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Inquiry into Pediatric Forensic Pathology in Ontario
December 19, 2007
Cross-examination of Dr. Glenn Taylor, Head of the Division of Pathology, Hospital for Sick Children, and Dr. Ernest Cutz, Pathologist, 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 19th 2007
25
. . . . .
[Page 109]
20 CROSS-EXAMINATION BY MS. SUZAN FRASER:
21 MS. SUZAN FRASER: Dr. Cutz, Dr. Taylor,
22 my name is Sue Fraser and I'm here on behalf of an
23 organization called Defence for Children International,
24 which is an international grassroots charitable
25 organization which aim is to promote and protect the
[Page 110]
1 rights of the child as spelled out in the UN Convention.
2 And, Dr. Cutz, I just wanted to pick up on
3 a point that you raised yesterday. And you made
4 reference to the fact that in 2004, you had sat on an
5 international panel with five (5) forensic pathologists,
6 three (3) pediatricians and discussed the type of
7 criteria -- this is what I understood, for determining
8 Sudden Infant Death Syndrome and Sudden Unexpected Death.
9 Did I understand that properly?
10 DR. ERNEST CUTZ: Yes.
11 MS. SUZAN FRASER: All right. And am I
12 right in understanding that that -- because you had also
13 at another time discussed the National Institute of
14 Health -- that that was a panel related to the National
15 Institute of Health?
16 DR. ERNEST CUTZ: It was convened by the
17 National Institute of Health.
18 MS. SUZAN FRASER: All right. And do I
19 understand properly that the purpose of that panel was to
20 reach a, sort of, consensus or international standard on
21 the -- on those types of definitions?
22 DR. ERNEST CUTZ: It was that plus it was
23 to update because in the intervening fifteen (15) or so
24 years, there's been development, new research and new
25 information available. So that was to update it to the
[Page 111]
1 current level of the knowledge.
2 MS. SUZAN FRASER: All right. So the
3 National Institute of Health, is that an American
4 organization?
5 DR. ERNEST CUTZ: Yes.
6 MS. SUZAN FRASER: All right. But it's
7 internationally recognized, as I understand it?
8 DR. ERNEST CUTZ: It's -- it's the major
9 funding agency for health research in the world.
10 MS. SUZAN FRASER: All right. And from
11 what I think you're telling me, is that fifteen (15)
12 years before 2004 -- so that's 1989 -- if I'm doing my
13 math properly, that there had -- they had convened a
14 similar panel and come up with a criteria for diagnosing
15 SIDS?
16 DR. ERNEST CUTZ: Yes. As I explained --
17 and my understanding for the panel, was to -- to set some
18 guidelines. And this was in advance of National
19 Institute of Health targeted funding for SIDS research.
20 There was to be about $50 million invested into SIDS
21 research.
22 And to make sure that the research is done
23 in well-characterized groups of patients -- so they call
24 in the panel to define the criteria. And then this was,
25 you know -- any centres who were competing for this
[Page 112]
1 funding had to, sort of, adhere or use these -- these
2 criteria that was to -- to ensure that the cases, which
3 are being analysed, you know, you -- you can produce
4 reproducible data.
5 MS. SUZAN FRASER: All right. So in --
6 it's -- it's purpose was for research. Is it also
7 something that pathologists are supposed to use when
8 making outside of the research context, say, in a
9 medicolegal context, are to also apply that criteria?
10 DR. ERNEST CUTZ: Yes. No, I think the -
11 - the panel has considered this. And, you know, one (1)
12 of the members of the panel was -- was a forensic
13 pathologist, and even at that time, the concern was that
14 some of the cases could not -- may not be genuine SIDS.
15 There was also concern about the sleeping
16 environment. So that there were sort of, if you like,
17 two (2) definitions. One (1) was for administrative
18 purpose, and one (1) was for research purposes.
19 And the administrative was, you know, to
20 dealing with legal issues and also dealing with providing
21 appropriate health statistics, so that the cases are
22 properly classified and then you can follow trends and --
23 and devise any sort of a procedure based on these trends.
24 MS. SUZAN FRASER: All right. And so I'm
25 just having trouble understanding how that would be
[Page 113]
1 useful because I think, later in your evidence, you said
2 that Ontario's falling behind. And so I'm interested,
3 both from a research perspective and also from a, sort
4 of, diagnostic or analysis, when a child dies to
5 determine whether it's actually a SIDS death, what you
6 would propose in terms of the applicability of the
7 National Institute of Health guidelines to the Ontario
8 situation?
9 DR. ERNEST CUTZ: Well, as -- as I
10 mentioned, the '91 guidelines, that was a basis which was
11 used since then and it was a little bit more refined in
12 the 2004 panel deliberation where it was recognized that
13 not all the SIDS -- SIDS are the same.
14 And there are some, you know, subgroups
15 which need to be pointed out or -- or separated out. And
16 it also dealt with some of the issues in terms of
17 overlaying, co-sleeping -- as some of these other issues
18 which came up in the -- during the '90s.
19 MS. SUZAN FRASER: All right.
20 DR. ERNEST CUTZ: So I -- I think, you
21 know, that -- that was recommended by the panel. It was
22 published in the Journal of Pediatrics, and I understand
23 it -- American Association of Pediatrics has also
24 endorsed this recommendation.
25 MS. SUZAN FRASER: All right. If you
[Page 114]
1 could turn then to the autopsy guidelines that you should
2 find in Volume II at Tab 67, which is PFP137592.
3 DR. ERNEST CUTZ: Yes.
4 MS. SUZAN FRASER: And turn to the first
5 -- the second page which is the actual first page of the
6 criteria. Have you reviewed these guidelines? Have you
7 had an opportunity to consider these guidelines? I know
8 you're not doing medicolegal autopsy --
9 DR. ERNEST CUTZ: Yes. No, I -- I was
10 not involved in designing these guidelines.
11 MS. SUZAN FRASER: All right. And would
12 it be useful for a pathologist approaching a suspected
13 SIDS case to have and to use the National Institute's of
14 Health guide -- National Health Institute's guidelines?
15 DR. ERNEST CUTZ: Well, it would be
16 helpful if they do, but I think this covers all kinds of
17 cases. It doesn't just cover SIDS, so this -- this
18 refers to the -- the total population of -- of pediatric
19 cases coming through the Coroner's Office.
20 MS. SUZAN FRASER: Right. And as a
21 pathologist with experience in dealing with SIDS and
22 identifying SIDS cases, --
23 DR. ERNEST CUTZ: Yeah.
24 MS. SUZAN FRASER: -- is the use of a
25 recognized protocol something that you believe is
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1 important?
2 DR. ERNEST CUTZ: Yes. There -- in fact,
3 there is a protocol for investigation of SIDS cases,
4 which is also part of the -- part of the document, but
5 you see I wish to point out that these guidelines, it
6 says, "for criminally suspicious deaths and homicides in
7 infant and children," so this doesn't really refer to the
8 investigation of SIDS cases.
9 MS. SUZAN FRASER: All right. And when
10 you're talking about the other guidelines for sudden
11 infant death, are you talking about the coroner's
12 investigation statement that comes to you when you -- as
13 a pathologist?
14 DR. ERNEST CUTZ: Well, the coroner's
15 statement just, you know, you mean like the coroner's
16 warrant or --
17 MS. SUZAN FRASER: Well, we -- I'm not
18 going to take your attention to it now, but we've --
19 we've heard evidence about the coroner having a form
20 that's used first -- was first used for deaths under two
21 (2) --
22 DR. ERNEST CUTZ: Yes.
23 MS. SUZAN FRASER: -- and now is used for
24 deaths under five (5).
25 Does that assist you?
[Page 116]
1 DR. ERNEST CUTZ: Yes, I think that more
2 refers to the scene investigation and information
3 regarding clinical history and some other details
4 relevant to the -- to the investigation.
5 Yeah, I think that's -- that would be part
6 of the SIDS protocol.
7 MS. SUZAN FRASER: All right.
8
9 (BRIEF PAUSE)
10
11 MS. SUZAN FRASER: I understood your
12 evidence yesterday that Ontario is lagging behind, and I
13 took that to be because of the coroner -- the arrangement
14 with the Coroner's Office, and for that reason, Ontario
15 is lacking -- or lagging behind in SIDS research, and
16 that is the -- the problem that was identified in terms
17 of research that came -- the prohibition against doing
18 research for medicolegal cases?
19 DR. ERNEST CUTZ: Yeah, it -- it is a --
20 it is part of -- part of the problem and I think there
21 are different approach in different jurisdiction.
22 MS. SUZAN FRASER: Yes.
23 DR. ERNEST CUTZ: And as I mentioned, in
24 the state of California -- and this was a specific
25 legislation enacted, which was actually supported by
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1 parents of -- of children who died of SIDS, they made it
2 happen, which then allows to develop, you know, a tissue
3 bank and investigate SIDS at a more sophisticated level,
4 using the modern methods of molecular pathology.
5 MS. SUZAN FRASER: All right. And is it
6 fair to say that the current state of affairs has got in
7 the way of good research on SIDS?
8 DR. ERNEST CUTZ: Well, I think there's
9 no research.
10 MS. SUZAN FRASER: All right. And if
11 there's no research, is it fair to say that it's hard to
12 develop Ontario standards if you don't have Ontario
13 research?
14 DR. ERNEST CUTZ: Well, it would --
15 desirable, I think, to -- to have it and I think, you
16 know, we have the resources at the Hospital for Sick
17 Children to do it.
18 MS. SUZAN FRASER: All right. Dr. Cutz,
19 are you familiar with the Paediatric Death Review
20 Committee from the Office of the Chief Coroner or
21 established by the Office of the Chief Coroner?
22 DR. ERNEST CUTZ: I heard about it, but
23 I'm not familiar with the details.
24 MS. SUZAN FRASER: All right. And I'm
25 just thinking of your Dextromethorphan case.
[Page 118]
1 DR. ERNEST CUTZ: Yes.
2 MS. SUZAN FRASER: And if, the Registrar,
3 if you could turn to Tab 79 of Volume II, and you should
4 have Volume II in front of you, I think. It's PFP056409.
5 You'll see in the fourth paragraph at the
6 bottom -- and this is the coroner's investigation
7 statement. It says:
8 "In addition, in the new year the
9 Paediatric Death Review Committee
10 intends to also bring this issue to the
11 attention of the medical profession at
12 large."
13 DR. ERNEST CUTZ: Yes.
14 MS. SUZAN FRASER: Do you see that, Dr.
15 Cutz?
16 DR. ERNEST CUTZ: Yes, mm-hm.
17 MS. SUZAN FRASER: And were you ever
18 invited to the Paediatric Death Review Committee to speak
19 about this case?
20 DR. ERNEST CUTZ: No, I was not.
21 MS. SUZAN FRASER: All right. And to the
22 best of your knowledge, were the lessons that you learned
23 in that case made available to the medical profession at
24 large?
25 DR. ERNEST CUTZ: I'm not sure if this
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1 particular case was -- was highlighted or -- or
2 advertised, but I think it -- it some -- you know, some
3 of these disorders are well-known in the pediatric
4 community.
5 MS. SUZAN FRASER: All right. And do you
6 agree with me that it's important, when lessons are
7 learned like this, that re -- that they be made
8 publically -- recommendations be made publically
9 available?
10 DR. ERNEST CUTZ: Yes, I think that would
11 be a logical conclusion. Now whether it was done in this
12 case or not, I'm not sure.
13 MS. SUZAN FRASER: All right. I thank
14 you, Mr. Commissioner, those are my questions.
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