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Inquiry into Pediatric Forensic Pathology in Ontario
December 21, 2007
Cross-examination of Dr. Joseph de Nanassy, Head, Division of Anatomical Pathology, Children's Hospital of Eastern Ontario (CHEO), Dr. Jean Michaud, past Head, Department of Pathology and Laboratory Medicine, Ottawa Hospital and CHEO, Dr. Blair Carpenter, Past Head, Division of Anatomical Pathology, CHEO, 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 21st 2007
25
. . . . .
[Page 18]
17 CROSS-EXAMINATION BY MS. SUZAN FRASER:
18 MS. SUZAN FRASER: Doctors, my name is
19 Suzan Fraser, and I'm here on behalf of an organization
20 called Defence for Children International, which is a
21 charitable organization founded in Geneva in 1979 and is
22 devoted promoting and protecting the rights of the child.
23 I have some questions flowing from your
24 evidence yesterday, which I read and listened to by
25 webcast. And I was struck, listening to your evidence by
[Page 19]
1 -- both on the memo, 631, which is the "think dirty" memo,
2 and on the recent changes regarding the medicolegal
3 autopsies -- as it seemed to me that in both of those
4 cases these were decisions that were made out of Toronto
5 or the -- the central office without consultation.
6 Am I right, Dr. Michaud, in understanding
7 that?
8 DR. JEAN MICHAUD: I cannot address the
9 first example that you gave, because I was not even in
10 Ontario --
11 MS. SUZAN FRASER: All right.
12 DR. JEAN MICHAUD: -- at that time.
13 MS. SUZAN FRASER: Yes.
14 DR. JEAN MICHAUD: The second one, Dr. de
15 Nanassy is the forensic pathologist at CHEO. He would
16 probably be in a better position to answer this. But the
17 fact is that we -- yes, we were never consulted for it.
18 MS. SUZAN FRASER: All right. And -- and,
19 Dr. Carpenter, was that the case with memo 631, that this
20 was something that was produced out of the Office of the
21 Chief Coroner without consultation?
22 DR. BLAIR CARPENTER: For the "dirty"
23 memo?
24 MS. SUZAN FRASER: Yes.
25 DR. BLAIR CARPENTER: No, I was not
[Page 20]
1 consulted on that. I -- I was told it exists and
2 explained what it meant and so on. I -- sorry. I -- I
3 was not involved in the decision of writing the memo and
4 the reason of why they did send the memo.
5 MS. SUZAN FRASER: All right. And it
6 seems to me that what that memo did was to import a
7 philosophy into a science.
8 Do you agree with me in my interpretation
9 of that?
10 DR. BLAIR CARPENTER: Yeah, I do agree
11 with you.
12 MS. SUZAN FRASER: All right.
13 DR. BLAIR CARPENTER: I -- I think it --
14 it tried to -- to show to the people -- the various
15 pathologists -- that they had to change their approach and
16 be more aggressive, more inclined to think that there was
17 something wrong underneath before saying there was
18 something right.
19 So the philosophy was to try and pick up
20 something wrong if it was there, or -- or at least try to
21 push at the issue.
22 I always looked at the autopsy and the
23 opposite side. You -- you want to rule out that was
24 something wrong, and then you say, Okay, the -- the child
25 died naturally.
[Page 21]
1 MS. SUZAN FRASER: Right.
2 DR. BLAIR CARPENTER: And only if it did
3 not that you say, Well, it was due to something that went
4 wrong. The -- to me the -- the mentality of the "dirty"
5 memo is to try and change that mentality.
6 Now, I think it's good if you send a memo
7 to people who do not realize that these cases exist. They
8 tend to be too nice and lenient towards the parents, or
9 the guardian, or whoever was responsible --
10 MS. SUZAN FRASER: But --
11 DR. BLAIR CARPENTER: -- for the child.
12 So you say to them, you put in face -- Think dirty, don't
13 think nice. You're goin -- those things exist. If you
14 look at it that way, it's a good memo.
15 On the other hand, the side effect is that
16 you maybe push a little too far and change the philosophy
17 of what I just mentioned.
18 MS. SUZAN FRASER: Right. But you -- I
19 think you'll agree with me that if there are particular
20 concerns about particular cases, where people have seemed
21 to have overlooked something or missed something, that
22 that should be addressed with the individual, correct?
23 DR. BLAIR CARPENTER: Well, I would --
24 MS. SUZAN FRASER: The pathologist who --
25 DR. BLAIR CARPENTER: If there was
[Page 22]
1 something wrong and something was missed, it has to be
2 looked upon and -- and try to see where the -- the
3 wrongdoing is.
4 MS. SUZAN FRASER: And would you also
5 agree with me that if you're trying to address a problem,
6 if there is a problem of people missing things, that
7 that's something that you really need to bring together
8 people about, rather than to dictate to people by memo?
9 DR. BLAIR CARPENTER: Well I don't think
10 it was dictated. That's a --
11 MS. SUZAN FRASER: All right.
12 DR. BLAIR CARPENTER: -- little too far.
13 It was written down to -- to stimulate people to think
14 that way. They didn't force people to do that. I don't
15 think so, at least not for in my case.
16 But I think it had to be brought forward.
17 Now to use the word, as you said, and put the emphasis on
18 it, it has a limit. And I guess it's proportionate to the
19 person who received the memo and what they wanted to do
20 with it.
21 MS. SUZAN FRASER: Right. Well I think
22 that's my concern, is that it seems to me we've heard
23 evidence both from Dr. Cutz, who was here, who I took it
24 as him say -- seeing the memo and -- and proceeding to do
25 what he had always done. And I -- I took a flavour of
[Page 23]
1 that from the evidence yesterday.
2 So it -- it just seemed to me, in terms of
3 decision-making style, contents of the memo aside, that if
4 you're trying to reach out to pathologists to address
5 concerns, that memo might not be the best way to do it.
6 And would you agree with me --
7 DR. BLAIR CARPENTER: I -- I can't really
8 say on that.
9 MS. SUZAN FRASER: All right.
10 DR. BLAIR CARPENTER: For me it was okay,
11 yet they -- it was a memo like another memo.
12 MS. SUZAN FRASER: All right. Yes, Dr.
13 Michaud?
14 DR. JEAN MICHAUD: Well as I mentioned
15 yesterday, I could not comment on the information -- or
16 consultation or lack of.
17 MS. SUZAN FRASER: Yes.
18 DR. JEAN MICHAUD: But I mentioned
19 yesterday that if I had seen that I would have reacted,
20 and I mentioned how I would have reacted.
21 As Dr. Carpenter said, this breaks the
22 philosophy that pathologists are used to work. We are
23 used to work with open minded. We have to be alert for
24 all fronts. To put emphasis on this it is shifting the
25 alertness on one side versus the other side.
[Page 24]
1 And second, as I mentioned yesterday, it
2 gives a negative colour to the work that -- that we do.
3 And finally I would say that this memo was
4 certainly not sent to pathologists only. I think the
5 message was probably more for other members of the inveg -
6 - investigation team --
7 MS. SUZAN FRASER: Right.
8 DR. JEAN MICHAUD: -- than just
9 pathologists.
10 MS. SUZAN FRASER: All right. All right.
11 I'll move on then. Just...
12
13 (BRIEF PAUSE)
14
15 MS. SUZAN FRASER: Dr. Michaud, you talked
16 about being in Quebec in the 1990s yesterday, and you
17 talked about an increasing awareness of child abuse in the
18 1990s.
19 And I think that the record will reflect
20 here, with some of the documents that have already been
21 filed with the Commission, that in Ontario there was a
22 similar development of our understanding and awareness of
23 child abuse.
24 And am I right in understanding your
25 evidence from yesterday that this awareness was really
[Page 25]
1 starting to come out in the mid-1990s?
2 DR. JEAN MICHAUD: I do not believe that I
3 phrased that exactly like this --
4 MS. SUZAN FRASER: You didn't say it that
5 way --
6 DR. JEAN MICHAUD: -- I was in -- in the
7 Province, it were -- between 1981 and 1997.
8 MS. SUZAN FRASER: Yes.
9 DR. JEAN MICHAUD: The awareness that --
10 that developed over the years, and certainly it was
11 already present in the '80s --
12 MS. SUZAN FRASER: Yes.
13 DR. JEAN MICHAUD: -- is that pediatric
14 autopsies had to be done in pediatric centres if we wanted
15 to get optimal results about the presence of true Sudden
16 Infant Death Syndrome --
17 MS. SUZAN FRASER: All right.
18 DR. JEAN MICHAUD: -- versus Sudden
19 Unexpected Death with identifiable causes.
20 MS. SUZAN FRASER: Yes.
21 DR. JEAN MICHAUD: If you -- you will
22 recall that following questioning by Ms. McAleer, that the
23 histology part of the autopsy in pediatric forensic
24 pathology has an importance that may not be as great as in
25 adult forensic pathology, for example.
[Page 26]
1 MS. SUZAN FRASER: Yes.
2 DR. JEAN MICHAUD: So I -- I believe that
3 the awareness that developed over the years in the
4 province was then enhanced role of pediatric pathology in
5 the proceeding of forensic -- pediatric forensic cases.
6 I do not believe that we became more aware
7 of --
8 MS. SUZAN FRASER: I see.
9 DR. JEAN MICHAUD: -- child abuse --
10 MS. SUZAN FRASER: I see.
11 DR. JEAN MICHAUD: -- in those years,
12 because I believe we had been aware of that all along.
13 MS. SUZAN FRASER: Okay. So I've come to
14 think of the SIDS case, or the Sudden Unexpected Death
15 Under Two, as being a real chicken and egg problem for
16 pathologists, because there's been a discussion here that
17 criminally suspicious cases should go to a forensic
18 pathologist.
19 And the pediatric pathologists tell us that
20 in the case of a Sudden Unexpected Death, that we don't
21 know whether it's criminally suspicious until we do the
22 autopsy.
23 These are very difficult cases, and there's
24 a huge work up. Dr. Carpenter, am I right that this is a
25 bit of a chicken and egg problem?
[Page 27]
1 DR. BLAIR CARPENTER: Well I don't know if
2 it's a chicken and an egg, but obviously if -- if it's a
3 sudden death unexpected at home, obviously you don't know
4 what the -- the cause is before you do the autopsy.
5 So it's -- it could be suspicious, or it
6 may not be suspicious. But it has to be suspicious to
7 start with because you don't know. So -- but it's not --
8 I think then you -- you have to work it up in --
9 MS. SUZAN FRASER: All right. So we're
10 talking about where there have been suggestions made about
11 a second doctor.
12 In terms of -- it seems to me that in
13 pediatric cases, with the SIDS cases being the most
14 difficult, that that might be a case where there -- that
15 you ought to have the pediatric pathologist and the
16 forensic pathologist working together, where there no
17 issue of wound interpretation, but it really is a sort of
18 classic SIDS case?
19 DR. JEAN MICHAUD: I -- I may -- I may
20 just say that SIDS cases are not difficult.
21 MS. SUZAN FRASER: All right.
22 DR. JEAN MICHAUD: This is our routine.
23 MS. SUZAN FRASER: All right.
24 DR. JEAN MICHAUD: This is routine work
25 for us.
[Page 28]
1 MS. SUZAN FRASER: Yes.
2 DR. JEAN MICHAUD: Okay? They may be --
3 they may be get complicated or difficult if we find
4 something that is unexpected or something. But SIDS cases
5 are part of our -- the routine work of a pediatric
6 hospital. And so I would not label them as difficult.
7 Our role is to ensure that there is nothing behind --
8 MS. SUZAN FRASER: Yes.
9 DR. JEAN MICHAUD: -- the sepsis,
10 congenital malformation, or something else that would take
11 these cases out of the SIDS category, that would help the
12 family to understand why this thing happened --
13 MS. SUZAN FRASER: All right.
14 DR. JEAN MICHAUD: -- because this is a
15 very important element. In fact, in SIDS cases we help
16 much more the family than we help the judicial system.
17 But we help the judicial system also by saying, This
18 autopsy does not show anything, okay.
19 And so with the other elements of the
20 investigation, at the end of the day you may say, This is
21 a Sudden Infant Death Syndrome or this is a Sudden
22 Unexpected Death related to, I don't know, poor bed
23 arrangement or things like this.
24 But for us it's routine. It's routine
25 work.
[Page 29]
1 MS. SUZAN FRASER: All right.
2 DR. BLAIR CARPENTER: And --
3 MS. SUZAN FRASER: So those cases prop --
4 in your opinion, Dr. Michaud, properly belong with the
5 pediatric pathologist?
6 DR. JEAN MICHAUD: Oh, definitely.
7 DR. BLAIR CARPENTER: If -- if anything,
8 they're difficult for non-pediatric pathologists. It's
9 the reverse of your question. When it comes to a
10 pediatric pathologist, they are routine. They -- they are
11 simple case. It's when you are not a pediatric pathologist
12 that you try to avoid those sudden infant deaths in those
13 case.
14 And that's why they can't just send them to
15 us and not us to them. I mean, it's the other side
16 around. It's the forensic pathologists are quite happy to
17 -- to have the case done by a pediatric pathologist.
18 MS. SUZAN FRASER: All right.
19 DR. BLAIR CARPENTER: In my experience,
20 anyhow.
21 MS. SUZAN FRASER: And just -- I want to
22 just -- Dr. Michaud, Dr. Cutz was here earlier this week
23 from the Hospital for Sick Children. And he talked about
24 the fact that in terms of SIDS research that it had --
25 there wasn't really much going on in the way of SIDS
[Page 30]
1 research.
2 And is the situation the same in Eastern
3 Ontario?
4 DR. JEAN MICHAUD: Research on SIDS, I
5 think, has been done over the last, I would say, twenty
6 (20), twenty-five (25) years. And I must say that the
7 Toronto Sick Kids is a place where a good amount of
8 research was done on SIDS.
9 MS. SUZAN FRASER: Yes.
10 DR. JEAN MICHAUD: Dr. Larry Becker took
11 part -- and his team took a good hint at problems related
12 to SIDS in -- as early as the '80s. And, in fact, he was
13 consulted by the Jeremy Rill Centre. You know this
14 publication we were mentioning yesterday?
15 MS. SUZAN FRASER: Yes.
16 DR. JEAN MICHAUD: He was, at some point,
17 invited and he was consulted by -- by this centre about
18 his research and so on. Dr. Cutz, himself, has done some
19 research through his expertise in lung pathology and so
20 on. There is a good deal of research being done also in
21 Boston by Dr. McKinney's (phonetic) group. So there is
22 some research going on.
23 But I think it just illustrates we don't
24 have -- there is no frontier that was -- that were broken
25 in -- in this avenue. Dr. Aurore Cote and myself, we have
[Page 31]
1 demonstrated, in the '80s, that there were some changes
2 that could be linked an ischemic changes.
3 And I believe that the notion of global
4 ischemia coming in these case is, you know, a fact that is
5 accepted by a number of individuals as -- no, there --
6 there is no real answer.
7 It's a complex problem. The brain a
8 complex organ, and there -- there are still a lot of work
9 to do, probably.
10 MS. SUZAN FRASER: All right.
11 DR. BLAIR CARPENTER: Personally, I think
12 it's -- it's expressed more the frustration of not having
13 found the answer, than the lack of people looking for the
14 answer. When you look and you look and you don't find,
15 and you don't have the answer, you always tend to be
16 frustrated and say, If we had more this, more this, or
17 more research or more people or more money or more -- we
18 would maybe get the answer.
19 But that is just again, human nature
20 responding to a frustrating situation. Where after all
21 these years SID is still at the level of not being
22 completely understood.
23 MS. SUZAN FRASER: I think you -- his
24 concern, and I'm -- I'm finishing up here, Mr.
25 Commissioner, but I think his concern as I understood it
[Page 32]
1 was that changes in the coroner's system, in terms of the
2 availability to study tissue, had a negative impact on the
3 ability to conduct research, and that -- that the research
4 had -- for, in part that and other reasons really ground
5 to a halt in Ontario.
6 Is that something that you --
7 DR. BLAIR CARPENTER: I can't comment. I
8 suppose that's an experience Dr. Cutz had.
9 MS. SUZAN FRASER: Yes.
10 DR. BLAIR CARPENTER: And he expressed his
11 -- his experience, his frustration, his knowledge, you
12 call it whatever you want, on the subject. It's not an
13 issue that we have met, but again, we did not look for it.
14 MS. SUZAN FRASER: Okay.
15 DR. JEAN MICHAUD: I have a comment on
16 this.
17 MS. SUZAN FRASER: Yes?
18 DR. JEAN MICHAUD: I think that Dr. Cutz
19 concern is real, that's my personal opinion. I believe
20 that it's due to the fact that it's essentially impossible
21 to get samples for research out of a coroner's system
22 network.
23 I've had discussion with Bill Bechard
24 (phonetic). In the early years I was in Ottawa, there was
25 a need to proceed to perhaps some sampling on some of
[Page 33]
1 those cases, and we were told -- no, I don't recall the
2 specifics of that, but you know, this -- this is a
3 concern.
4 MS. SUZAN FRASER: All right. And when --
5 DR. JEAN MICHAUD: You would have to make
6 a deal with the coroner's system and -- and you know,
7 through legislations and so on to get -- get access to
8 some tissue. It's not totally clear to us, but this is a
9 concern that in my view would be -- would be real.
10 MS. SUZAN FRASER: And -- and is that to
11 be contrasted where you have a family and it doesn't
12 become a coroner's case, and they consent to you using the
13 tissue to conduct research, versus a coroner's system
14 where --
15 DR. JEAN MICHAUD: Well, when -- when you
16 conduct research in hospital, you have to have a -- an
17 approval by the Research Ethics Committee --
18 MS. SUZAN FRASER: Yes.
19 DR. JEAN MICHAUD: -- and once you have
20 that, yes, you can obtain consents from family to take
21 some samples and conduct the research. So you have to
22 have a decent research project, it has to be
23 scientifically sound. The output of the possible research
24 needs to be useful, either for more basic research or for
25 clinical research, applied research and so on. So you
[Page 34]
1 need a consent.
2 And the coroner's system, I do not believe
3 that it's possible at this point in time, but I honestly
4 do not all -- know all the -- the details of that, but I
5 don't believe it is possible.
6 MS. SUZAN FRASER: All right. Thank you.
7 Those are my questions, Mr. Commissioner.
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