Inquiry into Pediatric Forensic Pathology in Ontario
December 14, 2007



Cross-examination of Dr. Helen Whitwell, a Forensic Pathologist in the United Kingdom, and Dr. Pekka Saukko, Professor of Forensic Medicine, University of Turku, Finland (panel), 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 14th 2007
25

                            . . . . .

[Page 194]

21 CROSS-EXAMINATION BY MS. SUZAN FRASER:
22 MS. SUZAN FRASER: Good afternoon. My
23 name is Sue Fraser, and I'm here on behalf of a
24 children's rights organization, which is called Defence
25 for Children International, and its goal is to promote


[Page 195]

1 and protect the UN Convention on the rights of the child.
2 And Mr. Commissioner, Doctors Whitwell and
3 Saukko, I think it important that I correct for the
4 record what Canadians think about when they think about
5 Finland.
6 COMMISSIONER STEPHEN GOUDGE: At least
7 add to it.
8
9 CONTINUED BY MS. SUZAN FRASER:
10 MS. SUSAN FRASER: Some of us think of the
11 greatest runner of all time, Pavo Cur -- Pavo Nurmi,
12 pardon me. Some of us who are not so inclined to think
13 about sports think of the famous modernist, Ero
14 (phonetic), and I -- I always mispronounce this, Sarinin
15 (phonetic), and those of us who love our hockey, but do
16 not like the Montreal Canadians, think more in favour of
17 Yari Kuri, Tikkanen and -- and Tammuz Laney (phonetic).
18 So let me just start with that.
19 Is there any question that, putting aside
20 the debate on shaking, that the vigorous shaking that was
21 once mentioned -- once -- once described in the early
22 studies on Shaken Baby Syndrome is a violent act that
23 should not be something that parents or caregivers do to
24 a child.
25 That -- that's not a matter of debate, is


[Page 196]

1 that fair?
2 DR. HELEN WHITWELL: That's fair.
3 MS. SUZAN FRASER: Okay, and we just
4 simply -- and -- and you'd agree?
5 DR. PEKKA SAUKKO: I agree.
6 MS. SUZAN FRASER: And that's just -- in
7 terms of what parents hearing this kind of evidence, and
8 caregivers, nobody should think that it's okay to
9 vigorously shake a baby; you both agree with that?
10 DR. HELEN WHITWELL: I would, yes.
11 DR. PEKKA SAUKKO: Yes.
12 MS. SUZAN FRASER: All right.
13 MS. SUZAN FRASER: Dr. Whitwell, I have a
14 couple of questions for you. I wanted to follow up a
15 point that was raised -- initially raised when Professor
16 Milroy was here a few weeks ago on November the 23rd.
17 And a question was put to him about what
18 protocols are used by a pathologist in approaching a
19 sudden and unexpected death.
20 DR. HELEN WHITWELL: Mm-hm.
21 MS. SUZAN FRASER: In infancy.
22 DR. HELEN WHITWELL: Right.
23 MS. SUZAN FRASER: And he made reference
24 to a protocol, the CESDI protocol, which he said is about
25 seventy (70) pages long, and I think your attention was


[Page 197]

1 drawn to it yesterday.
2 We might turn it up now.
3 DR. HELEN WHITWELL: I think we need --
4 my attention was drawn to a lot of things.
5 MS. SUZAN FRASER: No, sorry. Not in
6 this -- not while you were giving your evidence, but I
7 think --
8 DR. HELEN WHITWELL: All right, okay.
9 I'm sure somebody did --
10 MS. SUZAN FRASER: -- knew it was coming.
11 DR. HELEN WHITWELL: -- mention it, but I
12 -- I'll be honest, I --
13 MS. SUZAN FRASER: Okay.
14 DR. HELEN WHITWELL: -- haven't looked at
15 it since it was mentioned to me. So you'll have to
16 remind me and turn me to it.
17 MS. SUZAN FRASER: Okay. It's at
18 PFP301222, and I believe that's Tab 16.
19 DR. HELEN WHITWELL: Sorry, at which
20 Volume?
21 MS. SUZAN FRASER: Oh, Volume I of --
22 DR. HELEN WHITWELL: Okay.
23 MS. SUZAN FRASER: You know, maybe if we
24 just look at it on the screen, and then we'll --
25 DR. HELEN WHITWELL: Yeah.


[Page 198]

1 MS. SUZAN FRASER: Can you just -- I
2 understand that CESDI was -- is a confidential inquiry --
3 DR. HELEN WHITWELL: It is, yes.
4 MS. SUZAN FRASER: -- into sudden death?
5 DR. HELEN WHITWELL: That's correct.
6 MS. SUZAN FRASER: And then --
7 DR. HELEN WHITWELL: And they publish a
8 report.
9 MS. SUZAN FRASER: Okay.
10 DR. HELEN WHITWELL: In a book form every
11 so many years.
12 MS. SUZAN FRASER: All right. And it's
13 now merged with maternal death, as I understand it, the
14 actual name is the Maternal and Child Health, so it now
15 has a new --
16 DR. HELEN WHITWELL: Right, okay.
17 MS. SUZAN FRASER: -- acronym. Okay, and
18 I understood that was set up in 1992?
19 DR. HELEN WHITWELL: The child one (1)
20 was. I'm -- and I'm not -- well --
21 MS. SUZAN FRASER: CESDI --
22 DR. HELEN WHITWELL: Yes, that's correct.
23 But I'm -- I'm not sure about the maternal one (1).
24 MS. SUZAN FRASER: All right. And the
25 hope of that -- I take it it's a study?


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1 DR. HELEN WHITWELL: Essentially what it
2 is, it's been a method of reviewing all child deaths, and
3 I think this form that you're -- you're showing to me is
4 the one (1) that the pediatricians would fill in in any
5 given area.
6 I think it's fair to say that some areas
7 of England have been slower to develop than others.
8 MS. SUZAN FRASER: All right.
9 DR. HELEN WHITWELL: But -- but now,
10 every unexplained death in an infant, the family are
11 visited, interviewed, you know, medical histories taken
12 and that.
13 MS. SUZAN FRASER: And I understand that
14 the information in the form is delivered confidentially,
15 so that once it's entered into the database that
16 information isn't used for any other purpose oth -- other
17 than the statistical analysis?
18 DR. HELEN WHITWELL: That -- that's my
19 understanding.
20 MS. SUZAN FRASER: All right.
21 DR. HELEN WHITWELL: Yes. And that
22 generally applies -- there's been a number of
23 confidential inquiries into various types of death in
24 England and Wales. For example, post-operative deaths,
25 maternal deaths, et cetera.


[Page 200]

1 MS. SUZAN FRASER: All right. And are
2 those reports useful to pathologists in understanding the
3 developments in our understanding of sudden infant death
4 in -- sudden unexpected death in Infants?
5 DR. HELEN WHITWELL: They're more of an
6 overall survey --
7 MS. SUZAN FRASER: Yes.
8 DR. HELEN WHITWELL: -- to -- to
9 highlight to a certain point in time. I -- I find them -
10 - the -- the development of a pediatric -- pediatrician
11 being involved in an unexplained or unexpected death
12 useful because they act -- they actually provide
13 considerable information.
14 Much more detail for example than
15 investigating Coroner's Office or police officers --
16 MS. SUZAN FRASER: All right.
17 DR. HELEN WHITWELL: -- may do.
18 MS. SUZAN FRASER: So it is useful to you
19 as a pathologist to have whoever is involved in that type
20 of investigation to be following a standard protocol? So
21 if there's a sudden unexpected death --
22 DR. HELEN WHITWELL: Yes.
23 MS. SUZAN FRASER: All right.
24 DR. HELEN WHITWELL: And they do. Some -
25 - on some occasions before I've started a post-mortem on


[Page 201]

1 a -- an unexpected death, either myself or the other
2 pathologist has talked to the pediatrician.
3 MS. SUZAN FRASER: All right. And you,
4 as a pathologist, is there a protocol that you use in
5 terms of the types of --
6 DR. HELEN WHITWELL: Investigations, yes.
7 MS. SUZAN FRASER: Yes. And does that
8 have a name or is that a personal protocol?
9 DR. HELEN WHITWELL: The -- the protocol
10 was initially in -- and I'm afraid I don't remember which
11 -- which volume. It was -- it was A) published in a
12 histopathology journal, but B) it came into one of the
13 confidential Inquiry books.
14 MS. SUZAN FRASER: I see.
15 DR. HELEN WHITWELL: And it was devised
16 by, I think, Professor Barry and Professor Fleming from
17 Bristol and, essentially, there's a list of various
18 investigations.
19 There is an updated protocol, if you like,
20 in the Joint Royal College of Pathologists in Pediatrics,
21 the Joint Kennedy Report, which I think and -- and I
22 think it came out in 2004.
23 So in -- in there, there are lists of
24 investigation which -- which are fair -- fairly standard.
25 MS. SUZAN FRASER: All right.


[Page 202]

1 DR. HELEN WHITWELL: But in here we're
2 talking about unexpected deaths.
3 MS. SUZAN FRASER: Yes.
4 DR. HELEN WHITWELL: A number -- or
5 unexplained deaths. A -- a number of the head injured
6 children wouldn't actually fall into this group.
7 MS. SUZAN FRASER: Right. Right. And so
8 then for those children, the head injured children, is
9 there a proto -- an investigative protocol that you use?
10 DR. HELEN WHITWELL: In -- in the young
11 ones, one tends to do everything that's outlined in the
12 CESDI protocol. If, for example, you have a child who
13 dies in a road traffic collision, then -- then you don't.
14 MS. SUZAN FRASER: Right. Okay.
15 DR. HELEN WHITWELL: Because the -- the
16 Kennedy Report specifically said sudden, unexpected, or
17 unexplained deaths. So if you have a child who -- with a
18 -- an obvious explanation, then it doesn't actually fall
19 within the group that need extensive microbiology and
20 toxicology, et cetera.
21 MS. SUZAN FRASER: I understand. And --
22 COMMISSIONER STEPHEN GOUDGE: If the
23 death were obviously criminal, would you run all the
24 tests?
25 DR. HELEN WHITWELL: Obviously criminal


[Page 203]

1 in wh -- in what sort of --
2 COMMISSIONER STEPHEN GOUDGE: Or are you
3 talking about the only accidental deaths that -- where
4 the cause is obvious that you wouldn't run all the tests?
5 DR. HELEN WHITWELL: You -- I think if
6 there's any doubt, then you do all the --
7 COMMISSIONER STEPHEN GOUDGE: You do the
8 whole range.
9 DR. HELEN WHITWELL: -- investigations
10 you can. And then --
11 COMMISSIONER STEPHEN GOUDGE: What I was
12 really getting at is, if you're in a -- in the criminally
13 suspicious range, even if it's pretty obviously a non-
14 accidental injury, you'd do all the tests, wouldn't you?
15 DR. HELEN WHITWELL: There will be a
16 tendency now to do more than perhaps we did ten (10)
17 years ago.
18 COMMISSIONER STEPHEN GOUDGE: Yes.
19 DR. HELEN WHITWELL: I mean ten (10)
20 years ago if it had a skull fracture subdurals, a child
21 had -- then we wouldn't have done them ten (10) years
22 ago.
23 COMMISSIONER STEPHEN GOUDGE: Right.
24 Thanks.
25

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1 CONTINUED BY MS. SUSAN FRASER:
2 MS. SUZAN FRASER: Okay. Dr. Whitwell,
3 you had some thoughts on, or at least made reference to
4 some of the frailties of your death investigations system
5 in England and Wales.
6 DR. HELEN WHITWELL: That's correct, in
7 terms of the Shipman Inquiry.
8 MS. SUZAN FRASER: Yes.
9 DR. HELEN WHITWELL: Yeah.
10 MS. SUZAN FRASER: And -- and currently,
11 in terms of your -- what are the -- in your view, the key
12 elements to a good death investigation? And I'm -- I'm
13 thinking specifically of children under 5.
14 DR. HELEN WHITWELL: Well it -- in
15 fairness, they -- they -- these deaths are probably
16 investigated far, far better than most of the adult
17 deaths, because of the involvement of the pediatricians
18 on issues. You know, the CESDI protocol, and then the
19 protocols for the post-mortem. So, and I think there's a
20 -- potentially, I -- I think there's going to be even
21 more involvement, looking at all childhood deaths.
22 Because my understanding is that the
23 English home office want to reduce all child deaths from
24 whatever cause. So I think they are -- all of them, up
25 to age of about 18, are going to be even more fully


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1 investigated.
2 MS. SUZAN FRASER: All right. And so
3 then, if I could just stay with the CESDI protocol, and
4 if Mr. Registrar could go to the second page. What I
5 understand the process to be is that there is a first
6 interview where there's general information taken, and
7 there's a checklist on the right hand side.
8 DR. HELEN WHITWELL: Yes. I mean this is
9 my understanding. It's not a document that I personally
10 use.
11 MS. SUZAN FRASER: Right. Right. But I
12 -- but the information --
13 DR. HELEN WHITWELL: It's the
14 pediatrician who uses it.
15 MS. SUZAN FRASER: Right. So -- but does
16 the information come to you as a pathologist?
17 DR. HELEN WHITWELL: Sometimes it does.
18 Yes, it -- it -- if it doesn't come directly, then it
19 forms part of the whole investigation into the case.
20 MS. SUZAN FRASER: I see.
21 DR. HELEN WHITWELL: I don't -- I don't
22 see these. I may see a letter from the -- for example, I
23 -- I've done cases with Professor Fleming CH) from
24 Bristol, who's -- who's clearly one of the leaders in
25 this area. And often, there's been a referring letter


[Page 206]

1 with -- with -- outlining some of the background is here.
2 MS. SUZAN FRASER: Okay. And then,
3 there's a reference to -- I understand the pediatrician
4 also makes an attendant's -- or take this type of
5 information, and my question is, what type of support is
6 given to the family? Do -- is that something you know?
7 DR. HELEN WHITWELL: I don't know. I
8 mean, my understanding is that there is a lot of support
9 but -- but I don't know. That's not a field I'm involved
10 in.
11 MS. SUZAN FRASER: All right. Professor
12 Whitwell, and I'm sorry all the questions are for you.
13 Normally, we treat our visitors better,
14 but I understand from some research commissioned by the
15 Commission that at the time of the Goldsmith Review,
16 there was a parallel review of some of the family court
17 cases by the Minister of State for Children.
18 Do you know anything about that? And I'm
19 sorry to put upon you, but...
20 DR. HELEN WHITWELL: Yes, there was, but
21 my --
22 MS. SUZAN FRASER: You weren't involved
23 in that process?
24 DR. HELEN WHITWELL: No, no. No, you'd
25 had to refer me to any document that there -- there was


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1 because there has been an issue in England about the
2 openness or otherwise of the family courts.
3 MS. SUZAN FRASER: All right. And,
4 Professor Whit -- or Professor Milroy made reference to
5 the fact that one (1) of the issues there is that the
6 pathologist tends to give his evidence in -- in a private
7 setting, and so --
8 DR. HELEN WHITWELL: That's correct.
9 MS. SUZAN FRASER: -- it's subject to the
10 same kind of scrutiny?
11 DR. HELEN WHITWELL: That's correct.
12 MS. SUZAN FRASER: All right. And then
13 just finally, reference was made in -- in Ms.
14 Kirkpatrick's -- Kirkpatrick's evidence to a paper that
15 was commiss -- or was prepared by Dr. Smith. The paper
16 on -- with the Child Abuse Maltreatment Syndrome. And
17 I'll make this for Dr. Saukko.
18 Is -- is that a symptom -- syndrome? It
19 was called, "Fatal Child Abuse Maltreatment Syndrome,"
20 and it was published in the journal, I think, that you
21 edited, if I under -- if I recall properly.
22 Is that a syndrome that has -- is
23 generally -- generally well accepted?
24 DR. PEKKA SAUKKO: Sorry.
25 MS. SUZAN FRASER: The question was:


[Page 208]

1 There's a -- there was a paper authored and it was
2 discussing a -- a syndrome which was called Fatal Child
3 Abuse Maltreatment Syndrome.
4 And is that a syndrome of which you're
5 aware and that you support?
6 DR. PEKKA SAUKKO: I don't recall that
7 paper.
8 MS. SUZAN FRASER: If just -- all right.
9 It's at Tab 28 of Volume II, and it's PFP302067.
10 DR. PEKKA SAUKKO: Is it...?
11 MS. SUZAN FRASER: It's on the screen.
12 COMMISSIONER STEPHEN GOUDGE: Yes. No,
13 there it is. He has got it now.
14 DR. PEKKA SAUKKO: Okay. Yeah, I now --
15 I recall the paper, yes.
16
17 CONTINUED BY MS. SUZAN FRASER:
18 MS. SUZAN FRASER: And -- and Mr.
19 Manischen who was the counsel before you talked about
20 different syndromes and -- and the issue of something
21 sort of becoming popular.
22 Is this something that has made its way
23 into the textbooks or into the literature, otherwise?
24 DR. PEKKA SAUKKO: I don't know.
25 MS. SUZAN FRASER: You don't know, okay.


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1 And, Dr. Whitwell, do you know?
2 DR. HELEN WHITWELL: I take it that it's
3 -- yet another name like Shaken Baby Syndrome, Shaken
4 Impact Syndrome. You know, it's generally covering the
5 same thing.
6 MS. SUZAN FRASER: All right.
7 DR. HELEN WHITWELL: But it's not -- it's
8 not a term that we generally use in England, at all.
9 MS. SUZAN FRASER: All right. Thank you.
10 Mr. Commissioner, those are my questions.