Inquiry into Pediatric Forensic Pathology in Ontario
January 18, 2008



Cross-examination of Dr. David Dexter, Dr. Chitra Rao and Dr. Michael Shkrum, Regional Pathology Units, 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 January 18th, 2008
25

                            . . . . .

[Page 131]

7 CROSS-EXAMINATION BY MS. SUZAN FRASER:
8 MS. SUZAN FRASER: Thank you, Mr.
9 Commissioner. Doctors, my name is Sue Fraser and I'm
10 here on behalf of a children's rights organisation called
11 Defence for Children International, which is an
12 international movement in support of children's rights.
13 Dr. Shkrum, yesterday you spoke very
14 briefly about the 10 percent of cases in deaths under
15 five (5) where you would follow a protocol to rule out
16 suspicious trauma, and I just wanted to --
17 DR. MICHAEL SHKRUM: Not 10 percent, but
18 all -- all deaths under five (5).
19 MS. SUZAN FRASER: All deaths under five
20 (5). And just --
21 DR. MICHAEL SHKRUM: With some
22 exceptions.
23 MS. SUZAN FRASER: All right. And the
24 protocol I understood you to be speaking about is the
25 protocol established by the Office of the Chief Coroner.


[Page 132]

1 Is that correct, or is --
2 DR. MICHAEL SHKRUM: Yes, it goes back to
3 memorandum 631.
4 MS. SUZAN FRASER: All right. All right.
5 And I just wanted to clear that up. I'm going to move to
6 a discussion, and Dr. Dexter, I'll probably leave you out
7 of this since I don't -- I understand you don't have
8 experience with the committees, but I had some questions
9 for you about your experiences with the Paediatric Death
10 Review Committee and the Death Under Five Committee.
11 And, Dr. Rao, I understand that you did,
12 in the early -- or in the late 1980s, attend
13 approximately three (3) meetings of the Paediatric Death
14 Review Committee.
15 Is that correct?
16 DR. CHITRA RAO: That's correct.
17 MS. SUZAN FRASER: And I understand that
18 you had met Dr. Cairns at a meeting of the American
19 Academy of Forensic Sciences and, at the time, the
20 Committee was updating its protocol on autopsy
21 procedures.
22 Is that correct?
23 DR. CHITRA RAO: That's correct. At that
24 time it was a protocol for pediatric deaths under two
25 (2).


[Page 133]

1 MS. SUZAN FRASER: All right. And had
2 you met Dr. Cairns before that?
3 DR. CHITRA RAO: Oh, yes.
4 MS. SUZAN FRASER: Okay. Okay, so it
5 just happened you were both there and you had --
6 DR. CHITRA RAO: Correct.
7 MS. SUZAN FRASER: -- this discussion and
8 that led to the invitation to come to the Paediatric
9 Death Review Committee.
10 DR. CHITRA RAO: That's correct.
11 MS. SUZAN FRASER: All right. And you
12 did assist them in terms of, not the death investigation
13 protocol, but a protocol about what procedures are to be
14 taken in pediatric autopsies.
15 DR. CHITRA RAO: That's correct.
16 MS. SUZAN FRASER: All right. And I
17 understand that you did not attend the Paediatric Death
18 Re -- Review Committee after that.
19 DR. CHITRA RAO: No.
20 MS. SUZAN FRASER: All right. I
21 understand that you're -- and I'm -- I know that there
22 are -- you're -- you've currently been invited to attend
23 at the Death Under Five Committee, so I sort of wanted to
24 talk a little bit about the past before I get to what's
25 currently the situation, if I may.


[Page 134]

1 And I understand that when you do a
2 pediatric post-mortem report, that you send that report
3 to your Regional Supervising Coroner, is that correct?
4 DR. CHITRA RAO: That would be in the
5 past, yes.
6 MS. SUZAN FRASER: All right. And that
7 that pediatric -- or the Regional Supervising Coroner
8 would then send that under the death -- to the Death
9 Under Five Committee.
10 DR. CHITRA RAO: That's correct. At that
11 time -- are you talking about the past or the present?
12 MS. SUZAN FRASER: In the past.
13 DR. CHITRA RAO: Past is under two (2) --
14 under two (2).
15 MS. SUZAN FRASER: All right.
16 DR. CHITRA RAO: And then again they have
17 two (2) committee; one (1) Paediatric Death Review
18 Committee, and another was Review Committee Under Two.
19 MS. SUZAN FRASER: Right.
20 DR. CHITRA RAO: So, they will send the
21 report, yes.
22 MS. SUZAN FRASER: All right. So in the
23 -- before the establishment of the Death Under Two
24 Committee ,you only had the Paediatric Death Review
25 Committee, as I understand it.


[Page 135]

1 DR. CHITRA RAO: Yes.
2 MS. SUZAN FRASER: All right. And so
3 later on you were sending those reports either to the
4 Death Under Two and what's now the Death Under Five
5 Committee.
6 DR. CHITRA RAO: I wasn't sending, but
7 the report was forwarded through the Regional Supervising
8 Coroner.
9 MS. SUZAN FRASER: Right. And I take it
10 that you were never invited to the Committee to discuss
11 your decisions and the pathology and the autopsy work.
12 Is that fair?
13 DR. CHITRA RAO: That's correct.
14 MS. SUZAN FRASER: All right. So the
15 Committee -- the Death Under Five or the Death Under Two
16 or whatever committee was discussed in the post-mortem
17 report -- would have this discussion about the cause and
18 manner of death in absence of the pathologist who
19 actually did the autopsy.
20 DR. CHITRA RAO: That's correct.
21 MS. SUZAN FRASER: All right. And I take
22 it that there would have been some benefit for you,
23 personally, to attend those meetings to understand what
24 the discussion and the concerns might be or -- or what
25 the Committee thought of the report.


[Page 136]

1 DR. CHITRA RAO: Yeah, there's a benefit
2 to that. And even -- even if you don't attend, if you
3 have a report summation saying what took place; whether
4 they agreed with our opinion or if there is a difference
5 of opinion, we would like to hear that. But,
6 unfortunately, in the past, we have had no communication
7 to that effect.
8 Or if -- if we ask the Regional
9 Supervising Coroner what has happened, they'll say, oh,
10 the -- you know, satisfactory or that was okay, no
11 concern. But even if there's no concern, we would have
12 liked to know what it is.
13 MS. SUZAN FRASER: Okay. Okay, and Dr.
14 Shkrum, are your experiences the same?
15 DR. MICHAEL SHKRUM: Well, I've only had
16 -- I've attended one (1) meeting of the Death Under Five
17 Committee.
18 MS. SUZAN FRASER: I'm sorry, I didn't --
19 I didn't hear that.
20 DR. MICHAEL SHKRUM: I -- I've only
21 attended one (1) meeting of the Death Under Five
22 Committee.
23 MS. SUZAN FRASER: All right.
24 DR. MICHAEL SHKRUM: That was in
25 December. And again, I -- I asked Dr. Pollanen whether


[Page 137]

1 we could have some, you know, further educational
2 opportunities to -- for -- for pediatric forensic
3 pathology -- pathology, and he thought it would be a good
4 idea to have Dr. -- Drs. Rao and I participate in that
5 committee.
6 Also, to actually alleviate some of his
7 workload, so we would rotate on a rotational basis.
8 MS. SUZAN FRASER: You're not the first
9 person to express the concern about the workload that Dr.
10 Pollanen's taking on.
11 DR. MICHAEL SHKRUM: He has a lot of work
12 to do.
13 MS. SUZAN FRASER: All right.
14 DR. MICHAEL SHKRUM: In -- in the past
15 though, and similar to Dr. Rao's experience, I -- I did
16 ask a number of years ago a member of that -- of that
17 committee, and I -- again, I can't recall who it was, so
18 I don't want to make the wrong attribution, but I asked -
19 - you know, we don't get any feedback from that committee
20 regarding our work.
21 And the reply was, Well, we have -- your -
22 - your work is fine, there are large problems in the
23 Province.
24 MS. SUZAN FRASER: All right. One (1) of
25 the issues that my client has raised is that in -- in


[Page 138]

1 different forms, is that we don't know the work that the
2 Pediatric Death Review Committee is doing until it
3 produces a report, and it doesn't report on all of its
4 cases.
5 Would you, as pathologists, find a benefit
6 to having regular reporting on the types of discas --
7 cases that are discussed and the problems either in the
8 pathology or the discussions that they have.
9 Would that be useful to you, as
10 pathologists?
11 DR. CHITRA RAO: Yes, it's useful.
12 MS. SUZAN FRASER: Dr. Dexter's nodding
13 his head.
14 DR. DAVID DEXTER: Yes, I am.
15 DR. CHITRA RAO: Yes, it's useful. And
16 that report -- sorry.
17 DR. MICHAEL SHKRUM: I'm sorry, go ahead.
18 DR. CHITRA RAO: -- that copy of that
19 report can also go into our file, so in future in ten
20 (10) years time, somebody else is reviewing, so all the
21 facts will be in that file.
22 MS. SUZAN FRASER: All right.
23 DR. MICHAEL SHKRUM: Besides that would
24 be very helpful.
25 MS. SUZAN FRASER: All right. So not


[Page 139]

1 just your own cases, but what's going on in cases of
2 other pathologists or other cases that are going before
3 the -- either the Death Under Five Committee or the
4 Pediatric Death Review Committee?
5 DR. CHITRA RAO: The pathologist who is
6 responsible for the autopsy case should be notified of
7 the committee's finding.
8 DR. MICHAEL SHKRUM: But I think, as a
9 general principle of education, there should be some
10 feedback, if there -- you know, there are -- there are
11 issues that are being discussed during that meeting that
12 impact on our practices, in a general way, we should be
13 informed about it.
14 MS. SUZAN FRASER: It -- it seems to me
15 it's already a sort of built-in peer review, except that
16 the feedback's not getting back to the pathologist.
17 Is that fair?
18 DR. MICHAEL SHKRUM: Well, my experience
19 at this meeting -- I mean, there were issues raised
20 regarding other pathologist's report, and my
21 understanding there would be some type of feedback that
22 would be given to them by the committee.
23 MS. SUZAN FRASER: All right. And you're
24 currently, Dr. Shkrum and Dr. Rao, you've been invited to
25 participate in the Death Under Five Committee, and Dr.


[Page 140]

1 Shkrum you -- you talked about how you had those
2 discussions with Dr. Pollanen.
3 And I understand that that's on a
4 rotational basis with one (1) of you attending every
5 three (3) months, is that...?
6 DR. CHITRA RAO: Yes, Dr. Michael Shkrum
7 attended in December. I've been asked to attend in
8 February.
9 MS. SUZAN FRASER: All right. And prior
10 to you attending there, the -- the pathologists who
11 formed part of that committee were all from the Toronto
12 area.
13 Is that correct?
14 DR. CHITRA RAO: Most of the committee
15 members were -- consisted of people from the Toronto
16 unit, that's correct.
17 DR. MICHAEL SHKRUM: Yes.
18 MS. SUZAN FRASER: All right. All right.
19 Just want to turn briefly to the guidelines for
20 criminally suspicious deaths in infancy. And that's at
21 Tab -- and that's part of the general October 2007
22 protocol. You'll find it at Tab 2 -- sorry, Tab --
23 DR. CHITRA RAO: Volume.
24 MS. SUZAN FRASER: 53. Volume II, Tab
25 53. Pardon me. And that's PFP139350. So just looking


[Page 141]

1 at the first page; this, I understand, as what you
2 identified as being the current practice. And if we
3 could turn, Mr. Registrar, to page 35.
4 DR. MICHAEL SHKRUM: And understand that
5 these are not standards of practice, they -- they are
6 guidelines. I'm -- I'm sure that's been pointed out
7 already.
8 MS. SUZAN FRASER: Right.
9 DR. CHITRA RAO: And it's -- made it very
10 clear that the individual pathologist can choose --
11 DR. MICHAEL SHKRUM: Mm-hm.
12 DR. CHITRA RAO: -- you know, their way
13 of doing, but as long as we have the general principle of
14 it.
15 MS. SUZAN FRASER: All right. And these
16 guidelines, are they helpful to you, Dr. Rao?
17 DR. CHITRA RAO: Yes.
18 MS. SUZAN FRASER: All right. Dr.
19 Shkrum...?
20 DR. MICHAEL SHKRUM: Yes.
21 MS. SUZAN FRASER: All right. And if you
22 could turn -- I'm at the portion, you'll see on page 35,
23 with homicidal or criminally suspicious in infancy or
24 childhood. And I just wanted to turn the page to the
25 section that deals with the special challenges of


[Page 142]

1 pediatric forensic pathology that are set out at 45.4.
2 So that's on page 36 of that document.
3 DR. CHITRA RAO: Yes.
4 MS. SUZAN FRASER: And all of these
5 things, from the lay perspective, sound good to me, but I
6 want to know whether they speak to you as pathologists in
7 terms of you understanding what is meant by them. I
8 understand you've had some involvement and consultation
9 with respect to that.
10 So just looking at the pathology of the
11 different forms of acute and chronic physical and child
12 abuse, is that something that you understand as being
13 established into the literature as to what that pathology
14 is?
15 DR. CHITRA RAO: Yes.
16 DR. MICHAEL SHKRUM: Yes.
17 MS. SUZAN FRASER: And the pathology of
18 neglect and starvation, that is something that you as
19 pathologists understand what your looking for? There's a
20 general consensus on those issues?
21 DR. CHITRA RAO: Yes.
22 DR. MICHAEL SHKRUM: Yes.
23 MS. SUZAN FRASER: All right. And the
24 evolving nature of forensic pathology of infantile head
25 injury including the so called Shaken Baby Syndrome, what


[Page 143]

1 does that mean to you, Dr. Rao?
2 DR. CHITRA RAO: There are many cases
3 where a child can develop subdural hemorrhage. Every
4 subdural hemorrhage doesn't have to be Shaken Baby
5 Syndrome. And sometimes you also infantile -- during
6 difficult childbirth, the child can have some forms of
7 evidence of brain injuries.
8 So one has to take that into
9 consideration. And what it says is you know, you have to
10 know the background information and then correlate that
11 information with the autopsy findings and then come to a
12 correct conclusion of the case.
13 MS. SUZAN FRASER: All right. And I take
14 it that each of the -- the special challenges identify
15 sort of particular frailties of pediatric forensic
16 pathology, challenges that you might face in terms of
17 your decision making, and these point you to what you
18 need to be alive to, is that fair?
19 DR. CHITRA RAO: That's fair.
20 DR. MICHAEL SHKRUM: Yes.
21 MS. SUZAN FRASER: Okay. And just
22 finally, you talked a little this morning about
23 practising in isolation, and now that -- that there's a
24 change. And I take it, having listened to your evidence
25 over the course of two (2) -- or a day and a half now,


[Page 144]

1 that part of that is the development of the Regional
2 Forensic Pathology Units, that's -- that's part of moving
3 out of isolation, is that fair?
4 DR. CHITRA RAO: Yes.
5 DR. MICHAEL SHKRUM: Yes.
6 MS. SUZAN FRASER: Another factor would
7 be changes from the Toronto Office or the Chief Forensic
8 Pathologist that involves pathologists outside of
9 Toronto, is that fair?
10 DR. MICHAEL SHKRUM: Yes.
11 DR. DAVID DEXTER: Yes.
12 DR. CHITRA RAO: Yes.
13 MS. SUZAN FRASER: Okay. Dr. Dexter, can
14 you -- do you share that, that the practice has become
15 less iso -- isolationist and more collegial?
16 DR. DAVID DEXTER: Absolutely. And this
17 has been most marked since Dr. Michael Pollanen was
18 appointed.
19 MS. SUZAN FRASER: All right.
20 DR. DAVID DEXTER: He's made very -- very
21 strong efforts to do that. He's visited our unit, for
22 example, and spent a day educating us and seeing our
23 facilities and so forth.
24 He's reached out in many different ways.
25 MS. SUZAN FRASER: All right. And are


[Page 145]

1 there other factors that you would identify, Dr. Rao?
2 DR. CHITRA RAO: Factors in relation to?
3 MS. SUZAN FRASER: In terms of the
4 change. You -- you -- I think you spoke positively about
5 the changes --
6 DR. CHITRA RAO: That's correct.
7 MS. SUZAN FRASER: -- that are occurring,
8 and I want to just -- if you wanted to identify any other
9 things that you think help in terms of making the
10 practice of forensic pathology more collegial and more
11 instructive to you, so that you benefit, or --
12 DR. CHITRA RAO: Yes. I think Dr. Shkrum
13 had highlighted earlier that we have to have more
14 education courses concerning pediatric forensic
15 pathology. And then especially when a matter comes up
16 such as Shaken Baby Syndrome where there's so much
17 controversy, we have to be exposed to that and a decision
18 has to be made. Where do we stand on this?
19 MS. SUZAN FRASER: All right.
20 DR. CHITRA RAO: And it should be a
21 uniform -- uniformity across the province.
22 MS. SUZAN FRASER: And so what I -- I
23 think I hear you're say -- what you're saying is that you
24 would benefit from further development of consensus type
25 statements within the Ontario pathologists of how to


[Page 146]

1 approach particular problems; dilemmas that you might
2 face like what to do with confessions, sort of, on the
3 practical side as -- and also on the scientific side, is
4 that fair?
5 DR. CHITRA RAO: That's correct.
6 DR. DAVID DEXTER: Yes. Yes.
7 DR. MICHAEL SHKRUM: In a sense, these
8 guidelines are a consensus. They're the consensus built
9 up amongst forensic pathologist in the province, but
10 there may be some consensus required on legal issues such
11 as confessions.
12 MS. SUZAN FRASER: All right. Thank you
13 very much for your -- your answers, and thank you very
14 much for -- for the work that you do on behalf of my
15 client.
16 DR. MICHAEL SHKRUM: Thank you.
17 MS. SUZAN FRASER: I'd like to extend
18 that, thank you.
19 DR. DAVID DEXTER: Thank you.
20 DR. CHITRA RAO: Thank you.