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 25th, 2008 25


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


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


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 ) General for Ontario 7 Erin Rizok (np) ) 8 Kim Twohig (np) ) 9 Chantelle Blom (np) ) 10 11 Natasha Egan (np) ) 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 Michelle Booth (np) ) Robert Wood 20 21 22 23 24 25


1 TABLE OF CONTENTS Page No. 2 3 DAVID LEGGE, Affirmed 4 DAVID EDEN, Affirmed 5 ANDREW MCCALLUM, Affirmed 6 7 Examination-In-Chief by Mr. Mark Sandler 6 8 Cross-Examination by Ms. Luisa Ritacca 179 9 Cross-Examination by Ms. Alison Craig 225 10 Cross-Examination by Ms. Breese Davies 231 11 Cross-Examination by Mr. Julian Falconer 240 12 Cross-Examination by Ms. Suzan Fraser 306 13 14 Certificate of transcript 328 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 Mr. Sandler...? 8 MR. MARK SANDLER: Good morning, 9 Commissioner. This -- today you'll be hearing from three 10 (3) witnesses, Doctors McCallum, Legge, and Eden, and I 11 would ask our Registrar to swear each of the witnesses 12 please. 13 14 DAVID LEGGE, Affirmed 15 DAVID EDEN, Affirmed 16 ANDREW MCCALLUM, Affirmed 17 18 EXAMINATION-IN-CHIEF BY MR. MARK SANDLER: 19 MR. MARK SANDLER: Good morning, 20 gentlemen. 21 DR. DAVID LEGGE: Morning. 22 DR. DAVID EDEN: Morning. 23 DR. ANDREW MCCALLUM: Morning. 24 MR. MARK SANDLER: What I intend to do is 25 review with each of you briefly your curriculum vitae,


1 and then I'll examine each of you in turn, giving you 2 lots of opportunity to comment positively or negatively 3 upon the testimony that's given by those beside you. 4 If I can turn first to Dr. McCallum. And 5 if you'd look at Tab 1 of the book of documents that's in 6 front of you, PFP170428, which is, as I understand it, 7 your curriculum vitae. 8 DR. ANDREW MCCALLUM: That's correct. 9 MR. MARK SANDLER: It reflects on page 1 10 that you obtained your MD from McMaster in 1980, is that 11 right? 12 DR. ANDREW MCCALLUM: Correct. 13 MR. MARK SANDLER: That in 1987 you 14 became a fellow of the Royal College of Physicians and 15 Surgeons of Canada in emergency medicine? 16 DR. ANDREW MCCALLUM: That's right. 17 MR. MARK SANDLER: 1988 you obtained your 18 diploma of the American Board of Emergency Medicine? 19 DR. ANDREW MCCALLUM: Correct. 20 MR. MARK SANDLER: Since September of 21 2003, you have been the Regional Supervising Coroner for 22 Eastern Ontario, is that right? 23 DR. ANDREW MCCALLUM: That's right. 24 MR. MARK SANDLER: How many death 25 investigations would take place typically within the


1 eastern region in the course of a year. 2 DR. ANDREW MCCALLUM: It varies by year, 3 but between twenty-four hundred (2,400) and twenty-five 4 hundred (2,500) per year. 5 MR. MARK SANDLER: All right. And 6 approximately how many of those would -- would amount to 7 homicides? 8 DR. ANDREW MCCALLUM: Less than forty 9 (40) in a giv -- in any given year would be criminally 10 suspicious, and then probably ultimately twenty-five (25) 11 would be determined to be homicides. 12 MR. MARK SANDLER: All right. And how 13 many Investigating Coroner's do you have within your 14 region? 15 DR. ANDREW MCCALLUM: It varies, but it's 16 -- at the present it's about forty (40). 17 MR. MARK SANDLER: Okay. And if we look 18 at page 2 of your curriculum vitae, we see that one (1) 19 of your key duties as -- in your current position, is to 20 collaborate with outside health care providers to 21 establish new guidelines for death investigation. 22 And reference is made, for example, to the 23 guideline for investigation of sudden cardiac death 24 developed in collaboration with clinicians from CHEO and 25 Hospital for Sick Children as well as others.


1 Is that right? 2 DR. ANDREW MCCALLUM: That's correct. 3 MR. MARK SANDLER: This also reflects 4 that you are a member of the Senior Management Committee, 5 Office of the Chief Coroner for Ontario? 6 DR. ANDREW MCCALLUM: Correct. 7 MR. MARK SANDLER: And the Commissioner 8 has already heard what that Committee is all about. 9 We see that from October of 2003 to 10 present, you've served as and adjunct Associate 11 Professor, Department of Emergency Medicine at Queen's 12 University? 13 DR. ANDREW MCCALLUM: Correct. 14 MR. MARK SANDLER: And reflected in your 15 curriculum vitae is -- part of your responsibilities 16 include supervision of residents during forensic medicine 17 electives: two (2) residents to date, one (1) now 18 enrolled in forensic medicine program at Monash 19 University. 20 Is that right? 21 DR. ANDREW MCCALLUM: Correct. 22 MR. MARK SANDLER: Under professional 23 organizations it reflects that the Royal College of 24 Physicians and Surgeons of Canada, that you're a member 25 of the Speciality Committee until -- I'm sorry, you were


1 a member of the Speciality Committee until 2003? 2 DR. ANDREW MCCALLUM: That's right. 3 MR. MARK SANDLER: And what is the 4 Specialty Committee within the Royal College? 5 DR. ANDREW MCCALLUM: The specialty 6 committees of the particular specialties are the -- those 7 bodies that determine the priorities and issues that face 8 the specialty -- 9 MR. MARK SANDLER: All right. 10 DR. ANDREW MCCALLUM: -- on behalf of the 11 membership. 12 MR. MARK SANDLER: And then at page 3 of 13 your curriculum vitae it reflects that from July of 2001 14 to August 2003 you served as Chief of Staff at the 15 Hamilton Health Sciences Corporation. 16 DR. ANDREW MCCALLUM: That's right. 17 MR. MARK SANDLER: And we see -- and I 18 won't take you to all of the other positions -- but that 19 you served in a variety of capacities within the Hamilton 20 Health Services Corporation over the years, including as 21 Chief the Emergency Medicine, Medical Director of the 22 Emergency Program, Vice Chair of the Medical Advisory 23 Committee. 24 Is that right? 25 DR. ANDREW MCCALLUM: Yes.


1 MR. MARK SANDLER: And at page 5 of the 2 curriculum vitae it reflects that from 2000 to 20003 you 3 served as the coroner, Province of Ontario. 4 And I take it that was a part-time 5 position during that period? 6 DR. ANDREW MCCALLUM: It was. 7 MR. MARK SANDLER: And during that period 8 did you conduct investigations on behalf of the Chief 9 Coroner's Office? 10 DR. ANDREW MCCALLUM: And did. 11 MR. MARK SANDLER: And did you conduct 12 inquests during that period of time, as well? 13 DR. ANDREW MCCALLUM: I did not. 14 MR. MARK SANDLER: All right. And I'm 15 not going to go through the various faculty appointments 16 that are reflected in your curriculum vitae, but the 17 other material in you curriculum vitae, I can tell you, 18 Dr. McCallum, is available to the Commissioner and -- and 19 he'll be familiar with it. 20 COMMISSIONER STEPHEN GOUDGE: Can I just 21 ask two (2) or three (3) questions, Dr. McCallum? 22 First of all, you're full time as a 23 Regional Supervising -- 24 DR. ANDREW MCCALLUM: I am. 25 COMMISSIONER STEPHEN GOUDGE: -- Coroner?


1 Secondly, in terms of the supervision of residence, where 2 do they come from; I mean, what residency program? 3 DR. ANDREW MCCALLUM: They're enrolled in 4 -- in the two (2) emergency medicine residency programs 5 at Queens University. 6 COMMISSIONER STEPHEN GOUDGE: I see. 7 DR. ANDREW MCCALLUM: One (1) of them was 8 in the Royal College Pro -- there are two (2) streams for 9 emergency medicine certification. 10 COMMISSIONER STEPHEN GOUDGE: And 11 supervision of residents during forensic medicine 12 electives, are they in that emergency medicine residency? 13 DR. ANDREW MCCALLUM: They are in the 14 emergency -- 15 COMMISSIONER STEPHEN GOUDGE: Or is that 16 something that -- 17 DR. ANDREW MCCALLUM: It's -- it's an 18 elective, they choose to do it, and -- and -- 19 COMMISSIONER STEPHEN GOUDGE: How long is 20 it? 21 DR. ANDREW MCCALLUM: Both have spent a 22 month with me. One (1) of them is -- is mentioned in the 23 -- in the CV as actually enrolled at the Victorian 24 Institute of Forensic Medicine and -- 25 COMMISSIONER STEPHEN GOUDGE: Comes all


1 the way here to -- 2 DR. ANDREW MCCALLUM: She -- 3 COMMISSIONER STEPHEN GOUDGE: -- do a 4 residency? 5 DR. ANDREW MCCALLUM: It's distance 6 education at its utmost. 7 COMMISSIONER STEPHEN GOUDGE: And -- 8 DR. ANDREW MCCALLUM: She's actually not 9 a -- she's not a -- she's a Canadian national, but she 10 went to -- 11 COMMISSIONER STEPHEN GOUDGE: Went to 12 medical school there. 13 DR. ANDREW MCCALLUM: -- Australia to 14 study. No, she went to -- she went to -- here. She's a 15 -- I think she's a Calgary graduate, but she -- 16 COMMISSIONER STEPHEN GOUDGE: And then -- 17 DR. ANDREW MCCALLUM: -- decided she'd 18 train here. 19 COMMISSIONER STEPHEN GOUDGE: To do her 20 residency -- 21 DR. ANDREW MCCALLUM: Correct. 22 COMMISSIONER STEPHEN GOUDGE: -- at the 23 Victorian Institute. 24 DR. ANDREW MCCALLUM: And I think that's 25 something to be -- I'm editorializing already, but I


1 think it should be encouraged. 2 COMMISSIONER STEPHEN GOUDGE: Right. And 3 the third simplistic question is: What's the 4 geographical reach of the eastern region? 5 DR. ANDREW MCCALLUM: If you were to draw 6 a line approximately just east of Armprior on the Ottawa 7 River, and run it straight down to na -- just east of 8 Napanee, and then everything east of that. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 DR. ANDREW MCCALLUM: So it includes 11 Ottawa, Cornwall, Kingston, Brockville. 12 COMMISSIONER STEPHEN GOUDGE: Okay, 13 thanks. Thanks, Mr. Sandler. 14 15 CONTINUED BY MR. MARK SANDLER: 16 MR. MARK SANDLER: All right. And if 17 we'd go, Dr. Legge, to your curriculum vitae, which is 18 PFP303264, and it is at Tab 2 of the binder of materials 19 in front of you. 303264. 20 21 (BRIEF PAUSE) 22 23 COMMISSIONER STEPHEN GOUDGE: Our 24 technology takes a little while to wake up in the 25 morning.


1 DR. DAVID LEGGE: Just like me. 2 3 CONTINUED BY MR. MARK SANDLER: 4 MR. MARK SANDLER: I'll -- I'll proceed, 5 just while the document is being searched for. Dr. 6 Legge, your curriculum vitae at page 1 reflects that you 7 obtained your MD at the University of Toronto in 1968, is 8 that right? 9 DR. DAVID LEGGE: Correct. 10 MR. MARK SANDLER: That under 11 postgraduate training it reflects that you were the Chief 12 Resident, Family Practice Residency Program University of 13 Western Ontario, from 1972 to 1973? 14 DR. DAVID LEGGE: That's correct. 15 MR. MARK SANDLER: Under "employment 16 history" you've reflected that from 1969 to 1971 you were 17 a family physician, selection of recruitment to the new 18 Federal Government Sioux Lookout Program, providing 19 health care to First Nations in northwestern Ontario. 20 Could you explain what that entailed? 21 DR. DAVID LEGGE: This was a new program 22 that developed as a partnership between the Federal 23 Government and the Hospital for Sick Children, 24 principally Dr. Harry Bain at the time, who wanted -- who 25 became interested in provided physicians to that area to


1 be primary care of health providers to First Nations 2 people. 3 So myself and one (1) other person coming 4 out of the internship where I was at Western Hospital 5 here in Toronto said, Hey, this looks like an exciting 6 and appealing way to start our medical career, so we came 7 up to Sioux Lookout and got thoroughly into life in the 8 North, and management of these folks throughout that 9 whole area. 10 MR. MARK SANDLER: All right. 11 DR. DAVID LEGGE: The hub being Sioux 12 Lookout, and the Sioux Lookout Zone Hospital, and that 13 was a two (2) year contract, after which I went back 14 there on numerous occasions for teaching, and locums, and 15 stuff like that. 16 MR. MARK SANDLER: Okay. And your 17 curriculum vitae reflects that near the end of the 18 contract, you became the Interim Medical Director. 19 Is that right? 20 DR. DAVID LEGGE: I was, briefly, yeah. 21 Mm-hm. 22 MR. MARK SANDLER: There's a reference 23 there to the teaching of zone nurses for several years 24 thereafter. What is a zone nurse? 25 DR. DAVID LEGGE: Well, these were sort


1 of like nurse practitioners, who would go out and provide 2 primary health care in the communities, in the -- in the 3 nursing stations. 4 So I was doing a bit of teaching in that 5 regard. 6 MR. MARK SANDLER: All right. 7 DR. DAVID LEGGE: I'm not sure if I used 8 the right word in the CV. 9 MR. MARK SANDLER: No, that's fine. And 10 also at page 1, it reflects that you had a family 11 practice in London, Ontario, and then a family practice 12 in Thunder Bay -- 13 DR. DAVID LEGGE: Correct. 14 MR. MARK SANDLER: -- the latter from 15 1975 to 1997. Is that right? 16 DR. DAVID LEGGE: That's correct. 17 MR. MARK SANDLER: At the bottom of the 18 page, it reflects that you were -- served as a coroner 19 within the Ontario coronial system for some twenty (20) 20 years, from 1977 to 1997? 21 DR. DAVID LEGGE: Correct. 22 MR. MARK SANDLER: I'm sorry, to 2007? 23 DR. DAVID LEGGE: Mm-hm. 24 MR. MARK SANDLER: And then at page 2 of 25 the curriculum vita, you became the Regional Supervising


1 Coroner for Northwestern Ontario in 1997, and served in 2 that capacity until your retirement this past year. 3 DR. DAVID LEGGE: Correct. 4 MR. MARK SANDLER: Now, just stopping 5 there for a moment. What is the geographical boundaries 6 for the northwestern region? 7 DR. DAVID LEGGE: Interestingly enough, 8 when I first came onboard, the zone was from Manitoba 9 border to lets say Geraldton. Do you know where that is? 10 Maybe you don't. But it's slightly east of Thunder Bay 11 and north. 12 Then in 2000, that boundary increased 13 significantly, all the way over to the Quebec border, 14 which would then take in Cochrane, Timiskaming, and 15 Algoma. Then just recently, it expanded yet again, so 16 there's been -- well, within my realm there's been one 17 (1) expansion, and now -- now two (2) expansions. 18 So it's -- 19 COMMISSIONER STEVEN GOUDGE: So what is 20 it today, Dr. Legge; gigantic? 21 DR. DAVID LEGGE: Today -- today it 22 basically goes from Manitoba down to Parry Sound in the 23 south. It's -- it's, as you know, massive -- 24 COMMISSIONER STEVEN GOUDGE: Yes. 25 DR. DAVID LEGGE: -- massive, massive


1 land area. 2 COMMISSIONER STEVEN GOUDGE: And then 3 over on the east, to the Quebec border? 4 DR. DAVID LEGGE: Quebec border, and then 5 up through -- 6 COMMISSIONER STEVEN GOUDGE: Sort of 7 running -- 8 DR. DAVID LEGGE: -- up through -- 9 COMMISSIONER STEVEN GOUDGE: -- running 10 along Highway 17? 11 DR. DAVID LEGGE: I guess so. 12 COMMISSIONER STEVEN GOUDGE: To North -- 13 to North Bay, and -- 14 DR. DAVID LEGGE: Yeah. And right up to 15 James Bay, and right up to Hudson Bay, so -- 16 COMMISSIONER STEVEN GOUDGE: Right. 17 DR. DAVID LEGGE: -- it's -- I -- I 18 needn't remind people how massive this area is. I think 19 you all know that. 20 COMMISSIONER STEVEN GOUDGE: Right. 21 22 CONTINUED BY MR. MARK SANDLER: 23 MR. MARK SANDLER: All right. I -- I 24 recall from a -- from another inquiry reference being 25 made to the Nishnawbe-Aski Nation as comprising a


1 property larger than -- than France. 2 DR. DAVID LEGGE: I would say it's much 3 larger than France now. It may be France and a half, or 4 three quarters. 5 MR. MARK SANDLER: All right. And then 6 under teaching and supervision, you reflect supervision 7 of up to forty (40) coroners as the Regional Supervising 8 Coroner. 9 How many coroners are there within the 10 region at present, to your knowledge? 11 DR. DAVID LEGGE: My understanding is 12 approximately sixty (60) with -- with this recent 13 boundary change, but it was forty (40) throughout my -- 14 my charge. 15 MR. MARK SANDLER: All right. And I'm 16 going to ask you a little bit more about how those 17 coroners serve their function within that very large 18 region in a few moments. 19 DR. DAVID LEGGE: Sure. 20 MR. MARK SANDLER: And then I also see 21 under "personal interests" at page 3, I can't leave this 22 alone, that you've listed as your first personal interest 23 your wife, Penny, which I'm delighted to see you've put 24 ahead of wood carving and photography, which will please 25 her no doubt if she's watching.


1 DR. DAVID LEGGE: Indeed. She -- she 2 hasn't even seen the CV, but I -- that was my -- 3 MR. MARK SANDLER: I guess the secret's -- 4 DR. DAVID LEGGE: -- my list. 5 MR. MARK SANDLER: -- the secret's out. 6 All right. If I can turn to Dr. Eden briefly, and your 7 curriculum vita, which is at Tab 3, PFP170563. 8 Now, Dr. Eden, this reflects that -- that 9 you are the current Regional Supervising Coroner for the 10 north region. 11 DR. DAVID EDEN: That's correct. 12 MR. MARK SANDLER: And is the north 13 region and the northwestern region denoting the same -- 14 the same area? 15 DR. DAVID EDEN: There was a change in 16 boundaries on January 1st of this year, and that was when 17 the previous northwest region, which as Dr. Legge 18 described, started at Cochrane and then went west to the 19 Manitoba border, enlarged to include everything from 20 Parry Sound and Timiskaming up to the Quebec border, and 21 the -- the Manitoba border. 22 MR. MARK SANDLER: All right. 23 COMMISSIONER STEVEN GOUDGE: What was the 24 rationale for the expansion? I mean, it seems like a 25 huge, huge area.


1 DR. DAVID EDEN: It was not a decision of 2 the Chief Coroner's Office, it was actually a Management 3 Board decision that all Ministries were to have uniform 4 administrative boundaries. 5 COMMISSIONER STEPHEN GOUDGE: And is that 6 the administrative boundary for other Ministries for 7 other program delivery purposes? 8 DR. DAVID EDEN: Yes, sir. 9 COMMISSIONER STEPHEN GOUDGE: Wow. 10 11 CONTINUED BY MR. MARK SANDLER: 12 MR. MARK SANDLER: And, Commissioner, 13 we're going to be talking about some of the 14 administrative and infrastructure challenges in that 15 region a little bit later on in -- in the testimony of 16 Dr. Legge and Dr. Eden. 17 As reflected at page 1 of your curriculum 18 vitae, you obtained your MD from the University of 19 Western Ontario, Faculty of Medicine in 1987. 20 Is that right? 21 DR. DAVID EDEN: Yes. 22 MR. MARK SANDLER: And then if I -- if I 23 move over, and I'm not doing justice to the curriculum 24 vitae of any of our witnesses today, but if you'd look to 25 page 2 of the document, you've listed your appointments,


1 and they include a number of hospital appointments 2 including serving as an active staff member at a number 3 of facilities, including Niagara on the Lake Hospital, 4 Anson General Hospital in Iroquois Falls, Hotel Dieu 5 Hospital in St. Catherines, and Douglas Memorial 6 Hospital, Fort Erie, and Port Colborne General Hospital 7 in Port Colborne, Ontario. 8 Is that right? 9 DR. DAVID EDEN: Yes. 10 MR. MARK SANDLER: You've served as the 11 Deputy Chief, either in the Department of Emergency 12 Medicine, or the Department of Family Medicine, or the 13 Department of Family Physicians at the Hotel Dieu 14 Hospital and the St. Catharines General Hospital. 15 Is that right? 16 DR. DAVID EDEN: That's correct. 17 MR. MARK SANDLER: You later served as 18 the Chief of the Department of Family Medicine at the 19 Hotel Dieu Hospital and Chief of the Department of Family 20 Physicians at St. Catharines General Hospital? 21 DR. DAVID EDEN: Yes. 22 MR. MARK SANDLER: You've served as 23 courtesy staff at the Greater Niagara General Hospital 24 and at the Hotel Dieu Hospital, and ultimately Chief of 25 Staff at the Niagara on the Lake Hospital, from 1996 to


1 1997. 2 Is that so? 3 DR. DAVID EDEN: That's correct, yes. 4 MR. MARK SANDLER: At page 4 of your 5 curriculum vitae it reflects that since 1992 you have 6 served as a coroner within the Ontario coronial system? 7 DR. DAVID EDEN: Yes. 8 MR. MARK SANDLER: From 1996 you were an 9 inquest coroner as well? 10 DR. DAVID EDEN: That's correct. 11 MR. MARK SANDLER: From 1998 to 2003, 12 from 2004 to 2007, you served as the Regional Supervising 13 Coroner for the Niagara region. 14 Is that right? 15 DR. DAVID EDEN: That's correct, yes. 16 MR. MARK SANDLER: And there was a stint 17 in between, 2003 to 2004, when you served as the Regional 18 Supervising Coroner for Operations. 19 Is that so? 20 DR. DAVID EDEN: That's correct, yes. 21 MR. MARK SANDLER: Just stopping -- 22 COMMISSIONER STEPHEN GOUDGE: Yes, sorry, 23 you were going to ask...? 24 25 CONTINUED BY MR. MARK SANDLER:


1 MR. MARK SANDLER: Just stopping there 2 for a moment, what is the geographical region for 3 Niagara? 4 DR. DAVID EDEN: The region of Niagara 5 includes the regional municipalities of Niagara and 6 Hamilton, in addition to the county of Brant and the 7 counties of Haldimand and Norfolk. 8 MR. MARK SANDLER: All right. So that 9 would include for example, St. Catharines and Hamilton -- 10 DR. DAVID EDEN: Yes. 11 MR. MARK SANDLER: -- as the -- as major 12 centres within -- within that region? 13 DR. DAVID EDEN: Yes, it's got a 14 population of about a million. 15 MR. MARK SANDLER: All right. And how 16 many coroners serve within that region? 17 DR. DAVID EDEN: About twenty (20). The 18 reason I say "about", is that some of my coroners are on 19 the border so they also accept cases in other geographic 20 regions. 21 MR. MARK SANDLER: All right. And as 22 we've spoken about a little bit earlier on, very, very 23 recently you commenced your duties in the north region as 24 the Regional Supervising Coroner. 25 Is that right?


1 DR. DAVID EDEN: That's correct. 2 MR. MARK SANDLER: Now, you've listed in 3 your curriculum vitae some one hundred and thirty-seven 4 (137) presentations that you've given over the years, and 5 I don't in take -- intend to take you to them, but -- but 6 I did note that there were certain recurrent themes in 7 the presentations that you've provided, one (1) of which 8 is that it appears that on a regular basis you lecture or 9 present to the Hamilton Children's Aid Society on 10 investigating pediatric deaths. 11 Is that right? 12 DR. DAVID EDEN: That's correct, yes. 13 MR. MARK SANDLER: And I'm going to ask 14 you about that in the context of -- of protocols that 15 existed in the -- or that do exist in the Niagara region, 16 and that you've played a part in, that involved 17 Children's Aid and the Coroner's Office. 18 Is that so? 19 DR. DAVID EDEN: Yes, I've participated 20 in the development of those protocols. 21 MR. MARK SANDLER: All right. And we're 22 going to talk about those a little bit later, if we may. 23 Now if I can take you to page 16 of your 24 curriculum vitae, we see that from 1999 to 2002 you 25 served as a member of the Quality Assurance Committee


1 within the Chief Coroner's Office and became the Chair of 2 the Quality Assurance Committee from 2002 to the present. 3 Is that so? 4 DR. DAVID EDEN: That's correct, yes. 5 MR. MARK SANDLER: And just stopping 6 there. Dr. McCallum, you are or were a member of the 7 Quality Assurance Committee, as well, am I right? 8 DR. ANDREW MCCALLUM: Not at -- the Chief 9 Coroner, no. 10 MR. MARK SANDLER: No, okay. All right. 11 And then from 2003 to the present, Dr. Eden, you've also 12 been a member of the Best Practices Subcommittee. 13 Is that so? 14 DR. DAVID EDEN: That's correct, yes. 15 MR. MARK SANDLER: All right. Well, what 16 I'm going to do now, if I may, is turn to Dr. McCallum 17 and ask some questions that are grounded in large measure 18 upon your experience in the eastern region. 19 You've described the -- the boundaries of 20 the region. In addition to the major centres that -- 21 that we know of, Kingston and Ottawa, as I understand, 22 that you also service a number of remote communities that 23 are contained within the region. 24 Is that right? 25 DR. ANDREW MCCALLUM: Well, I think Dr.


1 Eden and Dr. Legge might contend that they're not remote 2 by northern standards, but they are -- there is distances 3 of 100 kilometres between say any kind of settlement and 4 the nearest hospital. 5 MR. MARK SANDLER: All right. And how 6 many cases are typically investigated by the coroners in 7 your region, per year? 8 DR. ANDREW MCCALLUM: Twenty-four hundred 9 (2,400), twenty-five hundred (2,500), depends on the 10 year. 11 MR. MARK SANDLER: All right. And you've 12 described how many investigating coroners there are in 13 your region. 14 Are they full-time, part-time, or some 15 combination? 16 DR. ANDREW MCCALLUM: They are all part 17 time, though some have a more -- a major component of 18 their practice in coroner's work in the urban areas, but 19 in the remote area -- or less urban areas they're all 20 part-time. 21 MR. MARK SANDLER: All right. And 22 typically what would these coroners be, would they be 23 family physicians generally, or -- or can you help us out 24 as to that? 25 DR. ANDREW MCCALLUM: In my area, 95


1 percent would be family physicians in general practice or 2 family practice. 3 MR. MARK SANDLER: All right. Do have 4 enough coroners in your region? 5 DR. ANDREW MCCALLUM: It depends on the 6 area. In the -- in the urban areas I have enough, but in 7 some of the rural areas it can be very difficult to 8 attract coroners to coroner work, simply because there 9 aren't enough in those areas to begin with, that's the 10 pool you recruit from. 11 MR. MARK SANDLER: Okay. 12 COMMISSIONER STEPHEN GOUDGE: Do you have 13 a compliment that you shoot for, Dr. McCallum? 14 DR. ANDREW MCCALLUM: It's really 15 determined by caseload, so if I have an area where I know 16 that there are gaps where -- where it's difficult at 17 times to find a coroner, and then I'll seek to recruit in 18 those areas. 19 COMMISSIONER STEPHEN GOUDGE: I see. 20 DR. ANDREW MCCALLUM: And also, 21 retirements and succession planning, et cetera, come into 22 play, so if -- 23 COMMISSIONER STEPHEN GOUDGE: That's part 24 of the management of the region. 25 DR. ANDREW MCCALLUM: It is.


1 COMMISSIONER STEPHEN GOUDGE: Yes. 2 3 CONTINUED BY MR. MARK SANDLER: 4 MR. MARK SANDLER: All right. Are there 5 communities in your region where there is no resident 6 coroner? 7 DR. ANDREW MCCALLUM: Many. 8 MR. MARK SANDLER: All right. And I've 9 asked you this a little bit earlier, but just to recap, 10 how many of the case investigated in your region per year 11 are homicides or criminally suspicious cases? 12 DR. ANDREW MCCALLUM: Year over year the 13 figure, or the gross figure, if you like, the criminally 14 suspicious, would be in the range of forty (40) total, 15 and of that forty (40) about twenty-five (25) would 16 ultimately be determined to be homicide as the manner of 17 death. 18 COMMISSIONER STEPHEN GOUDGE: Would they 19 largely be in the two (2) big centres? 20 DR. ANDREW MCCALLUM: Well, there would a 21 preponderance in the big centres, but they occur all 22 over, and the can occur in the remote areas, as well. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 25 CONTINUED BY MR. MARK SANDLER:


1 MR. MARK SANDLER: All right. And of 2 those cases, how many of them are sudden and unexpected 3 pediatric death cases, whether or not they're ultimately 4 classified as homicides? 5 DR. ANDREW MCCALLUM: There would be four 6 (4) to five (5) sudden unexpected deaths, and perhaps one 7 (1) of those would end up being determined to be 8 homicide, annually. 9 MR. MARK SANDLER: All right, so can I 10 take from that that some of those cases, or a number of 11 those cases, would present themselves at first instance 12 as a SID-like case? 13 DR. ANDREW MCCALLUM: Yes. 14 MR. MARK SANDLER: All right. Now, the 15 cases that we have examined here generally, with some 16 exceptions, start with a child who suddenly and 17 unexpectedly dies either at the home, or en route to, or 18 at the hospital, so let's take that scenario, if we may, 19 and I want to explore how those kinds of cases are 20 treated within the coronial system in your region, okay? 21 So I'll start by asking you this: How 22 does a coroner in your region first become aware of that 23 death? 24 DR. ANDREW MCCALLUM: Most often it's 25 consequent to the activation of the 911 system. So


1 typically in the case of a child death, the ambulance is 2 called first because there's a hope to resuscitate, and 3 then it becomes evident that that's not possible, one way 4 or another, and at that point police are involved. 5 There's a, as you probably have heard in 6 testimony, what's known a tiered response in 911 7 responses, meaning that police, fire, and ambulance 8 typically respond to sudden deaths, and particularly in 9 children. 10 And so the police are at the scene and 11 they will then, if -- at the -- at the appropriate time 12 notify the coroner through their dispatch system, 13 depending on where it is. It varies -- it's a very 14 heterogeneous approach from that standpoint or from that 15 position onward. 16 And by that, I mean that in, say Ottawa, 17 where there is a call system for coroners because there's 18 sufficient volume of cases to allow that, the coroner 19 would be notified through police dispatch and there would 20 be an identified coroner on any given day that would 21 respond. 22 And a re -- a more -- remote -- 23 MR. MARK SANDLER: So just stopping there 24 for a moment. 25 So that in Ottawa, for example, there


1 would be on-duty coroner whose name and -- and contact 2 information would be me -- named -- made known to the 3 police dispatch -- 4 DR. ANDREW MCCALLUM: Correct. 5 MR. MARK SANDLER: All right. Go ahead, 6 if you would. 7 DR. ANDREW MCCALLUM: In a medium sized 8 community, like Cornwall, there is a call system on 9 weekends because that's -- we -- we had identified that 10 was a particularly problematic time to find the coroner, 11 but during the week it's really a matter of going through 12 the rolodex, and calling the coroner. And the reason for 13 that is that there isn't sufficient volume for them to 14 devote that time to be of -- to be definitively 15 available, as they would in Ottawa. 16 In any case, in the main, the coroner is 17 located either through the police dispatch, or through 18 other means, and -- either through a call system, or 19 other means, I should say -- and would attend the scene 20 in the case of a -- of a pediatric death. 21 MR. MARK SANDLER: All right. Well, just 22 dealing with the dispatch issue for a moment, two (2) 23 questions arise out of that. 24 The first is that: What about the areas - 25 - and -- and taking your point that Dr. Eden and Dr.


1 Legge are truly dealing with remote communities, 2 nonetheless you've got some communities that might be a 3 100 kilometres or so away from the nearest coroner -- how 4 does dispatch work in those communities? 5 DR. ANDREW MCCALLUM: In my area, those 6 communities are typically served by the OPP, so it's the 7 OPP dispatch that would contact, or attempt to contact, 8 the coroner. They have the contact numbers for the 9 coroners that are local to the area, or as local as 10 possible, and they attempt to contact them. 11 If that fails, they call me, or -- or 12 whoever is on-call for me. We're always available. And 13 at times, I either can find a coroner for them -- and 14 then there's some issues with that, which I think the 15 Commissioner may hear recommendations about -- but at 16 times I have to deal with it remotely through the -- 17 through Section 16 of the Coroners Act, and authorize the 18 police officer to act in -- in my stead. 19 MR. MARK SANDLER: All right. And in the 20 perfect world, or more ideal world, how would you like to 21 see the dispatch system improved to address some of the 22 concerns that arise? 23 DR. ANDREW MCCALLUM: I think that there 24 should be a single number to call in the Province when a 25 coroner is needed, in any given area. And that number


1 should be staffed twenty-four (24) hours a day, full 2 time, seven (7) days a week, and it should be -- have its 3 component -- first communication with the coroner, locate 4 the coroners. 5 And secondly, a data collection function 6 so that the regional coroner would be av -- aware of the 7 case at the earliest time possible, and if necessary, 8 become involved in the management of the case, which does 9 happen. 10 The difficulty now is that we don't know 11 about the case. In some cases, I don't know about a case 12 for months. And that's not the case in pediatric cases, 13 because the coroners are attuned to calling me. But for 14 example, a case that might turn out subsequently to be 15 problematic, I may not know about for some time. 16 With a dispatch system under our control, 17 that would be possible, and there -- I could therefore 18 intervene at an early time to effect positive change, if 19 necessary. 20 MR. MARK SANDLER: All right. And what, 21 if any, impediment currently exists to prevent the 22 implementation of such a province-wide dispatch system 23 now? 24 DR. ANDREW MCCALLUM: I think it's 25 fundamentally a resource issue. I think that with


1 sufficient resources, it could be done. 2 There are models in the Province. There - 3 - for example, CritiCall, which is the single number to 4 call for locating critical care resources for patients, 5 works well in the Province. So there are models that 6 work, that could be used to -- as a, if you like, a 7 template. 8 COMMISSIONER STEVEN GOUDGE: So the call 9 would go in to the central number and there would then be 10 a contact of, what? The local investigating coroner with 11 information being collected and sent immediately -- 12 DR. ANDREW MCCALLUMS: Correct. 13 COMMISSIONER STEVEN GOUDGE: -- to the 14 Regional Supervising Coroner? Is that -- 15 DR. ANDREW MCCALLUM: Exactly. So -- 16 COMMISSIONER STEVEN GOUDGE: -- the way 17 you envisage the system? 18 DR. ANDREW MCCALLUM: I -- I would. And 19 the way I would see it would be much like what happens in 20 Toronto, with the Central Coroner's dispatch here, except 21 provincially. 22 So the coroner's dispatch would know the 23 closest coroner. They would be charged with being 24 familiar with the terrain, the geography, et cetera. And 25 -- and the human resources that are there call the most


1 appropriate coroner, whether it's a call system, or 2 whether it's the geographically closest local -- closest 3 coroner. 4 COMMISSIONER STEVEN GOUDGE: So the call 5 system in Ottawa would have to be supplied on a monthly 6 basis, or a bi-monthly basis, or something, to the 7 central number? 8 DR. ANDREW MCCALLUM: Exactly. 9 COMMISSIONER STEVEN GOUDGE: Yes. 10 DR. ANDREW MCCALLUM: Then that wouldn't 11 be a problem in a place like Ottawa, because it's all 12 ready done. They just give it to a different dispatch -- 13 COMMISSIONER STEVEN GOUDGE: Right. 14 DR. ANDREW MCCALLUM: -- number -- 15 COMMISSIONER STEVEN GOUDGE: Right. 16 DR. ANDREW MCCALLUM: -- or a different 17 dispatch group. 18 COMMISSIONER STEVEN GOUDGE: Right. The 19 dispatcher in Ottawa is -- 20 DR. ANDREW MCCALLUM: Police dispatcher. 21 COMMISSIONER STEVEN GOUDGE: Is a police 22 dispatcher? 23 DR. ANDREW MCCALLUM: Correct. 24 COMMISSIONER STEVEN GOUDGE: I see. 25 Okay.


1 2 CONTINUED BY MR. MARK SANDLER: 3 MR. MARK SANDLER: All right. Now, you -- 4 you said earlier to the Commissioner that some of your 5 coroners are obviously busier than others and that raises 6 not only recruitment issues, but I suggest to you also 7 training issues. 8 Is that right? 9 DR. ANDREW MCCALLUM: That's fair. 10 MR. MARK SANDLER: How do you deal with 11 that issue; the concern that a coroner doesn't have 12 enough work, and -- and therefore, one could argue that 13 his or her skills as a coroner might erode? 14 DR. ANDREW MCCALLUM: Well, there's a 15 number of strategies. One (1) is, on an ongoing basis 16 the involvement of the regional coroner is very 17 important. So that -- the regional coroner needs to be 18 available to provide advice, and support, and guidance, 19 to the investigating coroner, particularly when it comes 20 to homicides. 21 As I've said, there's only -- there are 22 only twenty-five (25) a year, and the chance that an 23 individual coroner, especially one in a remote area, will 24 see a homicide over the course of five (5) years is very 25 small. So they need --


1 MR. MARK SANDLER: And I take it you've 2 got coroners that have never done a homicide case? 3 DR. ANDREW MCCALLUM: Absolutely. And so 4 they need guidance. Unfortunately, what I do is I -- I 5 make every effort to make myself available to them so 6 they know they can call me and get assistance as to what 7 they ought to do to affect the investigation. 8 The practicality is that there is, in my 9 view, no good alternative; it simply could not be 10 arranged to have a coroner in those remote areas that's 11 full time. It just wouldn't be practical. 12 MR. MARK SANDLER: Of the questions 13 that -- 14 COMMISSIONER STEPHEN GOUDGE: And the 15 remoteness prevents triaging so that criminally 16 suspicious death would go to a particular set -- subset 17 of coroners -- 18 DR. ANDREW MCCALLUM: That's right. 19 COMMISSIONER STEPHEN GOUDGE: -- or even 20 -- that's just impractical? 21 DR. ANDREW MCCALLUM: Yes, sir. But I 22 think that the regional coroner's system is very 23 important to ameliorate that difficulty, and we can -- 24 COMMISSIONER STEPHEN GOUDGE: And where 25 possible, to stream the death investigation specialty


1 or...? 2 DR. ANDREW MCCALLUM: No, I -- I wouldn't 3 argue that, but what I would argue is that we need to be 4 involved in decision-making around the investigation at 5 the earliest time possible. 6 COMMISSIONER STEPHEN GOUDGE: So what 7 happens in the investigation as opposed to which -- 8 DR. ANDREW MCCALLUM: Correct. 9 COMMISSIONER STEPHEN GOUDGE: -- coroner 10 -- 11 DR. ANDREW MCCALLUM: Where is the post- 12 mortem going to be done? Where -- who's going to do it? 13 What -- what kinds of information ought to be given to 14 the forensic pathologist? What sorts of information 15 should the police be expected to gather as part of the 16 coroner's investigation -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. ANDREW MCCALLUM: -- and so on, and 19 that comes with experience. The -- the advantage that I 20 and my colleagues have is that we see or hear of forty 21 (40) cases a year, so it assists us in maintaining our 22 currency and we can provide guidance. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 25 CONTINUED BY MR. MARK SANDLER:


1 MR. MARK SANDLER: Just -- the 2 Commissioner anticipated the next question, and I just 3 want to follow up on it. I know that in the OPP model, 4 there are senior investigators that, as a result of 5 triaging, that are sent to smaller communities to conduct 6 an investigation. 7 And so the question arises, recognizing 8 the difficulty in having a full time coroner in a remote 9 community, is triaging impractical given the -- the 10 limited number of cases that we're talking about? 11 DR. ANDREW MCCALLUM: I -- I think -- my 12 view is -- personally, that it is impractical because we 13 do rely on physicians who are in full time practice too - 14 - so to say to them, you need to leave your practice, 15 you've got fully booked office hours for the next two (2) 16 days, you've got to give that up now and go somewhere and 17 spend two (2) days -- when, to be frank, the -- the value 18 added by doing that, I think, would be limited. 19 I wouldn't think it would be a very 20 practical use of our time, although it might, at first 21 glance, seem attractive. 22 MR. MARK SANDLER: Okay. Now, I noted 23 from the guidelines for death investigation that exist, 24 that -- that it is suggested that a request for an 25 investigating coroner should result in a telephone


1 response within thirty (30) minutes. 2 How does that work in practice? Can you 3 meet -- can you meet that guideline generally or...? 4 DR. ANDREW MCCALLUM: Candidly, no. 5 MR. MARK SANDLER: All right. 6 DR. ANDREW MCCALLUM: You know, I think 7 we can in the large urban areas. I think in the remote 8 areas it's not met. 9 MR. MARK SANDLER: Okay. How does the 10 Regional Supervising Coroner become aware of one (1) of 11 these deaths? You made reference to the fact that -- 12 that you had hoped that you would be informed and -- and 13 you'd like to have better tracking facility to -- to 14 ensure that you're informed in these cases. 15 Just take the Commissioner through the 16 process in which you do get informed in these cases. 17 DR. ANDREW MCCALLUM: Well, what happens 18 now, in eastern Ontario, is that if there is a criminally 19 suspicious or homicide type case, they call me and the 20 coroner calls me, and that is, I can say, uniformly done 21 at the moment. 22 That hasn't always been so, and it's been 23 a process of evolution. There were times in the past, 24 when I first started, that I would hear about a case 25 because it was in the papers. And that, of course, is a


1 -- not an ideal circumstance, so I've worked hard with 2 the coroners to adjure them to call me and to advise me 3 of what's going on with these cases, and I would say they 4 do it now universally. 5 MR. MARK SANDLER: All right. And that 6 would include criminally suspicious or homicide cases. 7 Would it include any pediatric cases, even if they 8 present at first instance as say a SIDS case? 9 DR. ANDREW MCCALLUM: They are required 10 to call me about all pediatric cases because -- 11 COMMISSIONER STEPHEN GOUDGE: That's 12 deaths under five (5)? 13 DR. ANDREW MCCALLUM: Yes. And in fact, 14 the fact that they call me about all pediatric cases, 15 because deaths in children are -- are uncommon, of 16 course, and they present, as this Commission -- 17 Commission knows only too well, special challenges, so 18 I've asked them to call me. 19 MR. MARK SANDLER: All right. 20 COMMISSIONER STEPHEN GOUDGE: By all, you 21 mean deaths of children -- 22 DR. ANDREW MCCALLUM: Children, period. 23 COMMISSIONER STEPHEN GOUDGE: -- above 24 five (5). 25 DR. ANDREW MCCALLUM: Yeah. And I don't


1 always hear about it in the immediate period, especially 2 if it's a case that appears to be purely medical -- 3 COMMISSIONER STEPHEN GOUDGE: Right. 4 DR. ANDREW MCCALLUM: -- but in general, 5 I do hear about them -- 6 COMMISSIONER STEPHEN GOUDGE: Right. 7 DR. ANDREW MCCALLUM: -- and certainly 8 all the criminally suspicious cases -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. ANDREW MCCALLUM: -- and all the 11 unexplained deaths. 12 COMMISSIONER STEPHEN GOUDGE: Right. 13 14 CONTINUED BY MR. MARK SANDLER: 15 MR. MARK SANDLER: Now I know, as you 16 mentioned earlier, that you'd -- you'd like to see a 17 better capacity for tracking the cases that make their 18 way to your coroners. 19 What I'm taking from what you say is 20 that's less a need in the kinds of cases that this 21 Commission is examining, but more a need in the -- in the 22 balance of the cases that make their way to your local 23 coroners; is that a fair comment? 24 DR. ANDREW MCCALLUM: Correct. And given 25 that what the Commission is seeing is the very small tip


1 of the iceberg in terms of the total case volume. We 2 desperately need to know about the other 99 percent of 3 cases at the earliest time possible. 4 MR. MARK SANDLER: Okay. In your region, 5 does the coroner always attend the scene? 6 DR. ANDREW MCCALLUM: I would say in the 7 urban areas, yes. I do have to deal with, at times, 8 situations where the coroner hasn't attended the scene. 9 My dictum or direction to them is that they must consult 10 with me if they're not going to attend the scene and move 11 the body prior to doing so, so that we can make a 12 decision together. 13 Sometimes it's appropriate. We certainly 14 don't want, for example, a doctor who's attending to the 15 needs of the living to leave that circumstance. It may 16 not be possible to do that. 17 So in circumstances there -- like that, it 18 may be necessary to transfer the body, but it should 19 never be done at the expense of the investigation. 20 MR. MARK SANDLER: All right. When we 21 were talking about the communities that are more remote, 22 would it be the rule or the exception that the coroner 23 would -- would attend the scene in the kinds of cases 24 that we're looking at here, namely criminally suspicious 25 or potential homicides involving children?


1 DR. ANDREW MCCALLUM: It would be the 2 rule that they would attend in those circumstances where 3 there's a heightened concern about the origin of the 4 injury that lead to the death, or -- or the fact of 5 whether or not there is injury that lead to the death. 6 MR. MARK SANDLER: All right. Now there 7 are a variety of police services within your region. 8 Your region is covered in -- by a -- by a number of 9 police services including the OPP, Municipal Forces and 10 the like. 11 Are there different responses by police 12 services as part of the coronial investigation depending 13 on which service is involved? 14 DR. ANDREW MCCALLUM: I think there are, 15 and I see it as largely related to resourcing. A very 16 small police force may have difficulty providing the 17 kinds of resources needed for a complex death 18 investigation. Whereas, the OPP has the ability to bring 19 to bear, for example, as you alluded to earlier, the 20 detective inspector from the criminal investigation 21 branch and so on. 22 So that's what I notice, is that the 23 smaller communities will have less capacity to deal with 24 complex death investigations. 25 But in the main, they do have ways and


1 means to get assistance from, for example, the OPP. Most 2 of the small communities have an agreement so they can 3 get CIV involved when -- when needed. 4 MR. MARK SANDLER: All right. Well now, 5 could you explain to the Commissioner how your role 6 continues as one (1) of the cases that we're looking at 7 makes it way through the system? 8 DR. ANDREW MCCALLUM: Well, once the -- 9 once I've been involved and have given direction and 10 advice to the coroner about where the autopsy ought to be 11 done, then my next job would be to ensure there's liaison 12 with the pathologist, so the pathologist is familiar with 13 the circumstances of the case, so that he or she can do 14 an appropriate post-mortem examination. 15 That police are -- 16 MR. MARK SANDLER: Now -- I'm sorry. Now 17 just stop there for a moment, I'm sorry to interrupt you. 18 But I suspect we know much of this as a result of what's 19 been heard about your region, but can you explain again, 20 dealing with the kinds of cases that we're looking at 21 here, which pathologists they would go to now? 22 DR. ANDREW MCCALLUM: At present? 23 MR. MARK SANDLER: Yes. 24 DR. ANDREW MCCALLUM: If they're -- 25 you're speaking now about pediatric cases?


1 MR. MARK SANDLER: Right. 2 DR. ANDREW MCCALLUM: Yeah. Pediatric 3 cases that are criminally suspicious or homicide cases 4 are all being done in Toronto from my region at the 5 present time. 6 MR. MARK SANDLER: All right. And what 7 about those cases that initially present as -- as a 8 potential SIDS case? Would those invariably go to 9 Toronto? 10 DR. ANDREW MCCALLUM: No. No, they would 11 not. If there were not issues in the background of the 12 case that suggested concern about something else going on 13 besides SIDS, they might well be done at CHEO where there 14 are competent pediatric pathologists who have significant 15 forensic experience. 16 MR. MARK SANDLER: Now just stopping 17 there for a moment, and I know I interrupted your earlier 18 answer, but this seems as good a time as any to raise the 19 issue. Let's take the scenario where the case initially 20 presents as a SIDS, and -- and you know what I mean by 21 that, a case that doesn't -- that doesn't raise red flags 22 other than the need for a thorough investigation. 23 The case goes to CHEO, a pathologist 24 becomes involved in the case, and the events demonstrate 25 that there are now causes for suspicion. For example,


1 the finding of a -- of a fracture of a bone within the 2 child's body as a result of x-ray. 3 What do you see as the model for how that 4 case should be dealt with? 5 DR. ANDREW MCCALLUM: Well, we had such a 6 case, very recently actually, where a child who had died 7 in -- hard to understand circumstances. It was not a 8 SIDS, but the child died without any real understanding 9 of why the death occurred, in hospital. 10 And autopsy was ordered at CHEO and 11 started and the pathologist discovered an unusual defect 12 in the skull of the baby which she thought might be a 13 fracture. So what she did was appropriately stop. She 14 called me. We had a discussion about next steps. 15 We involved Michael Pollanen. There was 16 an exchange of digital photographs. Michael and the 17 pathologist from -- from CHEO decided that it really 18 looked like it was a congenital defect in the skull, and 19 not, in fact, a fracture. 20 So they decided the -- the pm could 21 continue there which it did, and indeed, it was not a 22 fracture. It had nothing at all to do -- it was just an 23 incidental finding. But, of course, at the outset it 24 wasn't clear that was the case. 25 So that's an example of how the system


1 would work now, and I think it worked well in that 2 circumstance. 3 MR. MARK SANDLER: All right. And -- and 4 can I take it that by analogy, that -- because that 5 wasn't strictly speaking a SIDS case, but that if -- 6 DR. ANDREW MCCALLUM: Correct. 7 MR. MARK SANDLER: -- a SIDS case were 8 presented, the autopsy commenced at CHEO, and again 9 something would come to light that would raise issues as 10 to whether this is a suspicious death or a homicide, 11 would you envisage the same kind of process? 12 The autopsy stops; a consultation takes 13 place, facilitated by you to see what should happen from 14 then on? 15 DR. ANDREW MCCALLUM: Yes. 16 MR. MARK SANDLER: All right. 17 COMMISSIONER STEVEN GOUDGE: Suppose that 18 case had demonstrated a fracture that looked like a 19 fracture, not a congenital defect. What would have 20 happened -- 21 DR. ANDREW MCCALLUMS: Well -- 22 COMMISSIONER STEVEN GOUDGE: -- with the 23 consultation through the digital photography? 24 DR. ANDREW MCCALLUM: Well, there would 25 have been several options.


1 One (1) would have been to have one (1) of 2 the forensic pathologists from here go up to Ottawa to 3 participate in the further examination. 4 COMMISSIONER STEVEN GOUDGE: Right. 5 DR. ANDREW MCCALLUM: One (1) would have 6 been to move the body to Toronto. 7 COMMISSIONER STEVEN GOUDGE: Right. 8 DR. ANDREW MCCALLUM: And a third option, 9 and this is one (1) that could have been discussed, would 10 have been to have the autopsy continue there with the 11 involvement of Dr. Pollanen in every stage by 12 telemedicine, as it were. 13 COMMISSIONER STEVEN GOUDGE: And what 14 facilities are available for that? 15 DR. ANDREW MCCALLUM: In -- at Ottawa? 16 COMMISSIONER STEVEN GOUDGE: Yeah. 17 DR. ANDREW MCCALLUM: There -- there's a 18 full autopsy suite staffed by pediatric pathologists who 19 have forensic experience at CHEO. 20 COMMISSIONER STEVEN GOUDGE: And how do 21 you do the telemedicine? 22 DR. ANDREW MCCALLUM: Well, they would do 23 it by digital photography, and -- 24 COMMISSIONER STEVEN GOUDGE: Okay. So -- 25 DR. ANDREW MCCALLUM: -- electronic


1 transmission. 2 COMMISSIONER STEVEN GOUDGE: -- there's 3 no sort of live interchange -- 4 DR. ANDREW MCCALLUM: Not at present, to 5 my knowledge, no. 6 COMMISSIONER STEVEN GOUDGE: Okay. 7 8 CONTINUED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: All right. Now, in -- 10 in some of the cases that are under consideration here, 11 we've heard that there's been an issue surrounding the 12 hospital records making their way to the forensic 13 pathologist. 14 And those hospital records may reflect a 15 stay in the hospital on the part of the deceased, or they 16 may simply reflect the efforts made to -- to address the 17 child while in extremis on the day that the child died, 18 or shortly before the child died. 19 Can you explain what your understanding is 20 as to how the hospital records, should and can, make 21 their way to the forensic pathologist, whether it's at 22 CHEO, or -- or Toronto? 23 DR. ANDREW MCCALLUM: They would be 24 subject to seizure by the coroner's warrant, and the 25 procedure would be that the police would carry, or


1 transmit -- ensure the transmission of copies of the 2 record go to the hospital where the post-mortem is to be 3 done. 4 In Ottawa, for example, it's not much of 5 an issue because the records are there because it's in 6 the same hospital. It doesn't -- it doesn't make as much 7 of a -- much of an issue. 8 In other communities in my region, it's 9 necessary to ensure that the records go with the body 10 when transported to the hospital. 11 MR. MARK SANDLER: And I think the 12 concern is -- is not that that doesn't happen on 13 occasion, but ensuring that it's going to happen, as a 14 matter of course, in each and every cases -- that we look 15 at. 16 Do you have any suggestions or -- or 17 ideas, as to how one can ensure that that's the case? 18 DR. ANDREW MCCALLUM: Oh, I'm confident 19 it happens in my region because I'm involved in all these 20 cases. 21 And so the involvement of the regional 22 coroner, again, is very important to assist in making 23 sure those checklist items get done. Very important. 24 MR. MARK SANDLER: All right. We've 25 heard that the Coronial System is very mindful of the


1 distinction between a coronial investigation and a 2 criminal investigation, and what path -- when some of 3 these powers stop and start within the process. 4 Let's assume that the case presented right 5 from the outset as -- as highly suspicious, or -- or 6 almost inevitably a -- a homicide case. 7 Again, how would the hospital records be 8 dealt with, and what would the coroner's role, as you see 9 it, be in that process? 10 DR. ANDREW MCCALLUM: Well, review of the 11 hospital records is part of the necessary preparation for 12 an autopsy to be done by a pathologist which is a -- a 13 medical act. 14 And therefore, in my view, the records can 15 properly be seized under coroner's warrant to assist the 16 pathologist, and the coroner, in understanding the 17 medical background of the -- the case. 18 So if it's necessary to review them for 19 criminal purposes later on, of course, that goes outside 20 my purview, and I -- I wouldn't necessarily be able to 21 comment on that. 22 But the actual initial seizure of the 23 record is perfectly within the mandate of the coroner's 24 investigation, in my view. 25 MR. MARK SANDLER: I know, Dr. Eden, that


1 you've -- you've engaged in some education over this 2 issue. Do you agree with Dr. McCallum in that regard? 3 DR. DAVID EDEN: Oh, certainly. The -- 4 the coroner has a -- has the jurisdiction to determine 5 the answers to the five (5) questions, including the 6 cause and manner of death, and medical records often 7 provide critical information in making that 8 determination. 9 But it's one (1) thing for the coroner to 10 personally seize those records. What would be 11 inappropriate, and this is further to the Supreme Court's 12 ruling in Collaruso, is for the coroner to hand a warrant 13 to the criminal investigating office, and say, Go get me 14 the cri -- the medical record, because the criminal 15 investigator should not be using information gathered 16 from a coroner's warrant. 17 But for the coroner to obtain that 18 information, and then use it as part of the -- part of 19 the coroner's determination, in my view, is quite 20 appropriate. And certainly my reading of Colarusso is 21 that that's what the Supreme Court expects of the 22 coroner. 23 MR. MARK SANDLER: Okay. Now, Dr. 24 McCallum, I'm going to ask you one (1) other question at 25 this point in the examination, and then return to it a


1 little bit later, and that is that -- where are the 2 offices of the Regional Supervising Coroner located 3 within your region? 4 DR. ANDREW MCCALLUM: Well, there are two 5 (2) within my region, and this is consequent to the 6 evidence of Dr. Legge where we had changes in our 7 administrative boundaries because of the provincial 8 changes, so there is one (1) in Peterborough and one (1) 9 in Kingston, where I work. 10 MR. MARK SANDLER: All right. Do you see 11 some value in -- in marrying up the location of the 12 Regional Supervising Coroner's Office and -- and the 13 location where the pathologists perform their autopsies? 14 DR. ANDREW MCCALLUM: I do. 15 MR. MARK SANDLER: All right. Is there 16 consideration being given to -- to that possibility 17 within your region? 18 DR. ANDREW MCCALLUM: I don't know, to be 19 honest with you. You would have to ask the Chief Coroner 20 that at the present time, but certainly it's -- with the 21 change in the boundaries, it would make some sense to 22 have one (1) of the offices moved to Ottawa, which is 23 where the other -- there are two (2) forensic pathology 24 units in the region, one's Kingston and one (1) is 25 Ottawa.


1 COMMISSIONER STEPHEN GOUDGE: Do you 2 split your time? 3 DR. ANDREW MCCALLUM: Do I -- you mean, 4 am I in Ottawa a good deal, yes. 5 COMMISSIONER STEPHEN GOUDGE: All right, 6 but do you go Peterborough, too? I mean do you -- 7 DR. ANDREW MCCALLUM: No, I don't, Dr. 8 Peter Clark is the regional coroner responsible for that 9 area. 10 11 CONTINUED BY MR. MARK SANDLER: 12 MR. MARK SANDLER: Okay. Well, I will -- 13 I promise I will return to the eastern region a little 14 bit later, Dr. McCallum, but if I may turn to you, Dr. 15 Legge. 16 DR. DAVID LEGGE: Yes. 17 MR. MARK SANDLER: I'm going to ask you 18 some similar questions about the northwestern region, as 19 it was then called -- the north region, as it's now 20 called. You described the boundaries of your region to 21 the Commissioner a little bit earlier in your testimony. 22 Could you just give the Commissioner a 23 little bit of a snapshot of the -- some of the remote 24 communities that are serviced by your region? 25 DR. DAVID LEGGE: Well, the -- the region


1 is very heterogeneous, even more than Dr. McCallum's 2 region, with remote areas being anywhere from say 100 3 kilometres to 1,000 or 1,200 kilometres away from a major 4 centre, and even a major centre might be Thunder Bay, for 5 example. 6 If you look at the map, and many of you 7 have at scale, you might find a place like Peawanuck, 8 which is right up on James Bay, pretty well -- I mean, 9 that is a long, long way away. 10 And a death investigation there would 11 present tremendous challenges in terms of living up to 12 the standard that has been promulgated here in Toronto. 13 MR. MARK SANDLER: And I'm going to ask 14 you a little bit more -- 15 DR. DAVID LEGGE: Yeah. 16 MR. MARK SANDLER: -- about that in a few 17 moments. 18 DR. DAVID LEGGE: Let's head further 19 south. You come to a fairly large First Nation community 20 -- let's say Big Trout Lake -- which is still a long, 21 long way from Kenora or Thunder Bay. All of these are 22 serviceable by air, but not always can you get in because 23 of weather. And some of them are serviceable by a winter 24 road, and with climate change, some of the winter roads 25 aren't even passable.


1 And then you have a number of communities 2 that are linked by road to the Trans-Canada highway 3 system -- let's say a place like Hornepayne or Longlac -- 4 where you may or may not have any coroner at all. 5 MR. MARK SANDLER: All right. 6 DR. DAVID LEGGE: And these -- these 7 communities may be, for example, largely Francophone, so 8 there -- there's quite a bit of heterogeneity. There's - 9 - there are certainly many communities that are remote 10 that are part of the -- the native community, which are 11 almost entirely First Nations, others that are quite a 12 mixture, and some that are almost entirely Francophone. 13 MR. MARK SANDLER: All right. 14 DR. DAVID LEGGE: That's a start to your 15 question. 16 MR. MARK SANDLER: It is. 17 DR. DAVID LEGGE: I -- I could probably 18 go on, yeah. 19 MR. MARK SANDLER: It's a good start. 20 DR. DAVID LEGGE: Yeah. 21 MR. MARK SANDLER: How many cases are 22 investigated by the coroners in your region per year? 23 DR. DAVID LEGGE: I would think about 24 twelve hundred (1,200) plus a few extra. There -- there 25 are some that are difficult cases that end up going down


1 to Toronto, for example, for tertiary care and end up 2 dying there -- 3 MR. MARK SANDLER: All right. 4 DR. DAVID LEGGE: -- where -- where the 5 real action was in the North, but that's not a large 6 number. 7 MR. MARK SANDLER: And you've said that 8 your understanding is with the increase in the -- in the 9 region size, that there are approximately sixty (60) 10 coroners that service that region presently. 11 DR. DAVID LEGGE: Dave -- Dr. Eden might 12 have a slightly more definitive answer; I think it's 13 about sixty (60). 14 DR. DAVID EDEN: It's sixty (60) 15 coroners. And just to add to Dr. Legge's reply, that -- 16 his answer was for the northwest region as it existed 17 until December 31st. 18 The region as it exists now, from Parry 19 Sound to the Manitoba border -- we don't have a full 20 year, of course -- but from looking at the numbers in 21 those regions from previous years, we anticipate about 22 twenty-one hundred (2,100) cases per year. 23 MR. MARK SANDLER: All right. And, Dr. 24 Eden, I'm -- I'm going to give you the luxury that isn't 25 always accorded to some of our panel members, and I'm


1 directing the questions to Dr. Legge because of his 2 lengthy involvement in that region. 3 If -- if recent events have either changed 4 the information, then -- then please feel free to -- to 5 step in and -- and assist us any way you can. 6 DR. DAVID EDEN: Okay. 7 MR. MARK SANDLER: So -- so we've got 8 that number of coroners, and Dr. Legge, I'll ask you, are 9 -- are they full-time or part-time coroners? 10 DR. DAVID LEGGE: They're all very much 11 part-time. 12 MR. MARK SANDLER: All right. 13 DR. DAVID LEGGE: They're part-time 14 because most of them have very low volumes, and because 15 they have low volumes, there -- there is some resistence 16 to bringing in new coroners to a particular community 17 because that would -- there were be a dilutional effect 18 there -- 19 MR. MARK SANDLER: All right. 20 DR. DAVID LEGGE: -- which would reduce 21 their skill level. 22 MR. MARK SANDLER: And -- and I'm 23 assuming from everything that you've said, and that Dr. 24 Eden has said earlier, that many, many of these remote 25 communities do not have resident coroners.


1 DR. DAVID LEGGE: Yes, absolutely. 2 MR. MARK SANDLER: All right. And I 3 asked Dr. McCallum about the profile generally of those 4 who serve as part-time coroners, and I'll ask the same 5 question of -- of you. 6 Are these family physicians, or -- or can 7 you help me out as to that? 8 DR. DAVID LEGGE: I would say that 9 virtually -- well, 95 to 100 percent of all physicians in 10 the -- in the -- in that area of the North are family 11 physicians. And I'm -- I'm quite sure that all of them - 12 - all of the coroners that I had were family physicians. 13 MR. MARK SANDLER: All right. Do you 14 have -- 15 DR. DAVID LEGGE: But -- but many of them 16 will do extra work out of requirement, such as 17 anaesthesia for example -- 18 MR. MARK SANDLER: Sure. 19 DR. DAVID LEGGE: -- in a local hospital. 20 MR. MARK SANDLER: Are there any coroners 21 who are Aboriginal? 22 DR. DAVID LEGGE: No. 23 MR. MARK SANDLER: Is that a concern? 24 DR. DAVID LEGGE: Yeah -- well, it is a 25 concern. It's been a known fact for years and we've


1 worked in the absence of such, and having an Aboriginal 2 coroner would be wonderful. 3 MR. MARK SANDLER: All right. Do you see 4 in the future some ways in one could increase the 5 likelihood that -- that Aboriginal coroners could serve 6 at your region? 7 DR. DAVID LEGGE: I'm sure many of you 8 are aware that there is a new medical school in the 9 North, with campuses at Laurentian University, Sudbury, 10 and one (1) in Thunder Bay. And I'm sure that part of 11 their mandate is to include Aboriginal students in -- in 12 the medical undergraduate program. I know they are 13 there. 14 Clearly down the line, if -- if we could 15 graduate Aboriginal doctors who would be also taught some 16 forensic medicine, and have some input into our system, 17 and wanted to go back to these communities, it would be 18 clearly a great advantage. 19 That's well into the future, though. It's 20 several years off, at least, I'm sure. 21 MR. MARK SANDLER: All right. 22 COMMISSIONER STEVEN GOUDGE: When will 23 the medical schools start to graduate people? Or do you 24 know? 25 DR. DAVID LEGGE: One (1) or two (2)


1 years, I think. I think they've been into it about two 2 (2) years now. 3 COMMISSIONER STEVEN GOUDGE: Right. 4 DR. DAVID LEGGE: Yeah. 5 COMMISSIONER STEVEN GOUDGE: And they 6 have a preference for taking students from the North, and 7 from -- 8 DR. DAVID LEGGE: Yes. 9 COMMISSIONER STEVEN GOUDGE: -- 10 particularly Aboriginal communities -- 11 DR. DAVID LEGGE: I believe so. I don't 12 know what their formula is. They probably will have 13 other students that are mature-type students -- 14 COMMISSIONER STEVEN GOUDGE: Right. 15 DR. DAVID LEGGE: -- and what have you. 16 It's a lot different than when -- when I went to medical 17 school. Totally different. 18 COMMISSIONER STEVEN GOUDGE: All right. 19 20 CONTINUED BY MR. MARK SANDLER: 21 MR. MARK SANDLER: The -- the issues that 22 we're talking about raise -- raise two (2) related issues 23 for me that I want to ask all of you about. 24 The first is this: That one (1) of the 25 things that you want to see happen is -- is not only


1 heightened involvement of Aboriginal physicians, but I 2 take it a heightened interests from medical school on in 3 doing the work of a coroner. 4 DR. DAVID LEGGE: Mm-hm. 5 MR. MARK SANDLER: Is that a fair 6 comment? 7 DR. ANDREW MCCALLUM: It is. 8 MR. MARK SANDLER: Do you see the -- the 9 medical schools sufficiently addressing forensic science, 10 so as to encourage doctors to be interested in coronial 11 work? I'll ask Dr. McCallum that first. 12 DR. ANDREW MCCALLUM: I would say no, and 13 I think that the -- in fairness to the medical schools, 14 their curriculum now is so jammed in the four (4) year 15 period that's available to them that they have great 16 difficulty getting all of the necessary knowledge into 17 the student's heads. 18 So that's probably what's happened is, 19 that this is not something that is central to the work of 20 most doctors, and, so therefore there's not as much 21 exposure to forensic medicine as one would like ideally. 22 And as you've heard I think from other 23 witnesses, in the UK for example, that's not -- that's 24 not the case. And often it's the course that's favoured 25 by medical students, because it's interesting, it's


1 different. And I suspect that we would see -- see the 2 same effect here. 3 So I think that would be a very good thing 4 to encourage; exposure to forensic medicine. 5 MR. MARK SANDLER: All right. Dr. 6 Eden...? 7 DR. DAVID EDEN: If -- if I could add to 8 that. One (1) thing that's certainly known in the field 9 of medicine, and I think in most fields, is that 10 mentoring is a very valuable means of recruitment. So if 11 medical students have access to work with forensic 12 physicians, then that will encourage them to look at that 13 field further. 14 The other thing though, just from a 15 general public safety viewpoint, is that one (1) of the 16 things that we as coroners have identified in medical 17 care is that sometimes physicians lack a forensic 18 approach to cases. 19 And we've had situations where, for 20 instance, a child was brought into emerg with injuries 21 that were not consistent with what parents described, and 22 the physician has not been suspicious enough, and -- or 23 the -- or the nurses. And I could see a value to 24 providing that sort of forensic training to physicians, 25 just as -- much of it -- the same as what we tell our


1 coroners, which is that you look with your own eyes and 2 assess what you're being told in light of your own 3 clinical knowledge. 4 So I -- I wouldn't see this simply as for 5 the coroner's system only, but actually to enhance the 6 skills of physicians. 7 MR. MARK SANDLER: All right. Dr. Legge, 8 did you want to add anything to what your colleagues have 9 said? 10 DR. DAVID LEGGE: Well, just from my own 11 personal experience, over the years I have given appro -- 12 approximately once yearly lecture to the senior med 13 students on forensic medicine. They just love it. They 14 eat it up. 15 However, I -- I don't know what the -- the 16 people in charge of the curriculum are doing about this. 17 MR. MARK SANDLER: All right. 18 COMMISSIONER STEPHEN GOUDGE: You're 19 speaking of the Lakehead? 20 DR. DAVID LEGGE: Yeah, I'm speaking of 21 the -- I'm speaking of the Lakehead and the residency 22 programs that have been there for years. 23 And one (1) other example, if I may, I - I 24 have one (1) quite good young, very keen coroner who is 25 now established in Hornepayne, which is a very small


1 place. The rea -- the reason he decided to become a 2 coroner, I think, is relating to the fact he became 3 excited about -- I'm sort of bragging here, but he came 4 to an inquest I was presiding over and thought it was so 5 interesting, and there was opportunity for public 6 service, that he went down that path. 7 I mean, that was a bit serendipitous 8 perhaps. 9 10 CONTINUED BY MR. MARK SANDLER: 11 MR. MARK SANDLER: All right. 12 DR. DAVID LEGGE: So that's just one (1) 13 -- one (1) little story. 14 MR. MARK SANDLER: Now -- now I said that 15 -- that two (2) issues were raised. One (1) had to do 16 with forensic sciences and coronial work being taught 17 about or encouraged in the medical schools, and the other 18 is the extent to which, in the medical schools, students 19 are taught about Aboriginal health issues. 20 And I know Dr. McCallum at -- at my 21 request, you -- you've made an inquiry in that regard. 22 Can you assist the Commissioner as to the extent to which 23 that is or isn't happening? 24 DR. ANDREW MCCALLUM: Well, it's a -- I 25 had the opportunity to speak to Dr. Alan Neville who is


1 the -- in charge of the undergraduate medical curriculum 2 at McMaster, who happens to be leading a -- an initiative 3 that's Canada-wide through the Canadian Federation of 4 Medical Schools. 5 And I may have that organization wrong. 6 But it's the -- it's the governing umbrella body for 7 medical schools in Canada. 8 And public health and First Nation's 9 health are the two (2) themes that they are emphasizing 10 in undergraduate medical edu -- education as, if you 11 like, social health integration themes, and so it's very 12 much in the forefront at the moment. And there -- I 13 can't tell you the specifics of how they're going to 14 enhance or change the curriculum to meet those goals, 15 particularly the First Nation's goal, but it is very much 16 on their minds. 17 And when I called him he was quite happy 18 to hear that this is going to be part of the focus of 19 this Inquiry, as well. 20 MR. MARK SANDLER: All right. And, Dr. 21 Legge, the reason I raise that topic is because I know 22 you and I have spoken in the past about the fact that the 23 coroners that operate in the north region have varying 24 levels of experience or understanding or training on -- 25 on Aboriginal issues.


1 Is that a fair comment? 2 DR. DAVID LEGGE: Well, I think that some 3 communities are largely non-Aboriginal, in terms of their 4 demographic, others are very, very high. So that for 5 example, the -- the two (2) coroners who are veterans and 6 are as good as gold as far as I'm concerned, in Sioux 7 Lookout are very familiar with Aboriginal needs, 8 requirements and problems, and I think have a good 9 relationship in their dealings, except for the major 10 problem that I'm sure you're going to ask me about later 11 on, and that is the business of going to scenes. 12 MR. MARK SANDLER: Right. 13 DR. DAVID LEGGE: And just returning back 14 to medical school, I know that the Northern Ontario 15 Medical School does have quite a bit of Aboriginal 16 content in it. 17 In fact they have -- they're not even 18 electives, they're -- they're required slots where they 19 go out to communities and interact with First Nations 20 peoples, and they go to sweat lodges and that sort of 21 thing. That's a required part of the curriculum now, so 22 clearly, it's very encouraging. 23 MR. MARK SANDLER: Okay. 24 DR. DAVID LEGGE: But like anything else 25 in medical school, it's going to take years before it


1 sort of sees fruition, perhaps. 2 MR. MARK SANDLER: All right. Now -- and 3 I should ask you, in that score, apart from what's being 4 done in the medical schools, is there separate training 5 that you're aware of for coroners on Aboriginal issues? 6 DR. DAVID LEGGE: I would say basically 7 no, and it hasn't been -- it hasn't been a feature of our 8 system here in the Office of the Chief Coroner. 9 MR. MARK SANDLER: Okay. Now I was 10 taking you through the anatomy of how cases are dealt 11 with in the North, and if I can pick up where I left off. 12 And you had -- you and Dr. Eden together had described 13 how many cases one might typically see investigated 14 within the coronial system in the North in a year. 15 How many criminally suspicious or homicide 16 cases might we expect out of that range of twenty-one 17 hundred (2,100) now anticipated? I'll ask Dr. Legge and 18 Dr. Eden. 19 DR. DAVID LEGGE: Well, I'll -- I'll just 20 kind of guestimate, if I may, for -- for the -- the 21 region that I had, which is not the new expanded region. 22 Well, in Thunder Bay, there's three (3) or four (4) 23 homicides a year, and in the Kenora area, Grassy Narrows, 24 and up in some of those areas, four (4), five (5), or six 25 (6) per year, and scattered around the rest of the


1 region, so maybe ten (10) or twelve (12) homicides a 2 year; and a number of additional criminally suspicious 3 deaths, not -- not large numbers. 4 And I don't -- I don't think you would get 5 the numbers that would emanate out of major centres like 6 say Ottawa and Kingston, so it would probably be a little 7 bit -- a little bit less than Dr. McCallum, and that's a 8 bit of a guestimate. I didn't prepare an exact figure 9 for you. 10 MR. MARK SANDLER: Fair enough. 11 DR. DAVID LEGGE: Mm-hm. 12 MR. MARK SANDLER: And -- and out of 13 those cases, if -- if we were to look at sudden and 14 unexpected deaths of children, whether they ultimately 15 are treated as homicide cases, can you give me some sense 16 of what those kinds of numbers might be? 17 DR. DAVID LEGGE: Very low numbers of 18 homicides, I believe, in -- in children under five (5). 19 MR. MARK SANDLER: I think I had asked a 20 little bit -- 21 DR. DAVID LEGGE: Very low. 22 MR. MARK SANDLER: -- broader category, 23 which is, if one were to lump in cases of homicides 24 involving children, as well as cases that initially 25 present as SIDS and may ultimately turn out to be SIDS


1 cases. 2 Can you give me some rough sense of what 3 the kinds of numbers of those -- 4 DR. DAVID LEGGE: I'm not quite -- 5 MR. MARK SANDLER: -- category of cases 6 might be? 7 DR. DAVID LEGGE: I'm -- please just -- 8 COMMISSIONER STEPHEN GOUDGE: Take the 9 total deaths under five (5) and remove only the cases 10 that are obviously medical. 11 DR. DAVID LEGGE: I -- I think there's a 12 fair percentage of those that are accidental. I'm 13 speaking -- 14 COMMISSIONER STEPHEN GOUDGE: What would 15 the pool -- what would the number be out of -- 16 DR. DAVID LEGGE: Oh. 17 COMMISSIONER STEPHEN GOUDGE: -- given 18 anything. Would it be the same range of ten (10) to 19 twelve (12) a year, maybe? 20 DR. DAVID LEGGE: Perhaps, yeah, I think 21 so, yeah. 22 COMMISSIONER STEPHEN GOUDGE: It sort of 23 matches -- 24 DR. DAVID LEGGE: Yeah. 25 COMMISSIONER STEPHEN GOUDGE: -- the kind


1 of percentages we've been given about homicides over the 2 entire population of that number. 3 4 CONTINUED BY MR. MARK SANDLER: 5 MR. MARK SANDLER: All right. So, moving 6 ahead against -- against that background, do you have 7 enough coroner's in your region? 8 DR. DAVID LEGGE: That's an excellent 9 question. There's a catch-22. We -- we -- the -- the 10 whole huge problem up there is that coroners do not get 11 to the scenes in many situations, and it would ideal if 12 they did. 13 On the other hand, if we had a coroner in 14 each little whistle stop, they might get one (1) or two 15 (2) cases a year, and that -- that wouldn't work out 16 particularly well. There's a lot of variables up there. 17 There -- there may well be completely 18 adequate coronial coverage in Sioux Lookout, but then on 19 a given day, both of them might be away somewhere, so 20 that there -- we have this phenomenon of cross coverage. 21 We all know each other; we're all sort of 22 friends, the coroner and the -- the police might get a 23 hold of the Dryden coroner, for example, who would then 24 take this case on remotely, or they might get a hold of 25 me.


1 I've done lots of cases as the primary 2 coroner, even though I'm the regional coroner. 3 COMMISSIONER STEPHEN GOUDGE: How do the 4 police know where to go? 5 DR. DAVID LEGGE: Well, they have their 6 networking. It's -- there's no set way of doing it. 7 COMMISSIONER STEPHEN GOUDGE: Would they 8 go to you first, as the Regional Supervising -- 9 DR. DAVID LEGGE: No, no. 10 COMMISSIONER STEPHEN GOUDGE: -- Coroner 11 or would they have their own kind of internal roster? 12 DR. DAVID LEGGE: They have their in -- 13 they have their internal way of getting a hold of these 14 people. Again, it's -- it's as simple as me -- 15 COMMISSIONER STEPHEN GOUDGE: When you 16 know some -- 17 DR. DAVID LEGGE: -- knowing -- knowing 18 that the doctor might be out on in his sailboat or 19 something that. 20 COMMISSIONER STEPHEN GOUDGE: Yes. 21 Mostly OPP, I take it. 22 DR. DAVID LEGGE: Mostly OPP, but there 23 are First Nation policing in most of the remote 24 communities. 25 COMMISSIONER STEPHEN GOUDGE: Right.


1 DR. DAVID LEGGE: Yeah. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 4 CONTINUED BY MR. MARK SANDLER: 5 MR. MARK SANDLER: So you'd be dealing 6 with Nishnawbe-Aski Police Service -- 7 DR. DAVID LEGGE: Nishnawbe-Aski Police -- 8 MR. MARK SANDLER: -- you'd be dealing 9 with Treaty 3. 10 DR. DAVID LEGGE: -- Treaty 3, 11 Anishinabek down, in say, Garden River and Sault St. 12 Marie. There's -- there's a number of different police 13 forces -- 14 MR. MARK SANDLER: All right. So -- 15 DR. DAVID LEGGE: -- NAPS, I think, is by 16 far the largest. 17 MR. MARK SANDLER: Right. 18 COMMISSIONER STEPHEN GOUDGE: And then 19 you have local police forces in some the communities. 20 DR. DAVID LEGGE: Some of the 21 communities, right. 22 COMMISSIONER STEPHEN GOUDGE: Not many, I 23 take it. 24 DR. DAVID LEGGE: Well, there's Dryden. 25 Kenora's a good example of one (1) which I think is


1 undergoing major change now and may be taken over by OPP. 2 COMMISSIONER STEPHEN GOUDGE: Right. 3 DR. DAVID LEGGE: Thunder Bay, certainly, 4 Sault St. Marie. 5 COMMISSIONER STEPHEN GOUDGE: Certainly. 6 DR. DAVID LEGGE: Kirkland Lake. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. DAVID LEGGE: No, Kirkland Lake is 9 only OPP; there's a fair amount of variety there. 10 COMMISSIONER STEPHEN GOUDGE: Right. 11 12 CONTINUED BY MR. MARK SANDLER: 13 MR. MARK SANDLER: So -- so just stopping 14 there for a moment. You've heard what Dr. McCallum had 15 to say about the ideal dispatching province-wide. It 16 sounds fairly haphazard in -- in your region as to how 17 the police services is -- is going to get a hold of -- of 18 coroner in -- in one (1) of these cases. 19 What would you like to see happen if -- if 20 you ruled the world? 21 DR. DAVID LEGGE: I -- I really like the 22 idea of province-wide dispatch system, too. I -- I think 23 there would be some bumps, though, in the North. Term -- 24 in terms -- 25 COMMISSIONER STEPHEN GOUDGE: Especially


1 in the North, where it sounds like local knowledge on the 2 part of the police is very important in contacting -- 3 DR. DAVID LEGGE: Yes. 4 COMMISSIONER STEPHEN GOUDGE: -- the most 5 available coroner. 6 DR. DAVID LEGGE: That's correct. 7 COMMISSIONER STEPHEN GOUDGE: How would 8 you centralize that? 9 DR. DAVID LEGGE: I -- well, it -- one 10 (1) points for sure, they're not always going to be 11 timely notifications to dispatch. 12 COMMISSIONER STEVEN GOUDGE: Right. 13 DR. DAVID LEGGE: And that's another area 14 for discussion. And clearly having a central system for 15 the whole province and having the -- the regional coroner 16 become aware of a case very timely would be great. 17 COMMISSIONER STEVEN GOUDGE: Yes. That 18 seems like a major step forward. 19 DR. DAVID LEGGE: Oh, it's a major step 20 forward. But I mean, I've been in trepidation for ten 21 and a half (10 1/2) years of -- of having cases not going 22 well because of a timelag before I hear about them, much 23 like Dr. McCallum, but even more -- 24 COMMISSIONER STEVEN GOUDGE: Even more 25 acutely.


1 DR. DAVID LEGGE: -- more acutely. 2 COMMISSIONER STEVEN GOUDGE: Yes -- 3 DR. ANDREW MCCALLUM: If -- if I might, 4 Mr. -- Mr. Sandler. The -- the critical model, I 5 believe has great merit for consideration, because it's 6 the -- what they do is, their call-talkers or dispatchers 7 are highly skilled, and they have great local knowledge. 8 They -- they acquired the local knowledge through 9 actively going out and seeking it, so they have -- they - 10 - they understand the local environment actually quite 11 well. 12 So they'll know the local doctors, they'll 13 know the local -- and -- and I think that they are a 14 good -- 15 COMMISSIONER STEVEN GOUDGE: Who -- 16 DR. ANDREW MCCALLUM: -- template. It's 17 -- it's a provincial program. It's actually, I think, a 18 larger unit in -- in Hamilton, actually, and I was 19 involved with it when I was there. 20 COMMISSIONER STEVEN GOUDGE: They would 21 have to develop this local knowledge of critical care 22 service providers that -- 23 DR. ANDREW MCCALLUM: Exactly. 24 COMMISSIONER STEVEN GOUDGE: -- that 25 would be quite --


1 DR. ANDREW MCCALLUM: Much -- 2 COMMISSIONER STEVEN GOUDGE: -- quite 3 sophisticated. 4 DR. ANDREW MCCALLUM: It would be very 5 sophisticated. In fact, it is very sophisticated and the 6 -- and it's very detailed as well, and they've been able 7 to do that. 8 So I -- I see no reason why a 9 sophisticated call-taking, or dispatch service for the 10 coroner's system couldn't do an analogous thing. 11 COMMISSIONER STEVEN GOUDGE: I guess what 12 I think of as sort of the local challenge is, 13 particularly in the North, is what do you do when the 14 coroner in Hornepayne is out on his sailboat? 15 DR. DAVID EDEN: And that -- if I could 16 inject -- I think that can be operationalized -- 17 COMMISSIONER STEVEN GOUDGE: Not that 18 he's out on his sailboat much. I suspect he's not but -- 19 DR. DAVID EDEN: That -- that can be 20 operationalized, in that one (1) of the resources for 21 getting hold of the coroner, if you can't get him on his 22 office, or residence, or cell phone, would be to contact 23 the local OPP detachment. And -- these are small towns 24 and -- and ob -- from the detachment you can see -- 25 COMMISSIONER STEVEN GOUDGE: So -- okay,


1 fair enough. That makes sense to me. 2 3 CONTINUED BY MR. MARK SANDLER: 4 MR. MARK SANDLER: All right. So -- so, 5 Dr. Eden, kind of finishing off on this particular point, 6 again, I asked Dr. Legge if he ruled the world what would 7 he like to see to -- to address this issue. 8 Do you have any thoughts as to what you'd 9 like to see? 10 DR. DAVID EDEN: There's no doubt in my 11 mind that having a province-wide dispatch system, and 12 that would certainly apply to the North, would be 13 important. 14 It's just going to be materially different 15 in the North, in that what's happening when the -- when 16 the coroner in town -- if there is a coroner in town and 17 if that coroner is not available, it's kind of like 18 saying, Well, we don't have -- we got a death in Oshawa, 19 the Oshawa coroner isn't available, we'll try Kingston, 20 and if nobody's in Kingston, we'll try Montreal, or we'll 21 try Quebec City, because these -- these are the distances 22 we're looking at. 23 But from a -- an operational point of 24 view, this can be managed by having appropriately trained 25 staff who know -- who have the skills and the knowledge


1 to look for the local coroner who's most familiar with 2 that community, even if that coroner's a resident, and 3 then going to the - -the next centre. 4 MR. MARK SANDLER: All right. Well, Dr. 5 Legge, you've anticipated the call -- the question that's 6 going to follow and that is: How often in these rem -- 7 remote communities does the coroner actually attend the 8 death scene? 9 DR. DAVID LEGGE: It's going to depend on 10 what geographic area you are talking about. 11 If a death occurs in a little town called 12 Hudson, which is thirty-five (35) minutes drive out of 13 Sioux Lookout, the coroner would likely go there. 14 If a death occurs in Mishkeegogamang, 15 which is actually on the road and isn't that far from 16 Pickle Lake, the common scenario would be that a Sioux 17 Lookout coroner would -- would get the call, but it is 18 unlikely -- in fact I would say very unlikely -- that the 19 coroner would actually go there. 20 And this little example would apply 21 largely to a large number of these investigations 22 throughout the North. Now, I'm not saying they never go. 23 A coroner -- one (1) of the coroners went up to Summer 24 Beaver when there was an air crash, did a great job. 25 And these people are -- are quite skilled,


1 but again because of this geographical distance, and the 2 variables of weather, and their scheduling with their -- 3 with their living patients, and the value added they may 4 see or may not see in going, they have developed over 5 years of experience -- and this isn't just one (1) year; 6 this may be fifteen (15), twenty (20) years of being 7 coroners -- a good relationship with the police, and -- 8 and sort of a presumption, lets say, that -- that they 9 can get the job done over the telephone. 10 MR. MARK SANDLER: All right. 11 DR. DAVID LEGGE: And -- and clearly that 12 isn't ideal, and I -- and I have carried on with some 13 trepidation for eleven (11) years as a regional coroner 14 in those sce -- scenarios. 15 MR. MARK SANDLER: So -- so I take 16 several things from what you've -- what you've just said. 17 The first is that there -- that there will 18 be a number of communities or they may be a number of 19 communities in the North that -- that may never see a 20 coroner. 21 DR. DAVID LEGGE: I would say that's 22 probably fair, yes. It's -- certainly -- you know, in a 23 timely fashion to investigate a death and to view a body 24 which hasn't been moved or where the scene hasn't been 25 altered in some way. From a practical point of view,


1 this was going to be very difficult to attain by -- 2 MR. MARK SANDLER: All right. 3 COMMISSIONER STEPHEN GOUDGE: If it is 4 obvious -- 5 DR. DAVID LEGGE: -- hands on, eyeball- 6 to-eyeball contact. 7 COMMISSIONER STEPHEN GOUDGE: If it is 8 obviously a criminally suspicious death, Dr. Legge, does 9 that change the calculus? 10 DR. DAVID LEGGE: Well, you'd think it 11 would, but I -- I have to admit that it normally doesn't. 12 I think the -- 13 COMMISSIONER STEPHEN GOUDGE: Why not? 14 DR. DAVID LEGGE: The police seem to be - 15 - they're the -- they're the primary people there at the 16 scene. They -- they accept the fact or they tolerate the 17 fact that the coroner won't be coming. 18 MR. MARK SANDLER: So, what I -- what I 19 hear you say -- 20 DR. DAVID LEGGE: You know, in -- in 21 other areas, the police would say, You must come -- 22 MR. MARK SANDLER: Right. 23 DR. DAVID LEGGE: -- and that would get 24 them out of the -- off their fanny and go there. 25 COMMISSIONER STEPHEN GOUDGE: If I asked


1 each of the three (3) of you -- Mr. Sandler undoubtedly 2 would do this, but the more I think of it, let me ask it 3 now. 4 If you were, if I can put it this way, 5 scaling the cases of death investigation that you do as 6 to which are the more important for scene investigation, 7 would criminally suspicious, obviously criminally 8 suspicious, be at the top of the list? 9 DR. DAVID LEGGE: Yes, I think so. 10 COMMISSIONER STEPHEN GOUDGE: Would each 11 of you agree with that? That is, if there is any case 12 where an extra effort to go to the scene is important. 13 DR. DAVID EDEN: I -- I will say that I 14 would have -- I think that there are procedural reasons 15 that a -- a coroner should attend homicides and 16 criminally suspicious deaths. But if you look at the 17 value added to the investigation -- if you look at what 18 Mr. Justice Campbell said in the -- in his report; if we 19 look at the case in -- I believe, in Brampton, that went 20 to Coroner's Counsel where a -- there was a homicide 21 masked as an accident, very often, the coroner is the 22 most experienced death investigator on scene, and for 23 many of the police officers at a scene, this may be their 24 first death. 25 COMMISSIONER STEPHEN GOUDGE: And I


1 suppose in a truly criminally suspicious scene, it may be 2 a crime site and, therefore, the coroner doesn't get very 3 close to it. 4 DR. DAVID EDEN: Well, I think -- well, 5 there -- there's that, but my concern, actually, is the 6 missed homicide. In some ways it's easier when you have 7 a case where there's a, you know, a knife in somebody's 8 chest or something where you know that you're going to be 9 following the criminal investigation pathway -- 10 COMMISSIONER STEPHEN GOUDGE: Fair 11 enough. 12 DR. DAVID EDEN: -- because that's laid 13 out. But my concern -- and this is really what lead to 14 the -- this entire protocol for infant death 15 investigation -- is that there were a number of missed 16 homicides in this province, and that's the -- and that 17 was what the protocol was originally put together to 18 prevent. And it's not just infant homicides. 19 And because the coroner has that 20 experience and, hopefully, is looking with their own 21 eyes, I -- I believe there is significant added value. 22 So, I -- I would -- I wouldn't -- I 23 wouldn't say that if the -- that I'd put all my -- that I 24 would put my best resources on criminal cases. I would 25 want experienced people at ambiguous death scenes.


1 COMMISSIONER STEPHEN GOUDGE: Okay. 2 MR. MARK SANDLER: So -- so, if you had 3 to prioritize -- 4 COMMISSIONER STEPHEN GOUDGE: What do you 5 say, Dr. McAllen? 6 DR. ANDREW MCALLEN: I would agree with 7 that. I think that that's where the real valued added by 8 having an experienced death investigator at the scene is. 9 COMMISSIONER STEPHEN GOUDGE: Right. Dr. 10 Legge...? 11 DR. DAVID LEGGE: I'll change my answer. 12 I would agree with that. 13 COMMISSIONER STEPHEN GOUDGE: Yes, it 14 makes sense. 15 DR. DAVID LEGGE: Yeah, it makes sense, 16 yeah. 17 COMMISSIONER STEPHEN GOUDGE: Yes. 18 MR. MARK SANDLER: You're -- you're 19 allowed to change your answer -- 20 DR. DAVID LEGGE: Yeah. 21 MR. MARK SANDLER: -- it's all right. 22 COMMISSIONER STEPHEN GOUDGE: Sounds like 23 Jeopardy, the way -- 24 25 CONTINUED BY MR. MARK SANDLER:


1 MR. MARK SANDLER: So -- so, Dr. Eden, 2 kind of following up on this, because -- because this is 3 an issue where the burden's going to fall on -- on you. 4 I mean, if we all assume that -- that very high priority 5 should be given to having a coroner attend the scene in 6 these pediatric cases that may or may not ultimately turn 7 out to be suspicious or homicides, but maybe -- you hear 8 what Dr. Legge says, and at the risk of putting words in 9 his mouth, he -- he has said that not only are there all 10 of the logistics issues surrounding getting coroners 11 there, but -- but there also is a certain mindset to 12 where the coroners aren't going there and the police are 13 accepting of that. 14 How do you deal with that? 15 DR. DAVID EDEN: Well, I would look at 16 this from a logistics viewpoint. When I was regional 17 coroner in Niagara, I -- I dealt with the same issue of 18 coroners who were not attending every death and my 19 instruction to them was that you attend every death. And 20 police would call me if the coroner didn't attend. And 21 that's -- that is no longer an issue, but that -- that 22 was a cultural change that had to develop. 23 In the issue of -- sorry, for the -- for 24 remote communities, I think there -- it's not a cultural 25 issue on the part of the part of the coroner. It's a


1 logistical issue of flying somebody a considerable 2 distance to attend a scene, and things change over time, 3 and there's issues of securing the scene and so on. 4 So the -- the question is, is the value 5 added by the coroner's physical attendance worth the -- 6 the cost to the public person, also the cost in the 7 public who are getting health services from that coroner. 8 We need to balance that against the 9 experiences -- not just Ontario, but worldwide -- that 10 death investigators need to investigate deaths, to do 11 quality work. 12 You -- to have a death investigator who's 13 only doing a case every one (1) or two (2) years is not 14 going to produce the best results because you need to do 15 it. You need to be doing it regularly so you have 16 adequate volume. 17 And because the region is four (4) times 18 the size of the Island of Great Britain -- which is the - 19 - the way I think of it -- it's just impossible to have a 20 local coroner in every community who will have adequate 21 case volume. 22 So the -- the question's, How do we ensure 23 the coroner can view the scene? And in some cases, I 24 think, that will mean that we need to look at how the 25 coroner is viewing a scene and viewing the body even if


1 the coroner can't go to the scene. 2 And some of that is -- to me, is a 3 technological issue. 4 MR. MARK SANDLER: All right. So -- 5 COMMISSIONER STEPHEN GOUDGE: 6 Photography, I take it, is what you are implying? 7 DR. DAVID EDEN: Yes. 8 9 CONTINUED BY MR. MARK SANDLER: 10 MR. MARK SANDLER: Real time photography 11 is what you're talking about? 12 DR. DAVID EDEN: Real time ideally, but I 13 -- I have had cases where I've -- I didn't -- in my -- in 14 my old region of Niagara where I simply could not get a 15 coroner to a scene, and OPP have provided photographs to 16 me the next day before the autopsy was done, and I've -- 17 I've done so -- certainly as soon as possible. Real time 18 would be very nice, yeah, very good. 19 MR. MARK SANDLER: All right. 20 COMMISSIONER STEPHEN GOUDGE: How do you 21 do real time? 22 DR. DAVID EDEN: And that I'm not an 23 expert on, and one (1) of the issues is that -- 24 COMMISSIONER STEPHEN GOUDGE: My kids 25 have used a cell phone that took a picture.


1 DR. DAVID EDEN: The -- and one (1) of 2 the issues is that our -- our government network won't 3 even support the feed from -- from this. I can't watch 4 this from my office -- this proceeding from my office -- 5 because our government network doesn't support that. 6 So the network I have in my office would 7 not support a -- a remote teleconference. But there 8 certainly are facilities in the remote communities -- 9 there are telehouse facilities where patients can be 10 examined by a physician remotely. 11 And I could certainly see that, sort of, 12 facility which already exists, being used to assist in 13 coroner's investigations. How exactly that would work is 14 something we'd need to discuss with the owners of that 15 equipment. 16 And we'd need to have somebody trained on 17 scene, but it's certainly something that could be done to 18 assist the coroner in the investigation. 19 COMMISSIONER STEPHEN GOUDGE: Dr. 20 Legge...? 21 DR. DAVID LEGGE: Just a follow up on 22 that point. The person who directs this telemedicine 23 network in the North is actually a coroner out of 24 Timmins, who's a valuable resource. That's mainly what 25 he does. He may only have one (1) or two (2) cases


1 himself per year. 2 And I have done some research in it as -- 3 it's certainly a technologically feasible way to go about 4 it, but I gathered there are a lot of funding issues -- 5 6 CONTINUED BY MR. MARK SANDLER: 7 MR. MARK SANDLER: Okay. 8 DR. DAVID LEGGE: -- Federal government 9 versus provincial, Coroner's Office, et cetera, and I 10 have no idea where all that comes out, but I -- I agree 11 with Dr. Eden, that would be one (1) very good model or 12 option for us here. 13 MR. MARK SANDLER: All right. So moving 14 from there, this all -- this discussion's all taking 15 place because we know that the coroners don't attend a 16 number of the scenes in the -- in the remote communities. 17 So what does happen in those communities, 18 Dr. Legge, when the coroner does not attend? 19 DR. DAVID LEGGE: Again, somewhat similar 20 to what Dr. McCallum described. There would be 21 notification through -- well, let's say it's a -- a 22 remote First Nation community. And it may be the -- the 23 family would notify a Band Member or a Chief or -- or the 24 nurse at the nursing station who would then get a hold of 25 the local police.


1 Eventually word filters down and -- and 2 comes out to say, Sioux Lookout. There would be a bit of 3 a time lag there perhaps. And then the Sioux Lookout 4 coroner would -- would likely begin this investigation 5 with a conversation over the phone with -- with the 6 police officer. 7 The police would likely -- in -- in any 8 case where there's anything that required expertise, 9 launch a trip. They -- they'd get a plane ready as soon 10 as possible. It might be the next morning. 11 If they had their OPP plane they might go 12 in that, but that's like -- unlikely in most cases 13 because it's based down in Thunder Bay. It would likely 14 have to be a charter. 15 And that's -- that's -- and these are 16 private charters, and they're not always exactly 17 available all the time either, so the police would then 18 go up to the scene and hopefully these -- the scene would 19 be secured. 20 Now, whether or not it always is 21 adequately secured, I -- I really can't tell you, but I 22 suspect, theoretically, it wouldn't be secured in a lot 23 of situations. 24 MR. MARK SANDLER: And -- and I take it 25 that --


1 DR. DAVID LEGGE: And there we go from 2 there; you're -- you're already into the next day. 3 MR. MARK SANDLER: Right. 4 DR. DAVID LEGGE: Yeah. 5 MR. MARK SANDLER: And I take it, apart 6 from the logistics issues that you described, that -- 7 that there's uneven resources that are available 8 depending upon which police service is -- is brought to 9 bear. 10 Is that right? 11 DR. DAVID LEGGE: Well, I -- I think so, 12 yes, mm-hm. 13 MR. MARK SANDLER: If -- if in your 14 region there were a case such as the ones that we've 15 examined here, the suspicious pediatric deaths, who would 16 normally conduct the investigation on the part of the 17 police when the coroner isn't attending the scene? 18 Wou -- would it be Nishnawbe-Aski? Would 19 it be the OPP? Or some combination? 20 DR. DAVID LEGGE: Well, a native police 21 force, I -- I think routinely would ask for the 22 assistance of OPP in -- in a case. Anything like that, 23 they'd immediately get on the telephone with an 24 inspector. 25 There's one (1) in Thunder Bay and two (2)


1 in Kenora, and these people are absolutely superb, and -- 2 and they'd be up there as fast as they could get there. 3 So, I mean, that -- the -- the line of 4 police assistance is worked out pretty quickly. Again, 5 there's this whole conundrum of how quickly does the 6 regional coroner find out about it, and I'm -- I'm 7 distressed to have to tell you that, on occasion, it 8 isn't as quickly as it should be. 9 MR. MARK SANDLER: All right. 10 DR. DAVID LEGGE: And -- 11 DR. DAVID EDEN: If I could inter -- 12 interject here, that -- that the First Nations Police 13 call OPP, in my view, is absolutely appropriate; it 14 doesn't reflect -- poorly -- in fact, it -- it reflects 15 well on them. 16 They are -- they specialize in dealing 17 with a lot of very serious social issues. They don't 18 have a volume of deaths, and as with coroners, with 19 police investigators, you need to handle deaths 20 regularly, and it's not just First Nations Police that do 21 this. 22 For instance, in my former region, 23 Niagara, the Niagara Parks Police will ask Niagara 24 Regional Police to assist when there's a death 25 investigation because Niagara Parks Police are very good


1 at what they do, but they do not handle many deaths. So 2 that's actually something that's recommended for police 3 forces -- all police services in Ontario -- is if you 4 don't do many deaths, call a -- another police force, 5 which does. 6 MR. MARK SANDLER: Now, one (1) of the 7 issues that has been raised here at the Inquiry in some 8 cross-examinations is whether or not there is some need 9 in the North for the legislation to change to permit the 10 delegation of the investigation to someone other than a 11 police officer. 12 Do you see a need for that in the North, 13 and I'll ask Dr. Eden and then Dr. Legge? 14 DR. DAVID EDEN: I think I -- I would 15 step back to the principals that again are -- are 16 recognized world wide for good death investigators. And 17 that -- what -- what a good death investigator requires, 18 first is appropriate background and training, and as I 19 mentioned, volume. 20 Another thing that's important is 21 impartiality. The death investigator can't be a family 22 member of the deceased or otherwise close; shouldn't have 23 a therapeutic relationship with the deceased. 24 Impartiality is important, and this is 25 really what becomes an issue in -- in remote communities,


1 and, in fact, might guide this. The skill set of 2 somebody who could assist the coroner can certainly be 3 found in a police officer or a nurse by virtue of their 4 background. 5 I could see it as a layperson, as well, in 6 certain circumstances. I think the -- the issue for me, 7 though, is the impartiality of that person not having -- 8 or having the minimum connect, if possible, to the 9 deceased because that's going to make a difference in not 10 only having investigations done, but also how it's 11 perceived to be done. 12 MR. MARK SANDLER: All right, so -- so 13 you'd have some concern about -- about delegating to 14 someone in a very small community who lives in that 15 community. 16 DR. DAVID EDEN: Yes, and I have -- I 17 have lived in a small town, and one knows everybody in 18 town, and it is very difficult to be impartial in the 19 circumstance. And I've had, as myself -- myself, I'd 20 have the experience of the coroner, being called to a 21 scene and discovering it was my own patient and saying, 22 Well, I -- obviously I can't investigate this case, and I 23 switched hats and was my family physician hat. 24 I had my family physician hat on to help 25 the family cope with the death, and I asked another


1 coroner to look after the case. 2 MR. MARK SANDLER: All right. Dr. Legge, 3 did you want to add anything? 4 DR. DAVID LEGGE: Well, the Coroners Act 5 does provide for delegation to not only a police officer, 6 but another physician, so again, whether -- whether dealt 7 with on -- on -- the legislation needs to be changed; I 8 really don't know for sure, but I totally agree with Dr. 9 Eden; impartiality is a big issue. 10 And I would suspect that some of the First 11 Nations Police in small communities may be even related 12 to the decedent. 13 MR. MARK SANDLER: So they may be 14 confronted with the same issue. 15 DR. DAVID LEGGE: Oh, yeah. 16 COMMISSIONER STEPHEN GOUDGE: Does the 17 Coroner's Office have what I would call "conflict rules" 18 -- that is, you raise, Dr. Eden, I can't be the coroner 19 if the deceased was a patient. 20 Are there -- is there a set of rules, 21 guidelines, principles to maintain impartiality that the 22 Coroner's Office provides its investigating coroners? 23 DR. ANDREW MCCALLUM: That's something 24 that we teach new coroners. It's -- it's something where 25 there's a need for discretion because to some extent it


1 depends on circumstances, and the fact, for instance, 2 that a coroner saw this person ten (10) years ago in the 3 Emergency Room for a sprained ankle wouldn't disqualify. 4 But if the coroner was actively providing care to a 5 psychiatric patient who has now suicided, obviously 6 there's a conflict of -- 7 COMMISSIONER STEPHEN GOUDGE: Yes, I -- 8 DR. ANDREW MCCALLUM: -- interest so I 9 don't know -- 10 COMMISSIONER STEPHEN GOUDGE: How close 11 to codification are these norms, I guess, really is the 12 question I have, or is it left to the individual 13 investigating coroner's sense of what preserves 14 impartiality? 15 DR. DAVID EDEN: We -- we ask coroners to 16 be aware of it, and if there are concerns, to discuss 17 that with the regional coroner. 18 COMMISSIONER STEPHEN GOUDGE: But I 19 suspect in the training of new coroners, flags are 20 provided as to what might cause concern. 21 DR. DAVID EDEN: Yes, we do list things 22 like having a therapeutic relationship, a family, or 23 business relationship with the deceased and anything that 24 might affect one's partiality. 25 COMMISSIONER STEPHEN GOUDGE: In a small


1 town, if you belong to the same service club. 2 DR. DAVID EDEN: It could be a factor 3 depending, and this is the thing, there's some that are 4 very -- 5 COMMISSIONER STEPHEN GOUDGE: But 6 ultimately it's going to left, I suspect, to the 7 individual coroner's sense of what's enough distance to 8 preserve impartiality, taking into account the 9 circumstances, is that -- 10 DR. DAVID EDEN: We -- we would expect 11 them to turn their mind to it, and if there's any 12 concerns at all, to call the regional coroner. And then 13 the regional coroner may say, That's okay to proceed, or 14 may say, I'll -- I'll arrange for another coroner to look 15 after it. 16 COMMISSIONER STEPHEN GOUDGE: Okay. 17 Okay. Is this put on paper anywhere in the Coroner's 18 Office? 19 I'm just curious because this is the first 20 I've heard of it and it's an obvious issue, and it's 21 particularly relevant when you come to small communities, 22 Dr. Legge? 23 DR. DAVID LEGGE: I don't know whether 24 it's technically codified, but it's -- it's part of a 25 lecture that's given to every single new coroner that


1 takes the course. There's a lecture on confidentiality, 2 so it's brought up with all the new coroners. 3 COMMISSIONER STEPHEN GOUDGE: What I 4 would call conflict -- 5 DR. DAVID LEGGE: Yeah. 6 COMMISSIONER STEPHEN GOUDGE: -- that 7 is -- 8 DR. DAVID LEGGE: Conflict, I'm sure. 9 COMMISSIONER STEPHEN GOUDGE: Okay. 10 DR. DAVID LEGGE: But -- but in -- in 11 reality, there are some communities in my jurisdiction 12 where this was happening fairly frequently and as a bit 13 of a fine line sometimes -- 14 COMMISSIONER STEPHEN GOUDGE: I'm sure it 15 is. I mean, Kwarantane (phonetic) -- 16 DR. DAVID LEGGE: -- where the coroner 17 and the -- and the decedent -- 18 COMMISSIONER STEPHEN GOUDGE: -- 19 Kwarantane, I don't know how big it is, but I bet it's 20 little and -- 21 DR. DAVID LEGGE: Yeah. Yeah. 22 COMMISSIONER STEPHEN GOUDGE: -- I bet 23 your coroner there knows almost everybody in the -- 24 DR. DAVID LEGGE: Well -- 25 COMMISSIONER STEPHEN GOUDGE: -- community.


1 DR. DAVID LEGGE: Well, the coroner in 2 Kirkland Lake is an ex-mayor, so -- and -- and finding a 3 coroner for a place like that is not easy -- 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. DAVID LEGGE: -- so these are some of 6 the challenges we have. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 DR. DAVID LEGGE: Yeah. 9 10 CONTINUED BY MR. MARK SANDLER: 11 MR. MARK SANDLER: Just -- just 12 completing this area, Dr. Legge, we've been talking about 13 the coroners not attending the scene, and if I recall 14 correctly, the -- the guidelines that exist within the 15 Chief Coroner's Office say that if a coroner can't attend 16 a death scene, where the guidelines say that attendance 17 is required -- and we're talking about the kinds of cases 18 where attendance, as I read the guidelines, would be 19 required -- the coroners are supposed to discuss the 20 matter with the Regional Supervising Coroner. 21 Was -- was that invariably happening when 22 you were there? 23 DR. DAVID LEGGE: The answer is very 24 simple, no. They don't necessarily always call me up, so 25 they're breaching that guideline; it happens.


1 MR. MARK SANDLER: Okay. 2 DR. DAVID LEGGE: Mm-hm. 3 MR. MARK SANDLER: Now, if I can take 4 you, Dr. Legge, to -- to one (1) document that's very 5 helpful, and that's the Institutional Report that was 6 actually prepared for this Inquiry and comes from the 7 Office of the Chief Coroner. It's at Tab 24 of the 8 materials, PFP149431. 9 And I'm going to go to page 29 of the 10 document. And frankly, I'm trying to get a sense up 11 north, the extent to which there's a disconnect between 12 what one would like to see happening, what the coroner's 13 manual or the guidelines say should happen, and what is 14 happening in the North, and what, if anything, can be 15 done about it. 16 So you'll see at paragraph 82 it says: 17 "A key component of the coroner's role 18 during a death investigation involves 19 communication with the family of the 20 deceased early and throughout the 21 investigation. This gives the coroner 22 the opportunity to indicate his or her 23 involvement in the case, learn if the 24 family members have any specific 25 concerns, outline the procedures that


1 may be undertaken, such as an autopsy 2 or release of the body, and answer any 3 questions they may have. If a post- 4 mortem examination is ordered, the 5 family should be advised of that 6 decision, as well as being provided an 7 opportunity to obtain the results of 8 that examination." 9 Is that generally happening for remote 10 communities, including remote Aboriginal communities up 11 north? 12 DR. DAVID LEGGE: It's an excellent 13 question and one that I have struggled with. The reason 14 I've struggled with it is because I don't know for sure 15 whether it is happening in each case. I -- I definitely 16 suspect that it does not happen in each and every case; 17 particularly considering what we've discussed in the -- 18 much of the discussion is based on a telephone interview 19 with an officer who might -- might be at the scene. 20 If there's a -- if there's an Aboriginal 21 family involved in this death, I -- I would suspect that 22 frequently there is no direct contact with that coroner - 23 - between that coroner and this family. It may -- it may 24 go through the officer, being sort of -- another sort of 25 a delegated act, so to speak.


1 MR. MARK SANDLER: Or it may not happen 2 at all. 3 DR. DAVID LEGGE: Or it may not happen at 4 all. Now, I don't know for sure of how often that's 5 happening, but I -- I -- to be quite honest with you, I 6 suspect it doesn't happen on a fairly regular basis. 7 MR. MARK SANDLER: Okay. 8 DR. DAVID LEGGE: So there's -- there is, 9 therefore, a -- a breakdown in that communication system. 10 MR. MARK SANDLER: All right. Dr. Eden, 11 again, you seem to be inheriting some of these very 12 difficult issues. 13 What do you see as the solution to what is 14 undoubtedly a problem? 15 DR. DAVID EDEN: I -- I think it's 16 important for family to have an understanding of what's 17 involved in a coroner's investigation and where the 18 investigation is now, how long it's going to take. There 19 -- there are certainly issues here that make it different 20 from a case in Southern Ontario where the coroner will 21 often be able to meet the family face to face. 22 There are potential ways around that. And 23 -- for instance, in one (1) case that I've -- I've 24 managed to this point, the -- the police officer involved 25 had a good relationship with the family and, in fact,


1 acted as the intermediary between the Coroner's Office 2 and the family, with family understanding they could call 3 me or the investigating coroner directly if they wished. 4 But they were satisfied with that arrangement. 5 Again, going to technology, what I could 6 see us doing and -- is that -- is using those Telehealth 7 facilities where we could, for a death in a remote 8 community, have the family and -- and perhaps a -- a 9 social worker in a room in the nursing station in that 10 community, and then have the coroner or the regional 11 coroner linked using the Telehealth to discuss the case 12 with them. 13 We have that technology. We're not using 14 it for that purpose at the moment, but it's a -- it's an 15 example of what we could do to improve the communication. 16 MR. MARK SANDLER: All right. And -- and 17 I've just read one (1) paragraph of -- of a number of 18 paragraphs that address the issue of communication. But 19 I'll just raise with you some of the other features that 20 might be raised in the -- in the context of -- of this 21 dilemma. 22 The first is, in these cases, where does 23 the body generally go? So, first, I'll ask that question 24 of Dr. -- Dr. Legge. A young child dies -- 25 DR. DAVID LEGGE: Yeah.


1 MR. MARK SANDLER: -- in a remote 2 community, Aboriginal or -- or otherwise. Typically 3 speaking, where is the autopsy performed? 4 DR. DAVID LEGGE: The majority would be 5 autopsied in Toronto at Sick Kids Hospital. It's an 6 enormously long trip and a -- and a heartache for the 7 family, I'm sure. Those in the western zone, near the 8 Manitoba border, would likely go to Winnipeg, because we 9 have an excellent relationship with a pathologist who 10 works out of Health Science Centre, Winnipeg. 11 That's the current scenario. There -- 12 there was a point during my tenure when some of these 13 cases were being done in places like Thunder Bay. That's 14 no longer the case. 15 MR. MARK SANDLER: All right. So the 16 issue that's raised by that is ensuring that the -- that 17 the family knows where the body is going -- 18 DR. DAVID LEGGE: Mm-hm. 19 MR. MARK SANDLER: -- and when the body 20 is -- is coming back. 21 DR. DAVID LEGGE: Yes, it's huge. 22 MR. MARK SANDLER: And -- and that is a 23 difficulty, I take it. 24 DR. DAVID LEGGE: It's -- well, the 25 communication strategy is -- it's -- it's a big


1 challenge, and I don't think it's been set down and 2 properly dealt with at all. 3 COMMISSIONER STEPHEN GOUDGE: I have the 4 sense, Dr. Legge, that the scene investigation delegation 5 is something that is sort of relatively well understood 6 by the coroners service in the North. And let me just 7 underline the term "relative." 8 The communication issue, is that devoted 9 the same attention as the scene investigation; that is, 10 inability to attend with the family face-to-face? 11 DR. DAVID LEGGE: Well, yeah -- 12 COMMISSIONER STEVEN GOUDGE: Is there 13 same -- because presumably, delegation of the 14 communication role, or use of an intermediary through a 15 delegated function, could be done, if how it were done 16 were focussed on in some kind of concerted way? 17 DR. DAVID LEGGE: I -- I totally agree. 18 I think that is a large area of concern, because no doubt 19 someone would tell the family that your baby has to go to 20 Toronto, and historically, First Nations people do not 21 like their people to go out of town, a long, long way 22 away. 23 COMMISSIONER STEVEN GOUDGE: The 24 explanation for it is -- 25 DR. DAVID LEGGE: The explanation --


1 COMMISSIONER STEVEN GOUDGE: -- is quite 2 important. 3 DR. DAVID LEGGE: Well, the explanation 4 is important. I -- I really don't know how much 5 explanation goes on. The explanation may, in the end, 6 be -- 7 COMMISSIONER STEVEN GOUDGE: Is that 8 something, though, that could be focussed on -- 9 DR. DAVID LEGGE: Yeah. 10 COMMISSIONER STEVEN GOUDGE: -- in ways 11 to alleviate that difficulty? 12 DR. DAVID LEGGE: Well, I -- I have a 13 recommendation on -- 14 COMMISSIONER STEVEN GOUDGE: Oh, Okay. 15 DR. DAVID LEGGE: -- on paper that I'll 16 go -- 17 COMMISSIONER STEVEN GOUDGE: I am getting 18 ahead of myself. 19 DR. DAVID LEGGE: Well, I -- I -- yes, I 20 think that's a very important -- 21 COMMISSIONER STEVEN GOUDGE: Presumably 22 you could quite easily use a delegate, if I can use the 23 sort of notion in the legislation, that's different from 24 the person who is investigating the scene on your behalf. 25 DR. DAVID LEGGE: Mm-hm.


1 COMMISSIONER STEVEN GOUDGE: You could 2 use a family member for communications. That is, is 3 there the same need for impartiality in the communication 4 function, as there is in -- 5 DR. DAVID LEGGE: I don't -- I don't 6 think so. I think it's just simple, basic -- 7 COMMISSIONER STEVEN GOUDGE: 8 Interpersonal -- 9 DR. DAVID LEGGE: Interpersonal 10 compassion to let -- let people know what's going on 11 here. 12 COMMISSIONER STEVEN GOUDGE: Right. 13 Right. 14 DR. DAVID LEGGE: Because I -- I wouldn't 15 be a bit surprised if many of these young fam -- lets say 16 it's a young -- 17 COMMISSIONER STEVEN GOUDGE: Right, kids, 18 a dad, a young family -- 19 DR. DAVID LEGGE: -- family, with a 20 mother -- a mother of sixteen (16) and the boyfriend of 21 nineteen (19) -- 22 COMMISSIONER STEVEN GOUDGE: Right. 23 DR. DAVID LEGGE: -- they probably are 24 told very little about what's happening here. 25 COMMISSIONER STEVEN GOUDGE: Right.


1 DR. DAVID LEGGE: And it just be total -- 2 COMMISSIONER STEVEN GOUDGE: At sea. 3 DR. DAVID LEGGE: -- be a burden for 4 their grieving process, for sure, so. 5 COMMISSIONER STEVEN GOUDGE: Yes. 6 DR. DAVID LEGGE: Again, I may be -- I 7 may be wrong, and there -- there may well be native 8 people in the community who sit down with them. There 9 may be a social worker -- 10 COMMISSIONER STEVEN GOUDGE: But a 11 conscious -- 12 DR. DAVID LEGGE: -- or a Chief or 13 something. 14 COMMISSIONER STEVEN GOUDGE: -- a 15 conscious sort of strategy for how you might do that -- 16 DR. DAVID LEGGE: I don't think there's-- 17 COMMISSIONER STEVEN GOUDGE: -- could be 18 developed. 19 DR. DAVID LEGGE: I'm pretty sure there's 20 no strategy at the moment. 21 COMMISSIONER STEVEN GOUDGE: Yes. 22 DR. DAVID LEGGE: So -- 23 COMMISSIONER STEVEN GOUDGE: Dr. Eden...? 24 DR. DAVID EDEN: Yes, I think that we 25 should review our strategy, and that would include


1 looking at the Coroner's Off -- well, it would involve 2 the Coroner's Office, the police, and I would think 3 community organizations, and -- and political 4 representatives, such as NAN, to -- to look at how we are 5 dealing with this, and how we could do the best possible 6 job of -- of communicating. 7 COMMISSIONER STEVEN GOUDGE: Thanks. 8 9 CONTINUED BY MR. MARK SANDLER: 10 MR. MARK SANDLER: So two (2) things 11 arising out of that. The first is, if we're talking 12 about a communication strategy, we'd want to be looking 13 at a communication strategy that addresses the 14 investigation from start to finish. So we'd want to be 15 talking about upfront, this communication with the 16 family, as to what the coroner does. 17 DR. DAVID LEGGE: Mm-hm. 18 MR. MARK SANDLER: You'd want to be 19 talking to the family about what is anticipated that will 20 happen, whether autopsy or not. We'd want to be talking 21 about the fam -- to the family as to where the body is 22 going. We'd want to be talking to the family about when 23 the body is going to come back. We'd want to be talking 24 to the family as to what the results of the investigative 25 work are.


1 DR. DAVID LEGGE: Yes. 2 MR. MARK SANDLER: We'd want to be 3 talking to the family, if organs are being retained for 4 investigative purposes, that that is going to take place, 5 and when the organs could be expected to be returned. 6 And we'd want the family to have some understanding as to 7 their rights in accessing, for example a post-mortem 8 report, or other documentation. 9 Is -- is that a fair -- very simplistic, 10 but fair overview of the kinds of communication issues? 11 DR. DAVID LEGGE: I -- I think it's a 12 very well, thorough encapsulation of what's required. 13 MR. MARK SANDLER: Okay. And -- 14 DR. DAVID LEGGE: I totally agree with 15 all of those things. 16 MR. MARK SANDLER: And -- and I have a 17 suggestion about it, in a moment, but just when we're 18 dealing with each of those features, the one (1) thing 19 that just strikes me is -- is as we're speaking about it 20 today, is that -- is that in a number of these cases 21 we've heard, they go to the Paediatric Death Review 22 Committee for a determination as to cause and manner of 23 death, right? 24 And -- and we've heard that -- well I'll 25 ask you: I gather that it can be a very lengthy process


1 before the Paediatric Death Review Committee can finalize 2 what the cause of manner of death is? 3 DR. DAVID EDEN: Actually it's the Death 4 Under Five Committee -- 5 MR. MARK SANDLER: The Death Under Five 6 Committee -- 7 DR. DAVID EDEN: -- would be making the -- 8 MR. MARK SANDLER: -- I'm sorry. 9 DR. DAVID EDEN: -- determination. 10 MR. MARK SANDLER: All right. And is a 11 fairly lengthy process at times before that determination 12 is made? 13 DR. DAVID EDEN: Yes, it can be. 14 DR. DAVID LEGGE: My experience is it's - 15 - it can be. It can be up to two (2) years. 16 MR. MARK SANDLER: All right. So -- 17 DR. DAVID LEGGE: Maybe even more on 18 occasion. 19 MR. MARK SANDLER: All right. So that -- 20 DR. DAVID LEGGE: Between -- between the 21 time of the death and the piece of paper we get back. 22 MR. MARK SANDLER: So that -- so that one 23 (1) of the communication strategies has to reflect the 24 recognition that -- that the family has to be kept in the 25 loop, because you're dealing with the very large


1 challenge of this very lengthy time on occasion where -- 2 where the results aren't known? 3 DR. DAVID LEGGE: Yes. 4 MR. MARK SANDLER: Is organ retention a 5 particular issue in the Aboriginal community, Dr. Legge? 6 DR. DAVID LEGGE: I have -- excuse me, 7 I've had some specific cases recently which highlight 8 what I feel to be the answer to that, and that is I think 9 it is a very large issue. 10 Now I -- I don't know whether all 11 indigenous peoples are unhappy about this. I suspect 12 that on -- on the whole they -- they may be more 13 resistant to it, to have -- to -- to hear that body 14 organs are being retained for some examination far, far 15 away. 16 The -- the guidelines have come out, in 17 which we are supposed to notify families that this is 18 happening, and there have been some breakdowns in timely 19 notification of families about this. And I have had a 20 few cases where I have had the unpleasant task of 21 informing these families about the fact that a brain has 22 been retained on a case that went to Sick Kids. And they 23 -- they might not have known about this. 24 Now there -- there may be some 25 explanations for it that are valid, such as the fact the


1 original coroner couldn't get a hold of the family, which 2 I believe to be true in one (1) case. But clearly it 3 becomes a major source of upset when they find out about 4 it. 5 I have had some discussions with the Chief 6 Forensic Pathologist about this, and we -- we have 7 mentioned the fact that this is an issue throughout the 8 world, and that there is knowledge and maybe even 9 literature on this, from places like Australia or 10 Southwest United States, and that there may be other -- 11 there may be ways of dealing with it that are -- that 12 have to be considered by our system, such as, do we need 13 to have organs retained in each and every case where the 14 pathologist feels they want to do it? 15 Now clearly I would think a criminally 16 suspicious death or a homicide you would be routinely 17 doing it. But my understanding is now that a Sick Kids 18 pathologist will virtually routinely be taking a brain 19 out, even in medical cases, and I -- I don't know whether 20 this in the long run is worth the -- the effort if -- if 21 it takes a long, long time. 22 And -- and we -- we have to deal with 23 repatriation of organs, which -- in another case -- I'll 24 tell you, this happened -- we let this sixteen (16) year 25 old girl know about it and she became acutely suicidal.


1 So, I mean, the -- the burden on some of 2 these families, I think, is enormous in dealing with 3 this. So -- if it has to be done, it should be really 4 upfront notification of -- of the families to lessen that 5 burden. 6 MR. MARK SANDLER: All -- 7 DR. DAVID LEGGE: There's -- there's work 8 to be done here for sure. And maybe looking at other 9 models around the world. 10 COMMISSIONER STEPHEN GOUDGE: Only when 11 absolutely necessary, and only then when fully explained? 12 DR. DAVID LEGGE: Well I -- I -- in a 13 nutshell, I -- yes, that's my feeling. I don't know how 14 the pathologist would feel about it, and I think that 15 it's -- it had -- really requires more discussion. 16 Serious discussion. 17 18 CONTINUED BY MR. MARK SANDLER: 19 MR. MARK SANDLER: And -- and I said to 20 you that I was going to put a suggestion for your 21 consideration, and I'll -- I'll ask any one (1) of you to 22 comment on it. 23 Do you see some value in -- in the 24 creation of a position such as an Aboriginal liaison who 25 -- who'd be trained, whether through social work or other


1 background -- medical background or nursing background or 2 the like, and who has a real understanding of Aboriginal 3 issues as well, to -- to be involved in the communication 4 strategy that -- that must flow from some of the things 5 that we talk about? 6 DR. DAVID EDEN: I could see that being 7 of enormous value and, particularly, as such a worker 8 could engage in a therapeutic relationship with the 9 family while acting as a liaison with the Coroner's 10 Office to ensure that all the facts are communicated as - 11 - as promptly and fully as possible, and there's a -- an 12 opportunity for the family to ask questions through a -- 13 a trusted intermediary. 14 So I could see substantial value from 15 that. And this is an area -- we talked earlier about the 16 importance of the impartiality of investigators. This is 17 not something -- this is not an area where the person 18 needs to be impartial. In fact, it's of substantial 19 value if they are an advocate for the family in those 20 circumstances. 21 MR. MARK SANDLER: All right. And Dr. 22 Legge, do you agree? 23 DR. DAVID LEGGE: I totally agree. I 24 think it would be a wonderful idea. I -- I can even 25 think of a few people who would be excellent at that. I


1 know there are -- are lots of people who are First Nation 2 people who would be very good at it. 3 MR. MARK SANDLER: And I guess my lack -- 4 DR. DAVID LEGGE: I could -- I could 5 provide names later. 6 MR. MARK SANDLER: -- sure. And -- and I 7 guess as -- as -- just to round out this part of our 8 discussion before -- before the -- 9 DR. ANDREW MCCALLUM: Mr. Sandler, if I 10 might just add -- 11 MR. MARK SANDLER: Yes, of course. 12 DR. ANDREW MCCALLUM: -- one (1) thing to 13 that. The -- in my view, it's a -- that's a -- has great 14 merit; that idea. The only thing I would do is expand 15 it, somewhat, because we know that there is great 16 diversity in death beliefs and practices among the 17 various communities in Ontario. 18 And I think that the -- the general idea 19 regarding First Nations makes eminent sense. We 20 shouldn't neglect the other communities that have 21 Muslims -- 22 COMMISSIONER STEPHEN GOUDGE: There are 23 other communities for whom it's also an issue. 24 MR. MARK SANDLER: I'm -- I'm delighted 25 to say that you anticipated my next question, which is


1 that even though the -- the Aboriginal issues have -- 2 have an obvious special and unique quality to them, many 3 of the issues that we're talking about, about remoteness 4 and communication, have equal application to all of the 5 remote communities within the region we're describing. 6 Is that right? I -- I see the nodding 7 which -- which -- 8 DR. ANDREW MCCALLUM: Yes. 9 DR. DAVID EDEN: Yes, yeah. 10 MR. MARK SANDLER: And -- and the last 11 question in this area is that -- that any communication 12 strategy, I take it, that would be developed would be 13 mindful of the various stakeholders that are involved so 14 that that would include the Coroners Office and the 15 police and -- and the governance, whether First Nations 16 or -- or munic -- or municipal and local community 17 leaders and the like. 18 Is that -- is that a fair comment? 19 DR. DAVID EDEN: Yes. 20 MR. MARK SANDLER: All right. 21 Commissioner, if that would be an appropriate time. 22 COMMISSIONER STEPHEN GOUDGE: Sure. 23 We'll rise then for fifteen minutes. 24 25 --- Upon recessing at 11:17 a.m.


1 --- Upon resuming at 11:35 a.m. 2 3 THE REGISTRAR: All rise. Please be 4 seated. 5 COMMISSIONER STEPHEN GOUDGE: Mr. 6 Sandler...? 7 8 CONTINUED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: Thank you, 10 Commissioner. Dr. Legge and Dr. Eden, perhaps you'd look 11 with me, again, at the Institutional Report, PFP149431, 12 which is at Tab 24. And -- and I'm looking at page 31, 13 paragraph 88, and it reflects -- and I'm really want to - 14 - going to focus on the last line here. 15 It says: 16 "In investigating a death, a coroner 17 must answer five (5) questions. Every 18 coroner must keep a record of the cases 19 recorded in which an inquest was 20 determined to be unnecessary, providing 21 the results of the five (5) questions 22 and including relevant findings of any 23 post mortem examination and any other 24 examinations or analyses of the body 25 carried out.


1 This information should be made 2 available to family members of the 3 deceased and his or her personal 4 representative, upon request." 5 Now, we've already talked about the 6 challenges of the communication. I'm interested in the 7 words, "upon request." 8 Just understanding the particular dynamics 9 in your region, Aboriginal or otherwise, do you see any 10 concerns about putting the burden on the -- the family to 11 initiate that request, or -- or do you have any thoughts 12 about -- about that issue? 13 And I'll ask Dr. Legge that first. I 14 don't ask any easy questions, do I? 15 DR. DAVID LEGGE: No. Clearly, "upon 16 request" could conventionally mean simply writing a 17 letter or something like that saying, Please provide us 18 with this information, which, or course, does occur on -- 19 on occasion, and sometimes through legal counsel, et 20 cetera. 21 I have had quite a few years of experience 22 with First Nations peoples and I know that they are often 23 very reticent and shy, perhaps, and may not be terribly 24 aggressive about coming out and asking for something. 25 MR. MARK SANDLER: And that's what


1 motivated my question. 2 DR. DAVID LEGGE: Yeah, I thought it 3 probably was and therefore, I have thought about this a 4 great deal. If I, ideally, had the time and I wasn't 5 burdened with the administrative materials that I -- that 6 I have to deal with -- I mean, in an ideal world, I -- I 7 would make it part of my business to call up all of these 8 Aboriginal families and tell them the -- the results. 9 It just hasn't happened operationally 10 because of a variety of things. And -- and I mean, I can 11 rationalize it in my own mind that, Well, they will -- 12 they will get in touch with me. And certainly any time 13 I've ever had a request, I feel quite confident that I 14 have responded promptly. 15 Now, that according to the Coroner's Act 16 Section 18(2) is upon completion of the case, and that's 17 where the -- the rub is. 18 MR. MARK SANDLER: Right. 19 DR. DAVID LEGGE: Sometimes this is way 20 down the road so this business of whether or not a 21 coroner or a regional coroner -- providing that regional 22 coroner has sufficient time -- should be, somewhat, more 23 proactive in calling these people up de novo. I mean, I 24 -- I think ideally that would be great. 25 MR. MARK SANDLER: All right. Dr.


1 Eden...? 2 DR. DAVID EDEN: Yeah, paragraph 88 here 3 more or less recapitulates Section 18(2) of the Act which 4 -- which obviously governs us. And the -- the wording of 5 the Act is "upon request" so I think the plain reading of 6 that would be that the information is provided upon the 7 request of a family member. 8 And, in fact, if -- if I try out an -- if 9 -- if we took the words "upon request" out of the 10 legislation, for instance, we'd be in a situation where 11 the coroner would, in fact, have to find everybody who 12 might be eligible and see about contacting each of those 13 because the Act says that this information's available to 14 the spouse, sibling, parent, child, and personal 15 representative of the deceased, so that would actually, 16 in many cases, involve fifty (50) or -- up to fifty (50) 17 people that might be eligible for this information. 18 And, you know, if -- if a relative dies, 19 should everybody in the family receive a copy of the 20 autopsy? I mean, in my mind, that is not something that 21 would be seen as a good -- by people so it -- it appears 22 that this legislation as written makes sense. In fact, 23 what happens, operationally, is that one (1) member of 24 the family will be the one who liases with the coroner. 25 The legislation says the family can choose who it is and


1 then we will deal with that family member. 2 And again, operationally, what should be 3 happening is that at the outset of the investigation the 4 coroner is providing this information to family and 5 saying, Can you send me a request for the information and 6 then the coroner will provide that to the regional 7 coroner's Office, we keep it on file until the case is 8 complete, and then we mail that out to the family. 9 So that -- that -- so in terms of making 10 it practical, -- I think there is a practical way to do 11 this -- but it involves making sure the family is aware 12 at the outset of the investigation that they're entitled 13 to the results and that to obtain them, they should 14 appoint somebody from the family to -- to do that for 15 them. 16 MR. MARK SANDLER: So -- so in your mind 17 the -- the answer isn't to delete the words from the 18 Statute because that would have unintended adverse 19 consequences. The -- the approach to take is to 20 recognize that it is upon request but ensure that the 21 families are well aware of their ability to make the 22 request? That's what I hear you saying. 23 DR. DAVID EDEN: Yes. Yes, that's 24 correct. 25 MR. MARK SANDLER: Now, if -- if you'd go


1 with me to page 33 -- 2 DR. DAVID EDEN: And actually if I may 3 add, there are some families who do not want to see an 4 autopsy -- report -- 5 MR. MARK SANDLER: Right. 6 DR. DAVID EDEN: -- and I can -- I can 7 understand that. 8 MR. MARK SANDLER: And -- 9 DR. DAVID EDEN: I wouldn't want to force 10 them. 11 MR. MARK SANDLER: And that's one (1) of 12 the adverse consequences that you described if one simply 13 deleted the words? 14 DR. DAVID EDEN: Yeah. 15 MR. MARK SANDLER: And if you go to page 16 33 of the Institutional Report; paragraph 94 talks about 17 the content of the coroner's investigation statement. 18 And it reflects in the last line -- and I'm going to ask 19 of you this -- that the coroner's investigation statement 20 should indicate that communication has taken place with 21 the family of the decedent and whether or not they had 22 expressed any concerns about the death. 23 Can you help me out as to this? As -- as 24 a matter of practice, do the coroner's investigations 25 statements so indicate? I'll ask Dr. McCallum.


1 DR. ANDREW MCCALLUM: I've just started 2 to undertake the quality assurance review which you've 3 heard evidence about before and I have to say that this 4 is the one (1) area where I do not see indications in the 5 narrative routinely that communication has occurred. I 6 believe it does occur, but I'm not certain that it's 7 documented, and I can't say to the extent -- 8 MR. MARK SANDLER: Okay. 9 DR. ANDREW MCCALLUM: -- to what extent. 10 MR. MARK SANDLER: Dr. Legge...? 11 DR. DAVID LEGGE: Exactly the same thing. 12 MR. MARK SANDLER: And, Dr. Eden...? 13 DR. DAVID EDEN: Yeah, I agree, yeah. 14 MR. MARK SANDLER: Okay. 15 16 (BRIEF PAUSE) 17 18 MR. MARK SANDLER: Now the last question, 19 Dr. Legge, that I'm going to ask you about -- about the 20 Northern region for now, is -- is this, and I'll direct 21 it to both you and Dr. Eden. 22 Is one (1) Regional Supervising Coroner 23 sufficient for the region, having regard to it's current 24 size? 25 DR. DAVID LEGGE: Unequivocally not


1 sufficient in my view. Mind you, Dr. Eden may be -- may 2 have a different view. I -- I felt that in the last 3 number of years when -- when my region wasn't as large as 4 it is now, I was struggling to keep up. 5 MR. MARK SANDLER: All right. Dr. 6 Eden...? 7 DR. DAVID EDEN: There's really two (2) 8 issues here in my mind. One (1) is whether the region 9 itself makes sense, and then how many regional coroners 10 should there be managing it? 11 In my view, the region itself is a good 12 administrative region. And this is based on experience 13 again elsewhere in the world, looking, for instance, at 14 health care regions where it makes sense to have an 15 administrative region where all the cases are managed. 16 And there is no way to -- well, actually, 17 the -- the region really is a water-shed, in that any 18 case that occurs within that region will be managed 19 either within that region entirely, or through Toronto, 20 as for autopsy and other investigative purposes. 21 So it makes sense as an administrative 22 water-shed. The -- the number of senior managers, like 23 myself, that should be managing it, is something that I 24 think should be looked at. 25 Where we are definitely short is


1 administrative support staff. And I think it would be 2 reasonable to look at the task that is required here, and 3 say, What's the best way to ensure that -- that -- that 4 the goals are met. 5 The public has expectations. How do we 6 staff and resource to ensure that those expectations are 7 met? And right now, there is one full time person for a 8 region with twenty-one hundred (2,100) cases, sixty (60) 9 coroners, and that is impossible. 10 It -- it can't -- it can't happen. And so 11 I urgently need more staff and resources. I can see the 12 merits of having a second physician manager. I could 13 also see the merits of having an executive assistant who 14 is non-physician. 15 And I think some of this would be by 16 looking at the work that has to be done and saying, 17 What's the skill set and -- and staff hours that we need 18 to get this job done? 19 MR. MARK SANDLER: All right. I see, for 20 example, that when you were in Niagara, you had an 21 administrative assistant. But -- but I see that in the 22 North, there is no administrative assistant, at least on 23 the -- on the organizational structure that -- that I've 24 looked at? 25 DR. DAVID EDEN: Well, there -- there is


1 in -- in Niagara, I had a full time and a part time 2 administrative assistant. 3 Currently, the Thunder Bay office is 4 staffed with one (1) full timer that -- proportional to 5 case load -- would be about the same staffing as Niagara 6 had because the case load before was twelve hundred 7 (1,200) cases a year in the North, compared to two 8 thousand (2,000) cases a year in Niagara. 9 Now the Thunder Bay Regional Office is 10 managing more cases than Niagara so it should, obviously, 11 have, at least, proportional staffing. 12 MR. MARK SANDLER: All right. What about 13 the -- 14 COMMISSIONER STEPHEN GOUDGE: What is the 15 skill set of your administrative assistant now? 16 DR. DAVID EDEN: A lot of their job is 17 managing incoming cases. So they will be dealing with 18 cases that coroners have sent in as well as police 19 reports and pathology reports and compiling those as 20 files for me to review at the end of the investigation. 21 They also respond to telephone calls and 22 letters from families and actually spend a considerable 23 amount of their time on the phone explaining to the 24 family how to make a request for a -- an autopsy or 25 coroner's report.


1 So they -- 2 COMMISSIONER STEPHEN GOUDGE: Do they 3 need medical training? I mean, are these people nurses 4 or -- 5 DR. DAVID EDEN: No, they're not nurses. 6 They're clerical staff. 7 COMMISSIONER STEPHEN GOUDGE: Okay. 8 DR. DAVID EDEN: And a lot of their work 9 is clerical. It's file management. It's -- it's file 10 management at a high level, and -- and our staff are 11 expected to and, in fact, deliver a very high degree of 12 accuracy -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. DAVID EDEN: -- in their work. But 15 it's not a medical position per se. It might be 16 comparable in some ways to a medical receptionist -- 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. DAVID EDEN: -- although I wouldn't 19 take that analogy too far. But it's someone who provides 20 an interface but is not a medical or nursing 21 professional. 22 COMMISSIONER STEPHEN GOUDGE: Okay, thank 23 you. 24 25 CONTINUED BY MR. MARK SANDLER:


1 MR. MARK SANDLER: All right, just -- 2 just so that I understand the distinction, if you'll look 3 at page 99, just so you'll know what I was referring to. 4 DR. DAVID EDEN: Sorry, page 99 or 5 paragraph? 6 MR. MARK SANDLER: Page 99 of the -- of 7 same institutional study. And this is the organize -- 8 organizational structure that we've been provided. And 9 what prompted my question -- and this writing is too 10 small for -- for anyone to read -- and particularly me. 11 But what prompted my question is the 12 reflection that in some of the regions, we see a 13 designation of a regional administrative coordinator, as 14 well as an administrative assistant. 15 And I noted that in the northwestern 16 region, there was reference to a regional administrative 17 coordinator, but not an administrative assistant. What - 18 - what's the difference between the two (2) positions? 19 DR. DAVID LEGGE: I think -- I think it's 20 just a matter of semantics. They're both one (1) in the 21 same person, really. 22 MR. MARK SANDLER: Okay. 23 DR. ANDREW MCCALLUM: I'd like to just 24 add, the administrative assistant is usually a part-time 25 who --


1 DR. DAVID LEGGE: Oh, well -- 2 DR. ANDREW MCCALLUM: -- provides many of 3 the same functions, but doesn't have the same oversight 4 of the entire office operation as the Regional 5 Administrative Coordinator. 6 But, in fact, they have many of the skills 7 because they have to backfill -- 8 MR. MARK SANDLER: Okay. 9 DR. ANDREW MCCALLUM: -- when the 10 coordinator's away. 11 MR. MARK SANDLER: All right. Well, Dr. 12 Eden, we're going to draw upon your experience, not only 13 most recently in the North, but in respect of your role 14 as the Regional Supervising Coroner in the Niagara 15 region. 16 And so I now want to turn and ask you the 17 same kinds of questions that I asked Dr. McCallum and Dr. 18 Legge insofar as your experience applies to Niagara. 19 You've already told the Commissioner the 20 geographic boundaries of that region. Can you remind us 21 how -- how many cases are investigated by the coroners in 22 that region, about twenty-one hundred (2,100), did you 23 say? 24 DR. DAVID EDEN: It's about two thousand 25 (2,000).


1 MR. MARK SANDLER: Two thousand (2,000), 2 all right. And the number of investigating coroners in 3 that region? 4 DR. DAVID EDEN: About twenty (20). 5 MR. MARK SANDLER: And, again, these are 6 part-time positions? 7 DR. DAVID EDEN: We have one (1) 8 investigating coroner who's not full-time, but certainly 9 is -- I would say the majority of his work-time is as an 10 investigating coroner. The rest are part-time. 11 MR. MARK SANDLER: All right. And you've 12 heard the profile of the investigating coroners in the 13 North and in the east. How would describe the typical 14 coroner in the Niagara region? 15 DR. DAVID EDEN: The -- the coroners I 16 have fall into two (2) groups, which I would describe as 17 urban and rural. I have coroners, or I had coroners, in 18 the Niagara region who were quite busy handling more than 19 two hundred (200) cases a year in urban settings and 20 participating in the investigation directly by going to 21 scene, working with a pathologist, often attending the 22 autopsy, and so on. 23 And then I have rural cor -- coroners who 24 are primary in Haldimand, Norfolk, which are areas -- and 25 now, I guess, but certainly not similar to the North in


1 terms of having a very low population density. However, 2 in those areas, the coroner can and does attend almost 3 all death scenes. 4 There is some latitude in the guideline 5 for cases which are not cri -- which are neither 6 criminally suspicious nor pediatric nor are there other 7 issues where they don't attend, but they attend the vast 8 majority, and I do follow the guideline about coroner 9 attendance at scenes. 10 MR. MARK SANDLER: All right, and -- and 11 again, I'll ask you the same question that -- that has 12 been asked for the other regions, and that is, how many 13 cases would there be per year in the region that would 14 qualify as pediatric that are not obvious cases, for 15 example, of disease? 16 DR. DAVID EDEN: I didn't -- I didn't 17 spreadsheet that out. I have no reason to believe that 18 the numbers in my region would be any different from Dr. 19 McCallum's. 20 I can say that I have looked at numbers in 21 the past and they are fairly uniform across the Province. 22 MR. MARK SANDLER: Okay. And a similar 23 question that I asked in relation to other regions on 24 recruitment. I think some of us might assume that -- 25 that the recruitment issues that have been identified


1 extend to the North, but perhaps not in southern Ontario. 2 Do you have difficulty recruiting 3 coroners? 4 DR. DAVID EDEN: It's easier to recruit 5 in urban areas than rural, and I think there's two (2) 6 reasons for that. One (1) is that there are simply -- 7 there's a larger recruitment pool in an urban centre. 8 There may be four hundred (400) family physicians in 9 Hamilton or -- or some number like that, and that's a 10 larger pool than say, a half dozen family physicians to 11 recruit from or emergency physicians. 12 And the other thing is that the volume is 13 higher, so from a business standpoint, to be an urban 14 coroner is a way that one can make a living. To make a - 15 - to be a rural coroner is more a -- something which is 16 very much a public service and is not a -- it doesn't 17 make business sense, but is a good career development 18 public service option for family physicians. 19 MR. MARK SANDLER: All right. Now, you - 20 - you heard the exercise that -- that we engaged in, both 21 with Dr. McCallum, and Dr. Legge, to kind of take us 22 through the anatomy of how one (1) of the cases that -- 23 that we might examine at this Inquiry is dealt with in -- 24 in their regions. 25 So -- so I want to take you through that


1 process for Niagara, if I -- if I may. So let's assume 2 we have the sudden and unexpected death of a -- of a 3 child with no history of being treated for a particular 4 disease. 5 So it's a case that's possibly going to 6 turn out to be suspicious but not necessarily so at the 7 outset. Tell me about how that would come to the 8 attention of -- of the corner? What the dispatching 9 process is, in effect? And how the case would be 10 referred to the pathologist and where? 11 DR. DAVID EDEN: So from a dispatching 12 point of view, the Niagara region has a single answering 13 service, so any death within the Regional boundaries goes 14 to one (1), 1-800 number, and that -- the answering 15 service has information on how to contact coroners, and 16 they also have a -- a protocol that if they can't contact 17 a coroner within a reasonable time, they'll call the 18 regional coroner. 19 So that -- that would be how that call 20 would go through. Once the call goes through, the -- the 21 protocol in Niagara -- certainly in Niagara and Hamilton, 22 is that it's a triple agency investigation once we get a 23 report of a -- a child death; that coroner, police, and 24 Children's Aid are to be notified of the death; and then 25 each of those agencies is going to be involved as


1 appropriate. In that death, all three (3) will be 2 notified. 3 MR. MARK SANDLER: Now just stopping 4 there for a moment, what I hear you saying is that the 5 protocol provides that, for example, Children's Aid is 6 going to be notified regardless of whether, at first 7 instance, this is a suspicious death or not? 8 DR. DAVID EDEN: That's right. 9 MR. MARK SANDLER: All right. Could you 10 explain the protocol? How it would -- how it developed; 11 what its underlying rationale is, and how it operates in 12 practice? 13 DR. DAVID EDEN: The -- the protocol for 14 notification came as a result of investigative findings. 15 We have regular rounds on cases which include police; 16 pathologists and Children's Aid for pediatric cases. 17 And those cases are not just we're looking 18 at individual investigations, but also for learning about 19 how we could do better investigations in future. 20 And one (1) thing we found, actually, 21 about Children's Aid investigations -- the first thing is 22 that in infant investigations, Children's Aid have a 23 unique and very valuable expertise in childhood death 24 investigations which coroners and police don't. They 25 compliment the -- the skills that the coroners and police


1 have. 2 The other thing is that Children's Aid may 3 have information which is very relevant to our 4 investigation, but which would not come to us if we 5 didn't ask them. 6 And unfortunately, for instance, if we ask 7 a family, Is Children's Aid involved, they may say no; 8 and if we ask Children's Aid, Children's Aid may say yes. 9 So it turns out to ensure we get the most 10 reliable information by asking Children's Aid, Do you 11 have prior involvement. And then if there's anything 12 that's relevant to the death investigation, we can see 13 about obtaining that information from Children's Aid. 14 So that -- there's really two (2) -- two 15 (2) valuable parts of it. One (1) is that Children's Aid 16 bring their expertise which is valuable; and the second 17 is that Children's Aid may have information we wouldn't 18 obtain otherwise. 19 MR. MARK SANDLER: All right. Now, 20 continuing through the chronology, and I'm going to come 21 back and ask about the role of the Children's Aid in the 22 investigation as it proceeds through the process, but -- 23 DR. DAVID EDEN: I -- I wouldn't see it 24 varying substantially, particular from -- from what Dr. 25 McCallum described.


1 If the case is criminally suspicious, or 2 if there are other issues, we may convene an early case 3 conference. Otherwise, we would proceed -- and I think 4 Dr. McCallum would do the same thing -- we would proceed 5 to order the autopsy; obtain the medical records, and 6 essentially, carry out the protocol for sudden and 7 unexplained deaths of infants. 8 MR. MARK SANDLER: All right. And where 9 do your sudden and unexpected pediatric deaths go to for 10 autopsy? 11 DR. DAVID EDEN: Hamilton. Yeah. 12 MR. MARK SANDLER: And that's invariably 13 the case? 14 DR. DAVID EDEN: Yes. 15 MR. MARK SANDLER: All right. And if you 16 just continue on in -- in the process to this extent, and 17 that is that you've said that there's the protocol that - 18 - that governs the relationship between and the sharing 19 of information, between Children's Aid and the other 20 involved agencies. 21 Who are the signatores to the protocol? 22 DR. DAVID EDEN: And there's -- there's 23 three (3) protocols here. The -- and the first two (2) 24 are not from the coroners office; the ones in which the 25 coroners office participated.


1 So the first few are that -- FACS Niagara, 2 Family and Children's Services Niagara, and the Niagara 3 Regional Police and the Crown developed a protocol for 4 investigating deaths which had both child welfare and 5 criminal components. 6 And it's important to bear in mind that 7 these are mostly non-deaths so the -- that the coroner is 8 involved in a minority of those cases. So I was 9 consulted on that for the part relating to death 10 investigations, but that as I said is a minority aspect 11 of it. 12 Hamilton police have a similar protocol 13 with Hamilton Children's Aid and Hamilton Catholic 14 Children's Aid, again setting out how they're going to 15 investigate deaths which combine criminal and child 16 welfare issues -- 17 MR. MARK SANDLER: And -- 18 DR. DAVID EDEN: -- and again I was 19 involved but only to the extent of the coroners, which is 20 not actually a lot. Most cases -- most cases that employ 21 that protocol don't involve a death. 22 MR. MARK SANDLER: All right. And -- and 23 you were about to tell us about the third. 24 DR. DAVID EDEN: And then the third one 25 is a local one and that is the notification of Children's


1 Aid in every case and that was an initiative basically 2 after discussion between the heads of the Children's Aid 3 societies and myself. It was basically to say would it 4 be useful to both of us if we did that? The answer was 5 yes. 6 So that -- that was put on as a matter of 7 agreement between the Regional Supervising Coroner's 8 Office and the Children's Aid societies. 9 MR. MARK SANDLER: All right. And, Dr. 10 McCallum, I'll ask you, are -- are there similar 11 protocols in effect in -- in your region? 12 DR. ANDREW MCCALLUM: I would say they're 13 not as formalized, but there are protocols. And there's 14 communication for example in every case where Children's 15 Aid's involved and they're involved in the case 16 conferences that occur. 17 MR. MARK SANDLER: All right. And, Dr. 18 Legge what was the practice in that regard in the North? 19 DR. DAVID LEGGE: Less formalized still. 20 We get notification of deaths by Children's Aid, let's 21 say Tikinagin out of Sioux Lookout, but we don't -- I 22 don't have the same luxury of having case conferencing 23 with them as Dr. Eden does. 24 They've all -- they're all -- they're all 25 very, very cooperative, however, when I -- when I do


1 contact them. And it is often myself who actually asks 2 this question when I get notification of a children's 3 death: Was CAS canvassed? to see whether they're 4 involved. I'm -- I'm never quite sure whether the 5 coroner asks that question. 6 MR. MARK SANDLER: Okay. 7 DR. DAVID EDEN: And actually if I could 8 add, there -- there is one (1) part I missed, and that is 9 that in Niagara we have a policy that just about every 10 pediatric death is in fact case conferenced at the 11 conclusion of the case. And that case conference will 12 include the pathologists, police, investigating coroner, 13 often the toxicologist, and myself. 14 MR. MARK SANDLER: Now -- now, that's not 15 -- we've heard reference to case conferencing that takes 16 place much earlier in the process, with a view to -- to 17 informing where the investigation should go. You're 18 talking about a case conferencing that -- that follows 19 the completion of the case, is that right? 20 DR. DAVID EDEN: That's correct, yes. 21 MR. MARK SANDLER: And -- and is that set 22 out in writing that that case conferencing takes place? 23 DR. DAVID EDEN: No, we have regular 24 forensic rounds in -- in Hamilton, and that of course is 25 where the pediatric deaths are, and we have simply found


1 so much value from reviewing almost all pediatric deaths. 2 There -- there are some where we'll know there's no value 3 so we won't bring them there. 4 These are non-criminal cases as well. We 5 wouldn't bring a criminal case until after it's reached 6 disposition in the courts. 7 But we have found value from discussion 8 and the value is for the case itself to ensure that we've 9 done a complete investigation and our conclusions are 10 justified. And it's also useful for making sure that all 11 the steps were carried out and is there anything we can 12 learn about better investigations. 13 And it also has the value of allowing the 14 police, social workers, coroners, toxicologists to 15 develop better communications among each other. You know 16 who you're talking to. 17 MR. MARK SANDLER: And who initiated that 18 -- that process? 19 DR. DAVID EDEN: The -- the rounds were 20 something that started in 1998 when I became the regional 21 coroner. But I -- I would say I facilitated it but it's 22 happened because police, Children's Aid, pathologists, 23 toxicologists all have supported it. They want to be 24 there and they have found value from it. 25 MR. MARK SANDLER: All right. And do the


1 Crown attorneys participate in -- in that case 2 conferencing? 3 DR. DAVID EDEN: Not in that one. They - 4 - they -- I have invited them just on an educational 5 basis to learn about death investigations. I know that 6 Crown -- Crown attorneys have concerns about being 7 directly involved in an investigation. And that's a 8 legal issue on which I'm not an expert. 9 But the -- the types of forensic round 10 we're doing are not criminal cases, in fact criminal 11 cases are excluded from those rounds, for those that we 12 do in individual case conference, so that the Crown might 13 not have an interest of course in a case that -- which 14 isn't criminal, other than for educational purposes and 15 they're busy. 16 MR. MARK SANDLER: But what I gather 17 you're saying is that the criminal cases are case- 18 conferenced but individually. 19 DR. DAVID EDEN: Individual; that's 20 right. 21 MR. MARK SANDLER: All right. Dr. 22 McCallum, is there anything comparable to what's going on 23 in Niagara in -- in the eastern region? 24 DR. ANDREW MCCALLUM: There is. Each of 25 the two forensic path units has regular rounds on a


1 monthly interval that I attend wherever possible. I'm -- 2 I'm more successful in Kingston than I am in Ottawa just 3 because of the geography. 4 But -- and, again, they are non-criminal 5 cases. They are not as evolved, if you like, as what Dr. 6 Eden has put in place in Hamilton in that you typically 7 have the forensic pathologist and the coroners attending 8 in -- the rounds in my region and not the other 9 investigators who might be involved. 10 MR. MARK SANDLER: All right. 11 DR. DAVID EDEN: I could just give an 12 example of something we found from -- from a multi- 13 disciplinary case conference which we didn't expect, and 14 that was an infant death where there was an unexpected 15 toxicologic finding. 16 And we convened a case conference and, 17 actually, we -- what we found was that one (1) of the 18 investigators had information about the source, but 19 because of their -- they -- they weren't technical 20 experts, they didn't know that that was the source. 21 The other investigator suspected that this 22 substance might cause -- might cause it, but had no 23 information that that substance was in the household, and 24 it was only by having people gather round the table and 25 exchange information, that we managed to put this case


1 together. 2 MR. MARK SANDLER: Now, I'm going to turn 3 to each of you and -- and ask you if you have a wish list 4 that might be of assistance to the Commissioner. 5 Or, put another way, are there things that 6 you'd like the Commissioner to consider in drafting his 7 recommendations? 8 Dr. McCallum, I'll turn to you first. 9 DR. ANDREW MCCALLUM: I think, from my 10 perspective, the -- the information spine that underlies 11 all this is critical, so the dispatch system coupled with 12 a robust database notification system would be the first 13 thing, I think, that we should have. And I would ask the 14 Commissioner to consider that as a recommendation. 15 MR. MARK SANDLER: Dr. Eden...? 16 DR. DAVID EDEN: I -- I would -- I would, 17 yeah, I would make recommendations in two (2) areas. 18 And the first would be ensuring that we 19 have the staff resources and infrastructure. And without 20 saying exactly what it should be, I think it would be 21 sensible to look at what the public reasonably expect of 22 death investigations and say, How do we meet that 23 expectation? 24 And, to give an example, one (1) thing 25 that we've heard and I don't think it's an unreasonable


1 expectation, is that of case tracking; to say that every 2 case -- the office will make sure that every case is 3 moving forward at every step. And that is something we 4 simply don't have the resources to do at the moment. 5 That given, the resources we have for the 6 number of cases we have and the demands on staff, there 7 isn't enough staff time to review cases and make sure 8 they're moving forward. And I would certainly like to 9 have that, because that would probably give us an 10 opportunity to cut a substantial amount of turn-around 11 time from our cases. 12 But I -- it's certainly something I would 13 have loved to implement before, but we simply have not 14 had the staff to do it. 15 The information technology backbone is a 16 serious issue for us. Our network is very slow. The -- 17 the Regional Offices have a 100 kilobit connection and -- 18 and, by comparison, the average teenager in -- sitting in 19 the basement of a house similar will have a 5,000 kilobit 20 connection. So they'll be -- they'll have a fifty (50) 21 times as fast connection as we do. The average business 22 will have an even faster connection. 23 It would certainly be useful to us to have 24 the same sort of network speed as a residence and, even 25 better, as a small business. And the reason this is


1 important is that our staff actually spend a lot of time 2 looking at screens waiting for them to change. 3 And when I watch my staff, they can often 4 be waiting twenty (20) or thirty (30) seconds. And 5 that's, obviously, very disruptive to productivity. 6 They've got a lot of work to do, and they're spending a 7 lot of time looking at -- at screens. 8 COMMISSIONER STEPHEN GOUDGE: I got the 9 sense from you, Dr. Eden, that when you were in Niagara, 10 the support was better. 11 DR. DAVID EDEN: No, actually, the -- the 12 network speeds, from what I can see in the Regional 13 Offices, are pretty uniform. 14 COMMISSIONER STEPHEN GOUDGE: Okay, how 15 about the support, 'cause at one (1) point you compared 16 your support, sort of, per capita, in a way that made the 17 North relatively less well-serviced. 18 DR. DAVID EDEN: The -- well, until 19 December 31st, the northwest region had twelve hundred 20 (1,200) cases and one (1) full-timer. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DR. DAVID EDEN: And Niagara had -- 23 COMMISSIONER STEPHEN GOUDGE: You've now 24 got twenty-one hundred (2,100) -- 25 DR. DAVID EDEN: That's right.


1 COMMISSIONER STEPHEN GOUDGE: -- as 2 opposed to two thousand (2,000), and less than the 3 support you had in Niagara. 4 DR. DAVID EDEN: That's right. So it's 5 now substantially understaffed -- 6 COMMISSIONER STEPHEN GOUDGE: But when 7 you -- when you've been using the word "we" in your -- 8 DR. DAVID EDEN: Yes. 9 COMMISSIONER STEPHEN GOUDGE: -- in this 10 answer, do you mean "we" the North or "we" the regional 11 services that cross the Province? 12 DR. DAVID EDEN: In the case of staffing, 13 at the moment, the Northern Office is below the staffing 14 of -- of other offices. All the other regional offices 15 had one (1) full-timer and one (1) part-timer. 16 The North has -- now has the same case 17 load as the other regional offices, but has only one (1) 18 full-timer, so it's -- 19 MR. MARK SANDLER: Right. 20 DR. DAVID EDEN: -- much less per capita. 21 COMMISSIONER STEPHEN GOUDGE: So that's a 22 regional issue; the speed of the network. Backbone is a 23 province issue? 24 DR. DAVID EDEN: That's correct, yes, 25 sir.


1 COMMISSIONER STEPHEN GOUDGE: Okay, I 2 didn't want to cut you off, if you have anything else you 3 could help me with that would be wonderful? 4 DR. DAVID EDEN: I think on the -- on the 5 Northern issue there -- I think it's quite clear from -- 6 from the evidence here that there are specific challenges 7 for death investigations in Northern Ontario. 8 And I wouldn't profess to know what the 9 answers are. I'm -- I'm learning a great deal as I move 10 into this position. But I would certainly encourage 11 creative approaches. 12 And examples we thought about are the -- 13 using the telehealth facilities to assist the coroner. 14 Another thing we might do, for instance, is to give 15 training to specific police officers to act as coroner's 16 assistants. 17 And there's already an example of this; 18 there's police officers who receive scene of crime 19 officer or SOCO training, and we could apply a similar 20 model to give specific police officers training in death 21 investigations to assist the coroner. 22 That's just an example. I think we 23 definitely need to be creative and say, How can we 24 deliver a -- the same quality of death investigation 25 throughout the province, bearing in mind the specific


1 challenges that face us in Northern Ontario? 2 COMMISSIONER STEPHEN GOUDGE: Okay. 3 Thank you. 4 5 CONTINUED BY MR. MARK SANDLER: 6 MR. MARK SANDLER: Dr. Legge...? 7 DR. DAVID LEGGE: Well, before I came 8 down I, in fact, put my recommendations on paper. I 9 thought I was going to be very succinct, but I ended up 10 with 2 and a quarter (2 1/4) pages. 11 MR. MARK SANDLER: You take the time you 12 need. 13 DR. DAVID LEGGE: Okay. And -- and I 14 want to stress that these are all independent thoughts 15 from what Dr. Eden has come up with and Dr. McCallum. 16 And Dr. Eden is now succeeding the individual finders. 17 There's a common theme here. 18 Do you want me to just to read these, I -- 19 COMMISSIONER STEPHEN GOUDGE: Yes, why 20 don't you just give them to us, Dr. Legge, I'd be very 21 grateful. 22 DR. DAVID LEGGE: Read them? 23 COMMISSIONER STEPHEN GOUDGE: Yes, 24 absolutely. 25 DR. DAVID LEGGE: I'll -- I'll read them


1 and give you copies. Again: 2 Resources. 1. Personnel/administrative. 3 Second full time administrative assistant for regional 4 coroner, high priority. Consideration for second 5 Regional Supervising Coroner for Sudbury end of the 6 region. 7 B. Support; immediate upgrade of computer 8 system to bring speed up to par." [already mentioned] 9 COMMISSIONER STEPHEN GOUDGE: I'm going 10 to stop you as you go along -- 11 DR. DAVID LEGGE: Yeah, sure. 12 COMMISSIONER STEPHEN GOUDGE: -- if I 13 have questions. How would you create a second Regional 14 Supervising Coroner? Would they be co-Regional 15 Supervising Coroners, or does this really get back to 16 dividing the region in two (2)? 17 DR. DAVID LEGGE: You better speak to 18 this, yeah. 19 DR. DAVID EDEN: And this -- the concern 20 I would have about dividing into two (2) administrative 21 regions, is that because of the flow of cases with police 22 and pathologists, when you divide such a region, you end 23 up spending a lot of your time chasing cases between 24 regions. 25 So the -- the worldwide experience has


1 been, have a region in which you provide all the 2 speciality services. 3 COMMISSIONER STEPHEN GOUDGE: How do you 4 get the regional supervision across this big an area? I 5 mean, could you do it by way of a -- I mean, I'm just 6 throwing out this idea, Deputy Regional Supervising 7 Coroner in Sudbury to take an -- 8 DR. DAVID EDEN: I -- certainly that's 9 one (1) of the possibilities would be to have two (2) 10 regional offices in the same region. Another would be to 11 have a high -- high level executive assistant for the 12 Regional Supervising Coroner who could carry out a lot of 13 the -- the work on a delegated basis. 14 And I honestly don't know the answer to 15 that. I think it certainly merits further study. But 16 either of them has merit, either of them may have 17 drawbacks. 18 COMMISSIONER STEPHEN GOUDGE: You guys 19 are the ones that have to help on this. 20 DR. DAVID LEGGE: I'm sort of old school. 21 To me, it's important to have time to go around and meet 22 people face-to-face. 23 COMMISSIONER STEPHEN GOUDGE: Right. 24 DR. DAVID LEGGE: Dr. Eden is somewhat 25 younger and has more energy. There's no way I -- if I


1 was in his boots, I couldn't possibly do that job the way 2 it is now and feel happy about -- 3 COMMISSIONER STEPHEN GOUDGE: Getting to 4 Sudbury? 5 DR. DAVID LEGGE: Get -- getting it done 6 properly. 7 COMMISSIONER STEPHEN GOUDGE: Getting 8 the -- 9 DR. DAVID LEGGE: I just -- I couldn't do 10 it. And I'm not -- I'm not as adept at Blackberry work 11 and that sort of thing, as some of the other regional 12 coroners are. So -- 13 COMMISSIONER STEPHEN GOUDGE: That -- 14 DR. DAVID LEGGE: There's a big 15 difference in our -- 16 COMMISSIONER STEPHEN GOUDGE: -- with me, 17 Dr. Legge. 18 DR. DAVID LEGGE: Okay. Part C. 19 Immediate upgrade of regional office. The current office 20 in Thunder Bay is pitifully small. There isn't even a 21 conference room there. I've got to cram people in right 22 beside my desk -- and there's a post in the way -- to 23 have -- to have a proper meeting. 24 And there's certainly no room for a second 25 administrative assistant there:


1 Number 2. Addressing death investigation 2 quality in remote areas. 3 A. Office of Chief Coroner to decide 4 whether current standard absolutely mandates that all 5 scenes, however remote, require on-scene presence of a 6 coroner, or rather trained investigator. 7 Again, it's -- it's in the legislation and 8 it's parroted out day after day in our training of new 9 coroners, but it just doesn't happen. 10 B. OCC to dialogue with other 11 jurisdictions, or even research, if international, to 12 explore alternate systems, for example, medical examiner 13 systems and models where large remote indigenous 14 populations predominate, an example, Australia, southwest 15 United States. 16 Aboriginal leadership to be involved, at 17 least in the later stage, for input and advice, where the 18 communities in focus are the largely aboriginal. 19 And we've touched on this. I know that 20 they have a medical examiner system in Manitoba, and I 21 believe that many of these people who go to the scenes 22 are not -- are, in essence nurses, for example. 23 In Thunder Bay, I have a personal friend 24 who is a -- is an ex-medical examiner from Hennepin 25 County, Minni -- Minneapolis, who's a layperson, superb


1 training, so -- and so let's not fool ourselves; there's 2 other people out there who are non-physicians who can be 3 excellent death scene investigators. 4 COMMISSIONER STEPHEN GOUDGE: Why 5 couldn't you deputize -- 6 DR. DAVID LEGGE: I think it's worth 7 exploring these other options. 8 COMMISSIONER STEPHEN GOUDGE: Why 9 couldn't up deputize a non-police officer? Anything 10 wrong with that? 11 DR. DAVID LEGGE: A non-police officer? 12 COMMISSIONER STEPHEN GOUDGE: Yeah, a 13 nurse, for example -- 14 DR. DAVID LEGGE: Yeah. 15 COMMISSIONER STEPHEN GOUDGE: -- to go to 16 the scene. 17 DR. DAVID LEGGE: Well, I think they'd -- 18 COMMISSIONER STEPHEN GOUDGE: I guess 19 what I want to add is -- 20 DR. DAVID LEGGE: You want to -- 21 COMMISSIONER STEPHEN GOUDGE: -- does 22 this turn on the difference between the Coronial System 23 and the Medical Examiner's System, or does it turn on the 24 skill level of a person that is doing the scene 25 attendance if the coroner can't get there?


1 DR. DAVID LEGGE: I -- I really don't 2 think that a nurse from the nursing station would have 3 the skills. 4 DR. ANDREW MCCALLUM: I think that the -- 5 Mr. Commissioner, if I might, I think the issue really 6 turns on the knowledge and objectivity of the individual 7 who is deputized -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 DR. ANDREW MCCALLUM: -- and so obviously 10 one could train, as done in a number of jurisdictions, an 11 individual, not a physician, to do a very competent and 12 thorough death scene investigation. 13 The advantage that we have with the 14 Coronial System that we have in Ontario is that it's 15 relatively unique in that, as you know, in that we have 16 physician coroners. 17 COMMISSIONER STEPHEN GOUDGE: Right. 18 DR. ANDREW MCCALLUM: And so you -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. ANDREW MCCALLUM: We do know that 21 there are issues at scenes when lay people attend where 22 there -- and not so much in the homicide situation, but 23 more in the medical -- 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 DR. ANDREW MCCALLUM: -- situation, where


1 the subtleties may not be appreciated -- 2 COMMISSIONER STEPHEN GOUDGE: Right. I 3 was just getting at -- Dr. Legge was sort of raising the 4 medical examiner model as a way of -- 5 DR. ANDREW MCCALLUM: And you're 6 probably -- 7 COMMISSIONER STEPHEN GOUDGE: -- getting 8 better scene attendance, as opposed to the skill set of 9 the people attending the scene getting better scene 10 attendance. 11 DR. DAVID LEGGE: Just an example, all 12 I'm suggesting is looking at other options -- 13 COMMISSIONER STEPHEN GOUDGE: Right. 14 DR. DAVID LEGGE: -- and exploring 15 possibilities -- 16 COMMISSIONER STEPHEN GOUDGE: Right. 17 DR. DAVID LEGGE: -- and actually 18 speaking with say the -- the Chief Medical Examiner of 19 Manitoba and see -- see how well they do up in -- 20 COMMISSIONER STEPHEN GOUDGE: Right. 21 DR. DAVID LEGGE: -- the Pas or -- 22 COMMISSIONER STEPHEN GOUDGE: Right. 23 DR. DAVID LEGGE: -- places like that. 24 C. OCC -- OCCO, I guess, to consider a 25 model of dedicated police officer with extra specialized


1 training in death investigation to be appointed in trial 2 or targeted areas. 3 Well, this has been kind of mentioned 4 before. And if this were done, I would suggest that it 5 be done on a trial basis or maybe a targeted area. I -- 6 I don't whether you'd want to embark upon a training 7 program for -- to cover the entire area, because it would 8 make -- it would make -- prove to be a gross failure and 9 a lot of expenses would have been taken up, but if one 10 (1) or two (2) selected areas could be trialed, it might 11 be worth a try. 12 D. Explore with experts in real time, 13 again, back to telemedicine, the future of possibilities 14 of direct visualization of death scenes where the coroner 15 location is remote, technology is available and properly 16 funded in remote communities, and again, this has been 17 mentioned before. 18 Number 3. Communication, a province wide 19 registry be developed for improved notification of all 20 case reports. High priority, local coroners to be 21 reminded through direct or memo communication, lines of 22 necessity are timely contact with a Regional Supervising 23 Coroner, mentioned many times. 24 B. See also below under cultural 25 sensitivity.


1 Number 4. Improving quality of pediatric 2 investigations in remote areas of the North. 3 A. Appendix to be designed, implemented 4 to be added to the death under five (5) questionnaire. 5 To mandate that discussion has been held with families or 6 representatives to outline the purposes and expectations 7 of the autopsy process, to include information on time of 8 autopsy, location, anticipated return of body, and 9 consider printed pamphlet for Aboriginal families, 10 English and Creole Ojibway translations, or Oji-cree 11 translations. 12 B. Fast track timely return of bodies to 13 communities following autopsy to reduce burden to 14 grieving communities, self evident. 15 C. Chief of forensic pathology to meet 16 with Aboriginal leadership representative to discuss 17 culturally specific and sensitive ways to handle organ 18 retention problem. And this may include exempting usual 19 procedure in cases that are non-criminally suspicious. 20 Improved consistency re. organ retention notification 21 between investigating and Regional Supervising Coroners. 22 I think this has been covered before as 23 well. 24 D. The Chief of Forensic Pathology to 25 meet in person, and more than once, with pathologists in


1 northern Ontario, example: Thunder Bay and Kenora. 2 To advance and foster these communities as 3 centres of excellence, and bring them more into the 4 professional fold of forensic pathology in this Province, 5 and thus making them feel more like team members. The 6 same would apply to the pathologists in Winnipeg who 7 assists our system. 8 And 5) Cultural Sensitivity. There's need 9 for more dialogue and reduction of possible past and 10 present or future tension between Aboriginal communities 11 and both police and coroners. Case volume for Aboriginal 12 deaths will certainly be increasing in the future, 13 considering the rapid rise in this population 14 demographic. And we know that from STATS Canada 15 recently. 16 Communication on a day-to-day basis. 17 Individual cases requires improvement with simple 18 strategies, such as exchanging information on 19 whereabouts, contacts, following death investigation, 20 initiation, and continuation of initiatives to improve 21 understanding through Northern Ontario Medical School, 22 including fostering death investigation and forensics in 23 Aboriginal and all other grad -- undergrad medical 24 students. 25 That may sound dry, but I think it's a --


1 a recapitulation of a fair amount of what's already come 2 forward here. 3 COMMISSIONER STEVEN GOUDGE: Right. 4 DR. DAVID LEGGE: And it's just on paper -- 5 COMMISSIONER STEVEN GOUDGE: Right. 6 DR. DAVID LEGGE: -- for you. 7 COMMISSIONER STEVEN GOUDGE: Thank you, 8 Dr. Legge. 9 DR. DAVID LEGGE: Mm-hm. 10 MR. MARK SANDLER: Thank you very much. 11 12 CONTINUED BY MR. MARK SANDLER: 13 MR. MARK SANDLER: Thank you very much. 14 Now, Dr. McCallum, I have some more questions for you on 15 a -- on two (2) topics that are fairly unrelated to what 16 we've been talking about up until this point. 17 The first is toxicology. Could you 18 describe your experience in the eastern region with the 19 timeliness of toxicology results? 20 DR. ANDREW MCCALLUM: We have an issue in 21 -- in timeliness of toxicology results that it affects 22 the -- certainly the speed of death investigations, and 23 in my view, it has -- to use a metaphor of a tire, it's a 24 traction issue. 25 We -- we lose some traction in the


1 efficiency of the death investigation process, and the 2 ultimate conclusion of the investigation. We -- 3 COMMISSIONER STEVEN GOUDGE: You go to 4 CFS? 5 DR. ANDREW MCCALLUM: Pardon me? 6 COMMISSIONER STEVEN GOUDGE: Your 7 toxicology is done by CFS? 8 DR. ANDREW MCCALLUM: Yes, it is. It is, 9 and, so we are seeing turnaround times that exceed ninety 10 (90) days, not rarely. 11 And the reports downstream from that -- 12 the report of post-mortem examination; the coroner's 13 report which all devolve from those results -- are 14 delayed as a consequence. 15 So it's a concern. And I would like to 16 see -- and this was one (1) of the things that I was 17 going to recommend; is that there be some examination of 18 ways and means to improve the turnaround time for 19 toxicology. 20 21 CONTINUED BY MR. MARK SANDLER: 22 MR. MARK SANDLER: And do you -- 23 COMMISSIONER STEVEN GOUDGE: We have 24 heard very little about sort of Province wide stats on 25 that.


1 Do you know whether your turnaround time 2 is any different from experiences elsewhere in the 3 Province? 4 I mean, I assume in the North, you go to 5 the Northern forensic -- 6 DR. DAVID LEGGE: Sault St. Marie. 7 COMMISSIONER STEVEN GOUDGE: -- yes. 8 Yes. What are your turnaround times? 9 DR. DAVID LEGGE: They're not too bad. I 10 -- I mean, they're -- they're three (3) months, but 11 they're -- they don't go six (6) months, like I gather 12 happens elsewhere down here. 13 COMMISSIONER STEVEN GOUDGE: Right. 14 DR. DAVID LEGGE: Plus I have -- 15 COMMISSIONER STEVEN GOUDGE: What was 16 your experience in Niagara, Dr. -- 17 DR. DAVID EDEN: It was about three (3) 18 to four (4) months. 19 COMMISSIONER STEVEN GOUDGE: So do you 20 know, Dr. McCallum, if the -- 21 DR. ANDREW MCCALLUM: It's the same. 22 It's -- say it would be similar to Niagara. I don't 23 think there's any different in the southern regions 24 between the experiences. 25 COMMISSIONER STEVEN GOUDGE: And is it


1 your sense that the times are slipping? 2 DR. ANDREW MCCALLUM: It's hard to say. 3 I haven't -- I haven't tracked that. I would say they're 4 not improving -- 5 COMMISSIONER STEVEN GOUDGE: Right. 6 DR. ANDREW MCCALLUM: -- dramatically. 7 COMMISSIONER STEVEN GOUDGE: Right. 8 9 CONTINUED BY MR. MARK SANDLER: 10 MR. MARK SANDLER: One (1) of the things 11 that -- that I know you've raised is -- is whether or not 12 the wheel has to be reinvented every time a toxicology 13 report comes back, with the relevant literature and such, 14 as opposed to a template. 15 And we've actually heard some evidence 16 about that earlier -- earlier in the process. 17 DR. ANDREW MCCALLUM: I would -- I would 18 like to say at the outset that I think the collaboration 19 and cooperation and the opinions that we receive from the 20 forensic toxicologists are of a high order, and so I have 21 no criticism of that at all. 22 And in fact, that's a professional matter 23 for them to determine. But from the utility standpoint, 24 reading the reports, I'm not certain that having an 25 independent review of the literature -- concerning the


1 particular substance that's done -- to know each time, 2 adds tremendous value to my opinion. 3 And that's the thing that I think is 4 worth, at least, look at, and -- and I'm not saying that 5 to be critical of them, but it just may be an efficiency 6 matter for them. 7 MR. MARK SANDLER: Okay. The last topic 8 that I want to ask you about, Dr. McCallum, has to do 9 with some evidence that was given here on December the 10 20th of last year in a panel that included Dr. Michaud 11 and Dr. de Nanassy. 12 And -- and I'm going to take you to the -- 13 the testimony at page 174, and these are questions that 14 are being directed to Dr. de Nanassy by Ms. McAleer 15 commencing at line 24: 16 "Can you please indicate when it was 17 that you first became aware of the fact 18 that there had been a decision that 19 cases would no longer be sent to CHEO?" 20 Dr. de Nanassy responded: 21 "I don't know about any decision having 22 been taken. The way we found out was 23 in kind of a serendipitous way in that 24 one day there were police officers 25 sitting in the hallway in front of the


1 morgue. And there was a body in there 2 which was going to have a medicolegal 3 autopsy done, except the police 4 officers were there to accompany the 5 body to Toronto." 6 And he said: 7 "That was two (2) or three (3) months 8 ago, ballparking it." 9 And Ms. McAleer asks him: 10 "Did you make enquiries as a result of 11 that event? 12 I mentioned the occurrence to Dr. 13 Michaud and he wasn't aware of any 14 decision having been taken either. And 15 he asked me to enquire from the 16 regional coroner as to why that would 17 be happening. And so I contacted the 18 regional coroner, who happened to be 19 away on an inquest, and I spoke to his 20 replacement who was surprised that I 21 would not know." 22 And there's a reflection that the 23 replacement was Dr. Bechard. And then it goes on to say: 24 "Dr. McCallum is now the Regional 25 Supervising Coroner.


1 And what did you learn from your 2 conversation with Dr. Bechard? 3 Well, he was surprised that we wouldn't 4 know, and he thought we were under the 5 assumption that we are aware of that 6 change. 7 Sorry, and what was the change? 8 That criminally suspicious cases would 9 not be autopsied at CHEO, but would go 10 to Toronto -- but would go to Toronto. 11 Where in Toronto? [the Commissioner 12 asks] 13 I don't know exactly. I suppose the 14 Hospital for Sick Children. 15 And did Dr. Bechard explain to you his 16 understanding as to why that decision 17 had been made or who had made that 18 decision? No. But what he offered was 19 that he was going to have a meeting in 20 Toronto with all the other regional 21 coroners and the Chief Forensic 22 Pathologist, and he was going to raise 23 the issue at that meeting and feedback 24 to me. 25 And what was the next you heard on the


1 subject, Dr. de Nanassy? 2 Well, he called me back several days, 3 if not a week, later. So we were on 4 the phone. He said this is a temporary 5 measure. The criminally suspicious 6 cases would be bypassing CHEO until 7 such time that this Commission issues 8 its report, and the situation will be 9 reviewed. 10 Did he provide you with any other 11 explanations as to why CHEO was being 12 bypassed? 13 All he said was that it's not a matter 14 of competence -- professional 15 competence -- it's more a precautionary 16 measure. 17 And since that conversation, have you 18 had any other conversations with Dr. 19 McCallum with respect to this issue? 20 Yes, when Dr. McCallum resumed his 21 functions as regional coroner, he 22 called me one day on an unrelated issue 23 and since he was on the line anyway, I 24 took the issue up with him. And he 25 said, I thought we had discussed this


1 in the summer. And, in fact, we 2 hadn't. At least I don't have a 3 recollection of us having discussed 4 that. So I asked him to provide us 5 with something in writing as to why 6 those criminally suspicious cases would 7 be bypassing CHEO, to which he agreed. 8 He said he might send an email 9 confirming it so we'd have something in 10 writing. I'm still waiting." 11 And Ms. McAleer says: 12 "Since that conversation with Dr. 13 McCallum, have you learned anything 14 more on the subject? 15 No, I have not." 16 And then Ms. McAleer asks about his views 17 as to whether CHEO should be bypassed at present with 18 respect to criminally suspicious cases. And he expresses 19 the view that: 20 "We should not have been bypassed. I'm 21 not quite sure why we weren't involved 22 in the process. We weren't involved in 23 the decision. The decision wasn't 24 communicated to us. We kind of found 25 out as a surprise."


1 Your comments on that testimony. 2 DR. ANDREW MCCALLUM: Well, I did have a 3 conversation with Dr. de Nanassy in July of this year. I 4 don't remember the specific date, but I was -- 5 MR. MARK SANDLER: July of last year, I 6 take it? 7 DR. ANDREW MCCALLUM: -- July of 2007, 8 pardon me -- at which we discussed the issue that 9 required that homicides be temporarily moved from CHEO to 10 Toronto. There were some procedural issues that Dr. 11 Pollanen had identified and made known to me, and we 12 wanted Dr. de Nanassy to be the person who was going to 13 be the focus, as it were, of the homicide cases in CHEO, 14 to attend in Toronto for some continuing medical 15 education. 16 I discussed that with him, and I -- and I 17 see later in his transcript that he does recall that 18 aspect of the conversation. And I said that once that 19 had been accomplished, that it would be possible to 20 return homicides and criminally suspicious cases to CHEO. 21 MR. MARK SANDLER: Okay. 22 DR. ANDREW MCCALLUM: That's my 23 recollection of things. Unfortunately, unexpectedly, I 24 was taken ill and then away on this inquest, and I did 25 not make a note of this. The concern was there but


1 certainly we thought it was a temporary measure and still 2 do. And unfortunately with the intervening inquiry, Dr. 3 Pollanen's time has been obviously significantly occupied 4 and we simply have not got around to getting this kind of 5 case or this -- this process completed. 6 MR. MARK SANDER: All right. 7 COMMISSIONER STEPHEN GOUDGE: I take it 8 what you envisage was Dr. de Nanassy coming to Toronto 9 and spending some time with the forensic unit that Dr. 10 Pollanen runs. 11 DR. ANDREW MCCALLUM: Exactly. Have an 12 opportunity to participate in the rounds, to participate 13 in autopsies here, and also to attend court with Dr. 14 Pollanen -- 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 DR. ANDREW MCCALLUM: -- to assist in his 17 preparation for testimony in court. 18 COMMISSIONER STEPHEN GOUDGE: Right. 19 20 CONTINUED BY MR. MARK SANDLER: 21 MR. MARK SANDLER: All right. And then 22 Dr. Bechard -- sorry, then Dr. Michaud at page 179 is 23 asked this question: 24 "Have you had any discussions with Dr. 25 Bechard or Dr. McCallum or anybody from


1 the Office of the Chief Coroner with 2 respect to this decision to not send 3 criminally suspicious cases to CHEO, at 4 least for the time being? 5 DR. MICHAUD: No, I had not. I have 6 not had any discussion with either Dr. 7 Bechard or Dr. McCallum. 8 And what are you views on the subject? 9 I would like to endorse with it other 10 than, as he just mentioned -- there's 11 no major objections to make such a 12 decision. What I'm objecting very 13 strongly is the process. It 's alack of 14 transparency, a lack of collegiality. 15 The way the process evolved and the 16 decision was made, I think the process 17 was not optimal and wasn't adequate in 18 this case. 19 What would you have preferred, Dr. 20 Michaud? 21 It would have been very nice for the 22 authorities, whoever, to sit down with 23 us and explain the rationale for this 24 decision. We would have had the 25 possibility to discuss, argue, perhaps,


1 and so on, but at least we would have 2 had a word to say. And then a written 3 notice would have been nice just to 4 confirm the whole thing, but you 5 know..." 6 And then Commissioner asks: 7 "Who do you think made the decision? 8 DR. MICHAUD: We don't know. We don't 9 know. 10 Who do you suspect? The Chief Coroner? 11 The Chief Forensic Pathologist? 12 Combination? 13 Well, if the administrative system 14 works well I believe this is probably a 15 several-person decision. I don't known 16 -- but we don't know." 17 And Ms. McAleer says: 18 "And as I understand it then, Dr. 19 Michaud, you don't have any concern 20 with the fact that the decision was 21 made, simply your concern is with the 22 manner in which it was communicated or 23 not communicated to you. Is that 24 correct?" 25 Dr. Michaud says:


1 "You know, any administrative decision 2 has pluses and minuses. It's possible 3 we would have accepted the rationale 4 behind that decision but we were not, I 5 believe, treated in a collegial 6 fashion. I do not believe we were 7 treated in a professional fashion for 8 that specific aspect of the process, 9 and we never had a chance to have a 10 word about this, and we never had a 11 chance to even get the information." 12 And then he -- he goes on to -- to repeat 13 what Dr. de Nanassy had had to say about how it came to 14 light. 15 Any comments about that? 16 DR. ANDREW MCCALLUM: Well, I think that 17 it's predicated on the assumption that there was no 18 communication and there was. There was a verbal 19 communication between myself and Dr. de Nanassy, and I 20 regret that I didn't make a note of it at the time. The 21 events overtook me there. 22 So certainly I would accept that as a 23 criticism of the process, but there was communication and 24 the rationale was communicated. 25 MR. MARK SANDLER: Okay.


1 DR. ANDREW MCCALLUM: It's unfortunate 2 that we have a differing recollection of events. 3 MR. MARK SANDLER: All right. Those are 4 all of -- 5 COMMISSIONER STEPHEN GOUDGE: Did it make 6 any difference, Dr. McCallum, or would it? I mean, this 7 was really a determination about the pathology side of 8 the Chief Coroner's Office service. I mean -- 9 DR. ANDREW MCCALLUM: That's correct. 10 And it was Dr. Pollanen, myself, and Dr. McLellan, who 11 discussed this so it was to answer the -- 12 COMMISSIONER STEPHEN GOUDGE: But 13 ultimately would be, I suspect, the Chief Forensic 14 Pathologist that would have the skill set to make the 15 determination? 16 DR. ANDREW MCCALLUM: Yes. 17 COMMISSIONER STEPHEN GOUDGE: Why 18 wouldn't he make the communication? 19 DR. ANDREW MCCALLUM: I think it's 20 because of the organizational structure, as it currently 21 exists in -- in our office. I think -- 22 COMMISSIONER STEPHEN GOUDGE: Would it be 23 better -- 24 DR. ANDREW MCCALLUM: Yes. 25 COMMISSIONER STEPHEN GOUDGE: -- if there


1 was direct communication, Chief Forensic Pathologist -- 2 DR. ANDREW MCCALLUM: It would be. It 3 would be. And I think that speaks to the need to have 4 the Chief Forensic Pathologist in -- in the legislation, 5 that position, with clear description of their role in 6 regards to issues like this. 7 COMMISSIONER STEPHEN GOUDGE: Right. 8 Thank you. 9 MR. MARK SANDLER: Commissioner, those 10 are all the questions I have in examination-in-chief. I 11 have received estimates of time from the parties. 12 COMMISSIONER STEPHEN GOUDGE: Well, do 13 you want to break for lunch now, a little early, and 14 we'll come back, say, at quarter to 2:00 and carry on? 15 MR. MARK SANDLER: Yes. 16 COMMISSIONER STEPHEN GOUDGE: Okay. 17 We'll take our usual lunch break and come bach shortly 18 after quarter to 2:00. 19 20 --- Upon recessing at 12:32 p.m. 21 --- Upon resuming at 1:50 p.m. 22 23 THE REGISTRAR: All Rise. Please be 24 seated. 25 COMMISSIONER STEPHEN GOUDGE: Ms.


1 Ritacca...? 2 3 CROSS-EXAMINATION BY MS. LUISA RITACCA: 4 MS. LUISA RITACCA: Thank you, 5 Commissioner. Good afternoon, doctors. If I could ask 6 you to turn up Tab 5 of the binder in front of you, 7 that's PFP116877. And you see there that is a memo dated 8 June 28, 1996 from Dr. Chiasson, the then-Chief Forensic 9 Pathologist. 10 You all have that? 11 DR. DAVID EDEN: Yes. 12 DR. DAVID LEGGE: Yes. 13 MS. LUISA RITACCA: And we've heard from 14 Dr. Chiasson and others about his early efforts to 15 establish a list of pathologists from within the body of 16 pathologists doing work for the Coroner's Office that 17 could be used for complex cases or criminally suspicious 18 cases. 19 And we further understand that this 20 regional coroner Pathologist system is somewhat out of 21 use at this stage, but there is an evolving process 22 within the Coroner's Office to credential pathologists. 23 And so, Dr. Eden, I'd like to start with 24 you. Could you provide us with your views as to the 25 benefit of credentialing pathologists for the Coroner's


1 Office to do certain kind of cases? 2 DR. DAVID EDEN: Yes, the -- the 3 background training of pathologists in anatomic pathology 4 and the ability to perform autopsies is a -- is a core 5 skill set for pathologists. 6 But a medicolegal autopsy is a -- has a 7 particular set of demands which are different from the 8 hospital autopsies which pathologists are -- are largely 9 trained on. It's done by a different protocol, and it 10 involves working with the coroner, and in fact doing 11 tests and examinations to a certain standard that's 12 province-wide. 13 And so in order to do that, to ensure that 14 it's done consistently and to the best quality, it makes 15 sense to credential people to demonstrate that they're 16 able to do the test -- to do the autopsy at the same 17 level province-wide. 18 MS. LUISA RITACCA: And how do you see 19 this credentialing process working? 20 DR. DAVID EDEN: The -- and -- and I 21 would defer to Dr. Pollanen on this of course, but in a 22 broad sense I believe what this would involve is 23 pathologists putting themselves forward as interested in 24 doing this sort of work, and then requiring education in 25 the first instance, and then on an ongoing basis. And


1 then having their autopsies subject to peer review to 2 ensure that they're meeting standards. That -- that 3 would be the -- the overview. 4 MS. LUISA RITACCA: And do you think that 5 all pathologists doing medicolegal work should be 6 credentialed, or just pathologists doing criminally 7 suspicious cases? 8 DR. DAVID EDEN: My preference would be 9 that all pathologists who are doing coroner's autopsies 10 should receive some form of credentialing. I think 11 though, that autopsies in homicides and criminally 12 suspicious deaths are materially different from say a 13 motor vehicle collision, and so I think we could well 14 have different standards and amounts of education and 15 peer review for those two (2) different classes. But I - 16 - I certainly would support having credentialing for all 17 pathologists. 18 MS. LUISA RITACCA: And would the 19 credentialing process include a mechanism by which a 20 pathologist could be removed from a list? 21 DR. DAVID EDEN: I think it must -- and 22 this goes back to the goal of having a credentialing 23 process, which is to ensure that all autopsies in Ontario 24 will be done to the same standard. 25 And as with other performance issue if --


1 it's important that you audit to ensure that you 2 recognize any issues. In the first instance you'll 3 educate and offer remedial training and if that doesn't 4 work and can't work, then the person should not be doing 5 autopsies. 6 MS. LUISA RITACCA: Finally on this point 7 -- and I'll ask both Dr. Eden and Dr. Legge to comment if 8 -- if you can -- and do you see any practical 9 difficulties with a credentialing process or a list of 10 pathologists that may be unique to the Northern region? 11 DR. DAVID EDEN: I would certainly see 12 this as a provincial initiative. The -- I wouldn't see 13 it as being a separate list for the North. I think there 14 may be -- that it may be more difficult to recruit 15 pathologists in the North for the list, but I certainly 16 would not wish to suggest that credentialing standards be 17 any different. 18 We might simply have to approach the 19 recruitment issue a little bit differently in the North. 20 MS. LUISA RITACCA: Right. And certainly 21 I wasn't suggesting that the credentialing should be 22 different. I was really asking about recruitment of 23 pathologists in the North. 24 And, Dr. Legge, do you have any comment on 25 that?


1 DR. DAVID LEGGE: In terms of the 2 definition of credentialing, I guess that could vary all 3 the way from simple one-on-one discussions about how -- 4 how you're doing a case, to measurement through 5 examination, or something like that, and I -- I'm not 6 aware of that ever happening to any of the coroners -- or 7 any of the pathologists in the North. Their experience 8 is based on experience in just doing cases over X-number 9 of years. 10 In -- in the last year or two (2), I -- I 11 think the business of the guideline that was put out by 12 Dr. Pollanen, which is quite extensive, and I think it's 13 been revised once or twice, the -- the following of that 14 has been a way of sort of credentialing the Northern 15 coroners, and presumably the other -- sorry, the 16 pathologists -- 17 MS. LUISA RITACCA: Yes. 18 DR. DAVID LEGGE: -- as well as the other 19 pathologists in -- in Ontario. And where -- during a -- 20 a teleconference, lets say, certain procedures weren't 21 followed that should be followed, then -- then that's -- 22 that's a good way to maintain the credentialing. 23 Otherwise it's perhaps a bit vague, actually. 24 MS. LUISA RITACCA: The Commission 25 council asked you about recruitment issues for coroners


1 in certain areas, and each of you gave evidence on 2 recruitment difficulties in rural, or non-urban areas in 3 your regions. 4 And, Dr. McCallum, I'll ask you this 5 question: Do you think that there's some value to 6 providing coroners with an on-call stipend? 7 DR. ANDREW MCCALLUM: I think there would 8 be. It would bring the Coroner's Office in line with 9 what's done in the clinical world for physicians. There 10 is now an initiative to provide on-call stipends for 11 family physicians, emergency physicians, and specialists, 12 who cover hospitals. It's a retainer in effect that will 13 -- that allows them to free up some time to be available, 14 and compensations them to some degree for that. 15 So I think that would be a useful thing. 16 MS. LUISA RITACCA: Dr. Eden...? 17 DR. DAVID EDEN: Yes. I -- I think the 18 need for an on-call stipend varies with the -- with where 19 one is, in that if -- when the coroner is on-call in 20 Toronto, they are going to get a fair number of cases. A 21 coroner on-call -- even in a fair sized town like -- for 22 instance a region like Niagara or Hamilton may not have 23 any cases, and certainly there's the issue of being on 24 standby for three (3) days of a weekend without income, 25 which -- which is difficult to justify.


1 So I -- I wouldn't say that it -- it's 2 universal, and what I would suggest is that it be looked 3 at in low volume areas, where people are on-call and not 4 likely to get cases during that. Because we do want 5 coroners to be available and that -- that's going to 6 require perhaps that they be compensated for being 7 available if there won't be cases. 8 MS. LUISA RITACCA: And Dr. Legge? 9 DR. DAVID LEGGE: Well, I think it would 10 be some incentive, but it wouldn't -- it wouldn't bind 11 anybody from taking off for a weekend, or what have you, 12 because they -- they've long felt that it's a sideline 13 type of job. 14 And -- I -- I don't think a stipend would 15 really keep people necessarily in the community. 16 MS. LUISA RITACCA: Dr. McCallum, you 17 were asked a question about toxicology result times in 18 your region, and I believe you indicated that you -- you 19 expect results ninety (90) -- in ninety (90) days, and 20 that seems to be usual, or standard, in your region. 21 Is that fair? 22 DR. ANDREW MCCALLUM: It's rarely less 23 than that. 24 MS. LUISA RITACCA: Okay. 25 DR. ANDREW MCCALLUM: Often more.


1 MS. LUISA RITACCA: And in your clinical 2 practice, would ninety (90) days be an acceptable wait 3 time for a toxicology result? 4 DR. ANDREW MCCALLUM: Well, I'd like to 5 preface my answer by ensuring that the difference between 6 clinical laboratory testing and forensic testing is 7 understood. 8 Forensic testing, obviously, has to meet 9 the stringent criterial of the criminal justice system; 10 that there is a need for quality assurance that isn't 11 perhaps present to the same degree, for reasons other 12 than pure quality, that -- that exists in forensic 13 toxicology. So one expects it's going to be longer. 14 But for example, the chemistry -- the -- 15 the technical aspects of the testing would allow for drug 16 results to come back in an emergency department setting 17 in two (2) hours, three (3) hours. So going from two (2) 18 hours, three (3) hours, to the period of time that we 19 wait to get forensic toxicology is a significance 20 difference. 21 So what I -- I think I would say is that, 22 while we can't compare them exactly, there might be some 23 opportunities to re-examine that difference and see 24 whether or not there are ways to make it more -- the 25 timing more optimal.


1 MS. LUISA RITACCA: And can you elaborate 2 for us, Dr. McCallum, further as to how the late 3 toxicology reports affects the death investigation, and I 4 think your words were "down stream"? 5 DR. ANDREW MCCALLUM: Well, toxicology is 6 often the rate limiting step in the process, so that 7 until it occurs, or until -- until the results are 8 available, nothing else can happen, the -- the 9 pathologist can't finish his or her report. The coroner 10 can't finish his or her report until the path -- 11 pathologist finishes it, and so on, and so on, and so on. 12 It does impact the criminal justice at 13 times because toxicology is a -- is an intrinsic part of 14 the death investigation for homicides and criminally 15 suspicious deaths, particularly in children. 16 So, again, I think that there are effects 17 that are felt throughout the system as a consequence of 18 the delays that -- that occur in toxicology. 19 MS. LUISA RITACCA: And this may be an 20 obvious question, but do late toxicology reports effect 21 the timing of a case being presented to a committee -- 22 DR. ANDREW MCCALLUM: Yes. 23 MS. LUISA RITACCA: -- like the Death 24 Under Five Committee? 25 DR. ANDREW MCCALLUM: Yes, because of all


1 the aspects of the investigation that I alluded to 2 earlier. 3 MS. LUISA RITACCA: So the -- the case 4 wouldn't go to committee until -- 5 DR. ANDREW MCCALLUM: Well, it couldn't - 6 - it couldn't go to the committee until all the data was 7 in place, and -- and at every stage the, if you like, the 8 expectation that there is going to be further delay, 9 leads to delay in and of itself. 10 DR. DAVID EDEN: And if could -- 11 MS. LUISA RITACCA: Oh, sure, yes. 12 DR. DAVID EDEN: -- interject here? The 13 -- the latency of toxicology results has an effect, not 14 only within the office, but on resources from other 15 offices. 16 So, if, for instance, we have somebody who 17 has died and there's no anatomical cause of death, if we 18 had toxicology right away and if showed, for instance, an 19 overdose, then that would steer our investigation in 20 things like organ retention and police canvassing for 21 concerns about foul play. 22 But because we don't have the toxicology 23 for a long time, we have to proceed on the assumption 24 that it might lead us towards foul play, and that 25 requires a much broader investigation in the first


1 instance, than -- than we would do otherwise. 2 MS. LUISA RITACCA: And, Doctors, earlier 3 in this Inquiry we heard from the Toronto area Regional 4 Supervising Coroners and from the Directors of the 5 Regional Forensic Pathology Units, and they testified as 6 to really the importance and benefit of a strong 7 relationship between the regional coroner and the 8 Director of the various units. 9 First -- and again, maybe I'll start with 10 you, Dr. McCallum -- do you agree that it's important 11 that the regional coroner have a strong connection to a 12 forensic pathology unit within his or her region? 13 DR. ANDREW MCCALLUM: Yes. 14 MS. LUISA RITACCA: And how do you 15 achieve that in your region? 16 DR. ANDREW MCCALLUM: Through a 17 combination of correspondence, emails, face-to-face 18 discussions, attending rounds that they hold, case 19 conferences, or many of the things that we've alluded to 20 during our earlier testimony would all be applicable. 21 And then, of course, there's the ancillary 22 benefit of having a Chief Forensic Pathologist with whom 23 you link and interact, who also is interacting with them. 24 MS. LUISA RITACCA: Dr. Eden, do you have 25 anything more to add from this morning?


1 DR. DAVID EDEN: I think -- well, we 2 recognise that forensic pathologists provide an enormous 3 depth of skill on examination of the body. And in order 4 to do that job well they require a good deal of 5 information, so they should have access to all -- to all 6 the relevant information from the investigation, and we 7 need to treat them as a scarce resource, which is that we 8 should only be ordering autopsies in cases where it's 9 going to materially assist the investigation. 10 Certainly in my former job as the Regional 11 Supervising Coroner for Niagara, the forensic 12 pathologists were very much part of the investigation. 13 And that's -- modern death investigation it's a team 14 effort, and the forensic pathologist is a very important 15 member of the team who needs access to the information 16 and takes part, to some extant, in the decision making 17 throughout the investigation. 18 MS. LUISA RITACCA: And, Dr. Legge, are 19 you able to speak of your relationship with the Sudbury 20 Unit, while not a formal unit, but in name, a unit? 21 DR. DAVID LEGGE: I can certainly provide 22 my opinion that the individual who is the forensic 23 pathologist there provides excellent work, very helpful 24 in the teamwork concept, and is always available when he 25 is town -- he is not always in town -- and is a vital cog


1 to that whole area. 2 He's the only one, as far as I know, in 3 that whole area who does that type of work. 4 MS. LUISA RITACCA: And you're speaking 5 of Dr. Queen. 6 DR. DAVID LEGGE: That's correct. Mm-hm. 7 MS. LUISA RITACCA: The Toronto area 8 regional coroners also told us about their daily access 9 to the forensic pathologists, because they're actually 10 housed in the same facility, and they also described 11 their participation in morning rounds with the forensic 12 pathologist and others in the morgue. 13 What are some of the things that you can 14 do in your regions to maintain that same level in -- of 15 involvement, even though you're not necessarily present 16 for morning rounds? 17 Dr. McCallum, I'll start with you again. 18 DR. ANDREW MCCALLUM: Well to be 19 perfectly candid, we can't. It's not possible physically 20 to do exactly what's done in Toronto; to have co-location 21 in the same building really offers some advantage that 22 simply don't exist outside Toronto, So it's a different 23 circumstance. 24 We can do it virtually. Again, as I said 25 earlier, we don't now when a case occurs always, and so


1 therefore we don't have the opportunity to address it 2 with the pathologist, because we don't know about it. 3 So there -- there are significant hurdles 4 that are in -- that are there. 5 MS. LUISA RITACCA: Dr. Eden...? 6 DR. DAVID EDEN: Yes, in the -- Toronto 7 has some advantages in being geographically compact. 8 Having the cases entered into the database at the time of 9 creation and then the -- the regional coroner meeting 10 with the pathologist before the autopsy. In -- in both 11 Niagara and Northern Ontario there are multiple centres 12 doing pathology and it's not physically possible for the 13 regional coroner to be present at all of those. 14 So that's -- that is something that 15 creates -- that -- that means we don't have the advantage 16 that Toronto has there. They way that we have 17 accommodated it is to encourage the pathologist to 18 discuss the case. The coroner must discuss the case with 19 the pathologist and, as well, the pathologist or coroner 20 may well call the regional coroner if they think there's 21 concerns about the -- whether or not an autopsies 22 required or the scope of the autopsy. 23 MS. LUISA RITACCA: Thank you. And, Dr. 24 McCallum, if I could ask you to turn to Tab 12 in the 25 binder? And -- and that's PFP -- oh I'm sorry, I'm going


1 to ask you to go to the Coroner Investigation Manual, 2 which should be in a binder behind you in the trolley. 3 And that's PFP057584. 4 COMMISSIONER STEPHEN GOUDGE: It's a 5 black one I think, Dr. Eden. Yes, that's it. 6 DR. DAVID EDEN: Thank you. I'm sorry, 7 could you say the page reference again? 8 9 CONTINUED BY MS. LUISA RITACCA: 10 MS. LUISA RITACCA: Page 232 -- 11 DR. DAVID EDEN: I've got it now. I've 12 got it now. 232? 13 MS. LUISA RITACCA: Yes. 14 DR. DAVID EDEN: All right. 15 MS. LUISA RITACCA: And you should have 16 in front of you a memo from November 15th, 2004 on organ 17 and tissue retention. 18 DR. DAVID EDEN: Yes, I do. 19 MS. LUISA RITACCA: And I understand you 20 were involved in the creation of this memo. 21 DR. DAVID EDEN: I was. 22 MS. LUISA RITACCA: And could you tell us 23 about your involvement. 24 DR. DAVID EDEN: I was asked to lead a 25 working group which consisted of coroners, forensic


1 pathologists and myself, by Dr. McLellan, to codify our 2 approach to retain -- retention of organs, notification 3 of families. And what we would do to, if -- if you like, 4 ameliorate the effects of having to retain organs, how 5 would we -- for example, let families know how they could 6 get the organs returned to them, and so forth. 7 MS. LUISA RITACCA: And without taking us 8 through, line by line, the memo, could you tell us what 9 the protocol is for organ retention. 10 DR. DAVID EDEN: Certainly. The protocol 11 recognizes that it is sometimes necessary to retain 12 organs to facilitate an appropriate examination. But in 13 each case if -- the policy stipulates that the 14 investigating coroner will make reasonable efforts to 15 advise the family or next of kin that this is necessary, 16 and the reasons why it's necessary. 17 And then the pathologist is expected to 18 record all tissue specimens retained and to advise the 19 coroner as to what has been retained, because of course 20 at the outset it's often not known what will be required. 21 And then subsequently the coroner is then responsible for 22 letting the family know that there are tissues and organs 23 retained, and advising that if -- that we will honour 24 their wishes as to the method of dealing with those 25 organs and/or tissues.


1 And that would include a respectful 2 cremation at the -- the pathology site, or return of the 3 organs and/or tissues to wherever the remainder of the 4 body has been interred or has been cremated. And we 5 would obviously fund that so there would be no cost to 6 the family to do that. 7 MS. LUISA RITACCA: And we've heard this 8 morning that there is some difficulties surrounding organ 9 retention that is facing the Coroner's Office, and 10 particularly we heard that with regard to First Nations 11 communities. 12 Can you tell us about some of the other 13 difficulties facing the Coroner's Office on issues of 14 organ retention? 15 DR. ANDREW MCCALLUM: Well, in a province 16 as diverse as Ontario, we have to be mindful of the many 17 beliefs that exist in various communities and ethnicities 18 and creeds regarding death and the practices after death 19 for preparation of the body and burial, et cetera. 20 So we maintain contact with a number of 21 agencies that give us advice and assist us in dealing 22 with this for different faith groups, different cultures, 23 and that would include First Nations but in, for example, 24 Toronto it's a -- it's a society that's very diverse so 25 that we do have to deal with all those issues and be


1 mindful of them. 2 MS. LUISA RITACCA: And you mention that 3 you seek advice from various groups. Could you elaborate 4 on that a little bit? 5 DR. ANDREW MCCALLUM: We have found that 6 dealing with religious leaders, particularly, is very 7 helpful in dealing with issues that arise. And -- first 8 because it gives us an understanding of the expectations 9 and beliefs of -- of the family and next of kin, and 10 secondly because they are very useful as intermediaries 11 and people who can help us to help the families. 12 MS. LUISA RITACCA: And can you think of 13 alternatives to retaining organs in, at least, some of 14 the cases where they're currently being retained? And I 15 -- and I understand this may be more of a pathology 16 question but -- 17 DR. ANDREW MCCALLUM: Yeah -- 18 MS. LUISA RITACCA: -- from your 19 perspective? 20 DR. ANDREW MCCALLUM: I think you'd be 21 better to ask Dr. Pollanen or another pathologist but, 22 for example, as you've heard the brain is often retained 23 and that's because of the nature of the tissue. It's 24 very fragile. It needs to be fixed before it's examined. 25 But in cases where the brain is perhaps


1 not the central area of interest, some pathologists 2 believe that the brain can be cut fresh, in other words 3 not fixed, and therefore, wouldn't have to be retained. 4 I think you should speak to Dr. Pollanen 5 to understand better when those circumstances might arise 6 but that's a consideration that could be given, 7 especially in a circumstance where it's highly 8 problematic to retain organs. 9 MS. LUISA RITACCA: And, Dr. Eden, we 10 know that the coroner's investigation statement contains 11 both a determination as to cause and manner of death. 12 And we also know that under the legislation, it's in the 13 coroner's purview to make those determinations. 14 There's been some discussion here with 15 regard to the role of a forensic pathologist in opining 16 as to manner of death. What is your role as to the -- 17 what is your view rather, as to the role of the forensic 18 pathologist in opining as to the manner of death? 19 DR. DAVID EDEN: And this is an issue 20 that's been looked at other than in Ontario. 21 The manner of death is one (1) of five 22 (5): natural, accident, suicide, homicide, or 23 undetermined, and it flows from the cause of death. The 24 cause of death doesn't tell you what the manner is, but 25 you, generally, need to have a cause of death before you


1 can decide a manner. 2 Cause of death has a different evidentiary 3 basis than manner of death. The cause of death can 4 usually be established from examination of the body. 5 That's where almost all the information comes in most 6 cases. To determine a cause of death is from the 7 pathologist's examination of the body. 8 Manner of death is based on a much broader 9 evidentiary foundation and, for instance, if you have a 10 person in the morgue with a gunshot wound, the cause of 11 death is gunshot wound but is this an accident, a 12 suicide, or a homicide? To determine that requires a 13 very broad knowledge of the circumstances that resulted 14 in the gunshot wound. And so I don't believe that that 15 answer can be determined in the morgue. 16 The person who, in our system, has access 17 to the circumstantial information surrounding the death 18 is the coroner, and for that reason, it makes sense for 19 the coroner to make the determination of manner of death. 20 However, the forensic pathologist, 21 particularly, provides substantial input and it certainly 22 -- in Niagara, it's been my practice, and I know I'm not 23 alone in this, to discuss manner of death with a forensic 24 pathologist and they can provide very useful information. 25 For instance, a -- a wound to the chest -- a stab wound


1 to the chest -- is that more consistent with self- 2 inflicted wound or wound inflicted by somebody else? And 3 -- and they can certainly assist us. 4 But the finding of manner of death has to 5 be based on a very broad evidentiary basis, and that's 6 something that pathologist doesn't have and the coroner 7 does. 8 MS. LUISA RITACCA: Dr. McCallum, what do 9 you say about a pathologist opining as to the mechanism 10 of death? 11 DR. ANDREW MCCALLUM: Well, the same -- 12 MS. LUISA RITACCA: Do you see a 13 difference, I guess, is the first question? 14 DR. ANDREW MCCALLUM: Well, the mechanism 15 of death is the -- is the -- I'm going to be careful of 16 my terminology here. I don't want to use "means" because 17 that refers to manner. 18 Mechanism of death is the actual 19 physiologic way in which a person dies, like 20 cardiorespiratory arrest or asphyxia and they are not 21 anatomic causes of death, so in my view, the pathologist 22 might say that there are findings consistent with this, 23 but should not say that the mechanism was -- something. 24 MS. LUISA RITACCA: Dr. Eden...? 25 DR. DAVID EDEN: I would agree with Dr.


1 McCallum there. 2 MS. LUISA RITACCA: And, Doctors, we 3 understand that in the Coroner's System, the information 4 flows through the local coroner and the pathologist and 5 other sources to the regional coroner, who is ultimately 6 responsible to ensure that a case gets signed out, is 7 that correct? 8 DR. ANDREW MCCALLUM: Yes. 9 DR. DAVID EDEN: Yes. 10 MS. LUISA RITACCA: Okay. And what steps 11 do you take to ensure quality on the part of the local 12 coroners; start with that? 13 DR. ANDREW MCCALLUM: I review every case 14 in detail, from the demographics through to the various 15 statistical data that are collected, and then carefully 16 review the narrative to ensure that the narrative 17 supports the -- is -- that is consistent with the cause 18 and manner of death as -- as determined by the coroner. 19 Where I see issues of quality or 20 omissions, I will correspond with the coroner and ask 21 them to revise it. Often I -- I will revise the report 22 myself, but for example, we do see from time to time, and 23 I'd say this is in less than 5 percent of the cases, a 24 situation where we'll cha -- when we think the manner of 25 death is more appropriately accident then say natural.


1 And I'll change that and I always feed 2 that back to the coroner and ask them for their comments 3 and -- and their -- their response. 4 MS. LUISA RITACCA: And if you're not 5 always aware of a case, as we've heard that there's not 6 an appropriate notification system for you in place 7 provincially, are you able to ensure quality at any level 8 on the front-end, so, say, for example, the quality of 9 the warrants for post-mortem examination? 10 DR. ANDREW MCCALLUM: It's difficult 11 because we don't know about it. Obviously the small 12 group of cases, those forty (40) cases that I expect the 13 coroners to call me about -- the criminally suspicious 14 homicide cases -- which represents such a tiny fraction, 15 I do know about those cases but, in fact, I don't often 16 see the warrant, so I don't have the opportunity to give 17 them feedback on the warrant at that time. 18 MS. LUISA RITACCA: And when you're in 19 the midst of signing out a case, you also are in receipt 20 of the post-mortem report. 21 DR. ANDREW MCCALLUM: Correct. 22 MS. LUISA RITACCA: And what are you able 23 to do as coroners to ensure a certain level of quality in 24 the post-mortem report? 25 DR. ANDREW MCCALLUM: It would be


1 similar, although not as detailed, with the report of 2 post-mortem examination. So, for example, I would review 3 it with respect to the language, the terminology, the 4 internal consistency and logic of the conclusions. 5 And if there were terms or terminology 6 that were used that went outside what I believed to be 7 the legislative bounds of the pathologist's role in our 8 system, I would so advise the pathologists and request 9 that they consider revising. 10 MS. LUISA RITACCA: And, Dr. McCallum, 11 who, in your view, should be responsible for ensuring the 12 quality of the pathology or the technical component of 13 the report? 14 DR. ANDREW MCCALLUM: Oh, I strongly 15 believe it should be the Chief Forensic Pathologist, with 16 an appropriate administrative compliment, for example, 17 including Deputy Chief Forensic Pathologists, because 18 they have the necessary knowledge in depth and breadth to 19 do it. 20 MS. LUISA RITACCA: And if I could go 21 back for a moment to quality assurance of coroners. If I 22 could have you turn to Tab 23, and that's PFP032488. 23 24 (BRIEF PAUSE) 25


1 MS. LUISA RITACCA: And this is a memo 2 from the then Chief Coroner, Dr. McLellan, dated February 3 28th, 2007. Dr. Lauwers gave evidence with regard to the 4 audit tools that are discussed in this memo. 5 And I realize that the actual audit tool 6 isn't attached at this tab, so if you don't mind looking 7 at the screen for a moment, and I'll ask the Registrar to 8 turn up PFP032491. 9 Now, am I right that this was the audit 10 tool attached to the memo? 11 DR. ANDREW MCCALLUM: Yes. 12 MS. LUISA RITACCA: Do you use this in 13 your region? 14 DR. ANDREW MCCALLUM: I do. 15 MS. LUISA RITACCA: And is this -- is it 16 something that is easa -- easily done with forty (40) 17 local coroners? 18 DR. ANDREW MCCALLUM: Well, I -- I'll be 19 candid, I haven't been able to work my through -- my way 20 through the entire forty (40) of them, but -- because 21 it's a little bit different than the number of coroner's 22 we're responsible for in our regions than perhaps 23 Toronto. 24 But that being said, it is a -- it is a 25 straightforward tool. It's easy to use. It dovetails


1 very nicely with the quality assurance process that's 2 already in place with reviewing each case. 3 So what I instruct my staff to do is to 4 pull ten (10) charts for clo -- ten (10) files for 5 closure that are -- that relate to a particular coroner - 6 - authored by a particular coroner. 7 And that way I can get ten (10) of these 8 together and then provide detailed feedback to the 9 coroners. 10 MS. LUISA RITACCA: Dr. Eden, what's been 11 your experience with the audit tool? 12 DR. DAVID EDEN: Well, it's -- I've used 13 it. Started using it in Niagara, and will be using it in 14 the North. And it's a -- it was designed to be as 15 objective and reproducible as possible, so that you can - 16 - you can look at the coroner's report and, based on the 17 questions, come to an answer, which somebody else looking 18 at it would arrive at the same answer. 19 And it's -- it's relevant. It's all 20 directed to the quality and completeness of the report. 21 MS. LUISA RITACCA: Dr. Legge, have you 22 had an opportunity to use the tool? 23 DR. DAVID LEGGE: I use the tool 24 personally. 25 MS. LUISA RITACCA: Okay.


1 DR. DAVID LEGGE: I -- I find that -- 2 over the last year or two (2) that, somewhat by default, 3 I'm -- I'm the one who uses the tool most, because I -- I 4 edit these reports fairly substantially. 5 And that -- that reflects upon the fact 6 that many of the reports need a fair amount of 7 adjustment. And I'm just -- I was just getting to the 8 point of getting the feedback to the coroners. There's a 9 lot of work to be done there. 10 But certainly I endorse everything that's 11 being said about how valuable this tool is. 12 MS. LUISA RITACCA: Dr. Eden and Dr. 13 Legge, I wanted to ask you about the Quality Assurance 14 Committee. And if you go to Tab 24. 15 16 (BRIEF PAUSE) 17 18 MS. LUISA RITACCA: That's, in fact, the 19 Institutional Report. It's PFP149431, starting at page 20 165. 21 22 (BRIEF PAUSE) 23 24 MS. LUISA RITACCA: Oh, could I have the 25 next page, Mr. Registrar? Thank you.


1 And in the middle of the page here, it 2 reads: 3 "At the October 1999 regional coroners 4 Meeting, the Quality Assurance 5 Committee was made a standing committee 6 for the Office of the Chief Coroner. 7 The terms of reference for the 8 committee are: the Quality Assurance 9 Committee is a standing committee of 10 the Office of the Chief Coroner. Its 11 purpose is to make recommendations to 12 the Chief Coroner and Regional 13 Supervising Coroners that assure 14 quality coroners' investigations." 15 I'll start with you, Dr. Eden. Can you 16 provide us with any more information about the role of 17 the -- of this committee? 18 DR. DAVID EDEN: Yes. The -- the role of 19 the committee was to look at existing practices and 20 determine what the best practices should be, taking into 21 account the quality assurance -- not just in the 22 coroner's office, in any endeavour -- really a -- a 23 cycle. It's not a -- it's not a -- a one (1) step 24 process. 25 The first step of the cycle is to measure


1 what's going on; the second is to determine what the best 2 practice should be; and then the third is to implement 3 it. 4 And then you go back, and you measure how 5 people are doing. And you may well change the -- the 6 guidelines or standards that you provide. So it's an 7 ongoing process. 8 And, so what came out of the -- of the 9 creation of the committee was the -- was the first two 10 (2) steps, which were to look at what was happening and 11 then, based on that, to provide guidance to coroners 12 about how investigations should be conducted. 13 And that's the document which is here, 14 with all the guidelines in it. And now we're at the 15 stage where you see the audit tool that -- that was just 16 presented, which is an example of the next step in 17 quality assurance, which is saying how compliant are 18 investigators with the guidelines. 19 And then with that information, we'll go 20 back to this document, and it'll evolve over time. 21 MS. LUISA RITACCA: And Dr. Legge, is 22 that your understanding of the role of the committee? 23 DR. DAVID LEGGE: Yes, mm-hm. 24 MS. LUISA RITACCA: Dr. Eden, I also 25 wanted to ask you about the Forensic Pathology Issues


1 Committee. And there are a number of minutes from that 2 committee at Tabs 25 to 29. And I don't -- I don't 3 necessarily intend to take you to each of them, or -- or 4 any of them, quite frankly. 5 Could -- I understand you were a member of 6 this committee? 7 DR. DAVID EDEN: I have a recollection of 8 being on the committee, yes. 9 MS. LUISA RITACCA: Okay. 10 DR. DAVID EDEN: It's some time ago, 11 so... 12 MS. LUISA RITACCA: And so I guess this 13 question is going to sound a little silly. Does it 14 continue to exist today? 15 DR. DAVID EDEN: To my knowledge, it does 16 not. 17 MS. LUISA RITACCA: Okay. 18 DR. DAVID EDEN: But I -- I can say I 19 have not attended a meeting of it for some time. 20 MS. LUISA RITACCA: All right. And 21 perhaps we can go to Tab 27 as an example. And that's 22 PFP129474. 23 So it looks like you were at a meeting on 24 June 28th, 2000, of the -- 25 DR. DAVID EDEN: Yeah.


1 MS. LUISA RITACCA: -- Forensic Pathology 2 Issues Committee. 3 And under the terms of reference it sets 4 out the purpose of the committee. And it -- and that is 5 to advise, provide guidance, and make recommendations to 6 the Chief Forensic Pathologist on issues which impact on 7 the quality and delivery of the forensic pathology 8 services which are provided to coroners across the 9 Province of Ontario. 10 And was this your understanding of the 11 role of the committee? 12 DR. DAVID EDEN: That was my 13 understanding, yes. 14 MS. LUISA RITACCA: And are you able to 15 provide us with any information as to what items were 16 discussed at these meetings? What, if anything, was 17 implemented as a result of the formation of the 18 committee? 19 DR. DAVID EDEN: Other than the minutes, 20 no, I don't have a recollection of those meetings from -- 21 from that time. 22 Actually, in -- in response to an earlier 23 question, I -- I understand that there is a -- that this 24 has developed into a different forensic pathology 25 committee which works under a different terms of


1 reference. 2 MS. LUISA RITACCA: The Forensic Services 3 Advisory Committee, is that what you're talking about? 4 DR. DAVID EDEN: That would be the one, 5 yes. 6 MS. LUISA RITACCA: If you just turn the 7 page on those June 28, 2000, minutes there's a number of 8 items listed under "Goals: Scope of Committee to Consider 9 for Following Issues," including such things as OCC 10 Forensic Pathology Unit -- and I'm just picking and 11 choosing here -- the relationship with the university, 12 name, accreditation, rela -- Regional Forensic Pathology 13 Unit's relationship to the OCCO, pediatric forensic 14 pathology services, approval system for new pathologists, 15 continuing education in forensic pathology, role of the 16 Chief Forensic Pathologist in Ontario. 17 I take it these are items that were 18 discussed in June of 2000? 19 DR. DAVID EDEN: Yeah, to -- to my 20 recollection, this was a -- a brainstorming session about 21 areas that should be considered at some point in future. 22 There was no determination made about them. They were 23 simply listed as areas worthy of future consideration. 24 MS. LUISA RITACCA: And who was the Chair 25 of this committee?


1 DR. DAVID EDEN: I believe it was Dr. 2 Chiasson. 3 MS. LUISA RITACCA: Dr. Chiasson. And do 4 I take from what you've said that once Dr. Chiasson 5 ceased being the Chief Forensic Pathologist, there were 6 no longer any meetings. 7 Is that fair? 8 DR. DAVID EDEN: That -- that's my 9 recollection, yes. 10 11 (BRIEF PAUSE) 12 13 MS. LUISA RITACCA: Dr. McCallum, I 14 wanted to ask you a few questions about some of the 15 issues regarding both the Adult Forensic Pathology Unit 16 in Ottawa and the Children's Hospital of Eastern Ontario. 17 Could you describe your involvement in the 18 decision not to send homicide cases to the Adult Forensic 19 Pathology Unit? 20 DR. ANDREW MCCALLUM: Yes, I can. The 21 issue was drawn to Dr. McLellan's and my attention by Dr. 22 Pollanen based on a review of cases involving different 23 pathologists from that unit that Dr. Pollanen had 24 undertaken as part of his normal duties, as well as 25 several second opinions that he'd offered in cases.


1 And Dr. Pollanen expressed the view that 2 until some action was taken, that cases of homicides and 3 criminally suspicious deaths should not be autopsied in 4 Ottawa. And we met on or about December 12th, 2006, and 5 agreed on a plan, which was to involve Dr. Michaud -- 6 who's the head of the department -- discuss the options 7 available to him, to meet with the individual 8 pathologists who were going to be affected and offer them 9 some options so that we could have a resumption of those 10 cases in Ottawa. 11 And that was communicated to those 12 pathologists. And the cases were moved out of Ottawa, 13 and they remain going to other centres to this day. 14 MS. LUISA RITACCA: And without getting 15 into the specis -- specifics of your concerns, were your 16 concerns about the overall competence of the Ottawa 17 pathologists? Or were they more particular? 18 DR. ANDREW MCCALLUM: They were 19 particular. And I would say that cases involving 20 homicides and criminally suspicious deaths, whether it's 21 adult or pediatric, are among the most complex cases that 22 forensic pathologists do. 23 And so we had a narrow concern about their 24 work in those particular areas and therefore made the 25 decision that there would need to be some continuing


1 medical education involvement with the Provincial 2 Forensic Pathology Unit here, and Dr. Pollanen in 3 particular, as well as some education in the criminal 4 justice system to allow those individuals to return to 5 work. 6 But their broad competence was not in 7 question. These are competent pathologists who do, in 8 the case of the Ottawa Hospital, about seven hundred 9 (700) cases a year and are very important as a resource 10 to our system. 11 MS. LUISA RITACCA: Sorry, do they do 12 seven hundred (700) coroner's cases a year? 13 DR. ANDREW MCCALLUM: They do seven 14 hundred (70) medicolegal cases per annum at the Ottawa 15 Hospital. 16 COMMISSIONER STEPHEN GOUDGE: As a 17 practical matter, how many a year would that mean moving 18 to Toronto? 19 DR. ANDREW MCCALLUM: On the order of 20 twenty-five (25). 21 COMMISSIONER STEPHEN GOUDGE: And is the 22 practice still in place that they're moved to Toronto? 23 DR. ANDREW MCCALLUM: It is pro tem, 24 although I think you've evidence that are two (2) new 25 forensic pathologists who have been recruited in Ottawa--


1 COMMISSIONER STEPHEN GOUDGE: Right. 2 DR. ANDREW MCCALLUM: -- slated to start 3 July 2008. 4 COMMISSIONER STEPHEN GOUDGE: Right. 5 DR. ANDREW MCCALLUM: And at that time we 6 expect it to stop. 7 COMMISSIONER STEPHEN GOUDGE: And one 8 would anticipate a return to... 9 DR. ANDREW MCCALLUM: One would. I would 10 like to see the reintegration of the other pathologists, 11 because the numbers -- seven hundred (700) -- exceed the 12 capabilities of two (2) pathologists. And so the 13 involvement of those other pathologists, competent 14 pathologists, are very important. 15 COMMISSIONER STEPHEN GOUDGE: Yes. But I 16 assume they have continued doing the other coroner's 17 cases in Ottawa? 18 DR. ANDREW MCCALLUM: They are still 19 doing them, yes. 20 COMMISSIONER STEPHEN GOUDGE: So, they 21 are doing six hundred and eighty (680) cases, or 22 whatever? 23 DR. ANDREW MCCALLUM: They still are. 24 25 CONTINUED BY MS. LUISA RITACCA:


1 MS. LUISA RITACCA: Dr. McCallum, you 2 spoke a bit about this this morning with regard to the 3 issues at CHEO. 4 When did you first become aware of the 5 concerns with the pathology at CHEO? 6 DR. ANDREW MCCALLUM: In the Spring of 7 2007 Dr. Pollanen and I -- who have an ongoing dialogue 8 about many matters, but one (1) in particular was this. 9 Dr. Pollanen expressed some concern that 10 all of the standards for examination of children at CHEO, 11 where there is some issue of criminal suspicion, were not 12 being attended to. And therefore he felt that further 13 education was required. 14 MS. LUISA RITACCA: And again, the same 15 question that I had for you with regard to the 16 pathologists doing adult cases in Ottawa. 17 Did you have an overall concern about the 18 competency of the pathologists at CHEO or the -- 19 DR. ANDREW MCCALLUM: Absolutely not. 20 They are competent pediatric pathologists who do, in the 21 main, very good forensic work. 22 MS. LUISA RITACCA: And you answered this 23 in part in answering the Commissioner's question. 24 Ideally, what would you like to see happen 25 with the Ottawa unit and the unit at CHEO in the future?


1 DR. ANDREW MCCALLUM: I would like to see 2 the integration of the two (2) new forensic pathologists 3 and the reintegration of the existing forensic 4 pathologists so that they provide the full spectrum of 5 forensic pathology services, both for standard 6 medicolegal cases and for cases that touch on the 7 criminal justice system. 8 MS. LUISA RITACCA: And do you see a role 9 for the incoming forensic pathologists at CHEO? 10 DR. ANDREW MCCALLUM: Yes, I do. 11 MS. LUISA RITACCA: And what's that role? 12 DR. ANDREW MCCALLUM: Well, I think that 13 the cases that are thought to be criminally suspicious or 14 homicide cases would be led -- or the -- the work would 15 be led by those pathologists with the assistance of the 16 pediatric pathologists, as appropriate. 17 MS. LUISA RITACCA: And who would make 18 the decision at the front end to -- to steer a case to 19 CHEO or to the forensic pathologists with the assistance 20 of the pediatric pathologists? 21 DR. ANDREW MCCALLUM: Well, I think in 22 law it falls to the coroner and -- and in this particular 23 case, to myself or the person occupying the Regional 24 Supervising Coroner position, because it's our warrant 25 that commits this to be done.


1 So we would make the decision, obviously, 2 with the knowledge and -- and clearly with the input of 3 the pathologists involved. 4 COMMISSIONER STEPHEN GOUDGE: And I take 5 it with the input of the Chief Forensic Pathologist? 6 DR. ANDREW MCCALLUM: Absolutely. Thank 7 you. I wouldn't -- I wouldn't -- and the case I cited 8 earlier was such an example where the Chief Forensic 9 Pathologist was involved. 10 COMMISSIONER STEPHEN GOUDGE: And would, 11 I take it, in fact be the primary decider, if I can put 12 it that way? 13 DR. ANDREW MCCALLUM: Yes, absolutely. I 14 mean there would be local knowledge, but obviously the 15 Chief Forensic Pathologist has the best understanding of 16 the capabilities of the various pathologists in the 17 various units. 18 MS. LUISA RITACCA: And -- 19 COMMISSIONER STEPHEN GOUDGE: Can I just 20 ask you -- sorry, Ms. Ritacca. But can I just ask you 21 little bit, Dr. McCallum, I mean obviously the Ottawa 22 situation is of some interest in the local media there. 23 I take it the concern that you had was not 24 one that could be answered by some kind of remote peer 25 review, for example, by the Chief Forensic Pathologist.


1 And by "remote peer review," I mean a second look at the 2 post-mortem report together with the slides, for example. 3 DR. ANDREW MCCALLUM: That was in place 4 already and -- 5 COMMISSIONER STEPHEN GOUDGE: Yes, but 6 that obviously was deemed -- 7 DR. ANDREW MCCALLUM: It wasn't 8 sufficient, no, in the review of Dr. Pollanen, and 9 certainly the degree -- 10 COMMISSIONER STEPHEN GOUDGE: Why not? 11 DR. ANDREW MCCALLUM: Well, because of 12 the -- 13 COMMISSIONER STEVEN GOUDGE: I probably 14 should ask him, as opposed to you. 15 DR. ANDREW MCCALLUM: I think you'd be 16 better to ask him. But the fact is that these -- these 17 reviews occur after the fact, so that the post-mortem is 18 done and has been done for some time. 19 Dr. Pollanen, I think, thought the issues 20 that were present needed to be dealt with in real time; 21 in other words, at the time the autopsy was being 22 performed. 23 So you mentioned remote as -- remote 24 supervision. One thing that was considered, and would 25 still be considered, would be having a second pathologist


1 attend the post-mortem -- 2 COMMISSIONER STEVEN GOUDGE: Right. 3 DR. ANDREW MCCALLUM: -- from the 4 Provincial Forensic Pathology Unit. That would have 5 been -- 6 COMMISSIONER STEVEN GOUDGE: Right. 7 DR. ANDREW MCCALLUM: -- one approach 8 that could have been used and had the -- the post-mortem 9 done in Ottawa. 10 COMMISSIONER STEVEN GOUDGE: Was any of 11 the concern related to the -- if I can put it this way -- 12 the direct involvement of the pathologists in the 13 criminal justice system by way of preparing for or giving 14 evidence? 15 DR. ANDREW MCCALLUM: Yes. 16 COMMISSIONER STEVEN GOUDGE: So it was 17 that, too? 18 DR. ANDREW MCCALLUM: Yes. It was -- it 19 was a multi-factorial situation, and it didn't involve 20 just one (1) pathologist. 21 COMMISSIONER STEVEN GOUDGE: Okay. But 22 what that suggests is that -- and this is a useful lesson 23 for us, I guess, and that is that the peer review that we 24 have heard a good deal about is obviously not a complete 25 answer to every problem.


1 DR. ANDREW MCCALLUM: No. I think that - 2 - if I might just say that I -- I agree with you, and I 3 think that the involvement of the Chief Forensic 4 Pathologist, as the content expert, is very important. 5 And so we need to have that position 6 clearly strengthened and enshrined in legislation, I 7 believe, to allow for it to happen. 8 If you look at the period from 2001 to 9 2006, where there was no Chief Forensic Pathologist -- 10 COMMISSIONER STEVEN GOUDGE: Right. 11 DR. ANDREW MCCALLUM: -- you can see that 12 some of these issues began to arise, and -- 13 COMMISSIONER STEVEN GOUDGE: Right. 14 DR. ANDREW MCCALLUM: -- it was at the 15 time of the appointment of the Chief Forensic Pathologist 16 they came to light. 17 COMMISSIONER STEVEN GOUDGE: Right. 18 DR. ANDREW MCCALLUM: And they were dealt 19 with. 20 COMMISSIONER STEVEN GOUDGE: Right. 21 Thanks. That is helpful. 22 23 CONTINUED BY MS. LUISA RITACCA: 24 MS. LUISA RITACCA: And I just have one 25 (1) or two (2) last questions arising out of the


1 Commissioner's questions. 2 Dr. McCallum, was one of the concerns -- 3 and I'll -- I'll put this to you, and you can tell me if 4 I'm right or wrong. 5 Was one of the concerns that was facing 6 both you and the Chief Forensic Pathologist the response 7 by the Ottawa pathologists to the peer review? 8 DR. ANDREW MCCALLUM: I think that's 9 fair. There were concerns that there was some 10 resistence, or lack of amenability, to reconsidering 11 opinions. 12 MS. LUISA RITACCA: And -- 13 COMMISSIONER STEVEN GOUDGE: And I 14 suppose that is always a difficulty with any peer review. 15 I mean, we have heard other comments on that, Dr. 16 McCallum, that peer review butts up against professional 17 independence at some point. 18 DR. ANDREW MCCALLUM: It does, and I 19 think physicians are perhaps notorious for valuing 20 autonomy, perhaps, as one of the professional traits very 21 highly. But I think that there needs to be a balance 22 struck between carful reconsideration of opinions, 23 especially in light of a preponderance of opinion 24 contrary to your own. 25 COMMISSIONER STEVEN GOUDGE: Right.


1 DR. ANDREW MCCALLUM: And that's the 2 challenge. You want people to have the courage of their 3 convictions, but at the same time be willing to 4 thoughtfully -- 5 COMMISSIONER STEVEN GOUDGE: Right. 6 DR. ANDREW MCCALLUM: -- reexamine what 7 they're doing. 8 COMMISSIONER STEVEN GOUDGE: Right. 9 10 CONTINUED BY MS. LUISA RITACCA: 11 MS. LUISA RITACCA: My last question, Dr. 12 McCallum, do you think that there is a need to conduct a 13 review of the cases completed by Dr. Johnston, or others, 14 at the Ottawa unit? 15 DR. ANDREW MCCALLUM: Well, that would be 16 for the Chief Coroner, I think, to make the decision. 17 That would be my view. 18 MS. LUISA RITACCA: Do you have any -- 19 DR. ANDREW MCCALLUM: Do I have a 20 personal view? Well, I do. 21 MS. LUISA RITACCA: -- impressions, one 22 way or the other? 23 DR. ANDREW MCCALLUM: I do have a person 24 view, and the -- my personal view would be that I am not 25 aware of any case where the work of the pathologist in


1 Ottawa has led to a wrongful conviction. 2 Certainly, I think we would be most open 3 to reconsidering a case if that were thought to be true. 4 But I have not heard that, and I'm -- therefore don't 5 think that a systematic review would make a lot of sense 6 at this time. 7 MS. LUISA RITACCA: Are there any 8 differences between -- I -- I know that obviously there 9 are differences -- but between the type of review 10 completed by the Chief Coroner for the cases that are now 11 before us with Dr. Smith and pediatric cases and 12 reviewing adult cases? 13 Are there practical differences that would 14 make the same kind of review difficult? 15 DR. ANDREW MCCALLUM: Well, there -- 16 there are the logistic, and resource issues that clearly 17 would be a challenge. But if it were the right thing to 18 do, that shouldn't be acceptable as a reason not to do 19 it. 20 But from -- there are differences as well, 21 because the -- and this is as someone who deals with 22 pathology all the time but is not a pathologist, as is 23 clearly known to everybody. 24 The -- there are differences between 25 criminally suspicious cases in the adult sphere, and the


1 pediatric sphere -- vis a vis forensic pathology -- such 2 as there's much more likelihood that there's going to be 3 a definitive injury that will be obvious to all. 4 You can smother a baby and leave almost no 5 trace of doing it. It's very difficult to do that with 6 an adult, especially when -- with the assailant being 7 likely to be attacked and some retaliation to occur. 8 There's much more sharp force injury seen 9 in adults than -- than in children, so that the 10 definitive aspect of it, there's less subtly, in other 11 words. There's a great deal of subtly, and often there's 12 issues of exclusive opportunity and the like in -- in 13 pediatric forensic pathology. 14 And there's usually more ancillary 15 information. Witnesses are more commonly found, et 16 cetera, so that the -- in my view the pathology -- and 17 this is not to minimize the importance of forensic 18 pathology in adult criminal justice cases at all -- is 19 perhaps less turns on it at times. Not always -- 20 COMMISSIONER STEPHEN GOUDGE: It is less 21 likely -- 22 DR. ANDREW MCCALLUM: Yep. 23 COMMISSIONER STEPHEN GOUDGE: -- to be 24 the absolutely -- 25 DR. ANDREW MCCALLUM: Yep.


1 COMMISSIONER STEPHEN GOUDGE: -- central 2 evidence? 3 DR. ANDREW MCCALLUM: And we know there 4 are certain cases that are very difficult. Asphyxial 5 cases are very difficult. Sexual homicides, serial 6 killers, bodies that are partly decomposed or found in 7 water, those are difficult cases. There's no question 8 about that. 9 The guideline for forensic pathology do 10 speak to that. And -- and there's a memo, as you know, 11 that's been -- and don't remember the name -- the number 12 of the memo -- which stipulates that such cases are going 13 to go to the provincial forensic pathology unit 14 irrespective of whether or not there's a regional 15 forensic pathology unit that could do the case because of 16 the particularity and the difficulty of those cases. 17 18 CONTINUED BY MS. LUISA RITACCA: 19 MS. LUISA RITACCA: Thank you, Doctors; 20 thank you, Commissioner. 21 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 22 Ritacca. 23 Ms. Craig...? 24 25 CROSS-EXAMINATION BY MS. ALISON CRAIG:


1 MS. ALISON CRAIG: Thank you, 2 Commissioner. Good afternoon, Doctors. My name is 3 Alison Craig, and I'm one of the lawyers that represents 4 nine (9) individuals who were convicted of crimes in 5 cases in which Dr. Smith was involved. 6 And I have one extremely brief line of 7 questioning I just want to get your insights on this 8 afternoon. And perhaps, Dr. Legge, I'll -- I'll ask you. 9 One of the things we've heard a lot of 10 discussion about through this Inquiry is the idea of 11 defence autopsies or second autopsies. 12 And -- and by that I mean having people 13 who are accused of -- of a crime retaining their own 14 pathologist to attend at the autopsy or have a second one 15 conducted shortly thereafter. 16 And perhaps I should just start by saying, 17 would you agree that that's -- that's an important 18 practice to be available? 19 I know -- and -- and I'm -- I'm asking you 20 because -- I know you're not a pathologist, but I'm -- 21 I'm looking to get some input from the Northern 22 perspective, if I can put it that way? 23 DR. DAVID LEGGE: I haven't had any 24 experience with a specific case of that nature. And -- 25 but you're -- you're talking about a second autopsy being


1 done, correct? 2 MS. ALISON CRAIG: Right, by -- by a 3 pathologist retained -- 4 DR. DAVID LEGGE: Yes. 5 MS. ALISON CRAIG: -- by the defence, as 6 opposed to a paper and picture review somewhere down the 7 line. 8 9 (BRIEF PAUSE) 10 11 DR. DAVID LEGGE: Off the top of my head, 12 I would say I wouldn't have any concern about that being 13 done. 14 MS. ALISON CRAIG: Okay. And -- 15 DR. DAVID LEGGE: Mm-hm. 16 MS. ALISON CRAIG: -- Doctors, do you 17 have any other insights? Can you see the value in -- in 18 -- or the importance in that being done from the defence 19 perspective? 20 DR. DAVID EDEN: I'll say there's a -- 21 there's a concern related to the family of the deceased. 22 The -- the body is either -- well the -- the suspect in 23 the case may be a family member or may not. 24 And if the suspect is a family member, 25 then they have the authority to organize a second


1 autopsy. If the deceas -- if the suspect is someone who 2 does not have care and control of the body, then I think 3 there would be a reasonable concern the public would have 4 of the body of a loved one being subjected to a second 5 autopsy by a third party. 6 And I think that's something that would 7 have to be taken into account. I think second autopsies 8 may well have a value, but there -- there is a family 9 that has lost a loved one as a result of a violent crime, 10 and obviously their sensibilities have to be taken into 11 account as well. 12 MS. ALISON CRAIG: Of course. And where 13 I was really going with this is we've also heard a lot 14 today about the communication difficulties that affect 15 residents of Northern Ontario communities. 16 And would you agree it might be harder for 17 somebody who lives in a rural Northern community to have 18 the resources or the means to -- and a sufficient amount 19 of time -- for a second autopsy to be done, contact a 20 lawyer, retain a pathologist, have them perhaps travel to 21 Toronto? 22 Those are difficulties that are greater 23 for people in Northern Ontario communities than urban 24 centres. 25 Is that fair?


1 DR. ANDREW MCCALLUM: Yes, I -- actually 2 I think it's -- I think -- I agree with you that it's 3 more difficult, but I think it's difficult everywhere. 4 It wouldn't be easy -- there -- there's no question that 5 there are -- these are significant hurdles that people 6 have to get over. 7 MS. ALISON CRAIG: Absolutely. And -- 8 DR. ANDREW MCCALLUM: So -- but it would 9 be more difficult the more remote the situation. 10 MS. ALISON CRAIG: And would you also 11 agree that -- and we've heard talk about this -- in 12 Aboriginal communities there's a particular importance of 13 having the body returned back to the community as quickly 14 as possible, which would also inhibit the process of 15 holding the body for a second autopsy. 16 That's fair? 17 DR. ANDREW MCCALLUM: Yes. 18 MS. ALISON CRAIG: So my question is, 19 we've also heard a lot of discussion about the process of 20 videotaping autopsies. 21 And it would -- would you agree that 22 perhaps from the perspective of Northern Ontario 23 communities, given the difficulties that there would be 24 in retaining a defence pathologist to attend for a second 25 autopsy, that might be an appropriate alternative, for it


1 to be reviewed down the line? 2 DR. DAVID EDEN: I think that a videotape 3 would provide certain information, the extent to which it 4 would be useful over and above the other documentary 5 evidence when an autopsy, is really a question I -- I 6 would put to a forensic pathologist. 7 MS. ALISON CRAIG: Absolutely. But from 8 a Northern Ontario perspective, it may be the only 9 alternative. 10 Is that fair? 11 DR. DAVID EDEN: I think I would go back 12 to the principle that there should always be value added 13 by doing something and videotaping is a -- videotaping 14 sounds simple. But I think there would be considerable 15 resources involved in doing that. And I think there 16 should be opinion guiding that, about what should be 17 videotaped, which cases should be videotaped and how that 18 should be made available. 19 So I wouldn't say that it's simple, and -- 20 and I would defer to a forensic pathologist on that 21 issue. 22 MS. ALISON CRAIG: Gentlemen, do either 23 of you have anything to add? 24 DR. DAVID LEGGE: I would agree with Dr. 25 Eden.


1 MS. ALISON CRAIG: Okay. Thank you, 2 Doctors. Thank you, Commissioner. 3 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 4 Craig. 5 Ms. Davies...? 6 7 CROSS-EXAMINATION BY MS. BREESE DAVIES: 8 MS. BREESE DAVIES: Thank you, 9 Commissioner. Good afternoon. My name is Breese Davies. 10 I am generally counsel for the Criminal Lawyers 11 Association, but this afternoon I am also going to be 12 asking some questions on behalf of the Association in 13 Defence of the Wrongly Convicted. 14 I have ten (10) minutes, maybe shorter, 15 because Ms. Ritacca asked a number of my questions. So I 16 just have two (2) areas I'd like to cover, mostly with 17 you, Dr. McCallum. And the first deals with the -- the 18 issue that arose in Ottawa with the Ottawa pathologist. 19 And -- and I think we've heard evidence 20 that a number of problems were identified with more than 21 one (1) pathologist in Ottawa as a result of a quality 22 assurance review conducted by Dr. Pollanen, correct? 23 DR. ANDREW MCCALLUM: Correct. 24 MS. BREESE DAVIES: And you'll agree with 25 me that only a select number of the cases perfo --


1 performed by those pathologists were reviewed by Dr. 2 Pollanen in reaching those conclusions. 3 Is that right? 4 DR. ANDREW MCCALLUM: No. No. All of 5 the homicides -- well, you're correct, but I think what's 6 behind your question is all the homicide cases were 7 reviewed. Some of them were reviewed internally, and 8 some were reviewed by Dr. Pollanen. 9 MS. BREESE DAVIES: Okay, so if I -- 10 COMMISSIONER STEPHEN GOUDGE: By 11 homicide, you mean all those that were categorised with 12 homicide -- 13 DR. ANDREW MCCALLUM: Categorised as 14 homicides. 15 COMMISSIONER STEPHEN GOUDGE: -- as 16 manner of death? 17 DR. ANDREW MCCALLUM: Correct. 18 COMMISSIONER STEPHEN GOUDGE: Regardless 19 of whether conviction resulted or not? 20 DR. ANDREW MCCALLUM: That's right. Or 21 criminally suspicious, and I should add that as well. 22 23 CONTINUED BY MS. BREESE DAVIES: 24 MS. BREESE DAVIES: Okay. So all of the, 25 for example, all of the homicides conducted by Dr.


1 Johnston had been reviewed in reaching the conclusion. 2 Is that what I -- 3 DR. ANDREW MCCALLUM: That's correct. 4 MS. BREESE DAVIES: -- should understand? 5 Okay. 6 But not all of the autopsies conducted by 7 him -- or all of the medicolegal autopsies conducted by 8 him have been reviewed. 9 Is that right? 10 DR. ANDREW MCCALLUM: That's correct. 11 MS. BREESE DAVIES: And I take it that 12 your position that a more fulsome review isn't necessary 13 is because all of the homicides and criminally suspicious 14 cases have already been reviewed. 15 Is that -- 16 DR. ANDREW MCCALLUM: That's correct. 17 MS. BREESE DAVIES: Okay. And in your 18 view those are the ones that raised any level of 19 suspicion? 20 DR. ANDREW MCCALLUM: That's right, a 21 very narrow area of the most complex forensic pathology. 22 MS. BREESE DAVIES: Okay. And there's 23 no, as far as you're aware, no plan in place to review 24 anything more than what has already been reviewed -- 25 DR. ANDREW MCCALLUM: No.


1 MS. BREESE DAVIES: -- to this point in 2 time? 3 DR. ANDREW MCCALLUM: Not beyond the 4 normal review process that exists. 5 MS. BREESE DAVIES: Okay. 6 DR. ANDREW MCCALLUM: That's correct. 7 MS. BREESE DAVIES: The second area that 8 I have a -- 9 COMMISSIONER STEPHEN GOUDGE: Sorry, can 10 I just ask? 11 MS. BREESE DAVIES: Yeah. 12 COMMISSIONER STEPHEN GOUDGE: How far 13 back did that review go, do you know? 14 DR. ANDREW MCCALLUM: The review that Dr. 15 Pollanen was dealing with went back -- and I -- may I 16 refer to the tab here, because there is actually a -- 17 COMMISSIONER STEPHEN GOUDGE: Oh, sure. 18 MS. BREESE DAVIES: There's a chart, if 19 that's what you -- 20 DR. ANDREW MCCALLUM: There's a letter 21 and there's a chart. That's right. 22 MS. BREESE DAVIES: Yeah, it -- 23 DR. ANDREW MCCALLUM: And I just want to 24 give you -- 25 MS. BREESE DAVIES: I think it's Tab 44


1 of your material. 2 DR. ANDREW MCCALLUM: Right. 3 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 4 Davies. 5 6 CONTINUED BY MS. BREESE DAVIES: 7 MS. BREESE DAVIES: Tab 44. 8 DR. ANDREW MCCALLUM: And my -- my 9 recollection is those cases were all since my time, going 10 back to some, yeah, since 2003. 11 COMMISSIONER STEPHEN GOUDGE: Sorry. 12 Tab 44? 13 14 CONTINUED BY MS. BREESE DAVIES: 15 MS. BREESE DAVIES: I believe it's Tab 16 44. 17 DR. ANDREW MCCALLUM: You're right. 18 MS. BREESE DAVIES: It's PFP142010, the 19 second page, there's a chart of -- 20 COMMISSIONER STEPHEN GOUDGE: Correct. 21 22 CONTINUED BY MS. BREESE DAVIES: 23 MS. BREESE DAVIES: -- the ones in which 24 concerns were identified, correct? 25 DR. ANDREW MCCALLUM: That's correct.


1 MS. BREESE DAVIES: Or those were -- is 2 that the sum total of all of the cases that were reviewed 3 or just the ones where concerns were identified? 4 DR. ANDREW MCCALLUM: I'm not sure, to 5 tell you the truth. I think that they -- these are the 6 cases where concerns were identified and not the sum 7 total. 8 MS. BREESE DAVIES: Okay. But your 9 understanding is that all homicides from 2003 forward had 10 been reviewed, at a minimum? 11 DR. ANDREW MCCALLUM: Yes. 12 MS. BREESE DAVIES: Is it your 13 understanding that those are all of the homicide and 14 criminally suspicious cases that these pathologists have 15 done? 16 DR. ANDREW MCCALLUM: Yes. 17 MS. BREESE DAVIES: Okay. So they 18 started doing them in 2003? 19 DR. ANDREW MCCALLUM: No. They had 20 started before that. They pre-dated me. I'm not sure of 21 the exact year, but there was a review process in place 22 under Dr. Chiasson. So there was a -- there was a review 23 process for all cases that were homicides or criminally 24 suspicious. 25 MS. BREESE DAVIES: But Dr. Pollanen


1 didn't go back to look at those that had been reviewed -- 2 DR. ANDREW MCCALLUM: No. 3 MS. BREESE DAVIES: -- under Dr. 4 Chiasson. 5 DR. ANDREW MCCALLUM: He did not. That's 6 my understanding. These are cases he looked at 7 personally. 8 MS. BREESE DAVIES: And there's no plan 9 in place at the moment to go back and review those that 10 had previously been -- 11 DR. ANDREW MCCALLUM: Correct. 12 MS. BREESE DAVIES: -- reviewed under Dr. 13 Chiasson? 14 DR. ANDREW MCCALLUM: That's correct. 15 MS. BREESE DAVIES: Okay. Just a -- 16 COMMISSIONER STEPHEN GOUDGE: Did those 17 reviews cover the whole waterfront, in terms of time, 18 that is, did Dr. Chiasson's reviews go up to 2003? 19 DR. ANDREW MCCALLUM: They did. 20 COMMISSIONER STEPHEN GOUDGE: Okay. 21 DR. ANDREW MCCALLUM: And beyond, in 22 fact, because remember that he was -- there was a period 23 from 2003 to 2006 where Dr. Chiasson, though not the 24 Chief Forensic Pathologist, was still doing the reviews 25 on behalf of our office.


1 COMMISSIONER STEPHEN GOUDGE: Right. 2 MS. BREESE DAVIES: On a -- in a contract 3 basis? 4 DR. ANDREW MCCALLUM: Yeah, I'm not sure 5 what the arrangement he had with the chief -- the head 6 office was, but he was doing them. 7 8 CONTINUED BY MS. BREESE DAVIES: 9 MR. BREESE DAVIES: Okay. I -- I have a 10 couple of questions on the issue of toxicology reports 11 and delay, which you've also talked about this morning. 12 We've heard evidence from other witnesses 13 that there had been discussions between the Office of the 14 Chief Coroner and the Centre of Forensic Sciences in an 15 effort to reduce the turnaround times. 16 And I take it from your evidence you 17 haven't yet seen any improvement in the turnaround times 18 as a result of those discussions? 19 DR. ANDREW MCCALLUM: I think it would be 20 premature to see it, because the discussions, as I 21 understand it, only took place in the latter part of last 22 month. So one wouldn't expect to see an effect yet. But 23 no, the answer is no, to be fair, but that's the 24 background. 25 MR. BREESE DAVIES: Okay. And to your


1 knowledge, were those discussions between the Office of 2 the Chief Coroner and the Centre of Forensic Science 3 welcomed, or did they meet with any resistance? 4 DR. ANDREW MCCALLUM: I don't know. I 5 wasn't a participant. 6 MR. BREESE DAVIES: All right. Okay. 7 And we've also heard some evidence that there is some 8 opportunity to triage cases with the Centre of Forensic 9 Science that are criminally suspicious and homicide cases 10 and that those can sometimes be done more quickly. 11 Is that your experience, that reports in 12 criminally suspicious and homicide cases are in fact 13 produced by the Centre of Forensic Science more quickly 14 than others? 15 DR. ANDREW MCCALLUM: No, it's variable. 16 It doesn't -- they do get reports done more quickly in 17 some circumstances. Certainly a call from the regional 18 coroner asking them to expedite a case does assist, but 19 it is variable. 20 MR. BREESE DAVIES: So it's a case-by- 21 case basis -- 22 DR. ANDREW MCCALLUM: It is. 23 MR. BREESE DAVIES: -- as opposed to 24 there being a policy in place that criminally suspicious 25 or homicide ought to be done more quickly, from your


1 understanding? 2 DR. ANDREW MCCALLUM: That's my 3 experience. 4 MR. BREESE DAVIES: Thank you. 5 Commissioner, those are my questions. 6 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 7 Davies. 8 Mr. Falconer...? 9 10 (BRIEF PAUSE) 11 12 MR. JULIAN FALCONER: My apologies, Mr. 13 Commissioner. Being substantially older than Ms. Davies 14 it takes me a lot longer to get up here. 15 COMMISSIONER STEPHEN GOUDGE: Well, I 16 sympathise. 17 18 (BRIEF PAUSE) 19 20 CROSS-EXAMINATION BY MR. JULIAN FALCONER: 21 MR. JULIAN FALCONER: Good afternoon, 22 Doctors, Dr. Legge, Dr. Eden, and Dr. McCallum. My name 23 is Julian Falconer. I represent Nishnawbe-Aski Nation 24 and Aboriginal Legal Services of Toronto. 25 I'm fairly certain you know this, but I


1 think it's important to indicate Nishnawbe-Aski Nation is 2 a political organization that represents forty-nine (49) 3 First Nations communities in what are considered the 4 Treaty 9 Territories, which occupy two-thirds (2/3s) of 5 the Province of Ontario. 6 Aboriginal Legal Services is a legal 7 agency providing services to Aboriginal First Nations 8 communities across the province. 9 If I can start, Dr. Legge -- and -- and I 10 must confess, to -- to give -- to give Dr. McCallum some 11 comfort, most of my questions will be directed to Dr. 12 Legge and -- and some questions to Dr. Eden. 13 And it's not surprising -- basically, Dr. 14 Legge, you will have been in charge of the, what was then 15 called the Northwest Territory from 1997 to 2008, the 16 last eleven (11) years? 17 DR. DAVID LEGGE: That's correct. 18 MR. JULIAN FALCONER: Now I don't 19 necessarily need you to turn it up, but I'm happy if you 20 want to. On December 4th, 2007, Dr. Young testified. 21 And it's three (3) lines. I'm just going to read it to 22 you, and if you'd like me to turn it up I'd be happy to. 23 It's at page 107. 24 In answer to my questions Dr. Young said, 25 among other things, quote:


1 "We kept a regional coroner in 2 Northwestern Ontario despite the fact 3 that the volumes really don't -- don't 4 indicate it. And a good part of his 5 job was to -- was to pay careful 6 attention to -- to First Nations 7 issues." 8 And -- and obviously the -- the emphasis I 9 put there is -- is how Dr. Young described it, quote: 10 "A good part of his job was to -- was 11 to pay careful attention to First 12 Nations issues." 13 Is that accurate? 14 DR. DAVID LEGGE: I certainly don't ever 15 recall him letting me know that thought. I mean, that -- 16 that may be a conclusion of his, but it was never 17 transferred directly to me. 18 MR. JULIAN FALCONER: All right. 19 DR. DAVID EDEN: The -- the other -- the 20 other component of his statement was that we -- we kept a 21 regional coroner up there -- what -- what was -- how did 22 it go again? 23 MR. JULIAN FALCONER: And -- and I'm 24 happy to have it turned up -- 25 DR. DAVID LEGGE: Yeah.


1 MR. JULIAN FALCONER: -- if it's useful 2 to you. 3 DR. DAVID LEGGE: Yeah. 4 MR. JULIAN FALCONER: It's page 107 of 5 December 4th, 2007 transcript. 6 7 (BRIEF PAUSE) 8 9 MR. JULIAN FALCONER: And I apologize. 10 It was just three (3) lines, and I thought we could do it 11 quick, but I don't want to be unfair to you. I want you 12 to see the passage. I'll read it to you again though, as 13 we wait. 14 DR. DAVID LEGGE: Okay. 15 COMMISSIONER STEVEN GOUDGE: Can you get 16 that, Chris? 17 18 CONTINUED BY MR. JULIAN FALCONER: 19 MR. JULIAN FALCONER: Line 6; page 107: 20 "We kept a regional coroner in 21 Northwestern Ontario despite the fact 22 the volumes really don't -- don't 23 indicate it, and a good part of his job 24 was to -- was to pay careful attention 25 to -- to First Nation's issues."


1 DR. DAVID LEGGE: I'm not quite sure if I 2 agree with that logic, and I -- I never recall that being 3 part of any job description I received. 4 MR. JULIAN FALCONER: That -- 5 DR. DAVID LEGGE: Clearly -- clearly 6 First Nations' issues have emerged as being important, 7 but you -- you certainly need a regional coroner in that 8 area. It almost sounded like that was a -- an after- 9 thought that we -- maybe we didn't really need him there. 10 MR. JULIAN FALCONER: Well, this comes 11 from -- 12 DR. DAVID LEGGE: But I think that you -- 13 you need to have a -- 14 MR. JULIAN FALCONER: -- page 107, just 15 helping the -- 16 DR. DAVID LEGGE: -- you need to have a 17 regional coroner there. 18 MR. JULIAN FALCONER: Registrar, page 107 19 is where it comes from. 20 And the question that I asked that 21 prompted -- the question that I asked that prompted the 22 answer -- it's a long answer, so I have to go back a 23 page. 24 DR. DAVID LEGGE: Oh. 25 MR. JULIAN FALCONER: The question that I


1 asked that prompted the answer was: 2 "The Coroner's System accessed the 3 death investigation services; access to 4 coroner is and access to the kinds of 5 services that other members of the 6 province non-First Nations received as 7 a matter of routine." 8 And I had put to him that that same access 9 wasn't there. That was the gist of where we were at. 10 And at page 107, he stated, among other things: 11 "We kept a regional coroner in 12 Northwestern Ontario despite the fact 13 the volumes really don't -- don't 14 indicate it." 15 So that's the first part that I think you 16 were -- you were struggling with. You wondered what he 17 meant. 18 DR. DAVID LEGGE: Well, I was wondering 19 what he has meant, because it -- it almost implies that 20 there might have been an earlier thought that there was 21 no need to have any regional coroner there. 22 MR. JULIAN FALCONER: It sounds like it. 23 DR. DAVID LEGGE: Yeah. 24 MR. JULIAN FALCONER: Line 6; page 107. 25 Do you see line 6?


1 DR. DAVID LEGGE: Okay. It's up here 2 now. 3 MR. JULIAN FALCONER: 4 "We kept a regional coroner in 5 Northwestern Ontario despite the fact 6 that the volumes really don't -- don't 7 indicate it." 8 So -- 9 DR. DAVID LEGGE: Well, at that -- at 10 that time, the -- that part of the region was much 11 smaller than post-2000. 12 MR. JULIAN FALCONER: Was that ever 13 discussed with you, as regional coroner from 1997 14 onwards? 15 DR. DAVID LEGGE: Never. 16 MR. JULIAN FALCONER: All right. 17 DR. DAVID LEGGE: I -- I don't recall any 18 kind of a discussion like this, with me personally. 19 MR. JULIAN FALCONER: All right. And to 20 -- to properly contextualize this, Dr. Young would have 21 been the Chief Coroner in respect of your position over a 22 seven (7) year period, between 1997 and 2000 -- and 2004, 23 is that right? 24 DR. DAVID LEGGE: Yeah, that -- that 25 would be correct, yeah.


1 MR. JULIAN FALCONER: So there'd be a 2 seven (7) year overlap, where the first seven (7) years 3 of your work, it would have been under Dr. Young? 4 DR. DAVID LEGGE: Mm-hm. 5 MR. JULIAN FALCONER: And Dr. Young 6 neither discussed with you that the volume in your area 7 didn't warrant being a regional coroner there, correct? 8 That wasn't discussed? 9 DR. DAVID LEGGE: Not personally with 10 myself, no. 11 MR. JULIAN FALCONER: And -- and I'm 12 trying not to be too much of a lawyer about this. If it 13 was communicated to you on paper, or some fashion, did -- 14 was it communicated to you? 15 DR. DAVID LEGGE: No. 16 MR. JULIAN FALCONER: Okay. And then -- 17 and I noticed Dr. McCallum smiled about me trying not to 18 be a lawyer. All right. And I just want you to know, 19 even though I'm only asking questions of him, I watch the 20 others. 21 And then secondly -- secondly, I wanted to 22 ask you, he didn't discuss with you that a good part of 23 your job -- that's a quote, "good part of his job" was to 24 pay careful attention to First Nations issues? 25 DR. DAVID LEGGE: Not specifically at


1 all, no. 2 MR. JULIAN FALCONER: All right. 3 DR. DAVID LEGGE: No, he -- 4 MR. JULIAN FALCONER: And would you agree 5 with me that if someone is a subordinate reporting to a 6 superior in any capacity, it's always important that if 7 the superior has expectations of the subordinate, they 8 ought to communicate them? 9 DR. DAVID LEGGE: Sounds very logical, 10 and reasonable. Mm-hm. 11 MR. JULIAN FALCONER: And you're telling 12 me that that particular expectation was not communicated 13 to you? 14 DR. DAVID LEGGE: No, I cannot recall 15 that at all. 16 MR. JULIAN FALCONER: Thank you. 17 DR. DAVID LEGGE: Mm-hm. 18 MR. JULIAN FALCONER: Now, one (1) of the 19 things that the overview report that existed in respect 20 of the Coroner's System that was provided in -- in these 21 proceedings, and I can give you the -- the document 22 number, I apologize. I'll pull it up very quickly. 23 But one (1) of the things that it does is 24 it refers to the -- I apologize. It's Tab 13; Volume II 25 of your materials. You really don't need to turn it up,


1 because it's a general proposition. 2 It refers to the -- the Law Reform 3 Commission -- a report on the law of coroners -- the 1995 4 Law Reform Commission report. Do -- do you know the 5 document I'm talking about? It's located at Tab 13, 6 Volume II of your materials. 7 If you haven't heard of it, I'll get you 8 to turn it up because that's probably wiser. 9 DR. DAVID LEGGE: Please. 10 MR. JULIAN FALCONER: And if I could ask 11 -- it's actually document number 300822. If I could ask 12 that it be brought up on screen. 13 14 (BRIEF PAUSE) 15 16 MR. JULIAN FALCONER: Do you have Tab 13 17 of your binders, Volume II? 18 DR. DAVID LEGGE: I'm waiting for it to 19 come up on the screen. 20 MR. JULIAN FALCONER: Okay. 21 COMMISSIONER STEPHEN GOUDGE: You've 22 probably got a Volume II somewhere there, Dr. Legge. 23 DR. ANDREW MCCALLUM: There's a Volume 24 II. 25 DR. DAVID LEGGE: What tab was that


1 again, sir? 2 COMMISSIONER STEPHEN GOUDGE: 13. 3 MR. JULIAN FALCONER: Tab 13. And I'm 4 sorry, we're going to have to struggle through some 5 documents. I -- I'm usually better at this in not 6 bringing too much paper, but unfortunately, this time I'm 7 going to have to keep dragging tabs. 8 DR. DAVID LEGGE: Okay, that's -- 9 that's -- 10 MR. JULIAN FALCONER: If I could ask that 11 page 192 -- if page 192 of that document could be put on 12 the screen. 13 COMMISSIONER STEPHEN GOUDGE: That's page 14 10 of the document? 15 16 CONTINUED BY MR. JULIAN FALCONER: 17 MR. JULIAN FALCONER: Yeah, thank you, 18 Mr. Commissioner, I apologize. It shows as... 19 20 (BRIEF PAUSE) 21 22 MR. JULIAN FALCONER: I think there was 23 some highlighting on this document, so I apologize. I'm 24 going to take you through this very slowly, Dr. Legge. 25 DR. DAVID LEGGE: Mm-hm.


1 MR. JULIAN FALCONER: I first want to 2 understand something. The Law Reform Commission report 3 in 1995 in respect to the Coroner's System; it's my 4 understanding it's the only Law Reform Commission report 5 on the Coroner's System out there. 6 Had you ever heard of this document during 7 your eleven (11) years? 8 DR. DAVID LEGGE: I think I've heard of 9 it, but I really don't know it. 10 MR. JULIAN FALCONER: All right. 11 DR. ANDREW MCCALLUM: There's a -- it 12 isn't the only report. There's a 1971 report. 13 MR. JULIAN FALCONER: No, I'm referring 14 to -- since Dr. Legge took over as -- as regional 15 coroner. In other words, from 1997 to now, there's only 16 one (1) Law Reform Commission report. 17 Now, at page 192, which is the page 10, 18 there's a reference to First Nation services. 19 COMMISSIONER STEPHEN GOUDGE: That's hard 20 to read. 21 22 CONTINUED BY MR. JULIAN FALCONER: 23 MR. JULIAN FALCONER: You'll see it -- 24 it's six (6) lines down and it's on the left. So in 25 other words, the first page, the left side of the screen.


1 DR. DAVID LEGGE: Mm-hm. 2 MR. JULIAN FALCONER: 3 "Similarly, First Nations, 4 including..." Do you see that? 5 DR. DAVID LEGGE: Yes. 6 MR. JULIAN FALCONER: Thank you. 7 "Similarly, First Nations, including 8 the problems associated with life in 9 remote communities will require 10 responses that are consistent with the 11 cultural and social context. This has 12 not always been the case. Perhaps the 13 absence of clear definitions of the 14 purpose of investigations and inquests 15 in the current Act has contributed to 16 this situation." 17 And there is a footnote at the bottom that 18 I particularly want to draw to your attention: 19 "See, for example, the criticisms of 20 Grant, Bader, and Cromarty report of 21 the Osnaburgh/Windigo Tribal Counsel." 22 COMMISSIONER STEPHEN GOUDGE: Sorry, 23 which footnote is that, Mr. -- 24 MR. JULIAN FALCONER: Right underneath. 25 So if you go down and see "for example".


1 COMMISSIONER STEPHEN GOUDGE: And where 2 does that footnote fit in? 3 MR. JULIAN FALCONER: It fits in if one 4 goes backwards to that quote; in other words, 27. 5 COMMISSIONER STEPHEN GOUDGE: Is that 6 footnote 27? 7 MR. JULIAN FALCONER: Yeah, this has not 8 always been the case. 9 COMMISSIONER STEPHEN GOUDGE: Okay, 10 thanks. 11 12 CONTINUED BY MR. JULIAN FALCONER: 13 MR. JULIAN FALCONER: 14 "See, for example, the criticisms of 15 Grant, Bader, Cromarty report of 16 Osnaburgh/Windigo Tribal Counsel 17 Justice Review Committee prepared for 18 the Attorney General of Ontario. The 19 reported noted a number of cases in 20 which inquests were not conducted and 21 the authors were of the view that, had 22 the deaths taken place in a non-native 23 community, inquests would have been 24 conducted." 25 Now, I'm simply -- I'm -- I'm raising this


1 as a starting point to ask you a question, Dr. Legge. 2 This -- first of all, this report -- that is the Law 3 Reform Commission Report -- and the issue raised about 4 access to services, First Nations access to services, in 5 this case, inquest services. 6 Is that an issue that was raised with you 7 in -- in taking over the post or in occupying the post as 8 the regional coroner of Northwestern Ontario? 9 DR. DAVID LEGGE: The simple answer is 10 no. 11 MR. JULIAN FALCONER: All right. And 12 when the report refers to Osnaburgh/Windigo, the 13 Commissioner will know because this has been part of my 14 questioning before. 15 Osnaburgh/Windigo is actually the colonial 16 name for what is now Mishkeegogamang, all right? Did you 17 know that? 18 DR. DAVID LEGGE: Yes, I know -- 19 MR. JULIAN FALCONER: Okay. 20 DR. DAVID LEGGE: -- I know that that's 21 the -- a native name for it. 22 MR. JULIAN FALCONER: All right. And the 23 reason -- 24 DR. DAVID LEGGE: I'm thinking of it as a 25 community.


1 MR. JULIAN FALCONER: That's right. 2 DR. DAVID LEGGE: Yeah. 3 MR. JULIAN FALCONER: And in respect of 4 the Mishkeegogamang community, it's essentially actually 5 identified specifically in the Law Reform Commission 6 Report on coroners' systems in 1995, correct? 7 It's actually identified by way of a 8 report, correct? 9 DR. DAVID LEGGE: It certainly appears 10 so. 11 MR. JULIAN FALCONER: All right. 12 DR. DAVID LEGGE: Now, the reason I 13 raised that with you is that's in 1995 and then if you go 14 back and I've actually provided document notice -- sorry, 15 I've provided document notice in respect of the 16 Osnaburgh/Windigo report. And you'll find that if you 17 flip back to Tab 12. Could you do that, please? 18 And you'll see the Osnaburgh/Windigo 19 tribal council report and if you flip -- do -- do you 20 have that in front of you? 21 DR. DAVID LEGGE: Yes. 22 MR. JULIAN FALCONER: And if you flip to 23 the second page you'll see that's a 1990 report. 24 Now, if I could ask that we go the third 25 page of that document and it's Document Number 300857?


1 DR. DAVID LEGGE: Yes. 2 MR. JULIAN FALCONER: So the third page 3 in? Thank you. You'll see the last paragraph is the 4 portion I wanted to read to you. 5 "As previously mentioned the Scott, 6 McKay, Bain Health Panel Report noted 7 in 1989 that there had been no less 8 than eighty-five (85) violent deaths 9 over the previous eight (8) years at 10 Osnaburgh, a community of just over 11 seven hundred (700) people." 12 And of course we're still talking about 13 Mishkeegogamang, just for the record, so we're clear. 14 "In 1983 a young Osnaburgh boy age 12 15 went missing on the reserve. Three (3) 16 weeks later his body was found in the 17 bush and an autopsy revealed that the 18 youth had one (1) of the highest blood 19 alcohol levels ever recorded in North 20 America, 1434 milligrams per hundred 21 millilitres of blood." 22 And then the last three (3) lines of that 23 page: 24 "On the same reserve seven (7) children 25 ranging in age from six (6) to twelve


1 (12) years died when the stove in the 2 cabin where they were staying 3 overheated and ignited the cardboard 4 insulating the walls. There were no 5 windows. Flames barred the single 6 door. Further, Chief Kaminawash 7 (phonetic) reported that between 1985 8 and 1987 of thirteen (13) deaths at 9 Osnaburgh ten (10) were accidental or 10 violent with eight (8) being alcohol 11 related. 12 In none of these cases was an inquest 13 called, yet should such tragic events 14 have occurred in southern Ontario, 15 members of this committee are confident 16 that numerous inquests would have been 17 held." 18 The last paragraph on this page, please? 19 So just go to the bottom. Thank you. 20 "The reluctance to hold inquests may be 21 attributed in part to the problems of 22 language and culture. The coroner is a 23 medical doctor. His investigators are 24 members of the Ontario Provincial 25 Police and his counsel is the Crown


1 Attorney. None of them is a First 2 Nations Person. All or part of what is 3 perceived as an alien justice system, 4 lacking ability to conduct an inquest 5 or proceedings in the language of the 6 community. 7 Surely, such a state of affairs cannot 8 be justifiable reason for a failure to 9 call inquests. As the Scott, McKay, 10 Bain Health Panel Report has documented 11 15 percent of the population of 12 Osnaburgh has succumbed to violent 13 deaths over an eight (8) year period. 14 If such events had occurred in any non- 15 native community in Ontario, it is 16 difficult to believe that no inquests 17 would have been held. Are the lives of 18 First Nations members not as valuable 19 as those of non-native people in our 20 society? How can it be that so many of 21 them can die in such circumstances 22 without any public inquiry or other 23 publicity concerning their fate?" 24 And there's a series of recommendations at 25 the end of this report.


1 May I ask you, Dr. Legge, have you ever 2 read this report before? 3 DR. DAVID LEGGE: No, I haven't. 4 MR. JULIAN FALCONER: Now, I'm going to 5 go forward in time. We've -- we -- we went to the 1995 6 report that cited this report. Now, I'm going to go 7 forward in time to 2007 and it's Tab 7. 8 9 (BRIEF PAUSE) 10 11 MR. JULIAN FALCONER: And this is 12 document 300705. This is a report on Mishkeegogamang, an 13 assessment report of what's called the North/South 14 Partnership. 15 And for the record, the North/South 16 Partnership is a partnership of numerous First Nations 17 representatives: Chiefs, Elders, community members, along 18 with Southern Ontario-based memberships. This is at Tab 19 7, Dr. Legge. 20 DR. DAVID LEGGE: Mm-hm. 21 MR. JULIAN FALCONER: Do you have that? 22 DR. DAVID LEGGE: Yes. 23 MR. JULIAN FALCONER: The organizations 24 that it is in partnership with include Tikinagin Child 25 and Family Services, Save the Children Canada, the


1 Provincial Advocate's Office, and what's known as CHEO, 2 the Children's Hospital of Eastern Ontario. 3 Now what I want to do is basically take 4 you to a reflection of many of the same concerns again, 5 in January 2007. You'll see the cover of the report, 6 January 9th through 11th, 2007. 7 Do you see that? 8 DR. DAVID LEGGE: Mm-hm. Yes. 9 MR. JULIAN FALCONER: First of all, if 10 you could turn to page 12 please? 11 12 (BRIEF PAUSE) 13 14 MR. JULIAN FALCONER: The first main 15 paragraph at page 12 of the document -- I don't know if 16 we're able to -- I'm using the page numbers reflected on 17 the document. And I apologize for that. 18 If you'd go to the bottom of the page you 19 have up, Mr. Registrar, I can -- go to the next page 20 please, it's just the next page. Thank you. And then go 21 up to the first -- thank you. 22 Quote: 23 "Despite ongoing efforts by the First 24 Nations to improve community 25 conditions, Mishkeegogamang has the


1 undesirable distinction of having the 2 lowest recorded score among all 3 communities in Ontario on the Indian 4 and Northern Affairs Canada Community 5 Well-Being Index. This index reflects 6 conditions of education achievement, 7 employment, and family income. While 8 in 2001 the average score of all non- 9 Native communities was point eight five 10 (.85) and the average for all Ontario 11 Native communities was point six eight 12 (.68), Mishkeegogamang scored point 13 four six (.46), approximately half of 14 the score within the average Ontario 15 community." 16 If you turn to the next tab, by the way, 17 the Community Well-Being Index that the Federal Indian 18 and Northern Affairs turns out is -- is to be found. 19 It's a single index. 20 This community occupied the lowest -- 21 COMMISSIONER STEPHEN GOUDGE: Sorry, 22 where are you at? 23 MR. JULIAN FALCONER: Next tab, Tab 8, 24 you'll see -- 25 COMMISSIONER STEPHEN GOUDGE: Oh, Tab 8,


1 yes, right. 2 MR. JULIAN FALCONER: Yeah, you just see 3 the -- the single page that reflects the index, Mr. 4 Commissioner. 5 COMMISSIONER STEPHEN GOUDGE: Thanks. 6 7 CONTINUED BY MR. JULIAN FALCONER: 8 MR. JULIAN FALCONER: This community 9 occupies the lowest rung on the Well-Being Index put out 10 by the federal government. This is -- reflects the 2001 11 state of affairs as reported in 2007, in this report. 12 Were you familiar with that, Dr. Legge? 13 DR. DAVID LEGGE: No, I was not. 14 MR. JULIAN FALCONER: Would you agree 15 with me that if we combined that information with the 16 following -- and you can find this -- brief indulgence, 17 I'm just going to track the number for you. It won't 18 even be necessary to turn up the document, because I've - 19 - I've put it to previous witnesses. 20 The average death by accident rate in 21 Canada is 6 percent. The average death by accident rate 22 at Mishkeegogamang is 52 percent. That is, of the death 23 at Mishkeegogamang, on average 52 percent are due to 24 accident. 25 Did you know that?


1 DR. DAVID LEGGE: I didn't know that 2 specific figure, no. 3 MR. JULIAN FALCONER: Would you agree 4 with me that whether one looks at the Well-Being Index 5 put out by Department of Indian Northern Affairs or one 6 has regard to any of the other sites I've given you, that 7 that community is obviously in a state of serious, 8 serious demise and appalling conditions? 9 DR. DAVID LEGGE: Well your figures 10 support that. I don't think it's by any means the only 11 community that's got its significant problems. Plus, 12 these deaths that your referring to may well have come 13 earlier than my -- during my tenure. 14 I -- I'm just trying to think in my own 15 mind whether there's been a -- a cluster of deaths in 16 this community recently, and I don't think there have 17 been. 18 MR. JULIAN FALCONER: Have you every 19 been -- 20 DR. DAVID LEGGE: I'd have to review the 21 -- the details of the timing of this. 22 MR. JULIAN FALCONER: Have you ever been 23 to Mishkeegogamang? 24 DR. DAVID LEGGE: I have. 25 MR. JULIAN FALCONER: All right.


1 DR. DAVID LEGGE: Yes. 2 MR. JULIAN FALCONER: And in attending 3 Mishkeegogamang, do you recall who you met with? 4 DR. DAVID LEGGE: When I attended that 5 community, it was a long time ago. It was when I was 6 working for federal government. And I don't remember who 7 I visited or met with, but it was for the purposes of 8 conducting medical clinics. So it was not as a coroner. 9 MR. JULIAN FALCONER: All right. In the 10 time period where you were the regional coroner did you 11 ever attend that community? 12 DR. DAVID LEGGE: No, I don't. 13 MR. JULIAN FALCONER: All right. You had 14 asked that I assist you with the -- the numbers relating 15 to the accident rate in the same report that's at Tab 7, 16 so we're still at the assessment report, the January 17 2007, at page 8. So, Mr. Registrar, if you flip three 18 (3) pages back, I believe you will hit it. There will be 19 a subtitle next...keep going back...there, that's fine, 20 thank you. 21 Under population, the second paragraph -- 22 well I'll first give you the population numbers as 23 reported: 24 "The total population of 25 Mishkeegogamang First Nation is


1 currently fifteen hundred and sixteen 2 (1,516), an increase of 78 percent, 3 from eight hundred and fifty (850) in 4 1984. Of the current band members, 5 five hundred and thirty-six (536) live 6 off reserve, including approximately a 7 hundred and seventy-five (175) living 8 in the neighbouring, non-native 9 community of Pickle Lake." 10 The last line of the next paragraph: 11 "Between 1982 and 2001, 52 percent of 12 the deaths in Mishkeegogamang were 13 accidental, as compared with 6 percent 14 in the general Canadian population." 15 DR. DAVID LEGGE: Mm-hm. 16 MR. JULIAN FALCONER: So, between 1982 17 and 2001 would of course cover, among other things, the 18 four (4) year period that you were regional coroner, 19 correct? 20 DR. DAVID LEGGE: Yes. And that's -- 21 that's a high number, for sure. 22 MR. JULIAN FALCONER: That high number 23 did not come to your attention. 24 DR. DAVID LEGGE: Well, I haven't had an 25 opportunity to read this document, but it certainly


1 stands out clearly. 2 MR. JULIAN FALCONER: No, I'm saying, 3 while you were regional coroner between 1997 and 2008, 4 did this high number come to your attention? 5 DR. DAVID LEGGE: I don't recall that, 6 no. 7 MR. JULIAN FALCONER: It makes reference 8 to the non-native community of Pickle Lake right above 9 this paragraph. Do you see that? The neighbouring, non- 10 native -- 11 DR. DAVID LEGGE: Mm-hm. 12 MR. JULIAN FALCONER: -- community of 13 Pickle Lake? 14 DR. DAVID LEGGE: Yes. 15 MR. JULIAN FALCONER: While you were 16 regional coroner, had you ever visited Pickle Lake? 17 DR. DAVID LEGGE: No. 18 MR. JULIAN FALCONER: What -- I'm sort of 19 -- I'm trying to understand in terms of -- of information 20 flow that did come to you, we are now moving through at 21 least three (3) reports that all either were in existence 22 and very current when you became regional coroner or have 23 very recently been issued. 24 And they all paint a very bleak picture of 25 a community, correct?


1 DR. DAVID LEGGE: Yes. 2 MR. JULIAN FALCONER: What is the 3 mechanism, if any, for a regional coroner staying current 4 on community health as described in reports such as 5 these? 6 How do you stay current? 7 DR. DAVID LEGGE: Well, I -- I'd be aware 8 of a situation if I was dealing with individual death 9 cases. And if there are accidents occurring that are 10 non-fatal, I probably wouldn't hear too much about it. 11 There was media up in that area, and there are some 12 reports that circulate around, but they wouldn't 13 necessarily flow to me in Thunder Bay. 14 But there's -- there's plenty of 15 opportunity, in other words, for me to miss this 16 information. 17 MR. JULIAN FALCONER: You know, the 18 reason I, obviously, I ask this is I'm wondering with the 19 community in -- in this level of despair over this 20 extended period of time -- because you'd agree with me 21 that we're tracking now back to 1981. 22 Remember the numbers, 1981 to 1989, 23 eighty-five (85) deaths, yes? I gave that to you before. 24 Am I right? 25 DR. DAVID LEGGE: I guess you did, yes,


1 mm-hm. 2 MR. JULIAN FALCONER: All right. And 3 then we look at the numbers right up until 2001, and it's 4 not getting any better. 5 In other words, the next ten (10) years up 6 until 2001 continues to show a high death rate, not by 7 natural causes, correct? 8 DR. DAVID LEGGE: Yes. 9 MR. JULIAN FALCONER: And then we go all 10 the way to 2007, where the concerns of this community and 11 the concerns about this community's health appear still 12 not to have been alleviated, correct? 13 DR. DAVID LEGGE: Yes. 14 MR. JULIAN FALCONER: And I take it, it's 15 your evidence that you know of no initiative launched by 16 the Office of the Chief Coroner by way of special study 17 or reaching out to this community to help this community 18 with its extraordinary death rate? 19 DR. DAVID LEGGE: Well, that -- that is 20 correct. But on the other hand, I know of no mechanism 21 whereby this community has come to me to inform me in the 22 first place of their concerns in this area, including any 23 of these materials. 24 MR. JULIAN FALCONER: In terms of your 25 per -- your view of your role, I take it's fair to say


1 that as a civil servant and as the regional coroner in 2 charge of the region, you understand that your role is 3 more than passive? You're supposed to reach out and 4 address public health issues as they relate to deaths and 5 death investigations, no matter where they are in your 6 region. 7 In one fashion or another, you're supposed 8 to reach out. Is that right? 9 DR. DAVID LEGGE: Ideally, yes, mm-hm. 10 MR. JULIAN FALCONER: Okay. And you're 11 not really suggesting, are you, Dr. Legge, that a 12 community in desperate straits like this one (1) is -- is 13 to somehow be faulted by not calling you directly? 14 DR. DAVID LEGGE: No, I'm not suggesting 15 that. 16 MR. JULIAN FALCONER: All right. 17 DR. DAVID LEGGE: But I -- but I am 18 suggesting that I wasn't -- I -- I simply wasn't made 19 aware of these appalling figures, which I agree are 20 appalling. 21 MR. JULIAN FALCONER: And because of the 22 existence of reports documenting these disturbing 23 realities, would you agree with me that some kind of 24 epiphany today -- on January 25th, 2008 -- that these 25 people aren't getting services might ring hollow for


1 these people? 2 In other words, the acknowledgement today 3 really reflects the same acknowledgement I read to you 4 and the various reports I just went over. 5 Isn't that right? 6 DR. DAVID LEGGE: Are you saying there's 7 today, as a -- as in yesterday, an ignorance of what's 8 going on? 9 MR. JULIAN FALCONER: I'm suggesting to 10 you that what should cause these people to believe that 11 the acknowledgements today are going to lead to any 12 different result than the reflections of reports and 13 statistics of yesterday and the before? 14 In other words, what has changed? 15 DR. DAVID LEGGE: Well, I -- I would say 16 that nothing too much has changed. I -- I -- but I would 17 -- I would submit that I am aware that dreadful 18 conditions exist in many other communities, as well. 19 MR. JULIAN FALCONER: Would you agree 20 with me that one of the ways for reaching out would be 21 meeting the leadership of First Nations, that is one of 22 the ways of reaching out? 23 DR. DAVID LEGGE: Well, if -- if it 24 applies to my job, yes. 25 MR. JULIAN FALCONER: All right.


1 DR. DAVID LEGGE: If it applies to death 2 investigations, perhaps, yes. 3 MR. JULIAN FALCONER: Okay. Let's deal 4 first with you job. I notice we're close to break time. 5 What is -- what is your preference, Mr. Commissioner, 6 about the break? 7 COMMISSIONER STEPHEN GOUDGE: If you are 8 at an appropriate point, then I would like to break at 9 some point. 10 MR. JULIAN FALCONER: In approximately 11 five (5) minutes, is that all right? 12 COMMISSIONER STEPHEN GOUDGE: Whenever 13 suites you -- 14 MR. JULIAN FALCONER: All right. 15 COMMISSIONER STEPHEN GOUDGE: -- Mr. 16 Falconer. 17 18 CONTINUED BY MR. JULIAN FALCONER: 19 MR. JULIAN FALCONER: Nishnawbe-Aski 20 Nation would represent a very large political 21 organisation, from a First Nations perspective that was 22 involved in your -- in your region, correct? 23 DR. DAVID LEGGE: Yes. 24 MR. JULIAN FALCONER: The Grand Chief of 25 Nishnawbe-Aski Nation is Grand Chief Stan Beardy. I'm


1 advised that he's never met you face-to-face. 2 Is that true? 3 DR. DAVID LEGGE: That's not correct. 4 MR. JULIAN FALCONER: All right. 5 DR. DAVID LEGGE: I have met him. I've 6 in fact sat down with him and -- and expressed 7 condolences over the loss of his son. I -- I would 8 disagree with that. 9 MR. JULIAN FALCONER: All right. And I 10 appreciate that clarification, because that was the 11 information I was given. 12 DR. DAVID LEGGE: Mm-hm. 13 MR. JULIAN FALCONER: So I appreciate the 14 clarification. And -- and I want to be clear, I'm in no 15 way challenging that. If -- if that's your recollection, 16 that's fair enough. 17 DR. DAVID LEGGE: I haven't had -- I 18 haven't had a large numbers of meetings with him, but I 19 have met him, yes. 20 MR. JULIAN FALCONER: All right. And 21 have you ever engaged him or any of the Deputy Grand 22 Chiefs before last year? 23 Before 2007, have you either engaged the 24 Grand Chief or any of the Deputy Grand Chiefs prior to 25 last year, prior to 2007, in respect of the systemic


1 issues around access to services in the coroner's system 2 and First Nations? 3 DR. DAVID LEGGE: I would say not in a 4 formal sense, no. 5 MR. JULIAN FALCONER: The Deputy Grand 6 Chief in charge of health issues since 2003 is Deputy 7 Grand Chief Alvin Fiddler. And he advises -- and again, 8 this may warrant clarification by you, and I want to be 9 fair to you. 10 He advises that the first time he met you 11 was last year. Is that fair? 12 DR. DAVID LEGGE: I think that's correct, 13 yes. 14 MR. JULIAN FALCONER: You -- you fairly 15 or candidly stated that the Chief Coroner never brought 16 to your attention there was an expectation that you pay 17 particular attention to First Nations issues, correct? 18 DR. DAVID LEGGE: Not specifically, no. 19 MR. JULIAN FALCONER: Okay. This -- this 20 would be a good time, Mr. Commissioner. 21 COMMISSIONER STEPHEN GOUDGE: Okay. So 22 we will come back at twenty (20) to 4:00. 23 24 --- Upon recessing at 3:25 p.m. 25 --- Upon resuming at 3:41 p.m.


1 2 THE REGISTRAR: All rise. Please be 3 seated. 4 COMMISSIONER STEPHEN GOUDGE: Mr. 5 Falconer...? 6 7 CONTINUED BY MR. JULIAN FALCONER: 8 MR. JULIAN FALCONER: I wanted to direct 9 some questions to you, Dr. Eden. And we heard -- and I 10 can give some page citations for those -- for -- for the 11 sake of taking a note -- November 23rd, 2007, we heard 12 from Dr. Butt on the issue of -- of relationships amongst 13 First Nations and the police, among other things, and the 14 issue of community-based investigators. 15 And -- and first of all, am I -- am I fair 16 in saying that you know Dr. David Butt? 17 DR. DAVID EDEN: Dr. John Butt, yes. 18 MR. JULIAN FALCONER: Sorry, John Butt. 19 DR. DAVID EDEN: Yes, yes. 20 MR. JULIAN FALCONER: And you'd agree 21 with me that Dr. Butt -- those who know David -- 22 COMMISSIONER STEPHEN GOUDGE: We all know 23 David Butt; he's not a doctor, although he's a very smart 24 guy. 25


1 CONTINUED BY MR. JULIAN FALCONER: 2 MR. JULIAN FALCONER: You'd agree with me 3 that John is smarter than David Butt. All right, but I - 4 - I'm hoping the transcript removes the start of the 5 sentence. 6 You'd agree with me that Dr. John Butt is 7 an extremely reputable former Chief Medical Examiner and 8 former Chief Coroner. 9 DR. DAVID EDEN: He is a very respected 10 pathologist and death investigator, yes. 11 MR. JULIAN FALCONER: He opined on the 12 issue of the -- the sensitivities of relationships among 13 police and First Nations at pages 102 to 103 of the 14 transcript I've just referred to of November 23rd, 2007. 15 I don't want to go there. 16 I want to go, instead, to document number 17 303182, which is the Ipperwash report, and it's Tab 22 of 18 your binder, Dr. Eden, so document number 303182, it's 19 Tab 22. 20 COMMISSIONER STEPHEN GOUDGE: Do you know 21 what volume that is, Mr. Falconer? 22 MR. JULIAN FALCONER: Volume II. 23 COMMISSIONER STEPHEN GOUDGE: Okay, 24 thanks. 25


1 CONTINUED BY MR. JULIAN FALCONER: 2 MR. JULIAN FALCONER: And it's page 642; 3 the extract at page 642. 4 5 (BRIEF PAUSE) 6 7 MR. JULIAN FALCONER: It's a one (1) 8 liner and I'm going to do the same thing in another part 9 of the report. I'm only bringing it up because it's -- 10 it's a difficult issue to deal with, and my giving it to 11 you in a -- in a summary fashion is just going to get me 12 into more trouble. 13 I'm quoting from page 642, quote -- 14 COMMISSIONER STEPHEN GOUDGE: Sorry, 642? 15 MR. JULIAN FALCONER: Yes, of document 16 303182, so it should show as 642 -- 17 COMMISSIONER STEPHEN GOUDGE: What tab 18 did you say that was? 19 MR. JULIAN FALCONER: 22. It's my -- I 20 apologize, my -- my records show it is 303182; I'm 21 hearing that it's actually 187 -- what -- what is being 22 pulled up is 187 and it shouldn't be. 23 COMMISSIONER STEPHEN GOUDGE: Yes, but it 24 doesn't have a page 600. 25 MR. JULIAN FALCONER: No. What's -- Mr.


1 Registrar, that's the wrong document; you've got 187 up, 2 303187, and I'm looking for 303182. 303182. I can just 3 read you the line, Dr. Eden. 4 DR. DAVID EDEN: I'll see what I can do, 5 yeah. 6 MR. JULIAN FALCONER: 7 Quote: "One (1) of the factors that 8 contributed to the lack of a timely 9 peaceful resolution to the occupation 10 of Ipperwash Park was the element of 11 cultural insensitivity and racism that 12 existed within some of the ranks of the 13 Ontario Provincial Police Force." 14 COMMISSIONER STEPHEN GOUDGE: Did you 15 find it, Dr. -- 16 DR. DAVID EDEN: I got it. 17 COMMISSIONER STEPHEN GOUDGE: What tab is 18 it? 19 DR. DAVID EDEN: I have it as 303102, 20 page 58. 21 COMMISSIONER STEPHEN GOUDGE: What tab, 22 though? 23 DR. DAVID EDEN: And that's page -- 24 that's Tab 21 -- 25 COMMISSIONER STEPHEN GOUDGE: Thanks.


1 DR. DAVID EDEN: -- in my book. 2 COMMISSIONER STEPHEN GOUDGE: I've got 3 it. Give me the page again, Mr. Falconer, 6...? 4 MR. JULIAN FALCONER: 642. 5 COMMISSIONER STEPHEN GOUDGE: 642, 6 thanks. And that's page 58 of the document, Mr. 7 Registrar. Okay, we're all set. 8 MR. JULIAN FALCONER: I apologize, Mr. 9 Commissioner. 10 COMMISSIONER STEPHEN GOUDGE: That's 11 okay. 12 13 CONTINUED BY MR. JULIAN FALCONER: 14 MR. JULIAN FALCONER: Do you see that 15 first sentence -- 16 DR. DAVID EDEN: I do, yeah. 17 MR. JULIAN FALCONER: 18 "One of the factors that contributed to 19 the lack of a timely peaceful 20 resolution to the occupation of 21 Ipperwash Park was the element of 22 cultural insensitivity and racism, it 23 existed within some of the ranks of the 24 Ontario Provincial Police Force." 25 DR. DAVID EDEN: That's correct, yes.


1 MR. JULIAN FALCONER: And then what I'm 2 hoping, Mr. Commissioner, is -- is correct, as I give you 3 this one (1). Now we go to the -- to the next document 4 that Mr. Registrar did have up correctly, which is 5 303187, and you'll find it Tab -- 6 COMMISSIONER STEPHEN GOUDGE: That is Tab 7 22. 8 MR. JULIAN FALCONER: Thank you. 9 COMMISSIONER STEPHEN GOUDGE: That's 10 great. 11 12 CONTINUED BY MR. JULIAN FALCONER: 13 MR. JULIAN FALCONER: If you'd turn to 14 page 274. 15 16 (BRIEF PAUSE) 17 18 DR. DAVID EDEN: All right. 19 MR. JULIAN FALCONER: You'll see this 20 section refers to previous inquiries. 21 DR. DAVID EDEN: Got it. 22 MR. JULIAN FALCONER: 23 "Police/Aboriginal relations have been 24 the subject of several inquiries in 25 Canada over the past decade and -- or


1 decades." 2 And you'll see the reference to the 3 various inquiries. And at the bottom of that page: 4 "Several of these inquiries were called 5 after the death of an Aboriginal 6 person, in some cases at the hands of 7 the police; in other cases an inquiry 8 was called to investigate the police 9 response to such a death. These 10 reports and others have concluded that 11 police services have a systemic bias 12 against Aboriginal peoples." 13 Now, as tempting as it would be to ask you 14 to wade into the -- to the debate with your opinion, Dr. 15 Eden, I'm -- I'm not going to do that. 16 What I really hope to do in my question is 17 ask you, as the new regional coroner in charge of the 18 north region, I take it that you appreciate the fact that 19 there are sensitivities involved in the relationships 20 between First Nations' communities and the police? 21 DR. DAVID EDEN: I'm quite aware of 22 those, yes. 23 MR. JULIAN FALCONER: And that there may 24 well be ample reason to reconsider the notion of simply 25 having the present legislative choices of a medical


1 doctor or a police as the only potential investigators 2 within First Nations communities. 3 There may -- there may well be reason to 4 reconsider that; would you agree? 5 DR. DAVID EDEN: I would agree that's 6 fair. I would qualify that with a caveat that the 7 investigators must be appropriately qualified, have an 8 adequate volume to maintain skills, and be able to be 9 impartial at the scene. But subject to that, yes, I 10 think it's reasonable to look for a -- an option that 11 leads to the best quality death investigations. 12 MR. JULIAN FALCONER: And I start from 13 that just because Mr. Sandler had, very properly and in a 14 very informative way, had -- had a policy discussion with 15 the three (3) of -- of you doctors and -- and part of 16 that was a discussion around legislative change, correct? 17 Do you recall the legislative change 18 issues surrounding Section 18? The delegation -- 19 DR. DAVID EDEN: Section 18? That would 20 be Section 16. 21 MR. JULIAN FALCONER: Sorry, Section 16, 22 the delegation of investigative powers? 23 DR. DAVID EDEN: To my recollection there 24 was some discussion of broadening that, yes. 25 MR. JULIAN FALCONER: And as it currently


1 stands the only individuals that are identified as 2 delegates -- people who could receives these powers -- 3 would be either a police officer or medical practitioner, 4 correct? 5 DR. DAVID EDEN: That's the legislation 6 as it is currently, yes. 7 MR. JULIAN FALCONER: Right. And can we 8 all agree -- all four (4) of us -- speak up if any one 9 (1) of you doctors disagree with this proposition -- that 10 it is not realistic to expect medical practitioners to 11 actively take over the investigation portfolios in First 12 Nations remote communities as in a tent. 13 That's not realistic, and can we all agree 14 on that? 15 DR. DAVID EDEN: Yes, as currently 16 resourced, yes. 17 MR. JULIAN FALCONER: And can we all 18 agree that just as a group, plain and simple, that even 19 if we modified resources somewhat, it would take a huge, 20 both financial and cultural, shift to, all of a sudden, 21 parachute doctors into those First Nations communities 22 for death investigations? Can we agree on that? 23 DR. DAVID EDEN: For them to be resident 24 as coroners? That -- well, again that raises the issue 25 that in a town of five hundred (500) people --


1 MR. JULIAN FALCONER: No, no, I mean 2 parachute them in for the death investigation? 3 DR. DAVID EDEN: Oh, just case by case? 4 MR. JULIAN FALCONER: Yes. 5 DR. DAVID EDEN: The weather in and of 6 itself -- 7 MR. JULIAN FALCONER: That's right. 8 MR. DAVID EDEN: -- makes that 9 impossible. 10 MR. JULIAN FALCONER: So it's not going 11 to happen? 12 DR. DAVID EDEN: Right. 13 MR. JULIAN FALCONER: So that takes us to 14 the police officer. That's the only alternative in the 15 Act, correct? 16 DR. DAVID EDEN: Yes. 17 MR. JULIAN FALCONER: And we've just 18 discussed the difficulties and sensitivities around First 19 Nations/police relations, correct? 20 DR. DAVID EDEN: Are you including First 21 Nations police in that because they're the ones -- 22 they're the first responders. 23 MR. JULIAN FALCONER: I'm going to get 24 there in a minute. 25 DR. DAVID EDEN: Okay.


1 MR. JULIAN FALCONER: I'm going to get 2 there in a minute. I'm now referring to the OPP. 3 DR. DAVID EDEN: Right. So -- so the 4 question is...? 5 MR. JULIAN FALCONER: Currently, as 6 presently framed and in practice -- we've heard the 7 evidence -- the OPP are often used as the death experts 8 in death investigations in that area, correct? 9 DR. DAVID EDEN: They -- they are the -- 10 they're used -- they're used by the coroner as the scene 11 investigators, yes. 12 MR. JULIAN FALCONER: All right. So all 13 I'm doing is I'm getting us to the point where I think we 14 can agree that there is ample justification on the facts 15 as we currently know them for legislative change in this 16 area to broaden the powers of delegation for 17 investigators, correct? 18 DR. DAVID EDEN: Yes. 19 MR. JULIAN FALCONER: All right. And now 20 I go to the next area which is where do you broaden it 21 to, all right? 22 DR. DAVID EDEN: Yeah. 23 MR. JULIAN FALCONER: I'm going to 24 suggest this to you that when you're dealing with remote 25 communities, and I say First Nations remote communities


1 to properly contextualize this, you either have one (1) 2 of two (2) choices. You either parachute a service in on 3 a case-by-case basis or you draw from the community to 4 create this service. 5 Those are your two (2) choices, are we 6 agreed? 7 DR. DAVID EDEN: Actually, as it turns 8 out, no. 9 MR. JULIAN FALCONER: All right. You -- 10 DR. DAVID EDEN: There's -- there's a 11 middle ground, and that would be to have a local 12 investigator working with a remote investigator. So that 13 -- because of technology, even if weather's bad, it would 14 be possible to have the two (2) parties working together 15 in real time. 16 And that -- that -- and I mention that not 17 -- not in a show-offy way about technology, but because 18 of that issue of maintaining a partiality in a small 19 community. 20 MR. JULIAN FALCONER: Fair enough, but 21 even if you do what you've described, which makes a lot 22 of sense, I -- I can see that. You're saying that you 23 would be giving somebody supports that are in the 24 community, by way of communications, technology 25 communications, assistance; in fact, a form of mentoring,


1 a form of guidance. All of that would happen via 2 technology, yes? 3 DR. DAVID EDEN: There -- there would be 4 range of options there where at the one (1) extreme the - 5 - the person would be doing things in the remote 6 community almost -- sorry, the person in the community 7 would be doing almost all the investigation and just 8 asking questions. 9 At the other end of the extreme, the -- 10 you have the investigation directed by the person outside 11 the community with the local person acting as the eyes 12 and ears, and there's a whole lot of options in between 13 there. 14 MR. JULIAN FALCONER: Fair enough. But 15 those eyes and ears at one end, or fully running the 16 investigation at the other end, in both cases, they still 17 involve drawing from the community to create your 18 resource, don't they? 19 DR. DAVID EDEN: That's correct. 20 MR. JULIAN FALCONER: And so you either 21 have a choice; you either fly somebody in -- you 22 parachute them in -- or you rely on somebody from within 23 the community with the potential supports you described, 24 correct? 25 DR. DAVID EDEN: Correct.


1 MR. JULIAN FALCONER: Okay. Now given 2 the realities of resource limitations and time, distance 3 and weather, and I heard everything Dr. Legge had to say, 4 and I had the good fortune of flying up to 5 Mishkeegogamang and to Muskrat Dam -- and I appreciate 6 what we're discussing, the -- the huge spans of distance. 7 It's far more likely that you're going to 8 have to create a resource within the community, isn't 9 that right? 10 DR. DAVID EDEN: Yes, again for weather 11 reasons that we just can't get somebody to a community, 12 so it should be somebody who's normally resident in the 13 community. 14 MR. JULIAN FALCONER: And using Muskrat 15 Dam is a very good example, because that's pure fly-in. 16 There is no other way to get there other than some very 17 limited -- Dr. Legge's nodding in the affirmative. He 18 knows the area much better than me. 19 But that's a perfect example of a 20 community where rarely you can get in by land, but mostly 21 it's fly-in. And in that circumstance, it becomes key to 22 have a resource within the community if there's going to 23 be any kind of timely response, correct? 24 DR. DAVID EDEN: Yes. 25 MR. JULIAN FALCONER: Now where I go next


1 then in -- in my questions is, you've very much focussed 2 on the question of impartiality as -- as a concern, 3 correct? That's one (1) of the issues? 4 DR. DAVID EDEN: It's one (1) of them, 5 yes. 6 MR. JULIAN FALCONER: And obviously 7 issues around training would be important? 8 DR. DAVID EDEN: Training, yes, and case 9 volume; those would be the three (3) major ones. 10 MR. JULIAN FALCONER: All right. Now I 11 would like to suggest the following; have you heard of 12 the community health worker model currently used in -- in 13 remote communities in Northern Ontario, where individuals 14 who are not nurses -- 15 DR. DAVID EDEN: Yes. 16 MR. JULIAN FALCONER: -- not doctors, but 17 members of the community with some modicum of training 18 operate as a community health worker? 19 DR. DAVID EDEN: Yes, I'm aware of that. 20 I don't have detailed information, but I am aware of it. 21 MR. JULIAN FALCONER: All right. And 22 there's another example of that kind of model being used 23 in communities, and I -- and I apologize, it's in the 24 correctional context. 25


1 (BRIEF PAUSE) 2 3 MR. JULIAN FALCONER: Native Community 4 Correctional Workers, have you heard of them? 5 DR. DAVID EDEN: No. 6 MR. JULIAN FALCONER: If you look at -- 7 and I don't trust my numbering system that I'm guessing 8 about anymore, Mr. Commissioner, so I'm going to go very 9 slowly. If you look at Tab 19, which is Document 303550. 10 Tab 19 of Volume II. 11 You'll see a description of a Native 12 Community Correctional Worker. 13 DR. DAVID EDEN: Right. 14 MR. JULIAN FALCONER: And basically they 15 act as the representative of the Justice System in 16 managing offenders within the community. 17 DR. DAVID EDEN: Right. 18 MR. JULIAN FALCONER: They're present, 19 and they actually assist in managing offenders as it 20 relates to, for example, probation conditions or parole 21 conditions. 22 DR. DAVID EDEN: Right. 23 MR. JULIAN FALCONER: And you would 24 appreciate that would involve a certain level -- or need 25 for impartiality, correct?


1 DR. DAVID EDEN: I believe it would, yes. 2 MR. JULIAN FALCONER: If somebody 3 breaches parole you -- you don't really want it to be 4 their brother that has to manage -- 5 DR. DAVID EDEN: No. 6 MR. JULIAN FALCONER: -- the question or 7 report them? 8 DR. DAVID EDEN: Actually, the reason I'm 9 saying this is that there is -- there is some sort of 10 client relationship that a parole officer has with a -- 11 with a parolee, and I -- I think it is a little bit 12 different from what we would expect of a death 13 investigator. 14 But to say that they have to carry out 15 certain duties in an investigative fashion, I would agree 16 with that. 17 MR. JULIAN FALCONER: And so training and 18 impartiality become issues for different kinds of workers 19 and we go to the community -- 20 DR. DAVID EDEN: Right. 21 MR. JULIAN FALCONER: -- and create the 22 resource within the community, correct? 23 DR. DAVID EDEN: Yes. 24 MR. JULIAN FALCONER: And I use community 25 health officers or native community correctional workers


1 as examples because in both cases, drawing on a First 2 Nations community creates the unique advantage of 3 utilizing people that will have sensitivities to the 4 culture around them, isn't that true? 5 DR. DAVID EDEN: That's correct, yes. 6 MR. JULIAN FALCONER: And it also pays 7 the kind of respect to a First Nations community on a 8 community-to-community-nation-nation basis about helping 9 them to empower managing their own affairs, isn't that 10 true? 11 DR. DAVID EDEN: That -- that goes beyond 12 my expertise as death investigator. That's more a -- a 13 political question. 14 MR. JULIAN FALCONER: Now, in terms of 15 the questioning I had of -- of Dr. John Butt, as it 16 related to lay investigators, one (1) of the areas we 17 looked at, and -- and I'm going to have it brought up on 18 screen for you, is -- is what goes on in other 19 jurisdictions. 20 And in particular if I could ask Tab 19 -- 21 COMMISSIONER STEPHEN GOUDGE: This is 22 still Volume II, Mr. Falconer? 23 MR. JULIAN FALCONER: It should be, but 24 I'm going to check before I...no, it's not, it's Tab 18 25 of your Volume II. It seems I'm off by one (1) in all of


1 them. Volume II, Tab 18. 2 COMMISSIONER STEPHEN GOUDGE: The 3 Legislative Table -- 4 MR. JULIAN FALCONER: That's right. Now 5 if you... 6 And it's doc -- yeah, it's document 7 number -- 8 COMMISSIONER STEPHEN GOUDGE: Sorry, 9 300818. 10 11 CONTINUED BY MR. JULIAN FALCONER: 12 MR. JULIAN FALCONER: That's correct. 13 Now, the reason the table is being put in 14 front of you, 300818 -- 15 COMMISSIONER STEPHEN GOUDGE: Yes, there 16 it is. 17 18 CONTINUED BY MR. JULIAN FALCONER: 19 MR. JULIAN FALCONER: -- is it reflects a 20 number of realities within the -- this -- the Coronial 21 Systems or Medical Examiner Systems across the country. 22 It looks at thirteen (13) jurisdictions, ten (10) 23 provinces, and three (3) territories. 24 The first thing is I'd ask you to have 25 regard to that third column or fourth column over under


1 "Professional Qualifications of Investigators". 2 DR. DAVID EDEN: Right. 3 MR. JULIAN FALCONER: You will see that 4 the only -- there's only two (2) of thirteen (13) 5 jurisdictions that require the lead investigator be a 6 doctor, and that's Prince Edward Island and Ontario. Did 7 you know that? 8 DR. DAVID EDEN: Yes. 9 MR. JULIAN FALCONER: Okay. That, in 10 fact, eleven (11) of thirteen (13) jurisdictions do not 11 require the lead investigator to be a medical 12 practitioner. 13 DR. DAVID EDEN: That's correct, yes. 14 MR. JULIAN FALCONER: And in nine (9) of 15 the thirteen (13) jurisdictions and I suppose for the 16 record it's useful that I read them out: Newfoundland, 17 Nova Scotia, Quebec, Manitoba, Alberta, British Columbia, 18 Northwest Territories, Yukon and Nunavut and nine (9) of 19 thirteen (13), the police officers can either be a 20 layperson -- I'm sorry, the investigator can either be a 21 layperson or a police office, all right? 22 DR. DAVID EDEN: That's correct, yes. 23 MR. JULIAN FALCONER: So it's apparent on 24 a review of the various jurisdictions that Ms. Esmonde 25 worked so hard to create, that it is apparent that many


1 jurisdictions have worked with and employed lay 2 investigators to do the work of the -- of the coroner or 3 Chief Medical Examiner, isn't that fair? 4 DR. DAVID EDEN: That's fair. And if you 5 look at American jurisdictions, they have -- many of them 6 have lay death investigators as well. 7 COMMISSIONER STEPHEN GOUDGE: Who are not 8 police officers? 9 DR. DAVID EDEN: That's right, often 10 they're not. However, they do get to carry guns which is 11 interesting. 12 COMMISSIONER STEPHEN GOUDGE: So do a lot 13 of Americans -- 14 15 CONTINUED BY MR. JULIAN FALCONER: 16 MR. JULIAN FALCONER: It's a -- apparently 17 it's a constitutional right. I'm trying to stay away 18 from the gun issue today. 19 Dr. Eden, from the perspective of -- of 20 Dr. Butt -- he laid out a number of areas that he thought 21 a community-based investigator would have to satisfy and 22 you've spoken in terms of impartiality; you've referred 23 to training. Just for your own knowledge, Dr. Butt 24 referred to issue around support from the central office 25 is key, --


1 DR. DAVID EDEN: Right. 2 MR. JULIAN FALCONER: -- that is, 3 guidance -- 4 DR. DAVID EDEN: Yeah. 5 MR. JULIAN FALCONER: -- and support 6 educationally and financially. He spoke to the issue of 7 a buy-in from local police that that was essential there 8 be a good relationship between the community-based 9 investigator and the police, and -- and I want to 10 emphasize that the model that I'm -- 11 DR. DAVID EDEN: Right. 12 MR. JULIAN FALCONER: -- talking about 13 has no -- in no way suggests replacing police or moving 14 them out. It's about creating an alternative for 15 community to go to and to communicate with -- with the -- 16 the Coroner System. All right? 17 DR. DAVID EDEN: Well, just to be clear, 18 then I -- 'cause now I'm -- I'm understanding, is this -- 19 I see two (2) different aspects here, and they've both 20 been brought out in evidence. 21 One (1) is the -- is using -- is that a 22 person in a remote community who's actually performing 23 the initial investigation with some degree of contact 24 with somebody outside the community, and then there's a 25 second separate aspect which is that there's liaison


1 between the family and the Coroner's Office through 2 somebody who's in that community. 3 MR. JULIAN FALCONER: Well, you're 4 proving that we're in the embryonic phase of the 5 discussions, but I -- I want to emphasize that, in fact, 6 it's somewhat of a merge between the two (2), what I'm 7 raising with you, and it's for this reason. 8 Think of a larger urban setter -- setting, 9 Dr. Eden -- for example, whether it's Toronto, Ottawa or 10 elsewhere -- routinely you will have the lay component of 11 the investigation attend at the scene. And that lay 12 component will be assisted by the police, correct? 13 DR. DAVID EDEN: Yes. 14 MR. JULIAN FALCONER: And I suggest no 15 different a model in remote communities, but now the lay 16 component becomes satisfied by somebody other than a 17 medical doctor. 18 DR. DAVID EDEN: There -- I agree with 19 you there. The concern I have is that -- and it's just 20 to be clear -- that part of being impartial during an 21 investigation is not to develop a therapeutic 22 relationship with family. 23 And one (1) of the things that come out 24 about the -- that the -- the person who is liaising with 25 the Coroner's Office is that it might be beneficial to


1 the family if they did have a therapeutic relationship 2 with -- 3 MR. JULIAN FALCONER: That would be 4 somebody that would occupy the title or position of 5 almost an advocate for the family, and that would be 6 completely different than what we're talking about. 7 DR. DAVID EDEN: Yes, so just so we're 8 clear. 9 MR. JULIAN FALCONER: Yes, and I agree 10 with you that that would not be appropriate for a 11 community-based investigator to serve that function, 12 agreed? 13 DR. DAVID EDEN: That -- that's right. 14 You can't -- you can't both investigate and -- 15 MR. JULIAN FALCONER: That's right. 16 DR. DAVID EDEN: -- and -- and engage in 17 a therapeutic relationship, yes. 18 MR. JULIAN FALCONER: But what a 19 community-based investigator can quite properly do, and 20 what happens in the city, is a lay investigator can serve 21 as an important communication pipeline to the families on 22 the status of the investigation. 23 DR. DAVID EDEN: They could, yes. 24 MR. JULIAN FALCONER: And, in fact, to 25 the extent that is not happening in First Nations


1 communities or remote communities, that stands in stark 2 contrast to urban centres, correct? 3 In other words, in urban centres, families 4 are apprised of the status of the investigation by 5 coronial representatives among other things. 6 Isn't that true? 7 DR. DAVID EDEN: It is true that -- that 8 it -- it should be happening, yes, and -- and it largely 9 is happening. I -- I wouldn't say it is happening 100 10 percent of the time. 11 MR. JULIAN FALCONER: Fair enough. 12 That's the first time I'm arguing with the coroner about 13 how -- I'm pushing that you're doing it better. But -- 14 but -- in -- in -- remote communities, it's not 15 happening, is it? 16 DR. DAVID EDEN: Oh, it -- it is 17 happening. I know that there -- I know that it is 18 happening. I think, though, that the -- if you're saying 19 that it's -- that it's happening at a lower rate in -- 20 than in Southern Ontario, I would agree with you. 21 MR. JULIAN FALCONER: Well, Dr. Eden -- 22 COMMISSIONER STEPHEN GOUDGE: Mr. 23 Falconer, you're sort of running -- 24 MR. JULIAN FALCONER: Yeah. 25 COMMISSIONER STEPHEN GOUDGE: -- you'll


1 have to wind up before too long. 2 3 CONTINUED BY MR. JULIAN FALCONER: 4 MR. JULIAN FALCONER: All right. With 5 respect, we are in circumstances where, certainly, myself 6 and Ms. Murray for Aboriginal Legal Services; in our 7 work, going to communities, neither the leadership of 8 Mishkeegogamang nor the leadership of Muskrat Dam knew 9 what a coroner was. All right? Absolutely no 10 communication. 11 DR. DAVID EDEN: I -- actually, if you 12 went through Southern Ontario, most people in Southern 13 Ontario haven't met a coroner and don't want to. 14 It's -- generally, when a coroner comes to 15 the house, it's not a good thing. So I -- I consider 16 that I personally have discussed cases already at this 17 point with First Nations families. 18 So if -- if you're saying that it doesn't 19 happen at all, I know for a fact that it does happen. I 20 think we --we were saying that there's a proportion of 21 cases in which it's not happening. And I suspect that 22 proportion is higher in First Nations communities than it 23 is in Southern Ontario communities. But I would not 24 agree that it simply is not happening at all. 25 MR. JULIAN FALCONER: And what accounts


1 for the decrease in communication is, among other things, 2 the absence of a representative of the Coroner's Office 3 in those communities. 4 Isn't that right? 5 DR. DAVID EDEN: I don't know if it 6 accounts for it, but I can say that if -- on a forward- 7 looking basis, if we wanted to ameliorate it, to have a 8 representative of the Coroner's Office in the 9 communities, would be very helpful. 10 MR. JULIAN FALCONER: In the case of one 11 (1) of the families that we spoke to, a baby died in May 12 2006, and the mother was never contacted by the Coroner's 13 Office about the cause of death, not at all. She 14 contacted the OPP months later and received something 15 from a secretary. 16 DR. DAVID EDEN: I -- I don't know the 17 details of the case, so this -- this, to me, is an 18 allegation that I can't comment on. I would need more 19 information and I could look into it. 20 COMMISSIONER STEPHEN GOUDGE: Mr. 21 Falconer, you've really run out of time. 22 23 CONTINUED BY MR. JULIAN FALCONER: 24 MR. JULIAN FALCONER: Fair enough. There 25 is a roundtable proposed for many of the issues we're


1 discussing, correct? 2 DR. DAVID EDEN: That's my understanding, 3 yes. 4 MR. JULIAN FALCONER: And on behalf of my 5 clients, both Nishnawbe-Aski Nation and Aboriginal Legal 6 Services, to all three (3) doctors, and -- and this 7 system, we -- we want to express, and they've asked me to 8 express, their hope that it is a sign of good things to 9 come and the building of bridges that have thus far been 10 absent. 11 And so I bring that on behalf of Deputy 12 Grand Chief Fiddler, Grand Chief Beardy, and Ms. Murray 13 on behalf of Aboriginal Legal Services. 14 DR. DAVID EDEN: Thank you. And I'd like 15 to say that I look forward to working with NAN and I 16 appreciate the efforts that NAN has been making in public 17 safety, for instance, in youth suicide prevention 18 initiatives, and I very much look forward to -- to 19 working with NAN to improve public safety. 20 MR. JULIAN FALCONER: Thank you. 21 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 22 Falconer. 23 I'd just like to ask a couple of 24 questions, Dr. Eden, in the unique challenges of 25 remoteness and, particularly, with Aboriginal


1 communities. 2 I hear you saying that care has to be 3 taken in terms of the communication function that is 4 obviously so important in death investigations and that 5 one (1) of the issues is whether that function can best 6 be combined with a therapeutic relationship of the 7 communicator with the family and, therefore, has to be 8 removed from the death investigation itself. 9 Am I right about that? 10 DR. DAVID EDEN: That's right. It 11 certainly would be possible for one (1) person to be both 12 the investigator and the liaison, but they could not then 13 engage in a therapeutic relationship. 14 Now what -- when engaging with somebody 15 professionally and tactfully becomes a -- 16 COMMISSIONER STEPHEN GOUDGE: Therapeutic 17 relationship -- 18 DR. DAVID EDEN: -- therapeutic 19 relationship it is something that's -- 20 COMMISSIONER STEPHEN GOUDGE: -- a fine 21 line. 22 DR. DAVID EDEN: -- arguable, but in 23 principle, a death investigator has to be impartial 24 because family will have certain things that they wish 25 that --


1 COMMISSIONER STEPHEN GOUDGE: Could you 2 invent a system where there were kind of two (2) 3 different roles being played by two (2) different people 4 in a remote community, particularly an aboriginal 5 community; one (1), a communication function that might 6 as well be therapeutic and one (1) investigative? 7 DR. DAVID EDEN: We -- actually, either 8 way would work, and this would be something that might be 9 suitable for discussion to see what would best serve the 10 needs of the people, and also take into account the 11 resources available. 12 COMMISSIONER STEPHEN GOUDGE: Okay. The 13 other thing is in terms of what Mr. Falconer was asking 14 you about, that is, the use of local resources, and 15 you've been very clear and it's been very helpful about 16 the need for appropriate qualification, volume, and 17 impartiality. 18 You also posited the possibility, I take 19 it, as we go forward, to have the use of technology 20 provide real time supervision, if you like, from an 21 external point. 22 DR. DAVID EDEN: That's true. And I 23 think my -- my point was that we can use the technology, 24 and whether it would be for actual supervision or -- or 25 some other purpose --


1 COMMISSIONER STEPHEN GOUDGE: Or fairly 2 detailed direction. 3 DR. DAVID EDEN: Yes, yeah. 4 COMMISSIONER STEPHEN GOUDGE: I mean, one 5 conceptually could say, well, there could be a sort of 6 sliding scale of qualification, if you like, depending on 7 the degree of the tightness of the supervision from 8 outside; is that fair? 9 DR. DAVID EDEN: That's correct. It's in 10 the nature of death investigation that you want to have 11 good -- a good consistent approach, so I wouldn't suggest 12 a community- by-community approach, but I think it would 13 certainly be worthwhile for -- for instance, First 14 Nations' representatives, the Chief Forensic Pathologist, 15 and perhaps other experts to sit down and say, how can we 16 make this work. 17 COMMISSIONER STEPHEN GOUDGE: How can we 18 make it work and how can we make every death 19 investigation reach a basic level of quality control, if 20 you like. 21 DR. DAVID EDEN: Yeah. And the other 22 person that should be at the table is the information 23 technology person so we're not asking for the impossible. 24 COMMISSIONER STEPHEN GOUDGE: Right. 25 Right. But as opposed to envisaging a system where the


1 local eyes and ears of the coronial system all reach a 2 superb level of qualification, can one compensate for 3 that by the degree of directness of supervision through 4 technology, I guess is what I'm saying? 5 DR. DAVID EDEN: I -- I'd be sceptical, 6 but you -- it's in the nature of the death investigations 7 that you have to do a certain number to maintain your 8 skills. 9 And even with the best training, the best 10 motivated person -- 11 COMMISSIONER STEPHEN GOUDGE: And the 12 best supervision? 13 DR. DAVID EDEN: Well -- 14 COMMISSIONER STEPHEN GOUDGE: If that is 15 the -- 16 DR. DAVID EDEN: That -- and that -- 17 well, that goes to the degree of autonomy -- 18 COMMISSIONER STEPHEN GOUDGE: Yes. 19 DR. DAVID EDEN: -- of the -- the scene 20 investigator. 21 COMMISSIONER STEPHEN GOUDGE: Yes. I was 22 thinking of sort of precise things like the remote 23 supervision directing very precisely what pictures ought 24 to be taken, for example. 25 DR. DAVID EDEN: That's one (1) approach


1 and in some ways it's the simplest approach. I think 2 what Mr. Falconer was envisioning where -- was where the 3 local investigator had more scope of decision making in 4 the investigation and I think that to decide where that 5 should be you would -- 6 COMMISSIONER STEPHEN GOUDGE: Well, it 7 probably can't be done in the abstract; that's a 8 discussion that would have to be had. 9 DR. DAVID EDEN: That's correct. Yes, 10 sir. 11 COMMISSIONER STEPHEN GOUDGE: Okay. 12 Thanks. Okay. Thank you. 13 Ms. Fraser...? 14 15 (BRIEF PAUSE) 16 17 CROSS-EXAMINATION BY MS. SUZAN FRASER: 18 MS. SUZAN FRASER: Dr. Legge, Dr. Eden, 19 Dr. McCallum, this is a favourite time slot to get, 4:12 20 on Friday afternoon after a long week. 21 COMMISSIONER STEPHEN GOUDGE: Everybody's 22 still here. If this were a class, it would be empty. 23 24 CONTINUED BY MS. SUZAN FRASER: 25 MS. SUZAN FRASER: And I'm grateful but I


1 also understand you don't have a choice but to be here so 2 I'm -- I will try to be brief. 3 I'm here today on behalf of an 4 organization called Defence for Children International, 5 the Canadian Division and DCI is an international 6 grassroots organization founded in 1979 which is the 7 international year of the child and -- and founded in 8 Geneva and -- in response to many questions I get arising 9 out of this Inquiry, I don't actually get to go to 10 Geneva. I deal with the Canadian-based office. 11 DR. ANDREW MCCALLUM: I've been there. 12 It's a boring city. 13 MS. SUZAN FRASER: All right. There were 14 some questions put to you this morning about the kind of 15 information the families get and walk away with in -- in 16 -- at the start of a coroner's investigation or after 17 contact with a coroner. 18 Is there standard information, Dr. Eden, 19 that you provide to a family? 20 DR. DAVID EDEN: As in a -- a checklist, 21 no. And in fact, this is very much geared to the family 22 because family have just had a very terrible thing happen 23 and after people have had an emotional experience like 24 that, they will not remember much. 25 So, my experience, and many coroners as


1 well, at the first time we meet with family we'll really 2 want just to get one (1) or two (2) messages across and 3 it's not uncommon to require a second meeting once people 4 have -- once their emotions have settled down. 5 MS. SUZAN FRASER: All right. I'm -- I'm 6 thinking specifically of a pamphlet. At the first week 7 of this Inquiry -- 8 DR. DAVID EDEN: Yes. 9 MS. SUZAN FRASER: -- I asked Dr. 10 McLellan whether they leave pamphlets with the family 11 members and he indicated that there was a pamphlet. 12 DR. DAVID EDEN: Yes. Yes. 13 MS. SUZAN FRASER: It had never been my 14 experience for a client to actually receive one from the 15 coroner's office. 16 Is that something that your coroners 17 regularly provide to family members? 18 DR. DAVID EDEN: I know that there is a 19 pamphlet and that's been distributed to coroners and we 20 encourage that they give those to families. 21 MS. SUZAN FRASER: All right. 22 DR. DAVID EDEN: Again though, I -- I can 23 conceive of a situation where a family is grieving and 24 are given a whole lot of papers in the hospital and may 25 not remember that one.


1 So, it's certainly possible that it was 2 given but the family loses it and I can understand why 3 that would happen. 4 MS. SUZAN FRASER: I understand. Dr. 5 Legge, is that something that your coroners regularly 6 provide to family members? 7 DR. DAVID LEGGE: Well, I think in urban 8 areas they do. 9 MS. SUZAN FRASER: Yeah. 10 DR. DAVID LEGGE: Again, problematical in 11 remote areas. 12 MS. SUZAN FRASER: Oh, all right. All 13 right. 14 DR. DAVID LEGGE: Yeah. 15 MS. SUZAN FRASER: I'm going to just move 16 then to some of the issues relating to protocols because 17 I'm concerned -- and I'm talking about protocols that 18 would relate to the death of a child where there are 19 surviving siblings. 20 And the issues that I'm concerned about 21 are both the protection of the surviving siblings where 22 there may be danger to them, but also, ensuring that 23 while there's a death -- death investigation that 24 siblings are not -- surviving siblings are not 25 unnecessarily separated from their parents, so, there's a


1 tension there. 2 And, Dr. Eden, you made mention this 3 morning of some of your protocols and you talked about 4 three (3) different protocols that exist within the 5 Niagara region when you were Regional Supervising 6 Coroner. 7 And I take it that those protocols are 8 primarily directed to the coordination of the different 9 ongoing investigations; is that fair? 10 DR. DAVID EDEN: Well, the -- the first 11 two (2) cover the same area but they were between -- 12 mainly between police and Children's Aid -- 13 MS. SUZAN FRASER: Yes? 14 DR. DAVID EDEN: -- with coroner 15 involved, as necessary, and that was for coordinating 16 investigations which were criminal and Child Welfare. 17 MS. SUZAN FRASER: All right. 18 DR. DAVID EDEN: The third one was one 19 initiated by my office which was simply to notify 20 Children's Aid when we had the death of a person before 21 their 18th birthday. 22 23 (BRIEF PAUSE) 24 25 MS. SUZAN FRASER: Sorry, so the protocol


1 that you had when you were Regional Supervising Coroner 2 is that when there was a pediatric death, so before the 3 age of eighteen (18) that you would notify the Children's 4 Aid Society? 5 DR. DAVID EDEN: That's right. 6 MS. SUZAN FRASER: In every circumstance? 7 DR. DAVID EDEN: That's correct. 8 MS. SUZAN FRASER: All right. And what's 9 the purpose of that protocol? 10 DR. DAVID EDEN: The -- what we had found 11 from prior death investigations was that there were a 12 number of cases in which there was Children's Aid 13 involvement and Children's Aid had information which was 14 very relevant to our determination of facts. 15 And we would not have found or we would 16 not have out much later unti -- unless we had notified 17 Children's Aid. Similarly, Children's Aid were unaware 18 that it -- would not otherwise have been aware of the 19 death in that household. And there -- they have -- they 20 had to check to see if there were any protection issues 21 surrounding the children. 22 So there were -- both of them were on the 23 bas -- well they were on the basis of a good coroner's 24 investigation and ensuring the safety of the children in 25 the house.


1 MS. SUZAN FRASER: All right. And you're 2 aware, I take it, Dr. Eden, that in circumstances where 3 the Children's Aid Society already has an open and 4 ongoing file, that the Children -- and a death occurs 5 with a child, that the Children's Aid Society would 6 conduct their own internal investigation? 7 DR. DAVID EDEN: They do now, yes. Yes. 8 MS. SUZAN FRASER: All right. And you 9 say "they do now," I take it that -- that, in your 10 knowledge, it started from a particular point in time? 11 DR. DAVID EDEN: There -- there is now a 12 -- a set of rules from the Ministry -- 13 MS. SUZAN FRASER: Yes. 14 DR. DAVID EDEN: -- which guide the 15 invest -- the investigation, some of actually which -- 16 some of which is actually external. So there's -- 17 there's a review commissioned by the Children's Aid 18 Society which may be internal and external in -- in 19 components. 20 MS. SUZAN FRASER: All right. All right. 21 And the educational work that you do with the Hamilton's 22 Children's Aid Society, is that about how to conduct 23 those internal investigations or how to relate to the 24 other? 25 DR. DAVID EDEN: No, the -- the internal


1 reviews are -- are a separate matter and we don't 2 participate in those. That -- that's a matter the 3 Children's Aid works out. 4 What we are training people to do is what 5 to do if you are dispatched to a childhood death scene, 6 or as part of a childhood death investigation. What does 7 a Children's Aid investigator do in those circumstances; 8 That's a skill set we want to impart. 9 MS. SUZAN FRASER: And I'm -- I'm very 10 interested in that but, unfortunately, time doesn't 11 permit me to go there today. I have some other areas I 12 want to cover. 13 I'm interested in whether the protocols 14 that have been developed in the Niagara region speak to 15 the timeliness of investigations, and I'll -- I'll just 16 sort of give you the lead in to it. 17 I expect that the Commission will hear at 18 its policy round tables that the Child and Family 19 Services Act mandates a permanent placement of a child in 20 need of protection within one (1) year if the child is 21 under 6 years old. And within two (2) years if the child 22 is over 6. 23 So, the Child and Family Services Act 24 marches to a certain clock as mandated by statute; is 25 that something that you knew?


1 DR. DAVID EDEN: I -- I can say I'm aware 2 of it, but our office takes no role in -- we have no role 3 and I don't think we should have any role in the decision 4 making of the Children's Aid Society other than to 5 communicate the facts of our investigation so that they 6 can make an appropriate decision. 7 So there may be a role for us in saying, 8 This is what the child died of -- 9 MS. SUZAN FRASER: Right. 10 DR. DAVID EDEN: -- but we don't say, 11 Here's what you should do with the surviving siblings. 12 MS. SUZAN FRASER: And I expect that the 13 Commission will hear through the research that in some 14 cases that the only reason that there is an apprehension 15 and a placement outside -- permanent placement outside of 16 the family is because the sibling has died, that there 17 are not other parenting concerns. 18 I expect that that's what he'll hear at 19 his policy round table and through the research to the 20 Commission. 21 If -- if that's been the case, can you 22 agree with me that the timeliness of the coroner's 23 investigation is critical to what happens to the 24 surviving children? 25 DR. DAVID EDEN: Oh, I agree with you


1 that I wouldn't want children kept apart from their 2 parents simply waiting for the end of an investigation, 3 yes. 4 MS. SUZAN FRASER: All right. And can 5 you agree with me that if you start to look at these two 6 (2) investigations as -- as being important or -- or in 7 part three (3), there's a coroner's investigation, 8 sometimes a police investigation, and a CAS 9 investigation, that people should be alive to that Child 10 and Family Services' clock in terms of how the 11 investigation is triaged, how the toxicology is triaged? 12 DR. DAVID EDEN: I -- I would say there 13 are so many issues. Really what I would like to do is to 14 have all cases completed as -- as quickly as possible. 15 There are certainly cases which include criminal issues 16 and which include where children are separated from their 17 parents where one could make an argument that we should 18 triage those higher. 19 However, there's a price to pay, in that 20 other families are waiting for results, and every time 21 you reallocate resources, you end up with delays to other 22 families. So we have to be careful in how we do that. 23 MS. SUZAN FRASER: I understand that, but 24 I think that you'll agree with me that development that 25 happens with the child between the age of one (1) -- zero


1 and one (1) year of age is significant when you compare 2 it to the age of -- what happens in the development of a 3 human between, say, the age of thirty (30) and thirty-one 4 (31). 5 There's -- there's -- those are critical 6 early development? 7 DR. DAVID EDEN: No, I -- I'm -- I -- I 8 agree with you that it -- it should be a -- that it 9 should be a priority. But, as I said, we have to bear in 10 mind that resources are finite. 11 MS. SUZAN FRASER: All right. The case 12 conferences -- and -- and somehow this has become my 13 cross-examination of you, Dr. Eden, and that -- and 14 that's just the way the evidence evolved today. 15 But you talked about your case conferences 16 that you do in every pediatric death? 17 DR. DAVID EDEN: That's right. We have 18 forensic rounds, where we have the pathologist, police 19 officer, coroner, and often a toxicologist and myself, 20 yes. 21 MS. SUZAN FRASER: All right. And you -- 22 are you aware that in other jurisdictions that there are 23 similar protocols? For example, British Columbia reviews 24 every pediatric death? 25 DR. DAVID EDEN: There -- there are


1 different -- there -- there's reviews done in Ontario as 2 well. Some are paper reviews -- 3 MS. SUZAN FRASER: Yes. 4 DR. DAVID EDEN: -- some of them are 5 where you actually have the investigator sitting down at 6 the table. The one that we've used is where the 7 investigators sit down at the table. And I -- I don't 8 believe that's done in British Columbia. But I -- I 9 stand to be corrected if I'm wrong. 10 MS. SUZAN FRASER: All right. There's -- 11 obviously, there's different models and different models 12 that work. Some -- some models -- the one in British 13 Columbia involves the family from time to time, where the 14 family can come in and learn. 15 Have you -- do you understand that to be 16 one model that's used? 17 DR. DAVID EDEN: And I -- I have heard 18 about it. I have not spoken to anybody in British 19 Columbia. So other than to say I've heard of it, I 20 can't -- 21 MS. SUZAN FRASER: All right. 22 DR. DAVID EDEN: -- can't comment. 23 MS. SUZAN FRASER: Okay. I'm -- I'm 24 going to just move, very briefly, to another area, and 25 you should have -- and you can all, if you have Volume


1 III, Volume III should have four (4) tabs in it. And 2 these are the documents that I had given notice on. 3 Volume III, Tab 4, and, sorry, Mr. 4 Registrar, it's PFP303598. 5 6 (BRIEF PAUSE) 7 8 MS. SUZAN FRASER: And if you could look 9 -- this is actually the excerpts from the same law reform 10 report that Mr. Falconer took you to. And if you could 11 turn to page -- I think it should be page 182, which is 12 the thirteenth (13th) page, I think. 13 14 (BRIEF PAUSE) 15 16 MS. SUZAN FRASER: There's a section 17 entitled "Public Accountability." 18 DR. DAVID EDEN: Right. 19 MS. SUZAN FRASER: And basically what the 20 -- the Law Reform Commission does here is it talks about 21 the different level of knowledge that we can -- under the 22 current Coroners Act that the coroners system has 23 different method of delivering information about the 24 death investigation process. 25 And just partway down in that paragraph it


1 says, "a number of mechanism exists." Do you see that 2 part? 3 DR. DAVID EDEN: Right. 4 MS. SUZAN FRASER: All right. 5 "A number of mechanisms exist to assure 6 these people and the rest of the 7 community that the system operates in 8 the public interest. For interest -- 9 for instance, the results of inquests 10 are public documents and can be 11 obtained from the Chief Coroner's 12 Officer. Moreover, the Coroners Act 13 entitles certain members of the 14 deceased's family to request, in 15 writing, that an inquest be held. If 16 the decision is made not to hold an 17 inquest, the coroner must provide 18 written reasons for decision." 19 DR. DAVID EDEN: Correct. 20 MS. SUZAN FRASER: 21 "And the family members may also ask 22 the Chief Coroner to review a decision 23 making to call an inquest. The current 24 Act contains no further mechanism by 25 which interested individuals can


1 question a coroner's decision. Of 2 course, one can make inquiries 3 formally, and most coroners are 4 accommodating to a certain extent. As 5 well, there may be opportunities for 6 judicial review, but such applications 7 require the assistance of counsel and 8 are costly. In our view, it is 9 important that people be given the 10 opportunity to question certain 11 decisions without having to resort to 12 litigation. And this includes the 13 concommonate concern that access be 14 provided to sufficient information 15 about decisions in the system generally 16 and to enable appropriate decisions to 17 be made." 18 And I'm just interested in -- in each of 19 your views about the ability for others not interested, 20 not specifically, either related or where an inquest is 21 not called, for there to be a gap somewhere in-between 22 those systems; where somebody interested in a death can 23 make those inquiries to the coroner for there to be a 24 sort of mechanism beyond those two (2) limited provision 25 -- three (3) limited provisions provided for in the


1 Statute. 2 DR. DAVID EDEN: Well, the 1995 report 3 refers to and builds on the 1971 Ontario Law Reform 4 Commission report which is really the under-pitting of 5 the current coroner's system. 6 MS. SUZAN FRASER: Yes. 7 DR. DAVID EDEN: And what the -- and what 8 the OLRC in 1971 said basically was that the purpose of a 9 coroner's investigation was to determine the facts, and 10 it is a very second important step to use those facts to 11 further public safety. 12 MS. SUZAN FRASER: Yes. 13 DR. DAVID EDEN: And the 1971 report was 14 -- was quite clear -- and this is what's in the 1971 15 legislation and has not been substantially changed since 16 -- was that the coroner would report the results to those 17 people who were specified in Section 18 -- the family 18 members -- and family members also could request and 19 inquest. 20 In the 1995 Law Reform Commission report, 21 there were a number of suggestions about how the system 22 could be changed, and this was one (1) of them and the 23 1995 report was not adopted by the legislature. So we -- 24 we're looking at an opinion -- the 1971 report was 25 adopted by the legislature and is the foundation of the


1 current law -- the 1995 report was not adopted. 2 So there isn't a legal foundation in our 3 Act to -- to carry out the suggestions of the 1995 4 Commission report. 5 MS. SUZAN FRASER: Right. And so what 6 I'm interested in, sir, is whether, in your opinion, that 7 would be beneficial? 8 DR. DAVID EDEN: There -- there is recent 9 case law and this really goes to the purpose of inquest 10 and that is: Is the inquest a hearing that's held in the 11 public interest or is it in a private interest where a 12 family has some sort of issue or agenda that they wish to 13 push? Is that appropriate for an inquest? 14 MS. SUZAN FRASER: I'm intimately 15 familiar with the case law having acted for -- 16 DR. DAVID EDEN: Okay. 17 MS. SUZAN FRASER: -- one of the parties. 18 DR. DAVID EDEN: Yeah. So -- so the -- 19 that's -- and the current law, as it's written, says that 20 an inquest is in the public interest. 21 MS. SUZAN FRASER: Yes. 22 DR. DAVID EDEN: My own opinion is that 23 an inquest is about fact-finding recommendations to 24 benefit the public and my view would be that an inquest 25 should remain that the primary consideration in the


1 holding of an inquest on discretionary grounds is that 2 it's in the public interest to do so. 3 MS. SUZAN FRASER: All right. And I am 4 running out of time, sir, so my question is: Is that 5 we've heard about the fact that the -- Dr. Lucas and Dr. 6 Lauwers were here and talked about how there's very few 7 discretionary inquests, given the number of mandatory 8 inquests, and you're -- you're giving me an expression 9 that makes me think that you question that. 10 DR. DAVID EDEN: Well, I wouldn't say 11 there's few discretionary inquests. There's -- there's a 12 fair number of discretionary inquests. But the decision 13 is made on a case-by-case basis. There isn't a quota of 14 discretionary inquests. We look at the case, -- 15 MS. SUZAN FRASER: Right. 16 DR. DAVID EDEN: -- and then say, looking 17 at Section 20 of the Act and taking into account public 18 interest, would a discretionary inquest serve the public? 19 MS. SUZAN FRASER: All right. So, but 20 what I'm -- and coming back to the question of public 21 accountability and the recommendations of the 1995 Law 22 Reform Commission report, what I'm interested in is, is 23 there are instances where people are socially isolated or 24 kids who have been separated from their family, and for 25 the only access to information about a child's death to


1 rest with the family member, and siblings doesn't always 2 cover off all of who might be interested in a death and 3 need to have access to information. 4 Is that fair? 5 DR. DAVID EDEN: Who else are you 6 considering? Who -- who else would -- would you envisage 7 as having a legal entitlement to that information? 8 MS. SUZAN FRASER: Well, I'm -- I'm 9 asking for -- I'm not trying to draft the legislation 10 here, I'm interested if you -- to know whether you accept 11 that there are situations where just having access to the 12 family -- for a family to have access isn't sufficient 13 where an inquest isn't called? 14 COMMISSIONER STEPHEN GOUDGE: Do you have 15 any you would want to suggest to him? 16 17 CONTINUED BY MS. SUZAN FRASER: 18 MS. SUZAN FRASER: Well, in the interest, 19 for -- for example, if a child is in a group home and 20 dies; for other children who are in the group home to be 21 able to get information about that child's death, for 22 their own personal safety -- 23 DR. DAVID EDEN: Right -- 24 MS. SUZAN FRASER: -- where an inquest 25 isn't called?


1 DR. ANDREW MCCALLUM: Dr. Eden has been 2 answering most of the questions. 3 MS. SUZAN FRASER: Right. 4 DR. ANDREW MCCALLUM: And perhaps I can 5 interject. There is a mechanism through the public 6 safety provisions that the Chief Coroner has the option 7 to provide information if it's in the public interest to 8 promote public safety, so if the issue is a communicable 9 disease in a -- in a home and some child has died, the 10 other children certainly would be able to access that 11 information through the appropriate caregivers. 12 I think that the current legislation, as 13 drafted, satisfies the need for accountability because 14 there's two (2) levels of appeal with the -- within it -- 15 within, and then there's a further -- obviously the right 16 that any citizen has to appeal to the judiciary. 17 MS. SUZAN FRASER: All right. 18 COMMISSIONER STEPHEN GOUDGE: You're 19 going to have to wind up, Ms. Fraser. 20 MS. SUZAN FRASER: I know. And I'm so -- 21 so sad that I have to keep hearing that phrase. 22 COMMISSIONER STEPHEN GOUDGE: It is sad, 23 but -- 24 MS. SUZAN FRASER: I prefer the injury 25 time; it was just -- it was more jovial, but thank you,


1 gentlemen. Thank you, Mr. Commissioner. 2 COMMISSIONER STEPHEN GOUDGE: Thanks. 3 Ms. Ritacca...? 4 MS. LUISA RITACCA: I have no questions, 5 thank you. 6 COMMISSIONER STEPHEN GOUDGE: Can I ask, 7 I don't know whether any of the panel members can ask 8 this, but just -- and maybe it's for you, Ms. Ritacca, 9 and, Mr. Gover, but just out of curiosity, the passage 10 from the Law Reform Commission Report that Ms. Fraser 11 referred to cites an average annual death investigation 12 number of thirty-two thousand (32,000), as opposed to the 13 twenty thousand (20,000). 14 Is that the difference between 1995 and 15 today or is there some other explanation? 16 DR. ANDREW MCCALLUM: There was a change 17 in the -- in the investigation of long-term care deaths. 18 At that time deaths in any long-term care facility were 19 investigated, and for a variety of reasons, it was 20 determined that only every tenth (10th) death would be 21 investigated from that point on, and that -- 22 COMMISSIONER STEPHEN GOUDGE: And is that 23 the explanation for that different number? 24 DR. ANDREW MCCALLUM: I believe so. 25 DR. DAVID EDEN: It's -- it's a large


1 part of it. 2 MR. BRIAN GOVER: That's what we 3 understand to be the case, yes, and that was Dr. Young's 4 evidence. 5 COMMISSIONER STEPHEN GOUDGE: Okay. 6 That's great. I didn't -- that's interesting. It just 7 jumped out at me as a number, because I've been working 8 with the twenty thousand (20,000) number that you put to 9 me. 10 Mr. Sandler...? 11 MR. MARK SANDLER: I have no re- 12 examination, thank you. 13 COMMISSIONER STEPHEN GOUDGE: Well, 14 gentlemen, thank you very much. As with all our 15 witnesses, we're very grateful for the time and thought 16 you've put into preparing your evidence and for coming 17 and sharing your wisdom with us, so, thank you for 18 coming. 19 Have a safe trip back to your various 20 destinations. We'll rise, then, until 9:30 Monday 21 morning. 22 23 (WITNESSES STAND DOWN) 24 25 --- Upon adjourning at 4:33 p.m.


1 2 3 4 Certified Correct, 5 6 7 8 9 _________________ 10 Rolanda Lokey 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25