Inquiry into Pediatric Forensic Pathology in Ontario
August 8, 2007



Submissions on DCI-Canada's application for standing and funding, by Suzan Fraser, counsel for Defence for Children International-Canada.

The following is an excerpt from the transcript of the Inquiry into Pediatric Forensic Pathology in Ontario. For the official transcript, or for more information about the Inquiry, visit the Inquiry web site: http://www.goudgeinquiry.ca.


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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
17 Held at: Metropolitan Hotel
18 Toronto, Ontario
19
20
21 ********************
22
23
24 August 8th 2007
25
                            . . . . .

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4 SUBMISSIONS BY DEFENCE FOR CHILDREN INTERNATIONAL-CANADA:
5 MS. SUSAN FRASER: Good morning, Mr.
6 Commissioner. As you know, I represent Defence for
7 Children International-Canada; it's an international
8 organization. The Canadian version of it is based in
9 Ontario and it seeks to allow and -- parties allow
10 children -- and most importantly, to ensure that the UN
11 Convention on the Rights of the Child is respected in the
12 countries in which it advocates.
13 On a more broad-based level, DCI has done
14 grass work -- grassroots work with children and youth in
15 the Province of Ontario and that is highlighted in the
16 affidavit material of Les Horne, and I will not repeat it
17 here. It goes without saying that DCI is the only
18 organization here before you which intends to bring a
19 children's rights perspective to the Inquiry.
20 As the Inquiry is systemic based, DCI is
21 well situated to bring forward some of the unique issues
22 that are faced when investigating the deaths of children.
23 And in particular, in its affidavit material DCI has
24 focussed on institutional care and the deaths of young
25 people in institutional care. Those are of particular


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1 interest to DCI because those deaths occur behind public
2 view.
3 I wanted to, in these remarks to you, make
4 reference to the 1971 report of the Law Reform Commission
5 on the coroner system, and one quote that's relied upon
6 often by courts in dealing with the role of the Office of
7 the Coroner. And it's simply that:
8 "The death of the member of a society
9 is a public fact and the circumstances
10 surrounding that death, whether it
11 could have been avoided or prevented
12 through the actions of persons or
13 agencies under human control, or
14 matters within the legitimate scope of
15 all members of the community. And the
16 role of the Office of the Coroner must
17 keep pace with societal changes and
18 where necessary move away from the
19 confines of doctrines that are
20 inconsistent with community needs and
21 expectations in the 20th Century."
22 And this is as important now in the 21st
23 Century in that when we look at the Office of the Coroner
24 and the role of paediatric forensic psychiatry, that it
25 is informed by a broad-based social concern. And DCI can


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1 bring forward the unique concerns of children and youth.
2 It, as referred to in our affidavit
3 material, intends to form a children -- a group of
4 children and youth who have been in institutional care
5 and have been involved in investigations, whether through
6 the death of a member of -- when they were in
7 institutional care or otherwise.
8 Children will most often be witnesses to
9 deaths in institutional care and there are unique
10 concerns that arise out of their participation in any
11 investigation and it's the hope that DCI, if granted
12 standing, could help you, Mr. Commissioner, understand
13 those unique issues.
14 In terms of its substantial and
15 considerable knowledge of the coroner's system, we have
16 referred in our affidavit material to two (2) reports
17 released by DCI. The first was in 2003 and the report in
18 itself was really about the need for there to be an
19 independent child advocate.
20 But part of that report -- and you'll find
21 it at pages 23 to 24 of Exhibit A to the Horne affidavit,
22 that's the first report -- it talked about the need for
23 there to be an independent child review, child death
24 review system.
25 The report did look at some of the other


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1 jurisdictions and it talked about some of the failings of
2 the Paediatric Death Review Committee. The fact that,
3 while the committee could make recommendations in
4 response to death reviews, it did not have the power to
5 impose time limits or recommended actions, and it didn't
6 have the resources to conduct followup investigations or
7 monitor the implementation of recommendations. And
8 that's on page 24.
9 Also, the report highlighted some of the
10 concerns about the independence of the Paediatric Death
11 Review Committee where it was examining deaths in
12 institutional care, because some of the membership of
13 that committee was connected to the institutions; most
14 notably, the Ontario Association of Childrens' Aid
15 Societies, which was a member of the committee.
16 So DCI has been examining this issue since
17 2003 and in 2005, again called upon there to be an
18 independent advocate with the ability to do paediatric
19 death reviews. Now since that time, the work of DCI has
20 been successful in terms of the creation of an -- a
21 provincial advocate for children and youth. That has
22 come into being. The legislation has passed, although
23 not yet proclaimed, into force. But it does not have the
24 ability to conduct death review.
25 So that is still an important issue in


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1 terms of DCI, is creating a credible paediatric death
2 review system.
3 DCI has, as you know from our affidavit
4 material, assisted young people in participating in
5 coroners inquests. It has assisted young people and --
6 in terms of being victims violence, and it has also
7 engaged in litigation regarding children's right's
8 issues.
9 But for your perspective, the important
10 thing to note is that it is DCI's real hope that your
11 work can be informed by the voices of young people and
12 the expertise of people working in children's rights
13 issues, because the coroner's system is a foundation, is
14 part impartial of public safety, that the examination of
15 deaths and the recommendations that come out of a -- of
16 your Inquiry and re -- regarding the investigation of
17 deaths has bearing on change and institutional safety.
18 And so it's part and parcel, as we see it, of public
19 safety and DCI hopes to inform you in that respect.
20 So just in terms of summarizing the
21 substantial and that special knowledge possessed by DCI,
22 we feel that we have substantial special knowledge in
23 terms of the vulnerabilities of children in the care of
24 the state; in terms of the investigation of the deaths of
25 children in institutional care; in terms of paediatric


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1 death review as a component of public safety; in terms of
2 the need for a process for death reviews that is
3 independent of the agencies responsible for the provision
4 of care; in terms of elevating the voices of children of
5 youth in the legal process that affect them; and in terms
6 of providing a child's rights perspective, which is both
7 unique in terms of the applicants who are before you for
8 standing today.
9 Obviously, our interests are discreet,
10 that we are more interested in the systemic issue
11 relating to the investigation of children and youth, and
12 in terms of the creation of a meaningful paediatric death
13 review system.
14 We anticipate that only one (1) counsel
15 will be needed, that it's a discreet brief. We do not
16 see there being duplication, but we -- and we are most
17 mindful of the need for you to proceed expeditiously.
18 But we are very concerned that you do have knowledge of
19 the broader based issues from a children's rights
20 perspective and it is on that basis that we hope to be
21 able to assist you.
22 On the issue of funding, I think the
23 materials make clear that DCI is a not-for-profit
24 organization and the dollars that it does have are
25 targeted by its funding bodies for projects under SEDA.


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1 But essentially, it would not be able to participate
2 unless granted funding on -- by the Commission. Thank
3 you.
4 COMMISSIONER STEPHEN GOUDGE: One (1)
5 question I have for you, Ms. Fraser.
6 I take it from your submission that at
7 least a large part of the focus you seek to have, would
8 be on issues relating to, if I can put it this way,
9 children that survive in a family where there has been a
10 paediatric death and the issues that relate to them? Is
11 that...?
12 MS. SUSAN FRASER: There -- there are --
13 are two (2) issues, I think. The affidavit of Les Horne
14 relates to the false positives issue, in terms of
15 investigations where the wrong per -- there -- there's a
16 wrong conclusion, in terms of the mechanism by which the
17 death occurred.
18 And certainly in the voices of children
19 who have been subject to -- or have been participants
20 where their parent or caregiver has been wrongly
21 identified. Those voices are important for the
22 Commission to hear.
23 The other component of that is the false
24 negatives where there is a concern that if there is not a
25 credible death review system, that some of the deaths in


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1 institutional care may not be examined properly if the
2 voices of children in those institutions are not heard.
3 So it's -- it's really in two (2) parts,
4 that it is our hope that we can bring forth through our
5 knowledge of the investigation of deaths in institutional
6 care, I think that our knowledge lays more with the
7 latter in terms of bringing those voices forward and
8 improving investigations where there is a death in
9 institutional care.
10 You know, I think it's -- we can't --
11 certainly can't speak to the individuals affected, but it
12 would be our hope that we would be able to bring forth
13 both perspectives in terms of our youth advisory group.
14 But in terms of the special knowledge, right now that
15 knowledge is more based on the second part, the --
16 COMMISSIONER STEPHEN GOUDGE: What you
17 call a false negative?
18 MS. SUSAN FRASER: Yes, for lack of a
19 better term.
20 COMMISSIONER STEPHEN GOUDGE: Yes.
21 MS. SUSAN FRASER: But just the -- the
22 need for that paediatric death review to be meaningful
23 and independent.
24 COMMISSIONER STEPHEN GOUDGE: Okay.
25 Thanks, Ms. Fraser.


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1
2 MS. SUSAN FRASER: Thank you.