 8 How often do you testify for the defence, Dr. Dexter? 9 DR. DAVID DEXTER: I'm always available 10 to do that, but the answer is never. 11 MS. JENNIFER MCALEER: In all of your 12 experience, you've never -- 13 DR. DAVID DEXTER: In all of my -- 14 MS. JENNIFER MCALEER: -- had occasion? 15 DR. DAVID DEXTER: -- in all of my 16 experience I have never been asked to testify for the 17 defence. But as I said, the more -- the more important 18 aspect is I'm available to them at any time. 19 MS. JENNIFER MCALEER: All right. So 20 short of testifying, have you ever been asked by the 21 defence to consult on a case, to take a look at perhaps 22 the -- a report that has been authored by a pathologist 23 that the Crown intends to call, and to -- to provide your 24 comments? 25 DR. DAVID DEXTER: Yes, I have. I had a

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1 brief discussion with them about it to understand the 2 nature of what they were asking of me. And it turned out 3 that it was based on toxicologic subtleties of 4 interpretation. I think it was alcohol. 5 And I had to do what my colleagues would 6 do, is to basically say, If you need the type of expert 7 testimony and advice on this issue, I am not the one to 8 provide that, and I referred them to the Centre of 9 Forensic Science as a -- as a source point for that 10 expertise. 11 MS. JENNIFER MCALEER: So there's only 12 been the one (1) time, Dr. Dexter, that somebody has -- 13 DR. DAVID DEXTER: To date, yes. 14 MS. JENNIFER MCALEER: I see. Dr. Rao, 15 have you testified for the defence? 16 DR. CHITRA RAO: I have. 17 MS. JENNIFER MCALEER: And how often have 18 you been asked to do that? 19 DR. CHITRA RAO: Not very often. And 20 I've done on few occasions in Hamilton, St. Catherines, 21 as well as in Nova Scotia, but -- and Toronto only once, 22 and have had very bad experience with that, and after 23 that I do not. 24 I may take the case -- like I may discuss 25 a case, and I may advise the defence, and but -- then

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1 I'll ask him or her, are you going to ask me to testify? 2 If so, then I think you may have to find somebody else, 3 not me. And in fact, very often I've given Dr. Shkrum's 4 name. 5 MS. JENNIFER MCALEER: I see. And, 6 sorry, why is it that you don't want to testify for the 7 defence? You're -- you're -- as I understand it, you're 8 happy to consult on defence work, but not to testify? 9 DR. CHITRA RAO: Yes, because -- because 10 of the bad experience I had. And what happened was -- I 11 don't want to go into details, but then before I was to 12 testify, the Crown in charge of the case has contacted 13 their investigating officer to contact every police force 14 with whom I had contact, like I had worked, to find out 15 about me. 16 And then Dr. King -- at that time Dr. King 17 was sabbatic (sic) of the unit, and I was his associate, 18 and he started getting calls saying that, How come we are 19 getting calls asking about Chitra? Is there anything 20 wrong, you know. 21 And -- and then when I was cross-examined, 22 the first thing she challen -- -- the Crown challenged 23 my qualification, and the one (1) question was: Did you 24 train under Dr. Hillsdon Smith? And I said, No. Saying, 25 How can you qualify yourself as a forensic pathologist?

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1 And that's the way the case went on. 2 And also the person had doubts about my 3 training in Richmond, Virginia when I said that I did 4 autopsy. They said, No way, they don't allow foreign 5 pathologists to do. And they did call the Office of 6 Medical Examiner then they said, Yes, she did do all the 7 cases, and I said I do have a photograph, because at that 8 time the Chief Medical Examiner, he made sure that he 9 took a photograph of the visiting pathologist during an 10 autopsy. And still I've got two (2) photos pinned on my 11 bulletin board. 12 And -- so that wasn't very good, and very 13 hostile cross-examination. And then I thought, Why am I 14 subjecting myself to this? I'm quite happy where I am. 15 I don't have to come to Toronto and prove that I know 16 something. 17 MS. JENNIFER MCALEER: All right. But 18 would you -- would you testify for the defence outside of 19 Toronto then? 20 DR. CHITRA RAO: Yeah, I have done that. 21 In Hamilton I've done. And I -- I tell the difference, 22 can I call the Crown and tell them that I'm testifying, 23 and they have no objection. And I've called the Crown 24 and they said, Fine, you can do it, no problem. 25 Same thing in Nova Scotia. The Crown

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1 accepted, and I had no problem. 2 MS. JENNIFER MCALEER: So it's a bad 3 Toronto Crown Attorney experience? 4 DR. CHITRA RAO: Yes, that's one (1) 5 experience. I think that was enough. And at the same 6 time Dr. King also had similar experience. And so we 7 both feel now a bit hesitant to get involved with Toronto 8 cases. 9 MS. JENNIFER MCALEER: Dr. Shkrum, what 10 has been your experience testifying for the defence? 11 DR. MICHAEL SHKRUM: I testified twice 12 for the defence, ironically, both on Dr. Rao's cases. 13 MS. JENNIFER MCALEER: How did that go? 14 DR. MICHAEL SHKRUM: Fine. 15 MS. JENNIFER MCALEER: Have you been 16 asked in other cases to consult on defence work? 17 DR. MICHAEL SHKRUM: Yes, I have, and 18 actually currently I have five (5) files that I'm trying 19 to juggle for -- for the defence. 20 MS. JENNIFER MCALEER: And how -- how 21 often are you being asked to do that work, Dr. Shkrum? 22 DR. MICHAEL SHKRUM: Well actually in the 23 last year or so, increasingly. And as I said, I'm trying 24 to juggle a number of files, and -- I mean there are 25 limitations on my -- my time. I'm -- I certainly welcome

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1 taking them, but there does become a limit after a while, 2 because some of these cases are very time consuming. 3 You know, I -- I believe that, you know, a 4 person should have the best defence possible. I think as 5 part -- as a forensic pathologist, it's part of our 6 practice to -- to try to do defence work if we have the 7 time. 8 And a number of these cases are very 9 interesting. I always -- I always learn something from 10 them. 11 COMMISSIONER STEPHEN GOUDGE: Does the 12 system accommodate the time necessary to do defence work, 13 Dr. Shkrum? 14 It does seem to me that all three (3) of 15 you work for hospitals. You know, you have got hospital 16 responsibilities. 17 DR. MICHAEL SHKRUM: The -- well, the -- 18 COMMISSIONER STEPHEN GOUDGE: How does 19 that implicitly get accommodated in a hosp -- 20 DR. MICHAEL SHKRUM: Well my system is -- 21 yeah, is the hospital, and fortunately my Chair-In-Chief, 22 Dr. Berth Garcia is very supportive of my activities 23 doing -- doing forensic pathology, which includes defence 24 work. 25 I do get administrative time every week.

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1 Obviously not to just do defence work -- 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. MICHAEL SHKRUM: -- but -- but to do 4 other duties related to this. So that provides the 5 beginning of a bit of a safety valve for my time, but a 6 lot of this work is done after hours or on weekends. 7 And again, it's a real juggling act, and 8 again, logistics too. I mean, I've not actually had to 9 come to Toronto yet, I'm anticipating I might. But the 10 logistics of getting out of work, and it's basically a 11 day gone -- probably at least a day -- you know, that 12 remains to be seen how that -- how that works out. 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: Dr. Rao, you were 17 shaking your head? 18 DR. CHITRA RAO: Again, I have 19 cooperation with my colleague, so we understand. And 20 even though suppose I -- I'm supposed to be on service on 21 that particular case, I have to go to court that day, 22 then my colleague will take over. 23 And we don't have to inform our laboratory 24 director what's happening, as long as the service is 25 being done. The preparation we do after hours and we do

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1 it at home or weekends. And it's not during our working 2 hours. 3 And then like he said, quite a lot of 4 cases now I'm refusing. I don't accept it, because I do 5 not have time. And I have a large backlog of cases where 6 I have to complete them. So I don't, and then I refer 7 his name and somebody else's name. 8 MS. JENNIFER MCALEER: So the defence 9 work then -- the review, consultations you're asked to do 10 -- that gets slotted into weekends and evenings. 11 Is that fair? 12 DR. CHITRA RAO: Yes. That, and then 13 again second review requested by the regional supervising 14 coroner or for a Crown. All those cases will be done 15 after hours. 16 MS. JENNIFER MCALEER: All right. So 17 let's talk a little bit about that. So on occasion the 18 regional supervising coroner or a Crown Attorney may ask 19 you to review another forensic pathologist's work. 20 And that's quite distinct from being asked 21 by a defence lawyer to review -- 22 DR. CHITRA RAO: That's correct. 23 MS. JENNIFER MCALEER: -- somebody's 24 work? And how often does that happen? 25 DR. CHITRA RAO: That happens at least

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1 maybe one (1) or two (2) cases a month, either for the 2 regional supervising coroner or for the Crown. 3 MS. JENNIFER MCALEER: And are you also 4 asked to do that, Dr. Shkrum? 5 DR. MICHAEL SHKRUM: Yes, actually it's 6 been more concentrated. Just maybe in the last year or 7 so my Regional coroner, Dr. Jack Stanborough, that's S-T- 8 A-N-B-O-R-O-U-G-H, has requested that I review some 9 reports from other pathologists. 10 And also to review actually specific 11 organs, a windpipe -- windpipes from these various cases. 12 So in the past I haven't reviewed too many of these cases 13 but, as I said, in the last year or so it's been 14 increasing sort of consultation like that. 15 MS. JENNIFER MCALEER: Okay. Dr. 16 Dexter...? 17 COMMISSIONER STEPHEN GOUDGE: Do -- 18 MS. JENNIFER MCALEER: Sorry, go ahead. 19 COMMISSIONER STEPHEN GOUDGE: Sorry, no, 20 go ahead. You complete that then I will -- 21 22 CONTINUED BY MS. JENNIFER MCALEER: 23 MS. JENNIFER MCALEER: I was just going 24 to ask Dr. Dexter whether or not you're being asked by 25 your Regional Supervising Coroner to review work from

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1 pathologists in your area? 2 DR. DAVID DEXTER: Yes, I have been. It 3 was a pathologist actually out of my usual area. But, 4 yes, I have been asked to do that. 5 MS. JENNIFER MCALEER: All right. Sorry, 6 Mr. Commissioner, you were going to followup. 7 COMMISSIONER STEPHEN GOUDGE: We have 8 been challenged before, I say to the three (3) of you, 9 with this problem of limited pathology available in the 10 general field; that the cases that come to you through 11 the coroner's warrant process, you get involved with, and 12 if they take you to court, they take you to court. 13 The defence cases, in effect, come in a 14 side door by a defence counsel calling and asking for a 15 consultation. For people that are already stretched, it 16 is very hard to figure out ways in which the system might 17 better accommodate the provision of service to the 18 defence, apart from the understanding head of the 19 department. 20 I just wonder if any of you have any 21 suggestions about that? 22 DR. MICHAEL SHKRUM: Well, yeah, and I 23 think it's -- it's a problem because, you know, really 24 defence work -- I mean, we have, you know, retired 25 forensic pathologists that can do this work but, again,

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1 it shouldn't be necessary the purview of retired people. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. MICHAEL SHKRUM: I mean, it should be 4 part of an active practice of any forensic pathologist. 5 Now, the flipside is that, you know, as a 6 -- I think as a defence expert, you have to have some 7 independence. So if we're going to an Ontario system, 8 how much of, you know, of the individuals working 9 individual units, how much of our independence can we 10 maintain if we're working as part of a system - 11 independence in terms of consulting for the defence. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. MICHAEL SHKRUM: That's a bit of a 14 dilemma. I -- and I worry about that because, you know, 15 it does raise issues of conflict of interest. 16 COMMISSIONER STEPHEN GOUDGE: At least 17 perception? 18 DR. MICHAEL SHKRUM: At least that 19 perception, yes. 20 DR. CHITRA RAO: I think another solution 21 is we have to have more forensic pathologists. 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. CHITRA RAO: And so it doesn't just 24 start as soon as they finish their training. We should 25 start from the -- when they arri -- join a medical

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1 school. We have to have more exposure, forensic 2 pathology exposure, at the medical school -- 3 COMMISSIONER STEPHEN GOUDGE: At the 4 under graduate level? 5 DR. CHITRA RAO: Yes. And then get more 6 people. And once we have adequate members, maybe then 7 the department can decide, okay, who'll be interested in 8 doing defence work and -- and encouragement should be 9 given. And they should be given the opportunity to go 10 for continuing education. 11 COMMISSIONER STEPHEN GOUDGE: Yes. 12 DR. CHITRA RAO: And then not penalize 13 them and then don't give the name or -- you or him as a 14 hired gun, don't have that terminology. 15 COMMISSIONER STEPHEN GOUDGE: Okay. 16 DR. CHITRA RAO: And it should be open- 17 minded and the Crown should accept that too. 18 COMMISSIONER STEPHEN GOUDGE: Yes. And 19 then the supply question is one that obviously is central 20 to -- 21 DR. CHITRA RAO: Exactly. 22 COMMISSIONER STEPHEN GOUDGE: -- 23 advancing this part of the science. 24 DR. MICHAEL SHKRUM: Well, it -- it 25 strengthens the system. I mean, if you have a good

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1 defence pathology, it actually strengthen -- sorry, 2 strengthens the system. 3 DR. CHITRA RAO: Exactly. 4 COMMISSIONER STEPHEN GOUDGE: Let me ask 5 this, and I am -- Ms. McAleer maybe I'm sure coming to 6 this, but to link it to the discussion of giving 7 evidence. We have heard before that one (1) of the 8 issues about the attractiveness or lack thereof of 9 forensic pathology is the courtroom setting in which part 10 of the job has to be done, which is to a degree foreign 11 to medical science, which gets at truth by way of 12 discussion not conflict. 13 And I'm oversimplifying, obviously, but 14 the notion of being put in the context of conflict in 15 giving evidence is one -- I would be interested as 16 whether the three (3) of you ever found that to be an 17 adaptation that required some effort; that is, to get 18 used to the notion of the adversary system that the legal 19 process uses. 20 DR. DAVID DEXTER: I can comment a little 21 bit by example. There are a number of people -- we -- we 22 had two (2) hospitals in Kingston for -- for many years. 23 Until about ten (10) years ago they were both functional 24 pathology units, one (1) of whom was a four (4) person 25 unit, and the other eight (8) or so were in the larger

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1 institution. 2 A number of the individuals in the larger 3 institution did their medicolegal cases. There was no 4 real assignment of those cases at that point in time to 5 people that were recognized with special expertise but, 6 nonetheless, some of them would get called to go to 7 inquest, occasionally, some of them would get involved 8 with a case going to trial. 9 Several of my colleagues who are wonderful 10 teachers, they flourish in an academic environment, found 11 it very difficult to, if you like, survive the type of 12 questioning and argument that they were exposed to in the 13 Court setting and as a consequence of that, decided that 14 they would not do those sorts of cases. 15 COMMISSIONER STEPHEN GOUDGE: That is not 16 an atypical story, Dr. Dexter, we have heard that before. 17 Now, what can the system do? What can the legal system 18 do to mute that risk? 19 DR. DAVID DEXTER: I -- I don't know. 20 From my personal experience and this rich experience at 21 this table, from my experience, certainly going into the 22 -- the court setting, there is an adversarial component 23 to it; there is a tension about it all; there is a 24 component of the unknown because certainly as the 25 questions open to the defence, one is never quite certain

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1 where that will go. The issues of hypotheticals, all of 2 those sorts of sort of challenging scenarios certainly 3 get your blood pressure up a little bit, your pulse 4 really going and so forth -- 5 COMMISSIONER STEPHEN GOUDGE: Is there 6 education that could be undertaken of people as they are 7 going through the forensic pathology process to make them 8 aware of this so that perhaps when it happens the impact 9 will be lessened a little? 10 DR. DAVID DEXTER: I think that's one of 11 the potential strengths of this program we're talking 12 about, this fellowship program, that it's an environment 13 that we can provide experience, we can give people 14 techniques, we can give them some advice and tips on how 15 to survive and to flourish -- 16 COMMISSIONER STEPHEN GOUDGE: And some 17 understanding -- 18 DR. DAVID DEXTER: Mm-hm. And -- 19 COMMISSIONER STEPHEN GOUDGE: -- of why a 20 system that seems -- 21 DR. DAVID DEXTER: Yes. Yeah. Yes. 22 COMMISSIONER STEPHEN GOUDGE: -- quirky 23 operates that way. 24 DR. DAVID DEXTER: Yeah. 25 DR. CHITRA RAO: I think another solution

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1 is they should have joint meeting, the Crown and defence 2 should join together with the pathologist and discuss the 3 case before he goes to Court. And in some instances 4 where the Crown is expected to disclose everything to the 5 defence, and sometimes that's not the case, the reverse, 6 and so it shouldn't be that way. 7 And if the defence has got his own 8 expertise, the Crown's pathologist also should know, so 9 before going to Court they will know what sort of the 10 line they have to prepare then, what they are expecting. 11 Another issue where the hospital 12 pathologists don't like to go to Court is the timing, you 13 know, they may ask you to come to Court at such a time 14 and you're at the mercy of the Court because there may be 15 another witness and it's taking long, and they may have 16 to spend whole day there, and which some of them don't 17 like that. And so that's another issue too. 18 But then I think the main thing is 19 education, again, consultation, meet with both the 20 parties and see what you're up to. 21 COMMISSIONER STEPHEN GOUDGE: Dr. 22 Dexter...? 23 DR. DAVID DEXTER: That just triggered 24 something in my mind about that, and it's a bit of the 25 utopian concept, and that is that in dealing with

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1 pathology evidence, and perhaps there's another 2 pathologist for the defence and so forth, there is an 3 opportunity for establishing baseline knowledge and 4 agreement. 5 And the question is how you do that. And 6 I'm not certain that I know the answer to that but, 7 certainly, for the pathologist to meet and agree on those 8 things that they have no problem with and those areas 9 where clearly there is a division of -- of opinion. 10 I also think that it's an opportunity for 11 -- on the legal side of things for the Crown and defence 12 attorney to have at least some baseline knowledge of 13 where the thing is going. I -- I know I've had some 14 experience where the Crown appears much more informed 15 about the case - that's partly because I've had 16 consultation with them - and the defence is less so, it's 17 less informed and you can tell by the nature of the 18 questions, -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. DAVID DEXTER: -- they're perhaps a 21 little less direct, a little -- a little off target, 22 there's an element of -- of ignorance, perhaps, of -- of 23 some of the issues about the case. 24 Ideally, if there could be some forum for 25 -- prior to going to trial where at least we could

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1 establish what we know -- 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. DAVID DEXTER: -- and what we agree 4 on, and then we're not wasting Court time, we're moving 5 forward. 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 That is helpful. Dr. Shkrum...? 8 DR. MICHAEL SHKRUM: I am just going to 9 add that it's probably a question of attitude as well, 10 attitude and understanding. I think from the -- from the 11 forensic pathology sort of training perspective it's 12 important that the forensic pathologist, as an expert, 13 understands and has the attitude that he or she is there 14 to assist the Court, and even though you're call -- 15 called as a Crown witness, you're there to assist the 16 Court. 17 And then from the -- from the legal 18 perspective, and I think particularly -- well, both Crown 19 and defence should understand what the role of that 20 expert is, that, you know, they're aware -- they're there 21 to assist the Court. 22 And I -- I would say that that training 23 for def -- for lawyers should actually go back to law 24 school. There should be -- I mean, how many law schools 25 have courses that deal with how to handle expert

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1 witnesses, specifically, forensic pathologists? 2 COMMISSIONER STEPHEN GOUDGE: Very few. 3 Very few. 4 DR. MICHAEL SHKRUM: Right, so... 5 DR. CHITRA RAO: And then there should be 6 another body to oversee -- sometimes defence will call an 7 expert and that expert may call -- qualify themself as a 8 pathologist and they may not be a pathologist, they may 9 be an experimental pathologist, so people have to know 10 who are calling, what their qualification. 11 DR. MICHAEL SHKRUM: Right. 12 COMMISSIONER STEPHEN GOUDGE: Well, 13 that's very helpful. Sorry, that was a long digression, 14 Ms. McAleer, I apologise. 15 16 CONTINUED BY MS. JENNIFER MCALEER: 17 MS. JENNIFER MCALEER: That's fine, I'm 18 just crossing it off as we go. 19 Just following up on that line of 20 questioning, in your experience, and you just touched on 21 this, I think, a little bit, Dr. Shkrum, but do you have 22 a view that perhaps Crown attorneys and defence lawyers 23 both require additional training with respect to the 24 field of forensic pathology or dealing with forensic 25 pathologists and what their craft is really all about?

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1 DR. MICHAEL SHKRUM: Well, I agree, and 2 in fact, we have an initiative ongo -- on the go in our 3 unit, myself, and I think mainly at the initiative of Dr. 4 David Ramsay; R-A-M-S-A-Y, who is a neuro pathologist who 5 does forensic work in our Unit. 6 We've contacted Mary Park (phonetic), who 7 works with the Osgoode Law School. She was the 8 coordinator of a course that we attended at -- recently 9 that Dr. Dexter mentioned. 10 But the thrust of our -- of our proposal 11 is that perhaps there should be a course that actually 12 specifically deals with the limitations of the forensic 13 pathologist as an expert witness. 14 So, she's, I think, quite enthused about 15 it, so we'll work away at it. 16 MS. JENNIFER MCALEER: And just one (1) 17 final question on this area of defence pathology work. 18 Is -- is the fee structure in any way a disincentive/an 19 incentive to doing defence work? 20 DR. MICHAEL SHKRUM: Well, many of these 21 cases are -- are legal aid cases and I do accept those 22 type of cases. The -- the fee is approximately a hundred 23 dollars ($100) per hour and, you know, there -- there are 24 a certain set number of hours that may be put upfront; I 25 usually ask for about twenty (20) hours.

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1 I don't know how -- how long it's going to 2 take me to review a report. But it's not a -- you know, 3 not a real incentive. I mean, I -- I'm not really doing 4 these cases to -- to make money; it's -- it's, you know, 5 to help and -- and to -- to, you know, and also to learn 6 in the process but, yes, it is a disincentive, I mean 7 it's not well remunerated. 8 MS. JENNIFER MCALEER: Dr. Rao...? 9 DR. CHITRA RAO: It's the same, and 10 sometimes it takes a long time to get the payment and, 11 again, it's not for the payment we're doing; we're doing 12 because we can double up our expertise and then we -- you 13 know, I want to establish I'm not a Crown witness, I'm an 14 impartial witness, so I have experience on both sides. 15 And having said about the payment, 16 sometimes when we do review of our regional supervising 17 coroner, we don't get paid at all, but for the Crown, I 18 can bill the Crown and the Crown will pay, but not with 19 the regional supervising coroner, there's no... 20 MS. JENNIFER MCALEER: Right. And, Dr. 21 Dexter, since you haven't done any work for the defence, 22 I can -- 23 DR. DAVID DEXTER: Nor further comment. 24 MS. JENNIFER MCALEER: All right. So, 25 changing topics, then. Let's go back to talking about

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1 your particular units and, in particular, the peer review 2 that happens within the unit, and then a little bit later 3 we'll talk about the peer review or oversight that's 4 available to you from the Office of the Chief Coroner and 5 from the coroner's system. 6 But staying within your particular units 7 to begin, why don't we start with you Dr. Rao, what -- 8 what peer review or quality assessment mechanisms do you 9 have within your unit with respect to -- well, you do all 10 medicolegal work, so -- 11 DR. CHITRA RAO: Yes. 12 MS. JENNIFER MCALEER: -- taking that -- 13 DR. CHITRA RAO: I review all the cases 14 of suspicious and homicide cases done by Dr. King and Dr. 15 Fernandes, and any cases which goes to inquest, and all 16 pediatric cases under 5 a review. 17 And sometimes the Regional Supervising 18 Coroner may ask me to review cases originated from either 19 Guelph, Kitchener, or St. Catherines if those cases are 20 going to Court for inquest and -- but -- then motor 21 vehicle accident where there are criminal charges and 22 there's a potential for that case to go to court, I may 23 have to review that. 24 And my cases are reviewed by the Chief 25 Forensic Pathologist, Dr. Michael Pollanen.

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1 MS. JENNIFER MCALEER: Right, I don't 2 want to get into that yet. 3 DR. CHITRA RAO: Okay. 4 MS. JENNIFER MCALEER: And just -- just 5 staying within your unit. 6 DR. CHITRA RAO: Okay. 7 MS. JENNIFER MCALEER: So when you say 8 that -- that -- you gave us a list of the kinds of cases 9 where you review them, what does that review consist of? 10 Are you in the autopsy room? Are you 11 looking at the post-mortem report? Explain -- 12 DR. CHITRA RAO: Okay, for review, after 13 they have completed, I review the photographs of the 14 autopsy. I review the coroner's warrant. I review his 15 report. And I go through the toxicology. And if that 16 particular case had some medical charts, I'll go through 17 that. And I also go through the microscopic slides. 18 MS. JENNIFER MCALEER: How -- how long 19 does that take, Dr. Rao, for a typical case? 20 DR. CHITRA RAO: Okay. Depen -- 21 depending upon the type of case, it can take anywhere 22 from forty (40) minutes to three (3), four (4) hours. 23 MS. JENNIFER MCALEER: All right. And 24 you do that for all criminally suspicious cases, all 25 inquest cases, all deaths under five (5), and any other

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1 criminal cases in the sense that there are criminal 2 charges pending. 3 Is that correct? 4 DR. CHITRA RAO: That's correct. 5 MS. JENNIFER MCALEER: All right. Is 6 there any other internal review mechanisms? Do you have 7 rounds within your unit, or do you have discussions in 8 the autopsy room in the course of an autopsy? 9 DR. CHITRA RAO: Yes. We -- normally, 10 Dr. Fernandes and myself, we always exchange our 11 findings. And sometimes he's doing an autopsy, has got 12 some interesting finding, he'll call me to see it. Or if 13 he has any doubt he'll call me. 14 Same way when I'm doing a case, and I will 15 call him or the fellow or the resident so that they can 16 have a look at the lesion. And then we always consult 17 each other. 18 And suppose I'm signing out and I can't 19 make up my mind about a particular slide, I want somebody 20 else to say, Yes, you're -- you're in the right way of 21 thinking, so I'll show it Dr. Fernandes. 22 Or if it is a cardiac case, if the cardiac 23 pathologist's around, I'll go and show it to them, or 24 neuropathologist. 25 In that way our setup is very good, and we

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1 can go to any of the other submission-speciality 2 pathologists, and they have no problem to view. 3 And then I -- I may not ask them to give a 4 formal report. But in my report I'll say, The slides 5 were reviewed informally with so and so, and they 6 concurred with my opinion, or they suggested this. So 7 I'll put that in my report. 8 MS. JENNIFER MCALEER: All right. And 9 still within the unit, does anybody review your post- 10 mortem examination reports? 11 DR. CHITRA RAO: Not within the unit, no. 12 MS. JENNIFER MCALEER: All right. Dr. 13 Dexter, what internal review or quality assurance 14 mechanisms are there within your unit? 15 DR. DAVID DEXTER: It's similar. 16 MS. JENNIFER MCALEER: I'm sorry? 17 DR. DAVID DEXTER: It's similar. The 18 types of cases that I would review are those of my 19 colleague, Dr. Young. They would be all inquest-type 20 cases, criminally sus -- suspicious and homicide cases. 21 And I would review those in a similar was 22 to Dr. Rao. I would have available to me the CDs or DVDs 23 of the images or -- or films of the scene, the 24 medicolegal report, the coroner's warrant, slides, 25 toxicology reports, radiologic reports.

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1 And again, this would take a variable 2 period of time. In the simple, straightforward one it 3 may be thirty (30) to forty (40) minutes. In a more 4 complex one, that I might want to go to other reference 5 material, think about, maybe discuss with other 6 colleagues some particular issues on pathological 7 matters, it might take considerably longer. 8 And then I would give feedback to those 9 individuals indicating -- usually with a yellow sticky on 10 the report if that's where the issues are -- suggested 11 changes, or additional things that I feel would -- would 12 be necessary. 13 So that is the internal review from the 14 point of view of the reports. The reports would then go 15 back to the individual, and then they can sign them and 16 they can be sent out as complete reports. 17 Within the autopsy suite, at the time of 18 many of these cases I am available for consultation. And 19 I'm called down on a fairly regular basis, probably at 20 least once to twice a week, with a question or a query 21 from one of my colleagues. They may be doing medicolegal 22 cases. They would not be doing forensic cases. 23 But between Dr. Young and myself, we 24 occasionally ask each other to come and give an opinion, 25 as we're dealing with the actual mechanics of -- of doing

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1 a case. 2 With regards to another component of -- of 3 review, we have medicolegal rounds, which are held 4 approximately once a month. Present at those rounds are a 5 variety of people: the pathology residents in training; 6 the pathologists who did medicolegal cases, and they will 7 present a selection of those cases; coroners; case 8 coroners; and Dr. McCallum is the Regional Supervising 9 Coroner, attends fairly regularly. 10 And there is an opportunity there that 11 allows not only for discussion of the case, the case 12 material, other interpretations, other things that might 13 be considered, but it's also an opportunity to hear from 14 Dr. McCallum about issues from the coroner's perspective 15 that we need to know about pathologically: changes, 16 concerns that are gro -- coming, changes in approach and 17 so forth. 18 It -- it's a very valuable interplay, 19 actually. 20 MS. JENNIFER MCALEER: All right. So -- 21 so we've -- I think you were talking about two (2) 22 different things, then. 23 We've got internal review in quality 24 assurance, and then we have more of an external case 25 conferencing system?

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1 DR. DAVID DEXTER: Yes, we have some 2 external players there. 3 MS. JENNIFER MCALEER: All right. And I 4 know that, Dr. Rao, you also do that, as well -- 5 DR. CHITRA RAO: Yes. 6 MS. JENNIFER MCALEER: -- and we'll -- 7 we'll come back to you to talk about the case 8 conferences. 9 Sticking, though, with the internal peer 10 review, Dr. Dexter, did I understand you to say earlier 11 in your evidence today, as well, that you also -- you 12 check the caseload each morning to see what is on deck, 13 so to speak, and -- 14 DR. DAVID DEXTER: Yes, I do. 15 MS. JENNIFER MCALEER: -- and -- and then 16 you interact with your fellow pathologists -- 17 DR. DAVID DEXTER: Correct. 18 MS. JENNIFER MCALEER: -- according to 19 the level of difficulty that -- that you can -- 20 DR. DAVID DEXTER: Yeah, correct. 21 MS. JENNIFER MCALEER: -- discern from 22 looking at the coroner's warrant. All right. If we 23 could turn for a moment -- Dr. Shkrum, I'll come back to 24 you in a -- in a moment to see what internal review you 25 have at your unit.

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1 But if we could turn to Volume II, Tab 53 2 for a moment. These are the -- the guidelines on 3 criminally suspicious cases, the most recent version. 4 DR. CHITRA RAO: Yes. 5 MS. JENNIFER MCALEER: And if we go to 6 the very last page of that document, so it's page 52, and 7 this is PFP139350. 8 DR. CHITRA RAO: Yes. 9 MS. JENNIFER MCALEER: Right. So going 10 back to you, Dr. Rao, briefly, as I understand it, you 11 either use this document or something similar to this 12 document when you do the internal review of your 13 colleagues that you were discussing? 14 DR. CHITRA RAO: That's correct. 15 MS. JENNIFER MCALEER: All right. So -- 16 so in all those cases that you described -- the inquest, 17 criminally suspicious, deaths under five (5) -- when 18 you're reviewing your colleague's post-mortem examination 19 reports, do you actually complete this form or one 20 similar to it? 21 DR. CHITRA RAO: Yes, I do. 22 MS. JENNIFER MCALEER: All right. And 23 then you provide that to who? 24 DR. CHITRA RAO: Regional Supervising -- 25 the original copy will go to the Regional Supervising

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1 Coroner, and a copy will go to the original pathologist, 2 and I keep a copy in my file. 3 MS. JENNIFER MCALEER: I see, so it does 4 even go beyond your four (4) walls; it actually does go 5 out the Regional Supervising Coroner? 6 DR. CHITRA RAO: Yes. 7 MS. JENNIFER MCALEER: All right. Dr. 8 Dexter, do you use anything like this when you're 9 reviewing the reports of your colleagues? 10 DR. DAVID DEXTER: Yes, I do; it's very 11 similar. That completed, ordered report or review report 12 -- it's probably more of a review than an order. It is a 13 review, not an order. That report becomes incorporated 14 in the medicolegal report. So wherever that goes, this 15 goes. 16 MS. JENNIFER MCALEER: All right. So 17 just -- I'm trying to figure out how this works 18 practically. 19 So the -- the -- your colleague, you 20 junior, so to speak, would do their report, sign off on 21 it, then you would take a look at it, fill this out, and 22 attach it to the report, no? 23 DR. CHITRA RAO: It goes into their file. 24 MS. JENNIFER MCALEER: It goes into their 25 file.

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1 DR. CHITRA RAO: Yes. 2 MS. JENNIFER MCALEER: I see. But it 3 doesn't actually get circulated with the final post- 4 mortem examination report? 5 DR. CHITRA RAO: It will -- it will go -- 6 when -- once I have done -- it's a draft form, the post- 7 mortem examination. I'll finish, and if there is no 8 issue, there's no corrections or anything like that, I'll 9 complete this and put it in the file. 10 And then the pathologist will give it to 11 her secretary and she will get the final copy of it, and 12 then she'll send my original review report to the 13 Regional Supervising Coroner. 14 And then the -- it's understood, once I've 15 completed, the cases from our unit can be sent out. 16 MS. JENNIFER MCALEER: Okay. And how 17 long have you been doing this, either -- not specifically 18 this form, but some kind of form that documents your peer 19 review of your colleague? 20 DR. CHITRA RAO: Yeah, there was a memo 21 from the Chief Coroner's Office, I think it was in 2004, 22 when they had requested that the medical directors of 23 each unit will start reviewing their colleague's cases. 24 Initially, it was Dr. David Chiasson who was reviewing 25 all the cases. But then later on they decided, I think

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1 it was in 2004. 2 MS. JENNIFER MCALEER: All right, so 3 you're referring to the memo that's at Tab 45 of that 4 same volume, Volume II? It's PFP032542, from July of 5 2004 -- 6 DR. CHITRA RAO: Yeah. 7 MS. JENNIFER MCALEER: -- and then 8 attached at -- 9 DR. CHITRA RAO: Yes. 10 MS. JENNIFER MCALEER: -- at the very 11 next tab, Tab 46, is an autopsy report audit form. 12 DR. CHITRA RAO: That's correct. 13 MS. JENNIFER MCALEER: All right. So 14 that's the precursor to the document that we had been 15 looking at, at Tab 53? 16 DR. CHITRA RAO: Yes. 17 MS. JENNIFER MCALEER: I see. And so 18 that -- to answer the -- the question, then, starting -- 19 and it was in and around 2004 -- 20 DR. CHITRA RAO: Yes. 21 MS. JENNIFER MCALEER: -- that you 22 started to do these documented peer reviews? 23 DR. CHITRA RAO: That's correct. 24 MS. JENNIFER MCALEER: Is that 25 according --

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1 COMMISSIONER STEPHEN GOUDGE: Had there 2 been peer review before that? 3 DR. CHITRA RAO: Sorry? 4 COMMISSIONER STEPHEN GOUDGE: Had there 5 been peer review before that? 6 DR. CHITRA RAO: No, only time -- Dr. 7 David Chiasson reviewed our cases, but not regular cases. 8 9 The only thing is, Dr. McLellan, when he 10 took the role of Chief Forensic Pathol -- Chief Coroner, 11 he told us that we should do a spot check at random. And 12 so we used to do -- Dr. Fernandes used to pick a couple 13 of my cases -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. CHITRA RAO: -- and then I used to do 16 -- but we didn't do it on a regular basis. But we didn't 17 report it; we just looked at it. And then he came up 18 with this memo, and after that we started following. 19 DR. MICHAEL SHKRUM: Can just add to the 20 -- sorry, should just add, the original form, actually, 21 was a much simplified -- that we would receive from Dr. 22 Chiasson. It was just simply a box that was ticked 23 "review completed." 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 Right, I have seen that.

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1 DR. MICHAEL SHKRUM: It didn't have -- it 2 didn't have this detail, so... 3 COMMISSIONER STEPHEN GOUDGE: And that's 4 helpful. 5 MS. JENNIFER MCALEER: Right. 6 DR. CHITRA RAO: Yeah, and the most -- 7 COMMISSIONER STEPHEN GOUDGE: But none of 8 you would have had the practice in your localities of 9 peer review prior to three (3) or four (4) years ago? 10 DR. CHITRA RAO: No, only thing is, what 11 happened was we'll consult each other. If he had any 12 doubt or something, we'll consult each other. 13 COMMISSIONER STEPHEN GOUDGE: Fair 14 enough. 15 DR. CHITRA RAO: Yes. And on occasion -- 16 COMMISSIONER STEPHEN GOUDGE: But no kind 17 of formalised -- 18 DR. CHITRA RAO: No. 19 COMMISSIONER STEPHEN GOUDGE: -- peer 20 review as the three (3) of you had, or the two (2) of -- 21 DR. MICHAEL SHKRUM: No. 22 DR. CHITRA RAO: No, no. 23 24 CONTINUED BY MS. JENNIFER MCALEER: 25 MS. JENNIFER MCALEER: So -- all right,

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1 so Dr. Dexter, when -- when did you start? Did you start 2 using the report that we see at Tab 46, being PFP032544, 3 did you start using that in or around -- 4 DR. DAVID DEXTER: Yes. 5 MS. JENNIFER MCALEER: -- 2004? 6 DR. DAVID DEXTER: Yes. You'll notice my 7 name is on there as one of the reviewers. So yes, as 8 soon as that came out, I -- I adopted it and used it. 9 MS. JENNIFER MCALEER: All right. So -- 10 and just to clarify something in my mind, then, because 11 you -- you talked about Post-It notes that you would put 12 on your colleague's post-mortem examination reports. But 13 now we actually have these forms. 14 So I'm wondering, when do you use the 15 Post-It note? When do you use the form? Or -- or do you 16 use them at different times? 17 DR. DAVID DEXTER: Well, they'd both be 18 used. But what I would use the Post-It note is to just 19 direct the individual to certain areas where perhaps the 20 -- there could be clarification or there was a 21 misspelling. 22 And so it meant we were looking at the 23 wordsmanship, if you like, of the form, the structure of 24 the form, and so forth. 25 MS. JENNIFER MCALEER: Okay.

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1 DR. DAVID DEXTER: If -- if it was more 2 than that, I would speak them -- to them directly and go 3 over the specific areas and say, Look, I think this is 4 confusing. I would suggest you take these steps, just 5 sort of clarify it. 6 And so there were a variety of levels of 7 interplay that I took in reviewing that material. But 8 what I would do is, we would hold off finalising that 9 document until everything was in place, and that if it 10 was a significant change that the pathologist had 11 undergone in -- in making that report, I would re-review 12 it and say, Yeah, that makes sense. Okay, sign it off. 13 We'll get on. 14 MS. JENNIFER MCALEER: All right. So 15 turning to you, Dr. Shkrum, what internal peer review or 16 quality assessment mechanisms are there within the London 17 Unit? 18 DR. MICHAEL SHKRUM: Well, the one level 19 that's already been discussed, that I would review the 20 homicides and criminally suspicious cases that my 21 colleague, Dr. Tweedie, has -- has done. And I would use 22 a similar -- or the same peer review form. I would fill 23 that out. 24 And then he would submit a draft report to 25 me. And then once I've reviewed it, I would fill out

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1 this form. If there are any concerns, I would use a 2 Post-It note, and I would write that down, discuss the 3 case with Dr. Tweedie. He would make the appropriate 4 amendments as he saw fit, and then that report would be 5 sent to the Regional Coroner's Office. 6 MS. JENNIFER MCALEER: All right, so that 7 when Dr. Tweedie completes his report, not only is his 8 report being sent to the Regional Supervising Coroner's 9 Office, but your -- your report is going as well? 10 DR. MICHAEL SHKRUM: Well, I don't issue 11 a formal report; I will just make an informal note. But 12 I've -- I've indicated to Dr. Tweedie that that -- you 13 know, that note should be kept in the file because those 14 are my comments on the case. 15 Sometimes the comments are very minor. I 16 mean, he -- he does excellent reports. It may be a 17 question of left versus right, you know, sort of minor 18 things like that that Dr. Dexter sort of eluded to as 19 well. 20 COMMISSIONER STEPHEN GOUDGE: Do you 21 review the slides? 22 DR. MICHAEL SHKRUM: Not in all 23 instances. Many of the cases it doesn't rea -- they 24 don't really necessitate a slide review. 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. MICHAEL SHKRUM: I mean, if it's a 2 gunshot wound -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. MICHAEL SHKRUM: -- the slides may 5 not be -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. MICHAEL SHKRUM: -- as necessary to 8 look at. I seen -- 9 COMMISSIONER STEPHEN GOUDGE: But where 10 the histology is central, would you review -- 11 DR. MICHAEL SHKRUM: Yes, I would review 12 the slides. Now again, just like Doctors Dexter and Rao 13 have mentioned, you know, that there are images to 14 review, the report, the coroner's warrant, ancillary 15 reports, all -- all that forms part of my review. 16 So, again, the time -- time sequence is 17 similar, it's probably at least half an hour, forty-five 18 (45) minutes in that sort of time frame to review those 19 cases at least. 20 21 CONTINUED BY MS. JENNIFER MCALEER: 22 MS. JENNIFER MCALEER: Okay. Just 23 staying for one moment on this form that's at the last 24 page of Tab 53, just -- just so I'm clear, because I 25 think I'm still a little confused, and I may be the only

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1 one in the room, but when this form is filled out then, 2 when, if at all, does it go to the Regional Supervising 3 Coroner? 4 Dr. Shkrum, does it ever or does it always 5 stay inside your internal file? 6 DR. MICHAEL SHKRUM: Well I -- I have a 7 copy for my own file, it would be the original copy and 8 then the fax copy would go to the Regional Coroner's 9 Office. So once the report is ready to be completed and 10 it's no longer a draft, and Dr. Tweedie signs off on it, 11 now it is sent to the Regional Coroner's Office with this 12 peer review form. 13 MS. JENNIFER MCALEER: I see. And, Dr. 14 Rao, is that the same in your office? 15 DR. CHITRA RAO: Yes, but I send the 16 original one to the Regional Supervising Coroner and I 17 keep a copy and a copy goes to the file. 18 MS. JENNIFER MCALEER: All right. And 19 Dr. Dexter...? 20 DR. DAVID DEXTER: It's similar, but the 21 original goes on the medicolegal report, which I consider 22 is the original, so that goes into the pathology file. 23 Becau -- but we treat it slightly differently. 24 After some discussion, if I remember, with 25 Dr. McCallum, it's of value when these medicolegal

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1 reports come into inquest or -- or trial, for that 2 document to be part of it. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. DAVID DEXTER: And so we've taken the 5 approach to integrate it, so, along with the medicolegal 6 report will be the toxicology report, whatever other 7 ancillary reports comprise our report, but also will 8 include this. 9 COMMISSIONER STEPHEN GOUDGE: What does 10 it say to mean if you tick 'yes' opposite toxicology and 11 radiology? I mean, do you actually -- you review the 12 toxicology report from CFS? 13 DR. MICHAEL SHKRUM: The testing has been 14 done. 15 DR. CHITRA RAO: Done. 16 COMMISSIONER STEPHEN GOUDGE: So that's 17 all it does? 18 DR. DAVID DEXTER: Yes. 19 COMMISSIONER STEPHEN GOUDGE: It's not a 20 second set of expert eyes looking at toxicology? 21 DR. MICHAEL SHKRUM: No. 22 DR. CHITRA RAO: No. 23 COMMISSIONER STEPHEN GOUDGE: You rely on 24 CFS for their peer review process? 25 DR. MICHAEL SHKRUM: That's correct.

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1 DR. CHITRA RAO: Correct. 2 COMMISSIONER STEPHEN GOUDGE: And what 3 about the reading of the x-rays? 4 DR. CHITRA RAO: Same. Only thing is 5 sometimes in toxicology depends, if I feel the findings 6 we have to mention or could have played a role, and if 7 the pathologist haven't included them, I'll say, No, I 8 think we better use that and -- you know, include that in 9 the summary. 10 COMMISSIONER STEPHEN GOUDGE: Okay. 11 DR. CHITRA RAO: Other than that, we 12 won't go in detail about interpretation of their 13 findings. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: All right. So 17 just -- 18 DR. MICHAEL SHKRUM: I just -- 19 MS. JENNIFER MCALEER: Go ahead, Dr. 20 Shkrum. 21 DR. MICHAEL SHKRUM: Sorry, I just wanted 22 to add, just regarding this review form. So Dr. Dexter 23 includes it as part of the report, but we've also been 24 advised that at the end of our reports we should indicate 25 that the case has been peer reviewed, in -- in the actual

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1 text of the report. 2 So even though the review -- review form 3 may not actually accompany say reports from our 4 respective units, there is supposed to be a statement 5 there that says a case has been peer reviewed. 6 DR. CHITRA RAO: By the pathologist of 7 every case. 8 DR. MICHAEL SHKRUM: Right. 9 MS. JENNIFER MCALEER: All right. 10 COMMISSIONER STEPHEN GOUDGE: Sorry, Ms. 11 McAleer. 12 MS. JENNIFER MCALEER: No, go ahead. 13 COMMISSIONER STEPHEN GOUDGE: Can I just 14 ask a question about whether this kind of peer review 15 that the three (3) of you now do, that sounds like a 16 major step forward from where life was in the last 17 decade, whether that could be done remotely with today's 18 technology? 19 That is, suppose there was a medicolegal 20 autopsy done in Windsor, Dr. Shkrum, is the capacity 21 there to do the peer review, that is, you've got the 22 report in front of you, can the slides be digitized and 23 sent to London and so on? 24 Could you do it that way? 25 DR. MICHAEL SHKRUM: Well certainly -- I

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1 mean we -- we can certainly request the actual 2 microscopic slides. 3 COMMISSIONER STEPHEN GOUDGE: Or you 4 could actually have the slides themselves sent? 5 DR. MICHAEL SHKRUM: That's right. The 6 slides can be sent, the -- the images are provided on a 7 cd. It actually points up another issue, that -- you 8 know, it would be ideal if -- if there be some kind of 9 tele-medicine or teleconferencing ability. 10 So that when a pathologist is actually 11 doing a case and has an issue, that there be some kind of 12 hook up -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. MICHAEL SHKRUM: -- that allows the - 15 - you know, the consultant pathologist just to see what's 16 going on -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. MICHAEL SHKRUM: -- you know. And -- 19 COMMISSIONER STEPHEN GOUDGE: Even 20 without getting into that, just dealing at the point of-- 21 DR. MICHAEL SHKRUM: Right. 22 COMMISSIONER STEPHEN GOUDGE: -- peer 23 review where you have got the task that you directors are 24 now undertaking. I mean, this is obviously addressed at 25 a province the size of Ontario, you know, --

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1 DR. MICHAEL SHKRUM: That's right. 2 COMMISSIONER STEPHEN GOUDGE: -- where 3 not every medicolegal case can be done in one of your 4 units and how peer review can be done, with some degree 5 of efficiency, and I just wonder what the practicality of 6 that is from the perspective -- 7 DR. CHITRA RAO: Yeah. 8 COMMISSIONER STEPHEN GOUDGE: -- of the 9 three (3) of you? 10 DR. CHITRA RAO: I think that 11 responsibility is lying with the regional supervising 12 coroner. What happened the situation like St. Catherines 13 or Windsor of where do not have a proper regional 14 forensic pathology unit, but they do medicolegal cases, 15 and when the regional supervising coroner gets a report 16 and he reads it and then he has some doubts or he feels, 17 no, this is not proper, I need more clarification, and 18 that's the time they're contacting us. 19 COMMISSIONER STEPHEN GOUDGE: Yes. But 20 that may be the way it is done. I am just asking, Dr. 21 Rao, -- 22 DR. CHITRA RAO: Yes. 23 COMMISSIONER STEPHEN GOUDGE: -- whether 24 just as a matter of practicality it would be possible to 25 have the same level of peer review applied to medicolegal

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1 autopsies that are done outside elsewhere than in your 2 units -- 3 DR. CHITRA RAO: Yeah. 4 DR. MICHAEL SHKRUM: Yeah. 5 DR. CHITRA RAO: It can -- 6 COMMISSIONER STEPHEN GOUDGE: -- as 7 happens within your units. 8 DR. CHITRA RAO: Yeah. It can be done if 9 we have more forensic pathologists. 10 DR. MICHAEL SHKRUM: That's right. 11 COMMISSIONER STEPHEN GOUDGE: Yes. Yes. 12 It -- 13 DR. CHITRA RAO: More pathologists in 14 each regional forensic unit then we can say, okay, you 15 look after this area, I'll look after this area. 16 COMMISSIONER STEPHEN GOUDGE: Because it 17 could be done. 18 DR. CHITRA RAO: It can be done, for 19 sure. 20 COMMISSIONER STEPHEN GOUDGE: It could be 21 done remotely. 22 DR. CHITRA RAO: Definitely, yes. 23 DR. MICHAEL SHKRUM: Yes. 24 COMMISSIONER STEPHEN GOUDGE: Do you all 25 of you agree with that?

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1 DR. DAVID DEXTER: Yes. There obviously 2 has to be resources to do that, but I -- I think -- 3 COMMISSIONER STEPHEN GOUDGE: Yes, sure. 4 DR. CHITRA RAO: Yeah. 5 COMMISSIONER STEPHEN GOUDGE: It is 6 clearly a resourcing problem. I just was wondering about 7 the practicalities of it because it does seem to me that 8 electronics offers some -- 9 DR. DAVID DEXTER: Yes. 10 COMMISSIONER STEPHEN GOUDGE: -- advances 11 that would not have been available fifteen (15) years 12 ago. 13 DR. CHITRA RAO: That's correct. 14 DR. DAVID DEXTER: Yeah. I agree. It -- 15 it is resource intensive, we need the ability to make 16 electronic these records and so forth, and certainly the 17 issue of scanning slides is actually quite an expensive 18 task -- 19 COMMISSIONER STEPHEN GOUDGE: Is it? 20 DR. DAVID DEXTER: -- and a time 21 consuming task. There's a variety of techniques, Pario 22 is one company that does this. We've been scanning 23 slides for the last little while for some of the teaching 24 conferences that we do. 25 COMMISSIONER STEPHEN GOUDGE: Yes.

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1 DR. DAVID DEXTER: We've limited it to 2 scanning five (5) slides because of the time it takes to 3 do this. 4 COMMISSIONER STEPHEN GOUDGE: Out of 5 twenty-nine (29) or whatever -- 6 DR. DAVID DEXTER: Oh, yes. So you -- 7 COMMISSIONER STEPHEN GOUDGE: Yes. 8 DR. DAVID DEXTER: -- have to select what 9 you want to do. So if you have, perhaps, one of Dr. 10 Rao's cases in which it's a toughie, there's seventy-five 11 (75) slides, -- 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 DR. DAVID DEXTER: -- it ain't going to 14 work. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. DAVID DEXTER: But it is easy to ship 17 the slides. 18 COMMISSIONER STEPHEN GOUDGE: Yes. The 19 slides -- 20 DR. DAVID DEXTER: It's easy -- it's 21 easy -- 22 COMMISSIONER STEPHEN GOUDGE: The slides 23 can be transported. 24 DR. DAVID DEXTER: And if necessary, the 25 blocks.

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1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 DR. DAVID DEXTER: So that one can rework 3 at this. 4 But just to get back to the issue of 5 telepathology or telelinks, whatever, at least at one (1) 6 level there would be help in the units being interlinked 7 by some medium that would allow external consultation, 8 timely consultation on particular lesions that one is 9 seeing, and saying, eee, I'm not quite sure -- 10 COMMISSIONER STEPHEN GOUDGE: By "timely" 11 you mean during the autopsy? 12 DR. DAVID DEXTER: Yes. Mm-hm. 13 COMMISSIONER STEPHEN GOUDGE: That is 14 interesting. 15 DR. CHITRA RAO: Yeah. 16 COMMISSIONER STEPHEN GOUDGE: That does 17 not exist now? 18 DR. DAVID DEXTER: No. 19 DR. CHITRA RAO: But one advantage is now 20 as our residents are qualified and they're going in a 21 smaller hospital to work, they know us, so, they don't 22 feel hesitant to call for help. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. CHITRA RAO: And in our area like 25 Brantford and St. Catherine, a couple of our residents

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1 are staff there. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. CHITRA RAO: So they know -- and they 4 come to our unit, they know how we do, so they don't have 5 any hesitation to call and say, I've got this case, I 6 don't know how to go about it. Even now sometimes 7 they'll bring the whole caseload and we sit and sign out 8 together. 9 So -- so that's why it's more important to 10 have more manpower and people should know each other and 11 then when we have those conferences organized by the 12 Chief Coroner's office, that's the time all pathologists 13 come and meet and then we know each other and then you're 14 comfort -- you -- you are comfortable to contact somebody 15 for a second opinion. 16 COMMISSIONER STEPHEN GOUDGE: Right. The 17 question I had in my head and have had in my head, 18 relating to quality assurance in the real time that the 19 three (3) of you were speaking of, Dr. Dexter, that is 20 during the autopsy, is: What advantage is it to have 21 these units located in teaching hospitals? 22 DR. MICHAEL SHKRUM: Well, it's a 23 tremendous advantage because teaching hospitals, you 24 know, there's a -- a large number of pathologists that 25 are submission-specialized in other areas, so --

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1 COMMISSIONER STEPHEN GOUDGE: Would you 2 from time to time benefit from, and do you benefit from, 3 calling in the neuropathologist, -- 4 DR. MICHAEL SHKRUM: Oh, exactly. 5 COMMISSIONER STEPHEN GOUDGE: -- to take 6 an obvious example. 7 DR. MICHAEL SHKRUM: Sure. The 8 Neuropathologist, the cardiac pathologist, -- 9 DR. CHITRA RAO: Pediatric. 10 DR. MICHAEL SHKRUM: -- yeah, pediatric 11 pathologist, other, you know, other sort of submission- 12 disciplines like that that can provide a great 13 assistance, and the advantage of just walking down a hall 14 with a difficult slide to consult with somebody. It's a 15 tremendous advantage. 16 DR. CHITRA RAO: Especially in pediatric 17 cases, nephropathologists, pulmonary pathologists. It's 18 very important, and then in our setup they have 19 absolutely no hesitancy at all to help you out. 20 DR. DAVID DEXTER: But because of -- as 21 you're probably aware, brain examination is a -- is a 22 challenge, and we often will retain the brain and fix it 23 for -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. DAVID DEXTER: -- a period of time.

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1 We have in our setting the ability to pull together the 2 expertise of neurologists, neurosurgeons, 3 neuroradiologists, and neuropathologists, as well as 4 people in training. And the brain is examined with that 5 group of expertise around the table. 6 COMMISSIONER STEPHEN GOUDGE: That would 7 be after it was fixed? 8 DR. DAVID DEXTER: After it's fixed, yes. 9 And so I, as a forensic pathologist, would be present to 10 give what information I know about the case, and one is 11 getting input from the clinical side. In some cases 12 there might have been, you know, accidental injury and 13 neurosurgeons involved. You've got the -- 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. DAVID DEXTER: -- an amazing panel of 16 expertise. So things like that would not exist in a 17 community hospital, for example. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. DAVID DEXTER: So there's huge 20 advantages. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID DEXTER: I would agree with 23 Dr. -- 24 COMMISSIONER STEPHEN GOUDGE: I suppose I 25 could test it. I mean the fixed brain could be

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1 transported obviously? 2 DR. DAVID DEXTER: Yes, it could be, and 3 we do receive fixed brains -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID DEXTER: -- from a variety of 6 outlying hospitals -- 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. DAVID DEXTER: -- where there are -- 9 COMMISSIONER STEPHEN GOUDGE: Yes. 10 DR. DAVID DEXTER: -- those sorts of 11 issues. The -- 12 COMMISSIONER STEPHEN GOUDGE: The 13 irreplaceable advantage, short of tele-medicine, is 14 calling a neuropathologist in while the cutting is going 15 on, while the -- 16 DR. DAVID DEXTER: That's correct, yes. 17 DR. CHITRA RAO: I think in our unit in 18 Hamilton, there's an advantage, because Hamilton General 19 handles all the trauma cases. And so they have decided a 20 neuropathologist should be functioning at Hamilton 21 General. So I have that. 22 So when I'm doing an autopsy and I see 23 some abnormal finding, all I do is call them on the 24 intercom and say, Will you come and see this? And 25 they're there.

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1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. CHITRA RAO: And sometimes they 3 themselves will dissect the thing -- 4 DR. DAVID DEXTER: Yes. 5 DR. CHITRA RAO: -- and say, We'll do 6 this case. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. CHITRA RAO: So that's a great 9 advantage. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 Sorry that's very helpful. Thanks. Ms. McAleer, sorry 12 to take you away once again. 13 MS. MCALEER: That's fine. I see that 14 it's actually now 3:20, Commissioner. Did you wanted to 15 take a break? 16 COMMISSIONER STEPHEN GOUDGE: Okay. So 17 why don't we rise for fifteen (15) minutes and come back 18 at twenty-five (25) to 4:00. 19 MS. JENNIFER MCALEER: Thank you. 20 21 --- Upon Recessing at 3:20 p.m. 22 --- Upon Resuming at 3:35 p.m. 23 24 COMMISSIONER STEPHEN GOUDGE: Okay, Ms. 25 McAleer...?

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1 2 CONTINUED BY MS. JENNIFER MCALEER: 3 MS. JENNIFER MCALEER: Just to finish off 4 on the -- the topic we were dealing with before the 5 break. 6 Dr. Shkrum, we hadn't actually finished 7 with you with respect to the internal review process at 8 the London Unit. 9 Was there something you wanted to add to 10 that, please? 11 DR. MICHAEL SHKRUM: Yes, at one level is 12 the review of Dr. Tweedie's reports, the homicide and 13 criminally suspicious cases. 14 The second level review is I review all 15 the autopsy reports that are generated in the unit, 16 because we have about two (2) dozen pathologists that do 17 autopsies. I do review their reports as well. So like 18 Dr. Dexter, I use a lot of Post-It notes, and I make 19 comments on the reports. 20 And the -- the time to do these individual 21 reviews varies from maybe ten (10), twenty (20) minutes 22 on average per case. And I do about, the last couple of 23 years, over three hundred (300) reviews like that. 24 MS. JENNIFER MCALEER: All right. So 25 you're reviewing all of the medicolegal reports in your

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1 unit? 2 DR. MICHAEL SHKRUM: Yes, I'm not using 3 this form. It's just a -- just a review, just a Post-It 4 note. You know, minor things such as, you know, left 5 versus right, but then there's also issues related to 6 causes of death. 7 MS. JENNIFER MCALEER: All right. And, 8 Dr. Rao and Dr. Dexter, I understand that with respect to 9 the other post-mortem examination reports that do not 10 fall within the categories that you previously 11 identified, that you are not reviewing all of those post- 12 mortem examination reports except that they may be 13 subject to a random kind of auditing process within your 14 unit. 15 Is that correct, Dr. Rao? 16 DR. CHITRA RAO: That's correct. 17 MS. JENNIFER MCALEER: Is that correct 18 for you as well, Dr. Dexter? 19 DR. DAVID DEXTER: With -- with one (1) 20 minor exception that if a particular pathologist has some 21 issues or some concerns about that, I would integrate my 22 audit and review with helping them complete the -- the 23 case. 24 MS. JENNIFER MCALEER: All right. So 25 changing topics then to the case conferences that you all

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1 participate in, I understand -- 2 DR. MICHAEL SHKRUM: Excuse me. I just 3 wanted to add -- 4 MS. JENNIFER MCALEER: Sure. 5 DR. MICHAEL SHKRUM: -- one (1) -- just 6 one (1) other review that -- similar to Dr. Dexter, that 7 I do phone down to the autopsy suite every morning -- 8 particularly, you know, obviously, when other 9 pathologists are doing autopsies -- just to inquire as to 10 what is going on, if they have any concerns, and the 11 particular issue might arise at the conclusion of a case 12 if we have no anatomic cause of death. That is, the 13 cause of death is not found during the course of the 14 autopsy. I -- I discuss those cases with our pathologist 15 to make sure that the necessary ancillary tests that need 16 to be done are -- are in fact carried out. 17 MS. JENNIFER MCALEER: So for all cases 18 that are undetermined before they're -- classed as 19 undetermined, you make sure all of those tests are done? 20 DR. MICHAEL SHKRUM: Yes. 21 MS. JENNIFER MCALEER: Okay. 22 DR. CHITRA RAO: I do the same. Every 23 morning at 8:15 I call to find out what cases and what's 24 the circumstances. And sometimes Dr. Fernandes comes in 25 very early, so he'll fill me in with all the information.

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1 And then he'll tell me this is the way he was going to 2 proceed, and then I'll say, Fine. 3 MS. JENNIFER MCALEER: Okay. Case 4 conferences then. Dr. Dexter, I understand, and you 5 indicated a little bit earlier that there are medicolegal 6 rounds held once a month. 7 Who attends those rounds? 8 DR. DAVID DEXTER: As I indicated, in the 9 medicolegal rounds that -- that we hold there would be 10 the attendance of the pathologist. I chair those 11 meetings. Also attending would be the case coroners -- 12 not all of them, a proportion. And the Regional 13 Supervising Coroner would also attend. 14 We actually send notification of those 15 meetings and -- to the case coroners that their cases are 16 coming up for discussion at that round, so that they have 17 an opportunity, with their busy schedules, to see if they 18 can -- they can attend, so... 19 We've also made it into a maintenance and 20 certification level conference. So we've reviewed it 21 from the -- from the perspective of the Royal College and 22 -- and meeting educational or CME-type level 23 qualifications. So we also do that. 24 MS. JENNIFER MCALEER: All right. And in 25 addition to these monthly rounds that coroners might

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1 attend, you also have case conferences from criminally 2 suspicious cases? 3 DR. DAVID DEXTER: Yes. They're held 4 usually at the aegis of the Regional Supervising Coroner, 5 because they almost without exception would be aware of 6 and involved in -- and usually effectively managing the 7 case -- from coroner's perspective. 8 It's at their discretion. There have been 9 a number of instances where I've -- I've wondered whether 10 a case conference would be called on a case, because it 11 seemed to me to be one of those settings, and it hasn't. 12 So it is at the discretion of the rees -- Regional 13 Supervising Coroner. 14 MS. JENNIFER MCALEER: And I'm sorry, 15 what do you mean by "it's one of those settings"? What 16 are the criteria, in your view, as to when there should 17 be a case conference? 18 And let me add to that that it's my 19 understanding police attend these case conferences as 20 well? 21 DR. DAVID DEXTER: Yeah, the usual 22 attendance at those case conferences would be the 23 Regional Supervising Coroner, who would effectively chair 24 the meeting, make any notes of that meeting, and direct 25 any additional investigations from that meeting.

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1 The case coroner would attend. I would 2 attend. And the -- the detectives involved with the 3 case, the police involved with the case would attend. So 4 that would be the group. 5 MS. JENNIFER MCALEER: And what is the 6 criteria that you expect or where you anticipate that a 7 case conference will be held? 8 DR. DAVID DEXTER: Originally, I was 9 expecting it in all homicides and a proportion of 10 suspicious deaths. 11 MS. JENNIFER MCALEER: And when is it 12 occurring? 13 DR. DAVID DEXTER: I don't think it 14 occurs in all homicides. I think in some settings it's 15 viewed as perhaps more straightforward. I don't know. I 16 -- I'm not so aware of what criteria may be applied by 17 the Regional Supervising Coroner for calling those case 18 conferences. 19 MS. JENNIFER MCALEER: And what's your 20 understanding as to the purpose or what is accomplished 21 at those case conferences? 22 DR. DAVID DEXTER: The -- the first 23 premise about this is -- is it should be called in a 24 timely fashion, so perhaps a week or not much more than a 25 couple of weeks after the event. And it's an opportunity

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1 to review where we are in the investigation. 2 When I say "we," it reflects on the 3 individual parties, each of whom are carrying out a 4 component of that investigation. So it's the police, the 5 coroner, myself. 6 And it's an opportunity to -- to review 7 any outstanding issues, any concerns that have not been 8 addressed by the -- by the investigation to date. 9 MS. JENNIFER MCALEER: So do you -- do 10 you see yourselves as carrying out one (1) investigation? 11 Or are you each carrying out discrete 12 investigations that -- that somewhat overlap? 13 DR. DAVID DEXTER: There's an integration 14 to it as well. But certainly the police investigation, 15 I'm not privy to all aspects of that and certainly not 16 the continuance of it. After -- at the time I have 17 completed my autopsy, I -- I'd done my particular role in 18 that. But there's ongoing investigations that may be 19 leading to -- to other conclusions. And -- and it's an 20 opportunity for that to sort of come to the fore. 21 I think the other aspect of it is to 22 identify things that need to be done and that have not 23 been done. 24 MS. JENNIFER MCALEER: Dr. Rao, the case 25 conferences that you participate in, I understand there's

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1 the monthly meetings at the Hamilton Regional at your 2 unit? 3 DR. CHITRA RAO: Yes. 4 MS. JENNIFER MCALEER: And then every 5 three (3) months at other units within your region. Is 6 that correct? 7 DR. CHITRA RAO: That's correct. 8 MS. JENNIFER MCALEER: I probably 9 shouldn't call them units, but at other centres in your 10 region. 11 So every three (3) months there's a 12 meeting at Niagara, Brantford, or Hagersville. Is that 13 correct?? 14 DR. CHITRA RAO: That's correct. 15 MS. JENNIFER MCALEER: So in -- in fact, 16 there are meetings at each of these regions four (4) 17 times a year? 18 DR. CHITRA RAO: Yes. 19 MS. JENNIFER MCALEER: And what is the 20 purpose of those meetings? 21 DR. CHITRA RAO: Those, including our own 22 rounds, these are the cases -- doesn't have to 23 necessarily be suspicious or homicide. These are 24 straightforward medicolegal cases. 25 But if the family has raised some issues,

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1 they want some clarification; or if it is a -- a labour - 2 - connected with some labour dispute like an accident in 3 an industrial setup and motor vehicle accidents; and some 4 hospital admitted cases, where there's some issue about 5 treatment or issue about care. 6 And so those are the cases -- are sorted 7 out for discussion or toxicology. And that decision is 8 taken by the Regional Supervising Coroner. We don't have 9 any say in it. 10 So what we do -- what we get is about two 11 (2) weeks prior to these scheduled meetings -- it's 12 always the first Wednesday of the month. And what 13 happens, we get a list saying, The following cases will 14 be reviewed at this meeting. 15 And then some cases may be -- it can be 16 pediatric cases. So then maybe CAS people will come; or 17 sometimes labour issues, then Ministry of Labour, they 18 will send some representative. 19 We have police. We have OPP for motor 20 vehicle accident. We used to have -- all the coroners 21 used to attend. But lately we don't get that many 22 coroners because, again, funding issue, because they have 23 to give up their practice and come and there's no money 24 in that. 25 So it's the Regional Coroner who chairs

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1 the meeting, and we discuss each case. And then 2 sometimes the issue will come as manner of death, whether 3 it's natural or suicide or accident. And -- 4 MS. JENNIFER MCALEER: And do you 5 participate in that determination, as to the manner of 6 death? 7 DR. CHITRA RAO: We discuss as a group 8 and then the Regional Coroner will say, you know, Who 9 agrees with suicide? Who agrees with natural? And we 10 discuss why we call it natural or why we should say 11 accident, those issues. 12 And to this meeting is also attended by 13 Dr. King, Dr. Fernandes, myself, our fellow residents who 14 are doing elective in our department. If we have medical 15 students, they attend too. So the time criteria goes to 16 the other regions too. 17 MS. JENNIFER MCALEER: All right. So 18 that -- those are -- now, is that distinct from other -- 19 in -- in addition to that multidisciplinary case 20 conferences, or are these your multidisciplinary case 21 conferences? 22 DR. CHITRA RAO: Multidisciplinary. 23 MS. JENNIFER MCALEER: I see. Okay then. 24 So the police will attend too on occasion? 25 DR. CHITRA RAO: Yes. And the Coroner's

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1 Office, he always attends the meeting 2 MS. JENNIFER MCALEER: All right. And 3 are those meetings typically before you finalised your 4 report, or are they after? 5 DR. CHITRA RAO: Usually we have 6 finalised, but sometimes the report hasn't gone out 7 because we are waiting for something. 8 And another person I have to -- another 9 group I have to include is toxicologists. 10 MS. JENNIFER MCALEER: So if -- if you 11 haven't finalised your report, it's because you're 12 waiting for toxicology. Is that correct? 13 DR. CHITRA RAO: That's correct. 14 MS. JENNIFER MCALEER: As opposed to 15 waiting to get the views from the group at the 16 multidisciplinary meeting? 17 DR. CHITRA RAO: That's correct. And 18 sometimes what happens is I have completed, but I have 19 some issues, and I don't want to release a report. Then 20 I'll tell the local coroner that I have this concern, Why 21 not we discuss this case at the meeting? 22 Then he in turn will inform the Regional 23 Supervising Coroner. And then he'll say, Let's discuss. 24 MS. JENNIFER MCALEER: And is -- is that 25 because, Dr. Rao, you feel that you don't have sufficient

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1 evidence or sufficient background information to -- to 2 make a conclusion in your report? 3 DR. CHITRA RAO: That's correct, that's 4 correct. 5 MS. JENNIFER MCALEER: Okay. Dr. Shkrum, 6 do you have weekly rounds or do you participate in mulst 7 -- multidisciplinary case conferences? 8 DR. MICHAEL SHKRUM: We do have weekly 9 rounds in which our -- our resident pathologists do 10 participate. And on occasion, the Regional Coroner will 11 attend those rounds. 12 I'll just add that our Regional Coroner, 13 Dr. Stanborough, has logistical problems, because he 14 actually covers two (2) regions now. And he actually has 15 to travel some distance from the Hamilton/Burlington area 16 to -- to his office in London. 17 So these are weekly rounds. They're 18 mainly focussed on teaching of our trainees. But also we 19 do discuss some procedural issues that arise, and there 20 is follow-up of cases from -- from preceding weeks at 21 those rounds. 22 We do have the case conferencing. It's 23 also -- that Dr. Dexter mentioned, that in a sort of 24 timely fashion dealing with problematic homicides, 25 criminally suspicious deaths.

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1 There is an assembly of police officers, 2 regional coroner, toxicologist, pathologist involved in 3 discussing those cases to see the various investigative 4 avenues and how they're being followed and whether, you 5 know, reports, such as toxicology, needs to be expedited 6 to assist in the, you know, final outcome of that case. 7 MS. JENNIFER MCALEER: And typically 8 speaking, Dr. Shkrum, have you already finalised your 9 post-mortem examination before you participate in those 10 case conferences? 11 DR. MICHAEL SHKRUM: Usually not, 12 because, as I said, they are usually within a few weeks - 13 - generally within a few weeks -- of the incident. Of 14 course, the toxicology takes some period of time to -- to 15 be done, and we may not actually have the toxicology 16 results at that -- at that particular meeting. 17 So in those instances I'm obviously 18 waiting for a toxicology report, which may be still a few 19 months down the line before it's prepared. 20 DR. CHITRA RAO: Those are the homicides 21 and suspicious deaths? 22 DR. MICHAEL SHKRUM: That's correct, yes. 23 Yeah. So the third category of conferencing that you 24 mentioned are these multidisciplinary conferences that 25 deal with not necessarily homicides or criminally

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1 suspicious deaths, but just sort of problematic cases. 2 And again, we've only had one (1) meeting 3 like that. And so unfortunately, unlike the other areas, 4 we don't have this type of meeting well developed. We've 5 had one (1) to date, but again logistical issues of 6 trying -- having Dr. Stanborough try to arrange these, 7 given the fact that his distances and coverage of two (2) 8 areas is somewhat problematic so -- 9 MS. JENNIFER MCALEER: And -- and when 10 you said these are "problematic cases," are you talking 11 about on -- on-the-job deaths as Dr. Rao mentioned? Or 12 what's envisioned? 13 DR. SHKRUM: It could be that kind of 14 death or just an unusual injury. And again, these cases 15 generally have been finalised or near finalisation and -- 16 but nevertheless, the regional coroner has chosen these 17 cases because he just wants to make sure that what the 18 police have determined, in terms of their investigation, 19 sort of jives with what the pathologist is saying and 20 fits with the toxicologist, that everything sort of falls 21 into place. 22 MS. JENNIFER MCALEER: Okay. 23 DR. CHITRA RAO: I don't think I touched 24 with a conference for homicide and suspicious cases. We 25 have a meeting within a week or two (2) after we have

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1 done the case, and mainly again to oversee that we have 2 taken all for ancillary testing. And sometimes we take 3 quite a lot of specimens and give it to the exhibit 4 officers. And Toronto biology section don't want to 5 accept all that. 6 So during this conference we have 7 teleconference with the biologists. And then we'll tell 8 them these other things we have got. What do you want 9 for this particular case? So they will advise us. And 10 they'll say, Okay, we'll analyse this particular tube. 11 Why don't you send that? So that helps us 12 And -- and then in the discussion, if we 13 are having a discussion about two (2) weeks after a 14 homicide, maybe the investigating officers may have more 15 information. And so that is brought in at that time, and 16 so that also helps us. 17 MS. JENNIFER MCALEER: I see. Okay then. 18 So we've got rounds -- 19 DR. CHITRA RAO: Yes. 20 MS. JENNIFER MCALEER: -- in which the 21 Regional Supervising Coroner or the investigating coroner 22 may participate. We have case conferences in criminally 23 suspicious or homicide cases in which police officers 24 then attend as well -- 25 DR. MICHAEL SHKRUM: Right.

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1 MS. JENNIFER MCALEER: -- and then we 2 also have these multidisciplinary case conferences which 3 may have a whole variety of people, such as CAS workers 4 or police officers or health and safety officials? 5 DR. MICHAEL SHKRUM: Yes. 6 DR. CHITRA RAO: Yes. 7 MS. JENNIFER MCALEER: Okay. 8 DR. CHITRA RAO: And then informal rounds 9 with the residents and fellow. And in fact, like Dr. 10 Dexter said, we can use this for credits with the Royal 11 College. 12 So one (1) meeting a member from the Royal 13 College of Physicians and Surgeons, they did attend and 14 they were very impressed, the way the multidisciplinary 15 rounds were taking place. And then we have no problem in 16 claiming those credits. 17 MS. JENNIFER MCALEER: Okay. Moving on 18 then to the review practices by the Chief Forensic 19 Pathologist. 20 You've mentioned briefly the fact that 21 there was a review process in the past that was designed 22 by Dr. Chiasson, that that started in or around the mid- 23 1990s. 24 Can we all agree on that? 25 DR. MICHAEL SHKRUM: Yes.

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1 DR. DAVID DEXTER: Yes. 2 DR. CHITRA RAO: Soon after he took over 3 the position. 4 MS. JENNIFER MCALEER: All right. And 5 I'm just going to summarise it a little bit quickly, and 6 then we'll move on to the current situation. 7 But essentially you would complete your 8 post-mortem examination reports, submit them through the 9 Regional Supervising Coroner. They would then make their 10 way to the Chief Forensic Pathologist, being Dr. Chiasson 11 at the time. He would, it's your understanding, review 12 them. And then you would get back a one (1) page 13 document that essentially had a checkmark on it 14 indicating that the case had been reviewed. 15 Is that fair assessment? Would you all 16 agree with that? 17 DR. DAVID DEXTER: Yes. 18 DR. CHITRA RAO: Yes. 19 DR. MICHAEL SHKRUM: Yes. 20 MS. JENNIFER MCALEER: Okay. And in -- 21 in your opinion, how valuable was that process, Dr. 22 Shkrum? 23 DR. MICHAEL SHKRUM: Well, it was -- it 24 was gratifying to get the -- the tick mark, but -- but -- 25 COMMISSIONER STEPHEN GOUDGE: You're very

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1 diplomatic. 2 DR. MICHAEL SHKRUM: -- but there was no 3 feedback as to -- you know, maybe there was little 4 nuances there that maybe I wasn't appreciating. Not -- 5 usually wasn't feedback. 6 If -- if there was concern, there might be 7 an informal conversation about it. 8 COMMISSIONER STEPHEN GOUDGE: I think 9 that -- to be fair to Dr. Chiasson, he viewed it as a 10 start, but only a start. 11 DR. MICHAEL SHKRUM: That's right. 12 MS. JENNIFER MCALEER: Right. 13 DR. MICHAEL SHKRUM: This is a process in 14 evolution, that's right. 15 COMMISSIONER STEPHEN GOUDGE: And it was 16 only for criminally suspicious? 17 DR. MICHAEL SHKRUM: That's right. 18 DR. CHITRA RAO: Sometimes from Regional 19 Supervising Coroner's Office they decide, Okay, this is 20 going for an inquest, and it goes, and we were never 21 told. We never knew what other cases were reviewed. 22 And after -- once Dr. Chiasson has 23 finished the reviewing, if he had any concern or 24 something to discuss, it never came to us directly. We 25 got the information through the Supervising Regional

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1 Coroner, which we felt a little bit slighted, because we 2 wanted the professional contact, which was never there. 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 5 CONTINUED BY MS. JENNIFER MCALEER: 6 MS. JENNIFER MCALEER: So what is the 7 current process, starting with you, Dr. Dexter? 8 What -- can you explain to us the current 9 means in which your cases are reviewed by the Chief 10 Forensic Pathologist? 11 DR. DAVID DEXTER: Well, first of all, 12 it's my cases and the homicide and cri -- criminally 13 suspicious cases and some of the inquest cases. These 14 originally would be routed to the Chief Forensic 15 Pathologist via the Regional Supervising Coroner. 16 We changed that routine a little bit after 17 discussion that we've all had with Dr. Pollanen, that it 18 would be more appropriate to do a direct pathologist-to- 19 pathologist consultation request with a side note 20 informing the Regional Coroner that the case has been 21 sent for review. 22 Where does it go? It goes to Dr. Michael 23 Pollanen. 24 MS. JENNIFER MCALEER: What do you send? 25 DR. DAVID DEXTER: I send the warrant. I

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1 make a copy of all the image, so it's usually on a CD, 2 possibly a DVD. 3 COMMISSIONER STEPHEN GOUDGE: These are 4 the pictures and the -- 5 DR. DAVID DEXTER: These -- these are the 6 pictures -- moving, still, whatever -- that I have 7 received. Now they're a combination of the scene 8 photographs plus -- 9 COMMISSIONER STEPHEN GOUDGE: The autopsy 10 photographs. 11 DR. DAVID DEXTER: -- the autopsy 12 photographs, which usually have been taken by the 13 identification officers. 14 COMMISSIONER STEPHEN GOUDGE: Right. 15 DR. DAVID DEXTER: So they're all put on 16 one (1) CD so they're available for review. With some of 17 the movie film, we've had to go to DVD, but nonetheless-- 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 DR. DAVID DEXTER: -- the principle is 20 the same. 21 COMMISSIONER STEPHEN GOUDGE: The same 22 principle. 23 DR. DAVID DEXTER: Additionally, with 24 that would be a copy of my medicolegal report and any 25 other documents that comprise part of that. So if

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1 there's radiology reports to do with, say, bullet tracks 2 and fragments, that would be included. If toxicology is 3 available, that would be included. 4 So that package would go with a covering 5 letter from me asking for a review. 6 7 CONTINUED BY MS. JENNIFER MCALEER: 8 MS. JENNIFER MCALEER: Can -- can I stop 9 you there? Do you -- Dr. Shkrum and Dr. Rao, do you 10 agree? 11 Is that what you're sending? Or are you 12 sending more or less? 13 DR. CHITRA RAO: I send a copy of my 14 police report, too. 15 MS. JENNIFER MCALEER: Of the police 16 report that you've received, as well? 17 DR. CHITRA RAO: Yes. 18 MS. JENNIFER MCALEER: Okay. 19 DR. CHITRA RAO: So he'll have the 20 information, background information, and my report. We 21 don't sent the microscopic slides routinely. And if he 22 wants them, then he will request, and then we'll send it. 23 MS. JENNIFER MCALEER: All right. And, 24 Dr. Shkrum, do you agree? Is that typically what you're 25 sending?

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1 DR. MICHAEL SHKRUM: I typically send 2 that, and also in my cover letter to Dr. Pollanen I will 3 copy it to Dr. Stanborough so he is aware that that case 4 has gone for review. 5 MS. JENNIFER MCALEER: Your Regional 6 Supervising Coroner? 7 DR. MICHAEL SHKRUM: That's correct. 8 MS. JENNIFER MCALEER: Okay. And what is 9 your understanding as to the -- the standard at which 10 these are reviewed by Dr. Pollanen? 11 Do you -- do you know what he's looking 12 for? 13 DR. CHITRA RAO: We don't know whether -- 14 what he's looking for -- 15 DR. MICHAEL SHKRUM: Yeah. 16 DR. CHITRA RAO: -- but then we do get 17 comments saying that if he has agreed, there's no 18 question. Sometimes he will send us a letter, We have 19 reviewed and I agree with your cause of death, and that's 20 it. 21 Or sometimes if he has an issue or if you 22 think his thinking process was different from mine, then 23 he will give me a call and say, Chitra, I got your 24 report, and this is what -- have you considered this? 25 And then we'll have a discussion. And

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1 then he'll say, Okay, at the end of the discussion, 2 That's all I have to say, fine, you can release the 3 report. 4 Now recently what he's been doing is, our 5 cases, when we send, he sends those cases to the other 6 pathologist in the unit. Or once he sent my case to Dr. 7 Michael Shkrum. I received one of Dr. Dexter a couple of 8 weeks ago. So he's distributing to other pathologists. 9 MS. JENNIFER MCALEER: All right. So 10 just a couple of things. When you're sending your 11 reports to Dr. Pollanen for review, have you actually 12 signed them? 13 Are they final reports, or are you sending 14 them in draft? 15 DR. MICHAEL SHKRUM: Draft form. 16 DR. DAVID DEXTER: Draft. 17 MS. JENNIFER MCALEER: Dr. Rao? 18 DR. CHITRA RAO: Initially I send my 19 final report when the Regional Supervising Coroner was 20 sending, but now when I send it, it's a draft. It's a 21 draft. 22 MS. JENNIFER MCALEER: All right. And 23 then, Dr. Shkrum, how -- what's been your experience with 24 respect to getting feedback from Dr. Pollanen with 25 respect to his review?

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1 DR. MICHAEL SHKRUM: Well, at -- at the - 2 - usually it's the peer review form that's been filled 3 out and -- 4 MS. JENNIFER MCALEER: So that's the same 5 form that we were looking at -- 6 DR. MICHAEL SHKRUM: That's correct. 7 On -- 8 MS. JENNIFER MCALEER: -- at Tab 53. 9 So it's the same form that you use with 10 your peers, Dr. Pollanen is using with respect to his 11 review of your reports? 12 DR. MICHAEL SHKRUM: That's correct. 13 Yes, he -- 14 DR. CHITRA RAO: Page 52. 15 DR. MICHAEL SHKRUM: Yeah, he'll be -- 16 MS. JENNIFER MCALEER: Yeah, Tab 53, last 17 page, page 52. 18 DR. MICHAEL SHKRUM: That's right. So he 19 fills out that form and -- and the boxes are ticked off. 20 If there is a concern, there may be an email or a phone 21 call. 22 Now, in the past he has actually, as Dr. 23 Rao mentioned, will send sometimes a letter, either 24 agreeing with the report. But on some occasion -- at 25 least one (1) occasion -- he raised some other issues.

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1 And unfortunately, that created a bit of a 2 problem, because it probably could have been simply 3 settled over the phone. But now I had this -- this 4 document in my -- my file that had to be addressed. So - 5 - so I had to reply in letter form as well. 6 MS. JENNIFER MCALEER: So why does that 7 raise issues, Dr. Shkrum? 8 DR. MICHAEL SHKRUM: Well, because this 9 particular case -- and again, it's been through the court 10 system -- but there was a cause of death here that I gave 11 an opinion on. And it -- actually the -- the fellow, the 12 accused plead guilty on this particular matter, even 13 before my report was issued. 14 And -- and the circumstances were such 15 that, you know, it was consistent with what -- that had 16 occurred, or what I saw at autopsy. 17 Dr. Pollanen then did send a letter back 18 saying it could be another possibility. And I had to 19 reply back to him. And again, this is partly maybe, you 20 know, in -- in my initial letter I should have given him 21 perhaps more information as to what the circumstances 22 were. But I did have to reply back to him saying, This 23 is what actually happened; it's been through the court 24 system even before my report was available. 25 MS. JENNIFER MCALEER: Right. And -- and

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1 not -- without getting into the nature of the -- 2 DR. MICHAEL SHKRUM: That's right. 3 MS. JENNIFER MCALEER: -- dispute or 4 where you varied, but is -- is there a problem with 5 respect to having too much paper on the file or having 6 too many reports? 7 DR. MICHAEL SHKRUM: Well, then you have 8 a document, another document for disclosure. And I think 9 in this particular instance, you know, there could have 10 been better communication on both of our parts on this 11 particular matter. 12 MS. JENNIFER MCALEER: All right. And 13 does -- does that undermine in any way the quality 14 assurance aspect of this kind of review -- 15 DR. MICHAEL SHKRUM: No. 16 MS. JENNIFER MCALEER: -- if you know 17 you're going to get potentially in a -- and I don't know 18 if that's still the practice or not -- a -- a report back 19 from the Chief Forensic Pathologist? 20 DR. MICHAEL SHKRUM: Well, I think, 21 again, this is a process in evolution -- 22 MS. JENNIFER MCALEER: Mm-hm. 23 DR. MICHAEL SHKRUM: -- and may I -- I 24 think by sending a letter, you're acting more in a -- in 25 a consultant capacity as -- as opposed to review.

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1 Or I think if there was a problem with the 2 case, then I would certainly send it to Dr. Pollanen and 3 say, Can I please have your opinion on this case in a 4 written form, because I'm having difficulties with it? 5 And in fact there was another case that I 6 had difficulties like that. I had the suspicion that I 7 was on the right track. But I, in that case, I did 8 welcome a written report back from him. 9 MS. JENNIFER MCALEER: Okay. And then 10 Dr. Rao, you raised the fact that now your reports -- 11 your understanding is the reports are going to Dr. 12 Pollanen, but sometimes he's sending them off to, excuse 13 me, he's sending them off to other unit directors to 14 review. 15 Is that correct? 16 DR. CHITRA RAO: Other unit doctors -- 17 the other pathologist in his unit. 18 MS. JENNIFER MCALEER: I see. And do you 19 know why that's happening? 20 DR. CHITRA RAO: I think he is 21 overwhelmed with work, and he is busy with this Inquiry. 22 So I can understand that. And he also went overseas just 23 some time in December, so he was out of town, so... 24 MS. JENNIFER MCALEER: And have any of 25 you ever had the occasion to review Dr. Pollanen's

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1 reports? 2 DR. CHITRA RAO: Yes, I -- 3 MS. JENNIFER MCALEER: Or is it 4 anticipated that there is going to be a process in place 5 by -- which would -- which would allow you to review Dr. 6 Pollanen's reports? 7 DR. CHITRA RAO: He has said to me 8 directly with a letter saying that, I'm forwarding my 9 case and could you please review it? And recently he has 10 also included other members in his unit, their report. 11 And last week, in fact, I received two (2) of his 12 reports, along with David Chiasson's report, asking me to 13 review it. 14 MS. JENNIFER MCALEER: Mm-hm. 15 DR. CHITRA RAO: So -- 16 MS. JENNIFER MCALEER: Dr. Shkrum, have 17 you been asked yet to review Dr. Pollanen's reports or 18 those of his colleagues at the Toronto Forensic Unit? 19 DR. MICHAEL SHKRUM: I reviewed one (1) 20 of Dr. Pollanen's reports, actually, a while ago, but 21 nothing recently. But I have reviewed one (1) case from 22 Toronto -- one (1) of his colleagues -- and I have 23 another one (1) on my -- my desk awaiting my -- my 24 return. 25 MS. JENNIFER MCALEER: Okay. Dr.

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1 Dexter...? 2 DR. DAVID DEXTER: I have not reviewed 3 one (1) of Dr. Pollanen's, but I have reviewed one of Dr. 4 Toby Rose's. 5 MS. JENNIFER MCALEER: Okay, all right. 6 And do you all feel that you are in a position where you 7 have the requisite experience and skill set to review Dr. 8 Pollanen's work, given he's the Chief Forensic 9 Pathologist? Any concerns there? 10 DR. DAVID DEXTER: No. 11 DR. MICHAEL SHKRUM: No. 12 DR. CHITRA RAO: No. 13 MS. JENNIFER MCALEER: No? 14 DR. MICHAEL SHKRUM: No. 15 MS. JENNIFER MCALEER: Okay. So then 16 unless, Mr. Commissioner, you have any questions on that 17 topic. 18 COMMISSIONER STEPHEN GOUDGE: I take it 19 the three (3) of you now self-select which of your 20 reports are forwarded in draft form to Dr. Pollanen? 21 It's criminally suspicious and one (1) of you describe 22 the add-on as cases that may go to inquest. 23 DR. CHITRA RAO: And homicide cases. 24 DR. MICHAEL SHKRUM: Yes. 25 COMMISSIONER STEPHEN GOUDGE: Homicide

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1 cases. 2 DR. CHITRA RAO: Yes, and cases I have 3 sent -- one (1) or two (2) pediatric cases before 4 completion --, I've said, you know, I know, I need some 5 help and these are my appointed -- 6 COMMISSIONER STEPHEN GOUDGE: So you 7 self- select on those cases? 8 DR. CHITRA RAO: Yes. Yes. 9 COMMISSIONER STEPHEN GOUDGE: And that 10 would be true of each of the -- 11 DR. MICHAEL SHKRUM: Yes. 12 COMMISSIONER STEPHEN GOUDGE: -- three 13 (3) of you, I think. Thanks. Thanks, Ms. McAleer. 14 15 CONTINUED BY MS. JENNIFER MCALEER: 16 MS. JENNIFER MCALEER: Changing topics, 17 then, to an issue that's arisen in our Inquiry. It's the 18 relationship between pediatric pathology and forensic 19 pathology. 20 Now, you are all acting as Directors of 21 Forensic Units. Dr. Dexter, you're not doing pediatric 22 cases anymore, but Dr. Shkrum and Dr. Rao, do you feel 23 that you should be doing all of the pediatric forensic 24 cases? Or do you think that some of these cases should 25 be handled by pediatric pathologists in a hospital

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1 setting, or I should say in -- in another hospital 2 setting? 3 DR. MICHAEL SHKRUM: You go first. 4 DR. CHITRA RAO: I -- I think I don't 5 mind doing pediatric cases because I have an interest, 6 and I have gone for continuing education on child 7 pediatric cases, and I should be allowed to do it. 8 And I'm also at a level where I know my 9 limitation and if I need help, I have no hesitation to 10 get that help. And in our set-up, we have -- I can 11 easily call a pediatric pathologist to help me out and -- 12 MS. JENNIFER MCALEER: And have you had 13 occasion to do that, Dr. Rao? 14 DR. CHITRA RAO: Yes, I've had two (2) or 15 three (3) -- a couple of occasions per year, and I just 16 call well in advance and say, I'm getting this case and 17 I'm going to do it tomorrow. I may have some problem; 18 are you free? 19 So sometimes she's free and she'll say, 20 Okay, I'll come over, and then she will be there during 21 autopsy, especially after the child has undergone cardiac 22 surgery and then those cases come to autopsy. 23 Those are the time I need help. Or a 24 child with congenital abnormality or metabolic -- usually 25 metabolic disorder, I'm doing screening tests, and if

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1 something comes positive, then for interpretation, I may 2 go to the pediatric pathologist. 3 And so I also have neuropathologists. One 4 (1) of the neuropathologists who is very familiar with 5 pediatric neuropathology, so I have no problem with that. 6 A cardiac vascular pathologist; they are comfortable to 7 deal with pediatric cardiac issues. 8 And so I have no problem. And at the same 9 time, I have also no problem with pediatric pathologist 10 doing pediatric -- forensic pediatric cases, as long as 11 they have had training in forensic and they're 12 comfortable. 13 In my situation, Dr. Jacqueline Bourgeois, 14 she's not very comfortable doing medicolegal cases, so 15 she's happy that I do, but then she's ever willing to 16 help me out if I need it. 17 MS. JENNIFER MCALEER: She's -- she's the 18 pediatric pathologist that you call in on occasion. 19 DR. CHITRA RAO: Correct. 20 MS. JENNIFER MCALEER: And in those 21 situations, Dr. Rao, do you -- do you each author your 22 own report, or does she co-author your report with you, 23 or how does that work? 24 DR. CHITRA RAO: Okay, if she has 25 examined certain organs from my case, she will give a

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1 report and then I'll incorporate that report into my 2 report, and then we'll sign, but she won't cosign my 3 report. 4 Her report is included in my autopsy 5 report, and I will sign the final autopsy report. 6 COMMISSIONER STEPHEN GOUDGE: Do you 7 treat her as a consultant, rather than as a -- 8 DR. CHITRA RAO: That is correct. 9 COMMISSIONER STEPHEN GOUDGE: -- co- 10 pathologist double doctoring an autopsy? 11 DR. CHITRA RAO: We haven't done double 12 doctoring at all; either she takes the full 13 responsibility she does, and then before signing off 14 she'll say, Chitra, could you come and review this case 15 with me, and then she will include in her report, this 16 was reviewed by -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. CHITRA RAO: -- me and them. And 19 actually, she was my resident, so now she's a staff 20 there, and we have a good relationship. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 23 CONTINUED BY MS. JENNIFER MCALEER: 24 MS. JENNIFER MCALEER: Dr. Shkrum, what 25 are you reviews as to who should be doing these cases?

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1 DR. MICHAEL SHKRUM: Well, I think 2 pediatric pathology should be -- or pediatric forensic 3 pathology should be part of a forensic pathologist 4 practice. I mean, I think that's what we're trained to 5 do. 6 So I -- certainly it's part of -- part of 7 my practice, and, I mean, I should -- any forensic 8 pathologist should have that opportunity to do -- to do 9 pediatric forensic -- pediatric forensic pathology. 10 MS. JENNIFER MCALEER: Can I stop you 11 right there? And you said because that's what we're 12 trained to do? 13 DR. MICHAEL SHKRUM: Yes. 14 MS. JENNIFER MCALEER: I mean, is there a 15 training -- as part of your training, though, was there a 16 pediatric aspect to it? 17 DR. MICHAEL SHKRUM: Well, certainly when 18 I worked at the Medical Examiner's Office, there -- there 19 were pediatric cases that came. We were expected to do 20 those. There were -- there were no exceptions. 21 MS. JENNIFER MCALEER: Okay. So that 22 would be a unique situation for you though? 23 DR. MICHAEL SHKRUM: Yes. And getting 24 back to the -- to the Royal College piece in the 25 training, we're asking that trainees do about a hundred

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1 and fifty (150) medicolegal post-mortems during their 2 training of which at least fifteen (15) should be 3 pediatric cases. 4 So about a 10 percent of their caseload. 5 MS. JENNIFER MCALEER: So there's an 6 expectation if somebody's going to meet the designation 7 of sub-specialty in forensic pathology that they will 8 have some exposure and training in pediatric forensic 9 pathology? 10 DR. MICHAEL SHKRUM: That's correct. 11 And obviously, the training program must have access to 12 pediatric cases. 13 MS. JENNIFER MCALEER: All right. And -- 14 DR. CHITRA RAO: I had that exposure when 15 I was doing my senior residency. 16 MS. JENNIFER MCALEER: I'm sorry, Dr. 17 Rao? 18 DR. CHITRA RAO: I had that exposure -- 19 pediatric exposure -- when I was doing my Senior 20 Residency in forensic pathology. 21 MS. JENNIFER MCALEER: And, Dr. Shkrum, 22 do you agree with Dr. Rao that these cases could also be 23 handled by pediatric pathologists who have some exposure 24 or training in forensic matters? 25 DR. MICHAEL SHKRUM: I agree on that. I

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1 mean, I think as long as the pediatric pathologist has 2 some knowledge of, you know, what the forensic approach 3 is -- what the -- what the issues are -- I -- I think, 4 yes, certainly a -- a pediatric pathologist could do 5 cases like that. 6 MS. JENNIFER MCALEER: Okay. So moving 7 onto a different topic. With respect to recruiting and 8 retention of forensic pathologists; we touched on this a 9 little bit briefly earlier. Dr. Shkrum, is it your view 10 that the addition of the sub-specialty at the Royal 11 College of Physicians and Surgeons will have any impact 12 with the respect to pulling people into the field of 13 forensic pathology? 14 Do you think you'll get more people 15 interested as a result of this ability to be board 16 certified? 17 DR. MICHAEL SHKRUM: Well, I think it's - 18 - it's a tremendous advance. I mean, certainly now 19 you'll have a sub-specialty that not only is recognized 20 in practice, but also by -- by certification. So I think 21 it's a very positive step. 22 You know, just a word of warning though is 23 that, you know, it's going to take a period of time 24 before these people get into the system. Certainly, 25 they'll -- say that they start in July 2008, it'll take

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1 them a year to train. They get into the system. 2 Even though they are trained, they're 3 going to take a number of years to build up the requisite 4 experience. Obviously, they will be involved in the 5 Court System, but it may actually take them some time to 6 build up the necessary experience and expertise, 7 particularly to assist -- assist the defence bar because 8 that does take some time. 9 So it's going to take a number of years, 10 but I'm optimistic. I think it's going to attract a lot 11 of people. There'll probably be a number of training 12 programs -- it's estimated maybe three (3) to five (5) 13 probably, at least, across the country. 14 We certainly have interest from Hamilton 15 and from Toronto. So I'm very optimistic that this will 16 be a very positive step for the -- for the profession. 17 MS. JENNIFER MCALEER: What are the 18 current challenges to recruiting young doctors into the 19 field of forensic pathology? 20 DR. MICHAEL SHKRUM: Well, I think it 21 takes a particular mindset to have to do this kind of 22 work. I mean, look at -- look where we are here. I 23 mean, it's -- I mean, a lot of doctors do not like, you 24 know, going to court or, you know, that kind of exposure. 25

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1 And I think we've already -- we've already 2 discussed that. Dr. Dexter mentioned about his 3 colleagues in Kingston. That sure it's -- it's -- you 4 know, you work in a hospital setting. You can work in an 5 academic setting. You have a way of presenting your 6 findings or, you know, lecturing, but you get into court, 7 it's a -- it's a very -- very different sort of 8 atmosphere. 9 And it's an adversarial system. You're -- 10 you're there very much alone. And it -- it's very 11 challenging. So, you know, it takes a certain mindset; 12 obviously, the nature of the cases we deal with. We deal 13 with deceased individuals. 14 I mean, many physicians are trained to 15 drill -- deal initially with living individuals, but 16 obviously we deal with deceased individuals. These are 17 tragic cases. The -- the nature of the cases are 18 complex. Some of the cases are -- you know, they're -- 19 they're kind of distasteful. 20 You deal with decomposed bodies, 21 fragmented bodies; there's identification issues. So, 22 you know, again it takes a certain kind of person to want 23 to do those kind of cases, and it's not the stuff you see 24 on CSI or the -- you know, something on TV where it looks 25 quite glamorous.

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1 It's a very challenging profession. Very 2 demanding, you know, mentally, emotionally, and from a 3 timeframe, it certainly makes impositions on family time 4 to try to get all this -- all this work done. So it's -- 5 it's a challenge, but I -- I think, you know, there are 6 people out there interested. 7 And I think they'll -- you know, despite, 8 you know, the present adversity, I think people will 9 carry through and -- and become trained and, you know, 10 forensic pathologists. 11 COMMISSIONER STEPHEN GOUDGE: Would it 12 help, Dr. Shkrum, if there were windows on forensic 13 pathology at the undergraduate medical level? 14 DR. MICHAEL SHKRUM: Well, yes, there are 15 -- again, there are probably varying levels of 16 instruction in forensic medicine across the country. At 17 Western, I -- I do coordinate a forensic medicine course 18 which is offered to the fourth year medical students. 19 That course is approximately twenty-three (23) hours 20 long. 21 COMMISSIONER STEPHEN GOUDGE: Yes. 22 DR. MICHAEL SHKRUM: And it's not only 23 forensic pathology, but also offers other -- other 24 disciplines. Of course we have the coroner, Dr. -- Dr. 25 Stanborough comes in and talks about the Coroner's Act;

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1 we have a forensic pathologist, Dr. Tweedie, is involved; 2 I'm involved, obviously. 3 We talk about forensic neuropathology, Dr. 4 Ramsey comes in, so there's a number of pathology topics. 5 And we also have clinical people, like Dr. Warren, who I 6 mentioned before, talks about child abuse and SIDS. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. MICHAEL SHKRUM: We have Dr. McNair, 9 who talks about sexual assault, we have a lawyer who 10 comes in and talks about courtroom procedures and what's 11 expected of an expert witness, so, there's really a 12 diverse group of people that comes and lectures. 13 I'll -- I'll also mention we have a 14 forensic psychiatrist who also comes. So it's -- it's 15 quite -- quite diverse and to give some exposure to these 16 students. 17 Obviously, they'll -- they'll be dealing 18 with situations that required a notification of the 19 coroner at times, what are their practices. Some of them 20 may become coroners. 21 Certainly a number of them have expressed 22 that interest in their evaluations that it sounds like a 23 very interesting job. And certainly, if they work out in 24 more rural areas, there would probably be an expectation 25 as -- as a physician in that area that they may --

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1 COMMISSIONER STEPHEN GOUDGE: Just by 2 being a physician there, they -- 3 DR. MICHAEL SHKRUM: Yeah, they may 4 become the coroner; that's right. 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. MICHAEL SHKRUM: Some of them -- 7 there's obviously the rare student that actually wants to 8 do forensic pathology -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. MICHAEL SHKRUM: -- so that -- that's 11 good, it reinforces that -- that -- 12 COMMISSIONER STEPHEN GOUDGE: This is an 13 option in fourth here? 14 DR. MICHAEL SHKRUM: This is an option in 15 the fourth year. So out of a class of about a hundred 16 and thirty (130) students this year, we have about 17 ninety-one (91), ninety-three (93) students that are -- 18 that -- that take -- 19 COMMISSIONER STEPHEN GOUDGE: Wow. 20 DR. MICHAEL SHKRUM: -- this particular 21 option, so... 22 COMMISSIONER STEPHEN GOUDGE: Now, is 23 this a course you began? 24 DR. MICHAEL SHKRUM: Yes, I -- well, 25 actually, I took over the course. Dr. Mills, I mentioned

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1 before, who gave the course when I was in medical school 2 at Western, retired and when I came on staff in 1985 at 3 the Victoria Hospital, I took over that course, so, my 4 first year of lectures was 1986 and so that course has 5 been well -- offered well over twenty (20) years now. 6 And it has grown; it started off at about 7 twelve (12) hours and, as I said, it's well over twenty- 8 three (23) hours. In fact, it's a combined course with 9 the un -- undergrad bachelor of medical sciences courses. 10 We have twenty-five (25) students from 11 that program that also take this, so it's called 12 introduction to forensic sciences. It's combined with 13 this forensic medicine course for the fourth year medical 14 class. 15 COMMISSIONER STEPHEN GOUDGE: That's 16 interesting. What about McMaster, do you know, Dr. Rao? 17 DR. CHITRA RAO: Unfortunately, no, 18 because there -- it's a short course, three (3) medical 19 curriculum and it's called problem based. 20 So what happened was when I joined there 21 as a staff, they had -- when they joined medical school 22 in September, September to December they had pathology 23 exposure, and they had ten (10) systemic problems and -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. CHITRA RAO: -- we acted as resource

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1 people, and then the group will come to us. So what I 2 used to do was I used to have gross specimens to show 3 them because our students come from all walks of life, 4 some have done, you know, PhD in arts or literature -- 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. CHITRA RAO: -- and then they've 7 hardly done any science, so we had to go from basic, but 8 what I did was, under every system, like cardiac, I will 9 present a sudden cardiac death in a medicolegal situation 10 and then I'll always introduce a little bit of 11 medicolegal aspect. 12 And our hospital side -- the hospital 13 pathology rate is so low and I -- we used to always 14 encourage them to come and see autopsy, and so they'll 15 come and -- come and view our autopsy and we have -- some 16 of them have shown interest and they'll come for 17 electives. 18 And even though they'll say, okay, I think 19 I'm going to take pathology, I'm going to do forensic 20 pathology, but it didn't happen. Then later on the 21 coordinator of Unit 1 -- we go like Unit 1, Unit 2, they 22 said, no, the students are spending too much time in 23 pathology, let's limit to one (1) hour lecture from 24 different submission-speciality or pathology, so I 25 started giving a lecture of one (1) -- one (1) hour,

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1 saying that, what is forensic pathology, what is 2 coroner's system, what kind of cases we deal with. 3 The last two (2) years Dr. John Fernandes 4 has been giving that talk; that's all the exposure. 5 COMMISSIONER STEPHEN GOUDGE: That's all 6 there is. 7 DR. CHITRA RAO: Yes. 8 COMMISSIONER STEPHEN GOUDGE: What about 9 Queens, Dr. Dexter? 10 DR. DAVID DEXTER: There's no one near 11 this type of thing that Dr. Shkrum is describing. We 12 have a number of contacts that we try and make. I guess 13 the first premise is to try and get people interested in 14 pathology; that's step 1, and then step 2 is obviously 15 trying to ween out those that have the potential to -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID DEXTER: -- to choose forensic. 18 We actually start at the high school level and we have 19 classes come in of students to spend approximately a week 20 in the department in which we do expose them to forensic 21 issues and -- and, sort of, general terms and so forth, 22 and that's usually very, very well received and great 23 excitement. 24 The last batch, unfortunately, tended to 25 turn up with ball caps bearing the inscription "CSI" but

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1 nonetheless, the interest appeared to be there. 2 Within -- within the medical school 3 teaching, we have problem-based learning as well, and 4 it's taken away from some of the formal recognition of 5 subjects such as pathology, -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. DAVID DEXTER: -- clinical -- 8 COMMISSIONER STEPHEN GOUDGE: Let alone 9 forensic pathology. 10 DR. DAVID DEXTER: Let alone forensic 11 pathology. But we seized an opportunity to participate 12 in medical science rounds in which the pathologists; five 13 (5) of us from the department -- we empty it practically 14 -- commit to teach on a variety of different cases. One 15 of which the last episode of which I run, each one is 16 patient-based, -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID DEXTER: -- and then a follow 19 up discussion of pathological issues. The last one I 20 run with a patient that didn't make it. 21 So it's a forensic-based issue. So I go 22 over the coroner's system, -- 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. DAVID DEXTER: -- I go over -- 25 COMMISSIONER STEPHEN GOUDGE: Right.

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1 DR. DAVID DEXTER: -- forensic issues. 2 So I take that opportunity to begin to expose things, 3 forensic, to the medical students. 4 The last thing we use is something called 5 "bribery," and we have what's called a "pizza evening". 6 This is kind of a career choice type evening where, 7 again, five (5) of us in pathology -- because within our 8 department many of us have come from completely different 9 routes; our patent of practice and what we end up doing 10 is very different from each other; some are research, 11 some do, say, hemotopathology; some do a variety of 12 things. 13 So why do we do what we do? And why 14 should you consider pathology as a career choice? Of 15 which the Head of the Department, Dr. Young, often says, 16 Well, once you reach the age of let us say fifty (50), 17 fifty-two (52), do you still want to be up all night 18 delivering babies, or would you rather be a pathologist? 19 So these -- these are the types of effort 20 we try and increase the profile of -- 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID DEXTER: -- pathology. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. DAVID DEXTER: So it gives you some 25 idea.

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1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 DR. DAVID DEXTER: The -- the problem is 3 still that of pushing people within the pathology 4 residency program -- 5 COMMISSIONER STEPHEN GOUDGE: Right. 6 DR. DAVID DEXTER: -- to consider 7 forensic. 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. DAVID DEXTER: And quite frankly, 10 there has been an issue with the publicity. 11 COMMISSIONER STEPHEN GOUDGE: And it is a 12 worry. 13 DR. DAVID DEXTER: It -- it's a worry. 14 DR. CHITRA RAO: Yeah. 15 DR. DAVID DEXTER: It's bringing out 16 things that make these people say, Well, do I really want 17 to get into that challenging environment when there's 18 another option -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. DAVID DEXTER: -- that is less 21 challenging? 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. CHITRA RAO: Yeah. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. CHITRA RAO: Another thing I wanted

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1 to add was there is a forensic inquiry course done by the 2 inner city of Toronto. Dr. Michael Pollanen, Dr. Parai, 3 as well as Dr. Fernandes and myself, have taken part in 4 it and we teach, it's -- 5 MS. JENNIFER MCALEER: Dr. Rao, could you 6 just move a little closer to the mic? 7 DR. CHITRA RAO: Sorry. And so we go to 8 Mississauga campus and we lecture on forensic pathology. 9 Following that, each year we take a student from that 10 course for research and they spend the summer with us. 11 And doing that we have had two (2) 12 students who have gone into medical school. And one (1) 13 is doing residency in pathology and one (1) medical 14 student -- she's going to finish because Dr. Dexter knows 15 her. She's very keen and she always says, "I hope she -- 16 goes through the course," she says, "Don't leave until I 17 come because I want to take your position." So hopefully 18 she will come. 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. CHITRA RAO: That way we have 21 attracted from that course rather than from our own 22 medical -- 23 COMMISSIONER STEPHEN GOUDGE: Through 24 forensic studies -- 25 DR. CHITRA RAO: Yes.

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1 COMMISSIONER STEPHEN GOUDGE: -- via 2 medicine. 3 DR. CHITRA RAO: Yes. Because they're 4 exposed to -- 5 COMMISSIONER STEPHEN GOUDGE: Yes. 6 DR. CHITRA RAO: -- all aspects of 7 forensic medicine. 8 COMMISSIONER STEPHEN GOUDGE: Okay. That 9 is interesting. 10 DR. MICHAEL SHKRUM: I'm optimistic our 11 replacements are out there. 12 COMMISSIONER STEPHEN GOUDGE: Good for 13 you. 14 DR. DAVID DEXTER: And one last thing, we 15 -- we have two (2) summer positions in the pathology 16 department in which we hire medical students -- usually 17 after the first year, occasionally after the second year 18 -- to spend time with us; three (3) months in the 19 pathology department, and they will participate fully 20 within the autopsy service with the one (1) exception is 21 that we have to be careful with the homicide and 22 suspicious cases. 23 The particular individual that we share is 24 quite a character but she spent her summer studentship 25 with us and certainly is very committed to forensic

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1 pathology. So again, it's another opportunity to try and 2 work with these people. 3 COMMISSIONER STEPHEN GOUDGE: Right, 4 right. That is helpful. 5 6 CONTINUED BY MS. JENNIFER MCALEER: 7 MS. JENNIFER MCALEER: Okay. Changing 8 topics again. And -- and this will be our second-last 9 topic. 10 I understand, Dr. Shkrum and Dr. Rao, that 11 in -- some time early in 2006, you were asked by Dr. 12 Pollanen to participate in the review of Dr. Smith's 13 cases that was taking place. 14 Is that correct? 15 DR. MICHAEL SHKRUM: That's correct, yes. 16 MS. JENNIFER MCALEER: And that you each 17 reviewed five (5) of Dr. Smith's cases? 18 DR. CHITRA RAO: That's correct. 19 DR. MICHAEL SHKRUM: That's correct. 20 MS. JENNIFER MCALEER: And that upon 21 reviewing the cases you completed an Autopsy Report 22 Review Form? 23 DR. CHITRA RAO: Yes. 24 DR. MICHAEL SHKRUM: Yes. 25 MS. JENNIFER MCALEER: And I take it you

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1 -- I understand it, I should say, that you did not play 2 any role in designing the Autopsy Review Report Form? 3 DR. MICHAEL SHKRUM: No, we did not. 4 MS. JENNIFER MCALEER: And you played no 5 role in choosing the cases that you reviewed? 6 DR. CHITRA RAO: No. 7 DR. MICHAEL SHKRUM: No. 8 MS. JENNIFER MCALEER: And that your 9 review consisted of coming to Toronto and -- to the 10 Office of the Chief Coroner and spending, Dr. Rao, a day 11 reviewing the cases Dr. -- is that correct? 12 DR. CHITRA RAO: That's correct. 13 MS. JENNIFER MCALEER: And, Dr. Shkrum, 14 you did that as well, but on a different day? 15 DR. MICHAEL SHKRUM: That's correct. 16 MS. JENNIFER MCALEER: And that after you 17 had reviewed the cases, you had completed a report -- 18 sorry five (5) reports and that you then provided those 19 to Dr. Pollanen? 20 DR. MICHAEL SHKRUM: Yes. 21 DR. CHITRA RAO: That's correct. 22 MS. JENNIFER MCALEER: And, Dr. Shkrum, 23 did you have subsequent discussions with Dr. Pollanen 24 about the reports you had submitted? 25 DR. MICHAEL SHKRUM: No, there was just a

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1 brief discussion on one (1) of the cases, but there was 2 no subsequent discussion following that. 3 MS. JENNIFER MCALEER: And -- 4 DR. MICHAEL SHKRUM: That was on the same 5 day I was there. 6 MS. JENNIFER MCALEER: Okay. And, Dr. 7 Rao, did you have any followup discussions with Dr. 8 Pollanen about the cases that you had -- 9 DR. CHITRA RAO: No. 10 MS. JENNIFER MCALEER: -- reviewed? 11 DR. CHITRA RAO: No. 12 MS. JENNIFER MCALEER: Okay. Those are 13 all of my questions with respect to your involvement in - 14 - in the review of Dr. Smith's work. 15 Before we finish today, do you have any 16 other general comments that you'd like to provide to the 17 Commissioner about the practice of forensic pathology and 18 -- and what you see as the challenges or what you hope -- 19 hope that this Commission might be able to achieve for 20 the practice? 21 DR. MICHAEL SHKRUM: Do you want to 22 start? 23 DR. CHITRA RAO: I think things improving 24 and community hospital pathologists are now getting 25 familiar with regional forensic units. And they do call

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1 us for help. And we also are lucky in having very 2 interesting Regional Supervising Coroners, who are very 3 enthusiastic and who really want to improve the system. 4 And so they also is starting to have 5 rounds for community hospital pathologists, and they go 6 and talk to them. And then they also encourage them, 7 Don't hesitate if you have any problem, call me or call 8 the investigating coroner. We'll get you help. 9 And especially Dr. Jack Stanborough, they 10 know we are taxed a lot in my unit because we are only 11 two (2) and doing about six hundred (600) odd cases. 12 Plus we have assignment with the University, so we have 13 to do teaching, research. 14 So he knows, so now he is screening some 15 of the cases. And if he feels comfortable that the 16 community hospital forensic pathology or people who are 17 doing forensic pathology can do, he's diverting those 18 cases. 19 So -- and it's happening the same, Dr. 20 McCallum, because he used to be our coroner and then has 21 become Regional Coroner and gone to his area. And so we 22 are fortunate to have people like that. 23 And -- and now with the publicity of 24 different cases coming up, you know, people are taking 25 more cautious steps, and they want to make sure that they

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1 are doing a fairly good job as far as, you know, they can 2 in their ability. So I think those are the positive 3 issues. 4 And then I think I have to credit Dr. 5 Michael Pollanen, because he has really done quite a lot 6 of work in this, and he's still working on it to improve 7 the system more. 8 And with all this, I think there may be 9 more people coming up to say, Yes, I can do forensic 10 pathology. I think it will be okay. There will be a 11 support system. And only thing is the Ministry will have 12 to provide more funding for the forensic pathologists to 13 continue. 14 I think that's all my comments. 15 DR. MICHAEL SHKRUM: I -- I would fully 16 agree with Dr. Rao, I mean, the issue of human resources 17 and infrastructure. But a very specific request. 18 You know, the people that do pediatric 19 forensic pathology in this province, it's a really a 20 thin, grey line. I mean, there's just a few people, and 21 we're -- we're getting older. And, you know, obviously, 22 we've talked about replacements, but -- so, you know, 23 we've got to attract people to the profession. 24 But for the survivors that are continue to 25 do these cases, I -- I -- you know, I think there's a

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1 real thirst for continuing education. We really need to 2 be, you know, up to date on the issues related to 3 pediatric forensic pathology. We need some regular 4 education in this -- in this regard and you know, high 5 calibre education, even inviting speakers from outside 6 the -- outside the area. 7 MS. JENNIFER MCALEER: And, Dr. Dexter, 8 what do you see as the leading issues in forensic 9 pathology today? 10 DR. DAVID DEXTER: Well I think my 11 colleagues have touched on all the big ones. I mean, 12 part of the issue with pathology in general is that you 13 talk about the greying of pathologists. We do need to 14 encourage people to come into pathology in general, and 15 in particularly forensic pathologists. 16 I think we're very thin on the ground, and 17 we're getting increasingly stretched. Not are we -- not 18 only are we looking at increased numbers of cases, but 19 the complexity of the case and the length of time that we 20 spend with it has just gone like gang busters. And that 21 is still being done by the same few people. 22 So again, it's the issue of how do we go 23 about that? It's a question that's very difficult to 24 answer. I think that the issue of resources needs to be 25 revisited. The budgets assigned to the units have

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1 remained stable of -- virtually from the beginning of 2 those units. I think that needs to be looked at again. 3 I think we also need to look at, what can 4 we do in the way of communications? The modern computer 5 -- communications of interlinks, so that we have a 6 virtual forensic unit. And what I mean by that is we 7 have an interlink between Toronto, Hamilton, London, 8 Ottawa, and ourselves, that we can get on the blower, 9 that we can share some of the issues and problems with 10 each other. 11 So I think there's some things we -- that 12 we can do with that, and I'd strongly support the 13 educational aspect of things. And I'd absolutely insist 14 that the Royal College gets that certification program 15 going rapidly. 16 DR. CHITRA RAO: And thanks to TV 17 shows, public expectation of our performance also has 18 increased and the demand, and they expect if I do an 19 autopsy, the family wants a report next day. And they 20 say, If CSI can do that at the scene, why can't you do? 21 And they do ask those questions. So we 22 have to look into that too. 23 MS. JENNIFER MCALEER: Well thank you, 24 Doctors, those are all of my questions. 25 DR. MICHAEL SHKRUM: Thank you.

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1 COMMISSIONER STEPHEN GOUDGE: Thank you 2 all very much. 3 DR. CHITRA RAO: Thank you. 4 DR. DAVID DEXTER: Thank you. 5 COMMISSIONER STEPHEN GOUDGE: That's been 6 very helpful. We will rise now until tomorrow morning, 7 and if you would be good enough to return, others will 8 have some questions for you as well. 9 DR. CHITRA RAO: Okay. 10 DR. DAVID DEXTER: Thank you. 11 12 (WITNESSES RETIRE) 13 14 --- Upon adjourning at 4:30 p.m. 15 16 17 Certified Correct, 18 19 20 _____________________ 21 Rolanda Lokey, Ms. 22 23 24 25