Inquiry into Pediatric Forensic Pathology in Ontario
December 11, 2007



Cross-examination of Dr. David Chiasson, former Chief Forensic Pathologist for the Province of Ontario and Director of the Pediatric Forensic Pathology Unit, Hospital for Sick Children, 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.


[Page 1]

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 December 11th 2007
25

                            . . . . .

[Page 170]

21 CROSS-EXAMINATION BY MS. SUZAN FRASER:
22 MS. SUZAN FRASER: Thank you, Mr.
23 Commissioner. Doctor, is it Dr. Chiasson?
24 DR. DAVID CHIASSON: That's correct, yes.
25 MS. SUZAN FRASER: Okay. Dr. Chiasson,


[Page 171]

1 my name is Sue Fraser. Our paths have crossed at a
2 couple of inquests in the past, but you probably don't
3 remember me. Your role was a little more central then
4 mine.
5 But I'm here today on behalf of a group
6 called Defence For Children International. And that is a
7 children's rights organization founded in Geneva. And
8 its role -- or what it hopes to do is promote and protect
9 the rights of the children, as spelled out in the UN
10 Convention on The Right to the Child.
11 And so here, the sort of two (2) competing
12 rights are the right to survival and development, and the
13 preservation of their identity in family relationship.
14 So I heard your comments about your faith
15 in the unit at the Hospital for Sick Children as it's
16 currently constituted, and the benefits of having the
17 pediatric and the forensic pathology elements.
18 And I'm interested -- much of the focus
19 has been on Death of Under Five, and would you see those
20 benefits for pediatric cases in the traditional sense,
21 ie; those up to the age of seventeen (17)?
22 DR. DAVID CHIASSON: Well, certainly
23 there's an overlap between the work of the Pediatric
24 Forensic Pathology Unit and the Adult Forensic Pathology
25 Unit when you talk about the children between let's say


[Page 172]

1 ten (10) and twelve (12) and seventeen (17); teenagers
2 certainly.
3 We would do autopsies, certainly, in any
4 patient of the hospital who happened to die and became --
5 it was warranted under The Coroners' Act. And then
6 outside as to where the autopsy might be done very much
7 depends on the circumstances.
8 I mean, we don't routinely -- if a young
9 person was shot, that would normally go to the Coroner's
10 Office, for example. If there was a -- a young person
11 who had chronic neurologic disease or was a patient of
12 the hospital -- significant medical problems - who died
13 that was thirteen (13), fourteen (14), fifteen (15),
14 whatever; that -- that may well come to the -- our unit.
15 So there's a -- there's an overlap and it
16 really depends on the nature of the -- the case as to
17 where the autopsy would be done.
18 MS. SUZAN FRASER: Okay. So that it --
19 to the extent that there'd be any recommendations about
20 where cases should go, there should be some flexibility
21 in the, sort of, end of the spectrum of pediatrics, is
22 that fair?
23 DR. DAVID CHIASSON: That's fair. And I
24 -- I think we're -- we're -- anything certainly of a
25 medical nature, I would -- I would suggest is -- the unit


[Page 173]

1 really, is -- is -- still has -- pediatric expertise --
2 pediatric pathology, in a general way, does deal with
3 patients up to the age of sixteen (16), seventeen (17).
4 MS. SUZAN FRASER: All right. I want to
5 turn your attention to the Coroner's Investigation
6 Statement for Children's Under Two Sudden Unexpected
7 Death. That would be PFP142286, and it'll be on your
8 screen.
9
10 (BRIEF PAUSE)
11
12 MS. SUZAN FRASER: And if the Registrar
13 could turn to the twelfth page of that document.
14 This is the form that I understand is part
15 of the Coroner's Manual for investigation of sun --
16 Sudden Unexpected Deaths in Children Under Two, and are
17 you familiar with this form, Dr. Chiasson?
18 DR. DAVID CHIASSON: I have some
19 familiarity. I don't complete it myself, but I -- as
20 pathologists doing an autopsy on a Sudden Unexpected
21 Death now Under Five, as opposed to two (2), and I'm not
22 sure whether the form has been modified since --
23 MS. SUZAN FRASER: All right.
24 DR. DAVID CHIASSON: -- what we're
25 looking at here, but -- but in -- in essence, this would


[Page 174]

1 be the form that I would often receive, along with a copy
2 of the coroner's warrant.
3 MS. SUZAN FRASER: All right. And so --
4 and is it -- is it your expa -- experience that you
5 always receive it or that you sometimes receive it?
6 DR. DAVID CHIASSON: We don't always
7 receive it.
8 MS. SUZAN FRASER: All right.
9 DR. DAVID CHIASSON: Ideally, we should
10 receive it, and I would say currently we receive a copy
11 in the majority; probably three quarters (3/4s) of cases.
12 MS. SUZAN FRASER: All right. And I
13 wanted to -- in my review of the form, there was nothing
14 in the form that the investigator would have taken to
15 detail the child's sleep environment which I understand,
16 from the evidence we've heard, to be a pretty significant
17 factor in -- in a sudden unexpected death.
18 Would that be something that you would
19 expect to see as part of a form relating to sudden
20 unexpected death? Would that be a benefit?
21 DR. DAVID CHIASSON: Yes, and I -- I
22 thought it was in the form. Certainly the position at
23 the time of death of the infant would have been noted --
24 should have been noted.
25 MS. SUZAN FRASER: All right. And there


[Page 175]

1 don't seem to be questions in the form about describing
2 the baby's condition in the previous twenty-four (24)
3 hours.
4 Is that something that you'd want to know
5 as a pathologist?
6 DR. DAVID CHIASSON: Yes, but again, I --
7 I think there is some reference in the form to illness
8 within the last twenty-four (24) hours.
9 MS. SUZAN FRASER: All right. History of
10 present illness within forty-eight (48) hours of death,
11 that's --
12 DR. DAVID CHIASSON: Yes.
13 MS. SUZAN FRASER: All right. And so to
14 your knowledge, that speaks to more to than just medical
15 problems, rather than --
16 DR. DAVID CHIASSON: Well, I think it's a
17 combination. I mean, most of these are unexpected deaths
18 and any history of -- of a cold or sneezing, you know,
19 those kinds symptomotology -- that -- that's usually
20 where it's referred to.
21 MS. SUZAN FRASER: All right. And is
22 this kind of protocol helpful to you as a pathologist in
23 understanding the circumstances of death?
24 DR. DAVID CHIASSON: Very much so, yes.
25 MS. SUZAN FRASER: All right. And is it


[Page 176]

1 fair to say that the more information that's on the form,
2 if it's relevant to your determination, the better?
3 DR. DAVID CHIASSON: Yes.
4 MS. SUZAN FRASER: All right. I want to
5 turn then to the question of -- or the issue relating to
6 the SCAN Team. I have some questions about the SCAN
7 Team, and I understand that's the Suspected Child Abuse
8 and Neglect Team at the Hospital for Sick Children.
9 DR. DAVID CHIASSON: That's correct.
10 MS. SUZAN FRASER: All right. And you're
11 familiar with that team?
12 DR. DAVID CHIASSON: I am.
13 MS. SUZAN FRASER: All right. And what
14 was its -- what is your understanding of its relationship
15 to the Pediatric Forensic Pathology Unit during the time
16 that you were the Chief Forensic Pathologist? Was it a
17 formal relationship?
18 DR. DAVID CHIASSON: No, I didn't see
19 that there was any formal relationship. The SCAN Team
20 has, obviously, an important function to play within the
21 context of the hospital and the clinical work, and -- but
22 I -- I didn't think there was any formal connection
23 between the -- that unit and the Pediatric Forensic
24 Pathology Unit.
25 MS. SUZAN FRASER: All right. And what -


[Page 177]

1 - I guess, what is their current relationship with the
2 SCAN Team? Do they provide advice consults to the
3 Ontario Pediatric Forensic Pathology Unit now?
4 DR. DAVID CHIASSON: No.
5 MS. SUZAN FRASER: All right. And why is
6 that the case?
7 DR. DAVID CHIASSON: Why is -- why isn't
8 it not the case. Well, I should step back. There have
9 been on rare occasions where I have asked for assistance
10 at a post-mortem examination if I have concerns about the
11 possibility of sexual assault; it's -- it's a very
12 uncommon situation.
13 I have, in the past, consulted a -- a
14 representative of the SCAN Team in that context, but
15 beyond -- beyond that, there is a -- I mean, there's an
16 overlap to some degree.
17 If I -- if I'm dealing with the death of
18 child who has evidence of child abuse, I'm often asked
19 questions about the nature of the abuse and what kinds of
20 -- of events may have precipitated the trauma.
21 I will often give a degree -- a certain
22 level of opinion from my perspective, but it will often
23 suggest to the investigators that the SCAN personnel, the
24 physicians that work for the SCAN Team, are in a better
25 position to, in fact, often render opinions in this area


[Page 178]

1 because they deal with it much more frequently in -- in
2 the living.
3 So we -- we oft -- I'll often suggest that
4 they become involved in a case, but the -- it's -- they
5 carry on their function along one (1) track, if you will,
6 and it's -- it's separate and distinct from my -- my own
7 work.
8 MS. SUZAN FRASER: Would you agree with
9 me that they seem to function as forensic medical
10 professionals that their -- part of what they do in
11 detecting abuse has a necessary sort of interface or
12 interaction with the Justice System?
13 DR. DAVID CHIASSON: Clearly -- clearly
14 they do, yes.
15 MS. SUZAN FRASER: All right. And do
16 they have the same -- is there a same kind of forensic
17 training body -- you're -- you have your speciality, is
18 there a similar forensic speciality or certification
19 process for this area of expertise?
20 DR. DAVID CHIASSON: That's a good
21 question. I don't know the answer.
22 MS. SUZAN FRASER: All right. And do you
23 know when they're consulted whether they're subject to
24 the same side -- sort of peer review or oversight?
25 DR. DAVID CHIASSON: I don't know the


[Page 179]

1 answer to that either.
2 MS. SUZAN FRASER: All right. And in the
3 cases where you've had occasion to consult with them, did
4 those consultations form written report that would be
5 appended to the post-mortem?
6 DR. DAVID CHIASSON: Exactly. If -- if
7 I'm asking them to provide some kind of examination of
8 the body post-mortem that would there -- I would ask for
9 a report. And -- and that would be appended to my -- my
10 own report, yes.
11 MS. SUZAN FRASER: All right. And I
12 think you've already given your opinion on whether you
13 would co-author reports. You always see that if there's
14 a second person consulted that they would issue or author
15 their own report, is that fair?
16 DR. DAVID CHIASSON: Yes, I mean, most of
17 the time it's in specialized area. So just like I have
18 my neuropathologist prepare an neuropathology report on
19 examination of the brain, I don't carry out a concurrent
20 examination and so that's his role.
21 If -- if it's a sexual assault
22 examination, that potential, I would -- I'm asking him --
23 him or her to -- to do that then I'm -- I'm deferring
24 that role to them. And -- and they are providing an --
25 an opinion in that restricted area; that -- that report,


[Page 180]

1 I -- I would append.
2 MS. SUZAN FRASER: All right.
3 DR. DAVID CHIASSON: It's not a conjoint
4 -- I would not cosign their report, and I certainly
5 wouldn't expect them or ask them to cosign my full post-
6 mortem examination report.
7 MS. SUZAN FRASER: All right. In
8 circumstances where that type of evidence -- a
9 consultation report -- is being used for a purpose either
10 to affect somebody's liberty or to affect a familiar
11 relationship through -- a familiar relationship in a
12 child protection proceeding, can you see the need for
13 those types of opinions to be subject to some kind of
14 review?
15 DR. DAVID CHIASSON: Well, again, this --
16 it's clearly an area of work outside of my own -- my own
17 area. I certainly respect and -- and see the value of
18 having oversight. I mean, the large part of what we've
19 been talking about the last few days certainly and -- has
20 been the issues of oversight.
21 So if you will, it's -- it's, I think, a
22 good thing for us. I would expect in -- in a similar
23 fashion there -- there would be value in having oversight
24 on the -- on the SCAN Team reports, particularly those
25 that are aimed in -- in a -- in a Criminal Justice System


[Page 181]

1 or the Child Protection System.
2 MS. SUZAN FRASER: All right. And many
3 of the questions that have been put to you about how to
4 monitor testimony reports, evidence, forensic
5 pathologists in criminal proceedings would -- that would
6 have equal application for child protection proceedings,
7 is that fair?
8 DR. DAVID CHIASSON: I think certainly --
9 yeah, issues of child protection are -- are important
10 issues, and I think there -- there is a -- it's
11 reasonable to expect a -- a similar level of scrutiny in
12 -- in that kind of situation as there might be in a
13 Criminal Justice situation.
14 MS. SUZAN FRASER: All right. There has
15 been much talk about potential improvements in the system
16 to hope to -- in the future that we have good pathology,
17 good evidence that innocent people go free and that those
18 who are responsible for the deaths are convicted.
19 That's sort of the ultimate goal, you'd
20 agree with that, being tha -- a good situation?
21 DR. DAVID CHIASSON: Yes. One (1) of the
22 motto's that I've picked up over the years is from the
23 Seattle Medical Examiner's Office -- the King's County
24 Medical Examiner's Office, "The innocent shall be
25 exonerated and murder shall be recognized", which, I


[Page 182]

1 think, is what you're saying.
2 MS. SUZAN FRASER: All right. So
3 developing a system where -- I'm going to leave that to
4 some of the other evidence -- but where we don't get
5 those kinds of results and where we discover failings
6 after the fact, there seems to be some difficulty in
7 terms of tracking where evidence has been given and --
8 and when it's been given
9 And so my question for you is: Can you
10 see the benefit to tracking pathology evidence through
11 the Justice System, either in the Criminal Justice System
12 or in the Child Protection System?
13 DR. DAVID CHIASSON: I think you'd have
14 to elaborate on what you mean by tracking, and who --
15 who's tracking and --
16 MS. SUZAN FRASER: Well, that -- those
17 are some of the -- the issues that I think are raised,
18 but if a pathology report is used for a legal purposes --
19 purpose, is it important for us to know, a) that the
20 pathology report is going to be used for legal purpose,
21 when it was used as for legal purpose, and what the
22 outcome of that proceeding was?
23 So that if there's an issue after the fact
24 -- someone has made a suggestion that we review shaken
25 baby cases. Is it important for us to be able to track


[Page 183]

1 where that and when that evidence was used? And can you
2 envision -- envisage a way that that might happen?
3 DR. DAVID CHIASSON: Well, I'm -- I'm
4 struggling with envisioning a way, practically speaking,
5 how that could happen. I mean, I appreciate the concept
6 and the -- the value that there might be in -- in
7 tracking that.
8 I mean, in any given case, you have one
9 (1) pathologist. He certainly would keep track of what
10 he's testifying on and where he's testifying. That --
11 and how you would do that in some central way, I think,
12 as I understand -- at least the mechanisms of government
13 -- Coroner's Office -- I can't speak, of course, about
14 other ministries.
15 I -- I sense that would be, logistically,
16 a difficult thing to do.
17 MS. SUZAN FRASER: You can see from a
18 child's perspective -- somebody who's separated from
19 their parent -- the parent is wrongfully convicted or
20 wrongfully charged, and the result of that is that the
21 person is separated from their parent.
22 They might not even know that -- that --
23 that their parent was wrongfully charged. Is there a way
24 for this -- if -- if you're going to track testimony, and
25 the evidence that's given -- we've sort of identified


[Page 184]

1 that as being a key area for pathology, there's going to
2 have to be some way of basically following these cases in
3 the case of homicide. Would you not agree?
4 DR. DAVID CHIASSON: Well, I mean, in
5 terms of tracking what's going on when a pathologist
6 testifies in a criminal case, I mean, we've talked about
7 the Chief Forensic Pathologist potentially -- this was
8 raised this morning -- being given a -- a form or present
9 a form with comments about the --
10 MS. SUZAN FRASER: Yes.
11 DR. DAVID CHIASSON: -- pathology, which
12 would -- the pathologist testimony, and that would, of
13 course, depend on the -- the Crown or police or the
14 defence actually taking the time to -- to fill that out.
15 So the Chief Forensic Pathologist in that
16 system could have some sense, Okay, that on such and such
17 a day, such and such a pathologist testified at such and
18 such a proceeding. To try and somehow tie that in with
19 issues and subsequent -- what might happen down the road,
20 I -- again, certainly looking at it from my previous
21 position as Chief Forensic Pathologist within the
22 Coroner's Office, I -- I still find it difficult to see
23 how that Office could -- could somehow keep track of --
24 of that particular issue.
25 It -- it sounds like a big job --


[Page 185]

1 MS. SUZAN FRASER: All right.
2 DR. DAVID CHIASSON: -- a big
3 undertaking.
4 MS. SUZAN FRASER: But if -- if there are
5 two hundred and fifty (250) homicide cases in the course
6 of a year, as the Chief Forensic Pathologist or somebody
7 with oversight for pathologists, you might want to know
8 when those pathologists are giving evidence and what was
9 the evidence.
10 Would you agree with that?
11 DR. DAVID CHIASSON: Well, I mean, the
12 outcome of the evid -- I mean, it's the outcome of the
13 trial --
14 MS. SUZAN FRASER: Right.
15 DR. DAVID CHIASSON: It's not the
16 evidence, you know, the relevance of the evidence in --
17 in any particular homicide trial may be little or -- or
18 may be great; it -- it varies, so the two (2) aren't tied
19 together.
20 All travesties of -- of justice --
21 MS. SUZAN FRASER: Yes.
22 DR. DAVID CHIASSON: -- and wrongful
23 convictions aren't because --
24 MS. SUZAN FRASER: I -- I understand
25 that.


[Page 186]

1 DR. DAVID CHIASSON: -- of pathology --
2 MS. SUZAN FRASER: I -- I was thinking of
3 one (1) -- one (1) specific case where -- where the
4 pathologist was criticized by the trial judge and -- and
5 so there have been some questions about whether that's
6 something that should have come to the attention of the
7 Chief Coroner or the Chief Forensic Pathologist.
8 So I'm just trying to see if you can
9 envisage a way of tracking those, and I don't think that
10 you can at this point in time, is that fair?
11 DR. DAVID CHIASSON: Well, that's fair,
12 but I -- to me, I -- I agree with you. If -- if, in
13 fact, there is a judgment that is critical of a
14 pathologist, then I think that the -- the Chief Forensic
15 Pathologist should be made aware of that.
16 How that procedure happens, I -- I don't
17 think -- I can't see the Chief Forensic Pathologist
18 spending, you know, time sort of trying to --
19 MS. SUZAN FRASER: No, I think --
20 DR. DAVID CHIASSON: -- follow all of
21 this through, I mean --
22 MS. SUZAN FRASER: The Forensic
23 Pathologist might have a good clerk who does this for him
24 or her.
25 DR. DAVID CHIASSON: Well, no, but even -


[Page 187]

1 - even then, I mean, to me it's if there's a problem in a
2 -- in a -- whether it's the -- the judge, and I don't
3 know what the avenues are for a justice to do -- to do --
4 to actually send a report to the Chief Forensic
5 Pathologist, a judgment, or the Crown attorney, or a
6 defence counsel.
7 I mean, that to me is your -- your --
8 these are -- these are relatively isolated problems. The
9 way to -- that I would see -- see dealing with them is
10 that there is a problem -- an identified problem -- then
11 it's for the people that -- that know of the problem to -
12 - to pass the information on to the Chief Forensic
13 Pathologist; not that the Chief Forensic Pathologist sets
14 up some global scheme to try and pick this up. To me,
15 that -- that's getting the whole thing backwards.
16 MS. SUZAN FRASER: All right. Thank you,
17 Mr. Commissioner.
18 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms.
19 Fraser. Just one (1) question about the SCAN Team.
20 You've indicated that it now works,
21 essentially, on a separate track from you in any
22 particular case, that you -- your office -- that is the
23 unit might be involved in -- and from your perspective,
24 is that different than its relationship with the unit
25 when Dr. Smith was your predecessor?


[Page 188]

1 DR. DAVID CHIASSON: Well, I'm aware,
2 from some of the evidence that I think has been before
3 the Commission, that there were -- at least, one (1)
4 incidence where -- one (1) instance where Dr. Smith and
5 Dr. Mian appears to have co-written a report of some
6 sort.
7 So there's clear -- that's something
8 that's never happened on my watch and -- and something
9 that I personally would not -- would not do. So, I -- I
10 mean it's not to say that I don't -- SCAN Teams see the
11 same patients that I do after death; obviously they
12 render opinions.
13 I've had contact with SCAN Teams providing
14 me with some followup opinions because some of the
15 testing comes back later on. I think that's very
16 helpful. I take that information as part of the package,
17 but I don't sit down with the SCAN Team and say, Well,
18 you know -- you know, I -- whatever opinions they have, I
19 think, you know, I would take into consideration and --
20 and look at, but their -- their function and role, I
21 think, is quite clearly separate --
22 COMMISSIONER STEPHEN GOUDGE: Yes.
23 DR. DAVID CHIASSON: -- from the function
24 of --
25 COMMISSIONER STEPHEN GOUDGE: Yes.


[Page 189]

1 DR. DAVID CHIASSON: -- a pediatric
2 forensic pathologist.
3 COMMISSIONER STEPHEN GOUDGE: They deal
4 with the living and --
5 DR. DAVID CHIASSON: Well, they deal with
6 the living and -- and as I've said, I also -- I think
7 there's a lot of value because they deal with the living
8 and they deal with many more cases of rib fractures, for
9 example --
10 COMMISSIONER STEPHEN GOUDGE: Right.
11 DR. DAVID CHIASSON: -- than I would in
12 the deceased. The issue as to how a rib fracture might
13 have happened, I think they could well be in a much
14 better position to say, Well, you know, we have all this
15 experience, we see that we have this story of -- of falls
16 and -- and causing this kind of rib fractures, et cetera,
17 so there -- there's obviously a significant and very
18 important role that they -- that they play in terms of
19 how injuries might -- might occur.
20 But I don't see this as -- as being --
21 that's fine, that's their view and they're entitled to
22 their opinion. I -- I see it as a separate and distinct
23 opinion as to what my role is and -- and my opinion might
24 ultimately be into -- in a case.
25 COMMISSIONER STEPHEN GOUDGE: When you


[Page 190]

1 began as Director of the Unit, did you have any sense
2 that this description of the two (2) roles -- the SCAN
3 Team and pathologists in the unit, was -- you weren't
4 doing anything different, that is, did you have any sense
5 that you were changing a prior relationship?
6 DR. DAVID CHIASSON: Well, I think my
7 sense was that there was more connection between Dr.
8 Smith, who was a longstanding hospital physician in the
9 unit, and the SCAN Team. Then I -- I came on board, and
10 I didn't have any history with anybody on the -- on the
11 SCAN Team.
12 And I -- I -- my sense is the relationship
13 was -- was closer in some -- whether it's -- it's just
14 the personnel knowing each other and -- and --
15 COMMISSIONER STEPHEN GOUDGE: Right.
16 DR. DAVID CHIASSON: -- perhaps,
17 discussing cases, I -- I don't know the extent of that.
18 But it's -- probably was closer than certainly it is --
19 it is now.
20 I -- I, on rare occasion, have attended,
21 for example, SCAN meetings. I -- I'd like to, in fact,
22 go to more because I -- I learn about what they're doing.
23 I learn about trauma, and the kinds of stories and -- and
24 the kinds of circumstances where they're seeing trauma.
25 I think -- I think I -- I need to know


[Page 191]

1 about they're experience, but at the same time, I do see
2 them as -- as separate and distinct.
3 I don't see this as part of a -- I don't
4 see pediatric forensic pathology part of the SCAN Team
5 and --
6 COMMISSIONER STEPHEN GOUDGE: Or vice
7 versa?
8 DR. DAVID CHIASSON: -- or vice versa.
9 COMMISSIONER STEPHEN GOUDGE: Okay.