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Inquiry into Pediatric Forensic Pathology in Ontario
January 8, 2008
Cross-examination of Dr. Bill Lucas, Dr. James Edwards, Dr. Albert Lauwers, Regional Supervising Coroners, 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 8th 2008
25
. . . . .
[Page 181]
9 CROSS-EXAMINATION BY MS. SUZAN FRASER:
10 MS. SUZAN FRASER: Thank you, Mr.
11 Commissioner.
12 Dr. Lucas, Dr. Lauwers, and Dr. Edwards,
13 my name is Sue Fraser and I'm here on behalf of an
14 organisation called Defence for Children International,
15 which Dr. Lucas knows from in inquest that we were
16 involved, but -- which is children's rights organisation
17 and it's goal is to promote and protect the rights of the
18 child as set out in the UN convention on the rights of
19 the child.
20 So I wanted to pick up on Ms. Craig's
21 questions earlier, before the lunch break, and those
22 questions relating to the need for there to review -- of
23 your review of other cases.
24 And I think you'll all agree that where
25 evidence, pathology evidence, is used in criminal justice
[Page 182]
1 proceedings, it's also used in child protection
2 proceedings.
3 Correct, Dr. Lucas?
4 DR. WILLIAM LUCAS: That would make
5 sense.
6 MS. SUZAN FRASER: All right. And are
7 you aware of any cases where pathology evidence -- we've
8 heard pathologists give evidence that they do also give
9 evidence in child protection proceedings.
10 Are you aware where some of the pathology
11 evidence is -- in question in these cases, has also been
12 used in child protection matters?
13 DR. WILLIAM LUCAS: From my own personal
14 experience, I can't say that I am.
15 MS. SUZAN FRASER: All right.
16 DR. WILLIAM LUCAS: Because that's not
17 something that I would routinely be involved in.
18 MS. SUZAN FRASER: All right. But I
19 think that if you -- you can agree with me that if the
20 same pathology evidence was used in another matter, that
21 there may be a similar moral, ethical, and legal
22 obligation to children who might have been separated from
23 their families, their parents, their grandparents as a
24 result of -- result of flawed pathology evidence, for us
25 as a society to review those child protection
[Page 183]
1 proceedings.
2 Would you agree with that point, Dr.
3 Lucas?
4 DR. WILLIAM LUCAS: I would agree with
5 that in principle, yes.
6 MS. SUZAN FRASER: And Dr. Lauwers...?
7 DR. ALBERT LAUWERS: I would agree with
8 that in principle.
9 MS. SUZAN FRASER: Dr. Edwards...?
10 DR. JAMES EDWARDS: Yeah, likewise.
11 MS. SUZAN FRASER: All right. There's no
12 real reason to say that they should be reviewed in the
13 one (1) case, rather than the other. And obviously these
14 are difficult rema -- cases to review.
15 Would you agree with me that it may be
16 that the Minister of Children and Youth Services might be
17 in the best position to review child welfare files where
18 pathology evidence has to determine where and when
19 pathology evidence has been used?
20 Dr. Lucas...?
21 DR. WILLIAM LUCAS: In terms of who would
22 have jurisdiction over that, it -- it -- that makes
23 sense.
24 MS. SUZAN FRASER: All right.
25 DR. WILLIAM LUCAS: Whether that minister
[Page 184]
1 would have the expertise to assess that --
2 MS. SUZAN FRASER: I'm just talking --
3 DR. WILLIAM LUCAS: -- but -- okay.
4 MS. SUZAN FRASER: Sorry. I'm just
5 talking about actually trying to identify where the
6 evidence -- the first question being, where was the
7 evidence used, because we've heard that there's no way of
8 tracking that.
9 And I take it you'll agree with me that
10 there's no way, with -- at least within the Coroner's
11 Office, that information is tracked?
12 DR. WILLIAM LUCAS: Correct.
13 MS. SUZAN FRASER: All right. And so,
14 just in terms of identifying where and when that evidence
15 is used, it -- it may be that the Minister or an
16 organisation that's not the Coroner's Office is in the
17 best -- best position to do that.
18 DR. WILLIAM LUCAS: I -- I wouldn't
19 refute that.
20 MS. SUZAN FRASER: All right.
21 DR. WILLIAM LUCAS: I mean that sounds
22 reasonable.
23 MS. SUZAN FRASER: All right. And, Dr.
24 Edwards, you look --
25 DR. JAMES EDWARDS: I -- I just -- I mean
[Page 185]
1 I would agree with your general proposition that the best
2 organisation to deal with any legal proceedings that
3 arose that included in -- information that was -- that
4 came from the Coroner's Office would not be the Coroner's
5 Office. But I'm not really clear on where you -- what
6 you're -- if you're talking about going -- going forward
7 or looking back or...
8 MS. SUZAN FRASER: All right, I'll back
9 up a bit. Working from the hypothetical that there may
10 be some flawed path -- patha -- pathological evidence,
11 we're all working from that assumption, is that fair?
12 DR. JAMES EDWARDS: Okay.
13 MS. SUZAN FRASER: All right. And it's
14 fair to say that we may have a fairly good understanding
15 based on research that the Commission has done that
16 pathology evidence is used in child protection
17 proceedings.
18 All right. And you're all nodding your
19 heads, so -- that's good.
20 So then the question for us is that -- is
21 then that, how do we identify where and when that
22 evidence was used? And I understand that the Coroner's
23 Office doesn't currently track where pathology evidence
24 is given in child protection proceedings, fair?
25 DR. WILLIAM LUCAS: And -- and that's
[Page 186]
1 correct, yeah.
2 MS. SUZAN FRASER: All right. So one (1)
3 of the challenges in terms of identifying whether pathol
4 -- whether flawed pathology may have resulted in a
5 wrongful separation of a child from a parent or a child
6 from a caregiver is first to identify where and when that
7 evidence has been used, fair?
8 DR. WILLIAM LUCAS: Sure.
9 MS. SUZAN FRASER: And then it may be
10 that we have to engage other people like a Dr. Butt or
11 somebody else to review whether that had an impact,
12 whether there were other factors that lead to the
13 apprehension.
14 Fair enough?
15 DR. WILLIAM LUCAS: That's fair.
16 MS. SUZAN FRASER: Dr. -- Dr. Lauwers,
17 did you want to...?
18 DR. ALBERT LAUWERS: I'm just listening
19 carefully.
20 MS. SUZAN FRASER: Okay, okay. And then
21 society as a whole, and this doesn't really depend on
22 your expertise, has to think about a way that what you do
23 if you come to the conclusion that somebody may have been
24 wrongfully separated from a parent?
25 DR. WILLIAM LUCAS: Mm-hm.
[Page 187]
1 MS. SUZAN FRASER: And that's a -- a
2 different and very difficult question to answer as to
3 what comes next.
4 Fair enough?
5 DR. WILLIAM LUCAS: Mm-hm.
6 MS. SUZAN FRASER: All right. And do you
7 understand that the public in terms of the way that
8 medical evidence, pathology evidence, other evidence is
9 used that the public looks to the coroners to be their
10 guardians in a certain -- to -- to sort of identify where
11 there's problematic evidence and that -- that there's a
12 certain amount of public confidence or trust that the --
13 the public has given to coroners to help prevent flawed
14 pathology evidence being used in criminal proceedings?
15 DR. JAMES EDWARDS: I think we have a --
16 a definite concern about the quality of the product that
17 comes out of our office. I mean, there's no question
18 about that. Now, what -- what people do with that
19 product is another matter all together.
20 MS. SUZAN FRASER: All right.
21 DR. JAMES EDWARDS: And there's --
22 there's -- those are sort of two (2) distinct --
23 distinctly --
24 MS. SUZAN FRASER: You've put it a much
25 better way than I did, Dr. Edwards. What I'm talking
[Page 188]
1 about is that the public trusts the medical person to say
2 -- to -- to review that product and to say, what's coming
3 out my office is good product.
4 DR. ALBERT LAUWERS: Oh, yeah, that's
5 right.
6 MS. SUZAN FRASER: And you understand --
7 DR. ALBERT LAUWERS: No question.
8 MS. SUZAN FRASER: -- you understand that
9 you hold that public trust?
10 DR. ALBERT LAUWERS: Yes.
11 DR. JAMES EDWARDS: Yes.
12 MS. SUZAN FRASER: All right.
13 DR. WILLIAM LUCAS: I agree with that.
14 MS. SUZAN FRASER: And you also
15 understand as three (3) men who are sort of going forward
16 in a time that that public confidence is -- is low, at
17 the moment?
18 DR. ALBERT LAUWERS: We understand that,
19 yeah.
20 MS. SUZAN FRASER: All right. I want to
21 turn then to one (1) of the other components of the death
22 investigation, which is the inquest system. And I'm --
23 I'm going to just put some questions for no particular
24 reasons to Dr. Lucas.
25 But, Dr. Lucas, the Law Reform Commission
[Page 189]
1 and the Court have identified three (3) general purposes
2 of an inquest, and those being the -- a means of a public
3 ascertainment of the death, a means of formally focussing
4 community attention, and on initiating community
5 attention and community response to preventable deaths,
6 and a means of satisfying the community that no death
7 have been overlooked, concealed, or ignored.
8 Is that --
9 DR. WILLIAM LUCAS: That's correct.
10 MS. SUZAN FRASER: All right. And you've
11 uttered those words many times at many inquests, as that
12 being why a jury is there before you hearing evidence.
13 Fair enough?
14 DR. WILLIAM LUCAS: Correct.
15 MS. SUZAN FRASER: All right. And it --
16 other words that you have uttered from people first is
17 that it must never be forgotten that the inquest is being
18 held because a member of the community has died under
19 circumstances where the public interest requires
20 examination from the point of view of the deceased
21 persons, their families, and those associated or involved
22 in their death.
23 Fair enough?
24 DR. WILLIAM LUCAS: Correct.
25 MS. SUZAN FRASER: And the jury's role is
[Page 190]
1 to answer five (5) questions and to make recommendations?
2 DR. WILLIAM LUCAS: Yes.
3 MS. SUZAN FRASER: And in many
4 circumstances, the answers to the five (5) questions are
5 known, and the jury will do its work, harder work, in
6 making recommendations.
7 DR. WILLIAM LUCAS: That is -- that's
8 fair.
9 MS. SUZAN FRASER: And in some cases they
10 make no -- make no recommendations?
11 DR. WILLIAM LUCAS: Correct.
12 MS. SUZAN FRASER: And something that
13 sometimes your office or the Office of the Chief Coroner
14 or regional supervising coroner might do is to announce
15 that there will be an inquest into a death early where
16 there's a death of significant public concern, in order
17 to ease concerns about that death.
18 Is that fair?
19 DR. WILLIAM LUCAS: That happens on
20 occasion, that's correct.
21 MS. SUZAN FRASER: All right. And
22 sometimes inquests are very adversarial, as you've
23 mentioned, --
24 DR. WILLIAM LUCAS: Mm-hm.
25 MS. SUZAN FRASER: -- and sometimes
[Page 191]
1 they're processes of reconciliation and healing?
2 DR. WILLIAM LUCAS: It's not their
3 primary function, but I understand that they can be, yes.
4 MS. SUZAN FRASER: All right. And one
5 (1) of the areas in which the Office of the Chief Coroner
6 excels is in storing, recording, and following-up on its
7 verdicts.
8 And I don't know if the Commissioner knows
9 this, but you have a verdict secretary, correct?
10 DR. WILLIAM LUCAS: Correct.
11 MS. SUZAN FRASER: All right. And I can
12 call her and say, I would like to have all of your
13 verdicts on females who have died in custody by hanging,
14 and I will get those verdicts free of charge?
15 DR. WILLIAM LUCAS: Yes.
16 MS. SUZAN FRASER: All right. And that's
17 a function of the office because that's one (1) of the --
18 the public safety components; we learn from what happened
19 in the past?
20 DR. WILLIAM LUCAS: Correct.
21 MS. SUZAN FRASER: All right. And I
22 expect that you've all experienced at inquests,
23 institutions come and they come with their houses in
24 order. They've had time to reflect since the death,
25 they've reviewed their policy and revisited their
[Page 192]
1 policies and in most circumstances, an institution
2 arrives at an inquest saying, This is what we've done to
3 change, if there's an issue, and this is how we hope that
4 things can be different the next time around.
5 Is that fair, Dr. Lucas?
6 DR. WILLIAM LUCAS: It wasn't always the
7 case in the past, but I think I would agree with you that
8 we've seen that increasingly in recent years. Yes.
9 MS. SUZAN FRASER: All right. And so --
10 when we contrast the inquest process with the expert
11 committee process or a process by which the Regional
12 Coroner might make recommendations to an institution,
13 there's some obvious differences that I want to review
14 with you.
15 DR. WILLIAM LUCAS: Mm-hm.
16 MS. SUZAN FRASER: One (1) is, Dr. Lucas,
17 except by consultation with the coroner, the families are
18 not generally involved in the review committees or
19 process of making recommendations.
20 Is that fair?
21 DR. WILLIAM LUCAS: That's fair.
22 MS. SUZAN FRASER: All right. And while
23 the professionals involved in the death may be involved
24 in the committee process or in the drafting of
25 recommendations; you talked yesterday about, sort of,
[Page 193]
1 negotiating with the hospital like -- I, sort of, took it
2 as: We can do this the easy way or the hard way, and the
3 hard way being to go to Inquest, the easy way being,
4 Let's agree on a way to prevent this death and make some
5 recommendations.
6 Is that sort of a fair --
7 DR. WILLIAM LUCAS: That's probably a
8 reasonable way to categorize it, yes.
9 MS. SUZAN FRASER: All right. The only
10 problem with that is that those recommendations don't get
11 made publicly in many cases and stored on the -- in the
12 way that -- that verdicts are.
13 Is that fair?
14 DR. WILLIAM LUCAS: We have a process
15 whereby recommendations from Regional Coroners' reviews
16 theoretically are tracked by the Office of the Chief
17 Coroner. I can't speak to -- because that's not an area
18 that I'm involved with on a day-to-day basis -- I can't
19 speak to how reliably that's done.
20 I know, speaking for myself, that on
21 occasion, I've been guilty of conducting a Regional
22 Coroner's review and crafting recommendations and dealing
23 with an institution and maybe for a variety of reasons
24 have forgotten to transmit that information down to Head
25 Office so that they may not have access to it.
[Page 194]
1 But I think, you know, in that context
2 that's probably a fair comment that they're not tracked
3 as rigorously --
4 MS. SUZAN FRASER: All right.
5 DR. WILLIAM LUCAS: -- as inquest
6 recommendations.
7 MS. SUZAN FRASER: Right. And they're
8 not generally publically available?
9 DR. WILLIAM LUCAS: Now that,
10 unfortunately, I can't speak to. Maybe my colleagues
11 would have --
12 MS. SUZAN FRASER: All right. Dr.
13 Lauwers --
14 DR. WILLIAM LUCAS: -- information.
15 MS. SUZAN FRASER: -- Dr. Edwards, do you
16 know?
17 DR. JAMES EDWARDS: I know the
18 recommendations will be shared with family.
19 MS. SUZAN FRASER: Yes.
20 DR. JAMES EDWARDS: And they will be
21 shared beyond the institution if it's felt that there
22 would be a public safety reason to do so.
23 So in other words, if we went to a
24 hospital and we saw a problem with a piece of equipment
25 in the hospital and we had concerns that, perhaps, that
[Page 195]
1 was a more widespread problem in the Province, we would
2 spread -- disseminate that information to the hospitals
3 or the manufacturers of the equipment or whatever.
4 But it's -- you're correct that we don't
5 routinely make our -- those recommendations available to
6 members of the public at large.
7 MS. SUZAN FRASER: Right. So just using
8 the sort of -- the codeine metabolizer issue and that the
9 doctors are aware of it, the patient's probably not
10 generally aware of it, so that --
11 DR. JAMES EDWARDS: That's actually not a
12 good example --
13 MS. SUZAN FRASER: Okay.
14 DR. JAMES EDWARDS: -- because that --
15 that information actually was shared. That information
16 was published in The Lancet, which is a very reputable
17 organization. Physicians in Ontario will be aware of
18 that case.
19 MS. SUZAN FRASER: Right. But I'm
20 talking -- I'm thinking about the patient who might be
21 reading, you know, Jack Newman's guide on breastfeeding
22 rather than The Lancet and is not aware that this might
23 be a risk.
24 So when it comes to an informed consent
25 issue she might not be able to raise that issue with her
[Page 196]
1 physician. Whereas if it was the subject of, you know,
2 greater public debate that might...
3 DR. JAMES EDWARDS: That's probably not
4 the best example --
5 MS. SUZAN FRASER: Okay.
6 DR. JAMES EDWARDS: -- because that -- in
7 that case, the College would -- the Tylenol 3s are
8 prescribed by physicians.
9 MS. SUZAN FRASER: Right.
10 DR. JAMES EDWARDS: And, you know, unless
11 people were getting Tylenol 3s in other ways, and I think
12 most new mothers would be getting their medications from
13 the doctors, their doctors would be aware of it.
14 And I think -- I mean, well, obviously
15 it's -- it's most advisable that, you know, everybody in
16 the public is aware of all of these type of issues; in
17 that case physicians are aware of that.
18 MS. SUZAN FRASER: All right.
19 DR. JAMES EDWARDS: And that actually is
20 an example really of where our office has not only
21 identified a problem -- and again, it's not really our --
22 our office per se is more the -- the people who assist us
23 with the research of the Hospital for Sick Children
24 really took great efforts to disseminate that information
25 both to regulatory bodies and by getting the -- the --
[Page 197]
1 the case published in -- in one (1) of the most
2 reputable, if not the most reputable organizations in the
3 world.
4 So, you know, that's not really a good
5 example of, I think, what you're trying to illustrate.
6 MS. SUZAN FRASER: Okay. So -- but I
7 think you agree with me, Dr. Edwards, not withstanding
8 your concern about the example, that generally the
9 recommendations that are made either from a Regional
10 Coroner's Review, or within one (1) of the expert
11 committees, are private recommendations?
12 DR. JAMES EDWARDS: That's correct,
13 unless there's a need to make them public.
14 MS. SUZAN FRASER: All right. And in
15 terms of whether there's a need to make that public, the
16 public has to trust you that -- and I mean you in terms
17 of the Office of the Chief Coroner, has to trust you that
18 that is going to be done, fair enough?
19 DR. WILLIAM LUCAS: That's fair.
20 DR. ALBERT LAUWERS: That's fair, yeah.
21 DR. JAMES EDWARDS: Yeah.
22 MS. SUZAN FRASER: And so in terms of
23 your Committee, and I'm going to turn -- I just have a
24 few minutes left, Dr. Lauwers, to talk about the PDRC,
25 Pediatric Death Review Committee which my client has been
[Page 198]
1 critical of in that when a death in -- an open CAS file
2 is investigated, that the CAS continues to be on the
3 membership without, sort of, an external review.
4 Is it fair, from what I understood from
5 your evidence is that when the CAS file case is reviewed
6 before the Pediatric Death Review Committee, that the
7 Pediatric Death Review Committee relies on the internal
8 investigation completed by the CAS?
9 DR. ALBERT LAUWERS: That's correct, it
10 reviews our child welfare export -- expert reviews, the
11 CAS review of their -- their own internal review of their
12 actions.
13 But in addition to that, it doesn't rely
14 solely on that.
15 MS. SUZAN FRASER: All right. And can
16 you understand that at this time when public confidence
17 is low, that there is a need, -- or there's, at least
18 from my client's perspective, a perceived need to have
19 people involved in the review of pediatric deaths beyond
20 the professionals involved in the case, or professionals
21 that they're -- for example, the child advocate might be
22 a good member of the Pediatric Death Review Committee?
23 DR. ALBERT LAUWERS: Oh, I couldn't
24 support that.
25 MS. SUZAN FRASER: All right. And do --
[Page 199]
1 are -- do you understand what the role is of the
2 Provincial Advocate for Children --
3 DR. ALBERT LAUWERS: Perhaps you'd like
4 to explain it?
5 MS. SUZAN FRASER: All right. Well, one
6 of her primary functions is to promote and bring forward
7 the concerns of children and youth. So what -- in terms
8 of what possible role she might have on that Committee,
9 would be to bring forward the concerns of children and
10 youth who are in the care of the state, which might be
11 relevant to a case where -- where there's an open CAS
12 file.
13 DR. ALBERT LAUWERS: You know, Ms.
14 Fraser, in reference to this particular Inquiry, I think
15 one (1) of the lessons that needs to be learned is that
16 experts should not be advocates. And that's why I would
17 suggest to you that anyone coming on the Pediatric Death
18 Review Committee needs to be completely unbiased,
19 independent, and should not have an advocacy role at all.
20 MS. SUZAN FRASER: All right. So from
21 that point, do you see then -- putting the question the
22 child advocate -- the need for the voices of children and
23 youth who are in the care of the state to be heard by the
24 Pediatric Death Review Committee?
25 DR. ALBERT LAUWERS: If it's a function
[Page 200]
1 of -- the functions of -- the normal functions and
2 activities of the Committee, then that certainly is
3 something we'd be alive to.
4 MS. SUZAN FRASER: All right.
5 DR. JAMES EDWARDS: If I could just -- if
6 I could just add one (1) -- one (1) comment there. If
7 people bring forward to us information about a case that
8 we're going to be referring as Regional Supervising
9 Coroners to an expert committee, fam -- and it would
10 usually be family, we -- we make sure that we get -- list
11 all of the family members -- usually family members --
12 concerns, and forward that information to the Committee.
13 So the Committee does get information from
14 -- from the public, at least from involved members of the
15 public. And certainly if there was a case that was going
16 to be reviewed by an expert committee, and -- and your
17 organization or any other organization had concerns about
18 that particular case, if they were to get in touch with
19 the Regional Supervising Coroner, the Regional
20 Supervising Coroner would forward information about your
21 -- your concerns about that case to the -- to the
22 relevant committee, whatever committee it happened to be.
23 MS. SUZAN FRASER: All right. But you
24 can understand where there are deaths that are reviewed
25 public -- or reviewed privately, that people may not
[Page 201]
1 always know the circumstances that are being reviewed by
2 the committee, so there's a bit of a chicken and egg
3 problem there.
4 But, Dr. Crane, who was here from Northern
5 Ireland, talked about families being involved in a death
6 review process, do you see there being a place for that,
7 Dr. Lauwers, for families to actually come to the
8 committee when a death is being reviewed?
9 DR. ALBERT LAUWERS: The normal practice
10 is for the committee to render its opinion and -- and
11 provide that opinion to the Supervising Regional Coroner,
12 who can then meet with the family and discuss any issues
13 that arise.
14 MS. SUZAN FRASER: All right. And you
15 have the ability, taking on this position, to say, Are we
16 going to conduct business as usual or are we going to
17 take a new approach with respect to this committee -- the
18 committee not being governed by legislation, in terms of
19 its constitution. That's what done.
20 Do you see that there might be a benefit
21 to families to actually be able to participate in the
22 death review process outside of a formal inquest process?
23 DR. ALBERT LAUWERS: I think there are a
24 number of reasons why that wouldn't be practical with the
25 Paediatric Death Review Committee.
[Page 202]
1 MS. SUZAN FRASER: All right, and can you
2 tell me what those reasons are?
3 DR. ALBERT LAUWERS: Well, some would be
4 privacy issues, at the least. The other issues is -- is
5 we -- we do actually, respecting the fact that some of
6 these children are in care, at the time, of their
7 families, it may well be that the family have some
8 complicity with regard to the -- the care or lack there
9 of in the death of the child.
10 The next issue might be, we would -- may
11 have it -- we may have a challenge to actually having
12 experts agree to a process such as that, so I -- I think
13 there are -- are a lot of, in my view, reasons not to go
14 that way.
15 I think the current process in which the
16 committee issues its opinion -- you know, and the
17 prevalent issue is to the family factor into the opinion
18 that it's issued by the -- the Paediatric Death Review
19 Committee.
20 Sometimes there are insurance claims, for
21 instance, that hinge on such things as whether the death
22 is accidental or natural. And, you know, I -- also there
23 is those other issues which can be influenced by the
24 Criminal Justice System, as well.
25 I -- I cannot see the committee actually
[Page 203]
1 functioning in a meaningful way with the presence of
2 family and trying to mitigate the various circumstances
3 we discuss at the committee with family physically
4 present during the process.
5 MS. SUZAN FRASER: All right.
6 DR. ALBERT LAUWERS: I do think, however,
7 family has a voice as the process sets out, as in the --
8 what Dr. Edwards has suggested, and I do think that the
9 termination of our particular activity, the family can be
10 involved, and they do, by the way, they do provide
11 feedback to us when we -- they think or take exception
12 to, or are pleased with the various things we've said,
13 they will write back to us, communicate with us.
14 And we're, in fact, available to meet with
15 them, and we have done that in the past.
16 DR. JAMES EDWARDS: And I think just from
17 a broader -- a broader perspective, if I may interject,
18 that our death investigation system, we take into account
19 ev -- all information that is brought forward to us by
20 families, by -- by whatever -- whatever agency, by -- or
21 -- or group, but that -- that death investigation
22 process, in terms of death investigation by individual
23 coroners or by committees, needs to be done by people who
24 do not have an interest in the outcome of that
25 investigation.
[Page 204]
1 And I think that's really fundamental; if
2 we can't -- that -- that's -- we have to have a
3 dispassionate, neutral, unbiased review of the death, and
4 every -- and every member who is -- every person who is
5 participating in that investigation has to be neutral and
6 -- and unbiased.
7 MS. SUZAN FRASER: All right. I -- I'm
8 getting the look that I think is the hook, so I have some
9 followup questions, but I -- I think I'm at the end of my
10 rope, so I got to go.
11 Thank you very much, gentlemen.
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