Ontario's Goudge inquiry report calls for pediatric forensic pathology overhaul

With public confidence shaken by wrongful convictions and scandal, Ontario’s pediatric forensic pathology system is in need of major reforms, says the public inquiry’s report, issued on Wednesday.

The report produced by the inquiry’s commissioner, Justice Stephen Goudge (right), recommends 169 changes to remodel the province's approach to dealing with child homicide investigations.

"These changes are necessary if public confidence in pediatric forensic pathology and its future use in the criminal justice system is to be restored and enhanced," writes Justice Goudge.

In the 1,170-page report, Justice Goudge dissects how the existing system failed in the 1980s and 90s, ultimately leading to the much-publicized wrongful convictions that relied on the expert witness testimony of Dr Charles Smith, the man at the centre of the controversy over wrongful convictions whose own problems were the impetus for the Goudge inquiry's full-system review. But the report makes clear that the blame is not all Dr Smith’s: Justice Goudge directs a great deal of criticism at the failure on behalf of the government and the Office of the Chief Coroner for Ontario (OCCO) to establish effective oversight of the provice’s coroners and forensic pathologists.

“The oversight and accountability mechanisms that existed were not only inadequate to the task,” he writes, “but also inadequately employed by those responsible for using them.”

Justice Goudge’s report accuses former chief coroner James Young and deputy chief coroner James Cairns of lying to officials and to the public in an effort to cover-up Dr Smith’s errors and to protect their own reputations. Justice Goudge suggests giving coroner’s-office oversight responsibilities to a Governing Council.

The report applauds the Ontario government’s efforts to reform the system since 2001 but warns the “more must be done.” “In the last few years,” the report says, “new leadership has made a significant start in addressing this challenge. But as they acknowledge, much more must be done. To stop now risks a return to the troubled years [1981 to 2001] examined at the Inquiry.”

The Ontario government’s press release early Wednesday afternoon touted that progress, but highlighted progress counting back only five years, rather than the seven that Justice Goudge counts. The discrepancy may be explained by the fact that five years ago marks the date the Liberal Party, which currently holds a majority in the Legislative Assembly, came to power. In 2001 and 2002 -- the dates during which Justice Goudge says progress was made, but which today’s press release fails to mention -- the Progressive Conservatives, under Mike Harris and Ernie Eves, formed the government.

Justice Goudge points out, however, that the changes since 2001 haven’t solved the system’s problems. “Inadequate resources continue to undermine the laudable efforts of the new leadership of the OCCO to fix the many problems identified by our systematic review. This situation cannot be allowed to continue,” says the report, urging the province to act quickly to rebuild the forensic pathology system. Particularly crucial in the ongoing lack of resources, Justice Goudge writes, is the shortage of forensic pathologists in Ontario. Several recommendations deal with improving the education and credentialing of forensic pathologists.

Other recommendations in the report include changing the complaints process, starting up a police Child Homicide Team, and creating a government plan to compensate victims of the province’s pathology errors and wrongful convictions.

The Ontario government has promised a compensation plan and new legislation to reform how forensic pathology is conducted in the province.

However, the government's press release did not make clear what would that new legislation would comprise. The release did not declare that the government would accept all of the 169 recommendations, only saying that the new legislation would be “guided by Justice Goudge’s recommendations.” Nor did the release say when drafts of the new legislation would be available, nor whether the government intends to introduce the legislation during the current sitting of the Legislative Assembly. The current session is slated to end December 11.

To read all four volumes of the Goudge report in full, download each of these four PDF files: Volume 1: Executive Summary, Volume 2: Systematic Review, Volume 3: Policy and Recommendations, Volume 4: Inquiry Process.

Update, 5:30pm, Wednesday, October 1: We've received a response from Ontario's Ministry of Community Safety and Correctional Services, the government ministry that includes the Office of the Chief Coroner for Ontario. You can read the questions and their answer, from Stuart J McGetrick, Strategic Communications, Communications Branch, below.

Question 1: Your press release today says the new legislation to overhaul the forensic pathology system will be "guided by" by Justice Goudge's recommendations. Will the government adopt all 169 of Justice Goudge's recommendations or not?
Question 2: When can we expect to see this new proposed legislation? Will it be introduced during the current sitting of the Legislative Assembly?

ANSWER: Since 2003, the government has taken steps to improve the province’s death investigation system. One of those steps was to ask Justice Goudge to conduct this public inquiry. As we've only just received the report, it's important that we take the time to thoroughly review its details with stakeholders and our justice-sector partners before discussing the implementation of its recommendations. I can say, though, that the government intends to move quickly and aggressively to respond to the report.

As part of that response, the government is committed to introducing a bill in the fall session that, if passed, will establish a framework that will build on our efforts to date to strengthen the death investigation system, provide for greater oversight and accountability and improve coroner and forensic pathology services throughout Ontario.

Significant progress has already been made to improve the quality of death investigations in Ontario, something Justice Goudge recognized in his report. Justice Goudge’s recommendations will help us make the necessary further improvements.

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