Pathology: The Science

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1.0 Introduction

1.1 Legal Definition of Forensic Pathology

Forensic pathology is a specialized branch of pathology concerned with determining the cause and the manner of death through external and internal examinations of a corpse. A forensic pathologist is a medical doctor who has studied not only disease but also trauma, such as wounds and damage to the body that can lead to death. At the request of a local coroner or the overseeing medical examiner, forensic pathologists perform autopsies when a person has died unexpectedly, unnaturally, or under suspicious circumstances. Forensic pathology therefore plays an important role in the criminal justice system, as autopsies are often requested to aid criminal investigations [1].

1.2 Basic Terminology and Classification

An autopsy is the post-mortem examination of a corpse by a forensic pathologist or other legally authorized physician [2]. The main objective of an autopsy is to determine the cause and the manner of death. Other objectives include identifying the deceased, establishing a time of death and collecting evidence surrounding the death, such as foreign hairs, DNA and other data [3].

The cause of death is the disease or injury that initiated the lethal chain of events that led to death. Cause of death is divided into primary and secondary causes. A primary cause is a condition that sets the chain in motion. A secondary cause is a condition that contributes to the person’s demise [4]. Primary causes appear as a causal chain that maps the cessation of life, starting with the most recent condition and working back to the oldest. An example is produced below:

most recent condition – heart failure due to, or as a result of:

next oldest condition – pneumonia due to, or as a result of:

next oldest condition – surgery due to, or as a result of:

oldest/original condition – gunshot wounds [5]

The primary cause of death in the example above would be the gunshot wounds, as they set the lethal chain of events in motion. A secondary cause might be a pre-existing heart defect that contributed to heart failure during surgery. When determining the cause of death, however, injury always trumps disease. And so in the example provided, gunshot wounds – the injury – would trump a pre-existing heart defect – the disease – as the primary cause of the individual’s death [6].

The manner of death is the way in which the cause of death came to be. Generally, only four manners of death are recognized: homicidal, suicidal, accidental, and natural [7]. Natural deaths are caused by disease, whereas the other manners of death all involve trauma. Homicidal and suicidal deaths arise from acts a reasonably prudent person would believe had a high probability of producing bodily injury or death. The difference between suicide and homicide is simply the person who acted. If the deceased took the action, then the manner of death is suicide. If someone other than the deceased took the action, then the manner of death is ruled a homicide [8].

2.0 Post-Mortem Examination

2.1 Identifying the Deceased and Collecting Evidence

A forensic pathologist begins a post-mortem examination with an external inspection of the corpse [9]. This involves producing a detailed description of the decedent, including his or her age, sex, ancestry, height, weight, birth related abnormalities, and anything else that can assist with identification. If necessary, the forensic pathologist can have the decedent’s fingerprints run against any database. When the body is severely decomposed and fingerprinting is impossible, the jaw is removed and an attempt is made to identify the deceased through dental records [10].

Next, the forensic pathologist suspends the decedent’s clothing to air-dry in order to preserve bloodstains, DNA, or other evidence that may be important to a potential criminal investigation. If foreign looking stains, such as semen and saliva, are present on the clothing or the decedent, they are noted and swabbed for later DNA testing [11]. The forensic pathologist then combs the clothing and the body for unknown head and pubic hairs that are then forwarded to a forensic science lab for DNA testing and comparison with other hairs found at the crime scene [12].

When sexual assault is suspected, the forensic pathologist will use a sexual assault forensic evidence kit – or SAFE kit – to preserve evidence of the assault. This involves swabbing for foreign bodily fluids. If the decedent is female, then vaginal, oral, and rectal swabs are taken. If the decedent is male, oral and rectal swabs are taken. These smears are then examined microscopically for the presence of spermatozoa that, if present, is later sent for DNA testing [13].

2.2 Classifying Traumatic Deaths

The post-mortem examination continues with a detailed inspection of trauma to the body and any defensive wounds. Traumatic deaths are those resulting from injury and unnatural causes, and they are generally classified as being thermal, chemical, electrical, or mechanical [14].

Chemical trauma results from the use of drugs and poisons. The heavy consumption of alcohol or the use of barbiturates, for example, slows communications from the brain. This can lead to a coma, the cessation of breathing, and death [15]. Chemical trauma is hard to spot through external examination, and so blood and urine samples are extracted from the aorta and gall bladder and sent for toxicology screening to evaluate the role of chemicals in the cause of death [16].

Electrical trauma results from exposure to electricity. It is difficult to spot externally and is often discovered on inspection of the decedent’s internal organs and tissues [17]. Depending on the length of exposure, both low and high levels of electricity can force the heart to stop beating and will also produce electrical burns to the heart’s muscle tissue. Exposure to higher levels of electricity may further produce holes in the membranes of cells. This is known as poration [18].

Thermal trauma results from exposure to excessive cold or heat. Hypothermia is exposure to excessive cold and hyperthermia is exposure to excessive heat [19]. Both leave few demonstrable signs at autopsy, and so diagnosis usually requires the absence of other causes of death coupled with a history of exposure to an environment in which either hypothermia or hyperthermia could be expected [20]. For example, if the decedent was found outdoors in the middle of winter with alcohol in her system, this may point toward hypothermia. Conversely, if the decedent, for example a toddler, was found locked inside a vehicle on a sweltering summer’s day, this may suggest hyperthermia. In certain cases, external evidence of hyperthermia can be seen in the form of thermal burns. These are localized wounds resulting from contact with elements that have temperatures over 65°C. Thermal burns are often caused by exposure to hot liquids or flames [21].

Mechanical trauma occurs when the force applied to a tissue, such as skin or bone, exceeds the tensile strength of that tissue [22]. The resulting trauma can be classified as either sharp force trauma or blunt force trauma. Sharp force trauma is caused by sharp implements while blunt force trauma is caused by non-sharpened objects. Forensic pathologists can distinguish sharp force trauma from blunt force trauma through external inspection, as each leaves a distinct wound. Sharp objects produce incised wounds that are greater in depth than length or width. Conversely, blunt objects produce lacerations in the tissue, as well as contusions and hematomas, which are mild to severe accumulations of blood in the tissues surrounding the lacerations [23].

2.2.1 Firearm Injuries

A firearm injury is a subset of blunt force trauma [24]. Gunshots produce a large amount of carbon monoxide, nitrogen dioxide, carbon dioxide, and other gases that can provide evidence as to whether the wound is a contact wound, an intermediate range wound, or a distant wound. The gasses from a gunshot are projected only a few inches, and if these gasses make contact with the wound or are blown into the wound, they will blacken and lacerate the surrounding skin [25]. Such signs are often indicative of a contact wound resulting from a gunshot fired at close range.

As the distance from the barrel to the skin increases, the effect of the gas diminishes. The presence of stippling or tattooing, but no lacerations, around the wound is indicative of an intermediate range wound [26]. Conversely, distant gunshot wounds lack evidence of anything other than the effect of the bullet, rendering the actual range indeterminate. A typical distant gunshot wound produces a circular skin defect and a rim of abraded skin around the edges of the wound [27].

The forensic pathologist can also determine the speed with which the projectile was fired. The extent of injury produced by a firearm projectile increases with velocity, meaning that higher speeds produce greater trauma. High-speed projectiles may also leave white fragments of lead around the wound, called a lead snowstorm [28].  Ascertaining the speed of the projectile can later assist criminal investigators in determining and ruling out the type of weapon used, as high-speed projectiles are only seen in wounds inflicted by high powered hunting rifles and military rifles [29].

2.2.2 Asphyxia

Asphyxia is caused by interference with the oxygenation of the brain, and it may result from a number of causes, including alcohol consumption and drug use, low level electrocution, drowning and strangulation [30]. Petechiae are pinpoint hemorrhages found around the eyes and the lining of the mouth and throat, and they are a common, albeit inconclusive sign of hanging or strangulation [31]. Another common finding, and one more determinative, is hemorrhaging in the muscles of the neck that become contused by manual strangulation. Manual strangulation is distinguishable from ligature strangulation, as the latter leaves signs of a furrow in the neck [32]. 

2.3 Establishing a Time of Death

When an individual dies, the body goes through a number of changes that can assist in estimating the time of death. The deceased has a biological clock, and inevitable changes include rigor mortis, livor mortis, and algor mortis. It is important to note that none of these changes can produce a fully accurate time of death. They do, however, allow the forensic pathologist to estimate an initial time range that can later be modified as further information becomes available.

Rigor mortis is the stiffening of muscles after death. This occurs because the body uses up and no longer replenishes the chemical glycogen, which provides the energy for muscle contraction [33].  Rigor mortis typically sets in 4 hours after death but can appear sooner if glycogen has been depleted through the exercise or activity of the muscles prior to death. Stiffness generally disappears 2-3 days after death, as further decomposition of the muscles leads to their inability to remain fixed in rigor [34]. The presence or absence of rigor mortis can therefore assist a forensic pathologist in estimating whether the individual has been dead a few hours or for days.

Livor mortis is the discolouration of the body that occurs from the settling of red blood cells. When the heart stops pumping, blood ceases to circulate and gravity causes blood cells to settle throughout the body [35]. This leads to a purplish discolouration of the skin that sets in 1 hour after death, becomes fixed roughly 12 hours after death, and then slowly disappears 36 hours after death due to increasing decomposition of tissues and cells [36]. Like rigor mortis, the presence or absence of livor mortis may help determine if a person has been dead for hours or for days.  

Algor mortis is the cooling of the body after death. Post-mortem cooling initially occurs at a rate of 2-2.5°C per hour and then falls below a rate of 1°C per hour after 12 hours. Because the body cools at a known rate, the forensic pathologist can evaluate the difference between the body’s current temperature – measured via the liver – and a normal body temperature of 37°C [37]. He or she can then use the total loss of temperature to estimate an initial time of death. Algor mortis, however, has a lower accuracy rate and can only produce a rough estimation. Factors such as ambient temperature, the presence or absence of clothing, and air currents can manipulate body temperature, making it difficult to estimate a time of death using algor mortis alone [38].

Stomach contents can also assist with estimating an individual’s time of death, as it is assumed in the medical profession that the stomach empties at a known rate. Liquids generally empty from the stomach in 1.5 hours, while solid foods empty from the stomach after 2+ hours depending on their density. For instance, light meals are usually digested after 1.5-2 hours, medium meals after 3-4 hours, and heavy meals after 4-6 hours. Given this assumed rate of digestion, if food is still present in the stomach, it may suggest that the person has been dead less than 6 hours. Stomach contents, in theory, may therefore be used to provide an initial estimate as to time of death [39]. It is important to note, however, that the rate of digestion –  like post-mortem cooling – may vary with the individual characteristics of the decedent’s body and circumstances.

3.0 The Goudge Inquiry

In 2007, after an increasing number of wrongful convictions and miscarriages of justice due to flawed expert testimony, the Inquiry into Pediatric Forensic Pathology in Ontario, or the Goudge Inquiry, was created to address growing concerns over the state of Ontario’s forensic pathology system. The goal was to come up with improvements to ensure that these mistakes would not be repeated. Justice Stephen T. Goudge served as commissioner and his report was released on October 1, 2008. In it he offered a systemic review of the problems facing Ontario’s forensic pathology system and recommendations for restoring public confidence in that system.

3.1 Dr. Charles Smith

To address growing concerns over Ontario’s forensic pathology system, the provincial government appointed Justice Goudge to conduct an inquiry into the state of the profession. Numerous cases were ultimately reviewed and reexamined, but the majority of cases being reinvestigated involved those in which Charles Randal Smith had given his expert opinion. From 1981-2005, Smith worked as a pediatric pathologist at Toronto’s Hospital for Sick Children, where he developed a personal interest in autopsies [40].  By 1990, most of Smith’s work was in forensic pathology. Despite having no formal training or certification in the field, he was appointed director of the Ontario Pediatric Forensic Pathology Unit in 1992 [41].  Shortly thereafter, Smith began lecturing on forensic pathology to Crown counsel, police officers, and coroners, and he became known as the expert to see for the most criminally suspicious cases in pediatric deaths.

In spite of his reputation, signs of Smith’s ineptitude as a forensic pathologist began to surface. Justice Goudge identified several aspects of Smith’s involvement in the criminal justice system that contributed to wrongful convictions and miscarriages of justice. These included:

  • lack of qualification, training, and certification in forensic pathology;
  • misinterpretation of post-mortem artefacts (natural changes after death);
  • failure to complete autopsy reports in a timely manner;
  • failure to respond to requests for clarification of opinion in a timely manner;
  • failure to give proper consideration to evidence contradictory to his conclusions;
  • mishandling of exhibits in order to ensure their availability for subsequent testing;
  • failure to disregard irrelevant or prejudicial information, often provided by police;

problematic performances as an expert witness, including inadequate preparation for trial, overstatement of his qualifications, giving testimony beyond his expertise, use of inexact language, failure to reference supporting literature, lacking impartiality in his roles as an objective expert, and offering critical attacks on his professional colleagues [42].

Justice Goudge found that Smith’s lack of training and education in forensic pathology led to a number of mistakes at trial. In one case, Smith mistook dog bites for stab wounds [43]. In another, he misidentified the natural expansion of the anus after death (a post-mortem artefact) as penetrating trauma and a sign of sexual abuse [44]. Justice Goudge was vocal in attributing these errors to Smith’s lack of training in injury identification and forensic pathology in general.

Additionally, Justice Goudge found that Smith did not stay within the limits of his expertise when testifying in court, and that he had overstated his knowledge in certain areas [45]. Smith, for example, insisted that short-distance household falls were not fatal. He based this assertion on his own observations of having seen his children fall at home. A team of pathologists, however, later refuted Smith and found that in rare circumstances, low-level falls can cause death in children [46].

Lastly, Justice Goudge concluded that Smith was unaware of the importance of his role as an expert witness. Smith believed that his role was to be an advocate for the Crown, and he often acted to further police investigations, even though expert witnesses are meant to be independent, impartial and objective [47]. Moreover, Smith rarely came prepared for trial. On several occasions he produced his autopsy reports only after he was issued a police subpoena or court order [48].  As a result, Justice Goudge found that concerns with Smith’s work were not limited to misdiagnoses and overstated opinions, but further included a complete disregard for his duties as an expert.

Included with these findings was a report from a panel of trained and certified forensic pathologists that reviewed the 45 cases in which Smith had provided his expert opinion. The panel disagreed with the opinions given by Smith in 20 of the 45 cases, 12 of which had led to convictions [49].  In the years since the Goudge Inquiry, a number of those convictions have been overturned, most notably in R v Mullins-Johnson [50] , R v Sherret-Robinson [51], and R v Marquardt [52].

3.2 Systemic Problems in Ontario’s Forensic Pathology System

Justice Goudge ultimately drew a correlation between Charles Smith’s flaws as a forensic pathologist and flaws in Ontario’s forensic pathology system as a whole. These flaws included the absence of accountability mechanisms, inadequate quality control measures, faulty legislative and institutional arrangements, and a lack of domestic training programs in the field.

First, Justice Goudge emphasized that managerial and accountability measures needed to combat increasing problems such as insufficient qualifications, a lack of impartiality, and erroneous expert opinions were simply not available. The Coroners Act, for example, offered no provisions for the management of forensic pathology in Ontario, nor did it specify any forensic pathology services, those who might run them, or even those who should be permitted to perform post-mortem examinations [53]. In short, Justice Goudge found that there was virtually no legislative framework to help define, control, and organize Ontario’s forensic pathology system. 

Next, Justice Goudge determined that the profession lacked institutional means for the management and accountability of forensic pathologists working in Ontario. Fee-for-service pathologists were then conducting most of the autopsies in Ontario, as no primary forensic pathology service existed [54]. Consequently, there was no system for tracking and reviewing autopsy reports. This limited the possibility for peer review of post-mortem findings and the potential identification of errors or misdiagnoses therein. Additionally, there was no way to monitor a forensic pathologist’s involvement in criminal investigations and cases, which made it more difficult to identify erroneous or otherwise inappropriate expert testimony [55].

In addition to a lack of supervisory and managerial measures, Justice Goudge found that there were no institutional mechanisms to ensure the accountability of forensic pathologists working in Ontario. Crown prosecutors, defence lawyers, police officers, members of the public and other individuals involved in the criminal justice system had brought a number of complaints against Charles Smith. These complaints, however, were mostly ignored because no entity had been assigned to receive complaints against forensic pathologists in Ontario [56].

Lastly, Justice Goudge found that there was a severe shortage of forensic pathologists in Ontario. Most autopsies were then being performed by fee-for-service pathologists who had neither training nor certification in forensic pathology [57]. Their involvement in the field was instead based on personal interest and work related experience. Justice Goudge concluded that this was a result of too few institutions offering training and education in forensic pathology [58].  

3.3 Recommendations for Change

Justice Goudge recommended a number of changes to professionalize forensic pathology in Ontario, as well as to enhance public faith in the profession. His recommendations included:

  • legislative change defining the role of forensic pathologists in death investigations;
  • institutional change providing proper organization of a forensic pathology system;
  • a commitment to the recruitment and retention of qualified forensic pathologists;
  • a commitment to providing forensic pathology education, training, and certification; and
  • adequate, sustainable funding to grow and professionalize forensic pathology in Ontario [59].

Furthermore, Justice Goudge stressed the need to include instruction on a forensic pathologist’s intended role in the criminal justice system in all educational and training programs. This would allow persons training in forensic pathology a better understanding of their duties going forward. Justice Goudge stated that instructors should particularly emphasize the need for forensic pathologists to (a) adopt an independent and evidence based approach that emphasizes the importance of thinking objectively, (b)remain independent of coroners, police, prosecutors, and defence counsel, (c) exercise care in recording and preserving evidence so that their work can be reviewed and either confirmed or challenged, (d) seek assistance and consult with colleagues in difficult cases, and (e) commit themselves to neutrality, quality, and the search for the truth [60]. 

In addition to improving educational and training programs in forensic pathology, Justice Goudge emphasized the need for courts to take seriously their role as gatekeepers. He insisted that expert opinion must always be scrutinized and that courts should actively seek to investigate:

  • the reliability of expert witnesses and whether they are testifying outside their expertise;
  • the reliability of scientific theories and practices and whether they are generally accepted;
  • whether the expert can relate his or her particular opinion to a tested theory or technique;
  • whether there is serious dispute or uncertainty about the science, theory, or technique;
  • whether the expert has properly considered alternative explanations or contrary opinions;
  • whether the expert’s conclusions are available for others to either challenge or confirm;
  • whether the expert uses clear, unambiguous language to state his or her conclusions; and
  • whether the expert has expressed his or her opinion in a manner such that the trier of fact will be able to reach an independent conclusion on the reliability of the expert’s opinion [61].

3.4 Legislative Changes to Ontario’s Forensic Pathology System

Soon after the release of the Report on Pediatric Forensic Pathology in Ontario, the Government of Ontario introduced Bill 115, An Act to Amend the Coroners Act. The bill was designed to address Justice Goudge’s recommendations for legislative and institutional change to Ontario’s forensic pathology system. After much consideration, lengthy legislative debate, and multiple public hearings, the amendments came into effect on July 29, 2009, laying the groundwork for substantial change to the delivery of death investigation services in Ontario [62].

Whereas the Coroners Act did not previously contemplate the existence of forensic pathologists, section 1 of the Act now establishes necessary credentials for those entering into the field, thereby ensuring adequate qualification and authorization. The Act defines a forensic pathologist as a pathologist who has been certified by the Royal College of Physicians and Surgeons of Canada in forensic pathology or has received equivalent certification in another jurisdiction [63].

In an effort to establish strong supervisory and managerial mechanisms, section 7(1) of the Act now provides for the role of a Chief Forensic Pathologist who shall (a) be responsible for the operation of the Ontario Forensic Pathology Service; (b) supervise and direct pathologists in the provision of death investigation services; (c) conduct programs for the instruction of pathologists who provide death investigation services; (d) prepare, publish, and distribute a code of ethics to guide pathologists in the provision of death investigation services; and (e) perform such other duties as are assigned to him or her under this or any other Act or by the Lieutenant Governor in Council [64].  Moreover, section 29(1) of the Actnow stipulates that a pathologist who conducts a post-mortem examination of a body shall report in writing the entirety of his or her findings and analyses to the coroner who ordered the examination, as well as the Chief Forensic Pathologist [65].

3.5 Institutional Changes to Ontario’s Forensic Pathology System

In accordance with section 6 of the Coroners Act, the Ontario Forensic Pathology Service (OFPS) was established in July 2009 [66]. The OFPS was created to provide forensic pathology services in accordance with the Act, including autopsy services for public death investigations. The OFPS currently performs 6000 autopsies each year and works closely with the Office of the Chief Coroner to provide high quality death investigation services [67]. In addition to offering services of the highest caliber, the OFPS maintains a public pathologists register to help ensure that pathologists are appropriately matched to autopsies consistent with their level of expertise [68].

The OFPS also provides registered pathologists with a code of ethics to inform them and enhance the quality of their work. The OFPS Code of Ethics reaffirms that forensic pathologists:

  • are independent, neutral, and obliged to the tell the truth;
  • serve the courts and not the prosecution, the defence, or the police;
  • must record and keep evidence according to the highest standards of the profession;
  • must engage in discussion and testimony in a way that respects the profession;
  • must challenge their own assumptions and test them against other available evidence;
  • must challenge each other’s assumptions and engage in respectful debate and discussion;
  • must learn new skills and contribute to the development of new techniques; and
  • must communicate effectively and honestly with the public and criminal justice system [69].

Lastly, to ensure accountability, the OFPS is equipped to receive formal complaints regarding their services and registered pathologists. Members of the criminal justice system and individuals from the greater public alike may contact the OFPS directly with their complaints [70].

Alternatively, aggrieved persons may contact and file a formal complaint with the Death Investigations Oversight Council (DIOC), which was established by section 8(1) of the Act and declared an official agency on December 16, 2010 [71]. The DIOC’s duties include offering advice and recommendations to the Chief Coroner and Chief Forensic Pathologist on matters involving financial resource management, strategic planning, quality assurance, compliance with the Coroners Act, performance measures, accountability mechanisms, and the administration of a complaints process. In addition, the DIOC itself also administers a public complaints process [72].

3.6 Domestic Educational and Training Programs

The University of Toronto and McMaster University are at present the only institutions to offer programs in forensic pathology. Students studying anatomical or general pathology at these schools can apply for a one year residency in forensic pathology. Both programs are certified by the Royal College of Physicians and Surgeons and offer these minimum training requirements:

  • 12 months of approved residency in forensic pathology;
  • 11 months of training in death investigation and post-mortem examination;
  • 1 month of training in an elective (e.g. forensic science, pediatric pathology, etc.); and
  • research and added training in forensic pathology as approved by the program director [73].

In order to be certified in forensic pathology by the Royal College of Physicians and Surgeons, an applicant must (a) be certified in anatomical pathology or general pathology; (b) successfully complete a 1-year accredited program or residency in forensic pathology; and (c) successfully complete the certification examination in forensic pathology. The 1 year program outlined above satisfies the minimum training requirements. Additional training may be ordered by the program director to ensure that competence in the field has been achieved by the student [74].

 

1 Max Houck, Modern Methods of Solving Crime (Connecticut: Praeger Publishers, 2007) @p 49-51 [Houck]

2 Stuart James and Jon Nordby, Forensic Science: An Introduction to Scientific and Investigative Techniques, 2d ed (Florida: CRC Press, 2005) @p 19 [James & Nordby]

3 Houck, supra note 1 @p 51

Ibid @p 50

5 James & Nordby, supra note 2 @p 43

Ibid.

7 Houck, supra note 1 @p 51

8 James & Nordby, supra note 2 @p 44

9 Houck, supra note 1 @p 52

10 Ibid @p 57

11 Ibid

12 Ibid

13 Ibid

14 Ibid @p 53

15 James & Nordby, supra note 2 @p 53

16 Ibid @p 21

17 Ibid @p 55

18 Ibid @p 56

19 Houck, supra note 1 @p 55

20 James & Nordby, supra note 2 @p 55

21 Ibid

22 Houck, supra note 1 @p 53

23 Ibid

24 James & Nordby, supra note 2 @p 46

25 Ibid @p 47

26 Ibid @p 8

27 Ibid

28 Ibid @p 47

29 Ibid

30 Ibid @p 56

31 Houck, supra note 1 @p 56

32 James & Nordby, supra note 2 @p 57

33 Max Houck and Jay Siegel, Fundamentals of Forensic Science (Oxford: Elsevier, 2006) at 168 [Houck & Siegel]

34 Ibid

35 Ibid

36 Ibid

37 Houck, supra note 1 @p 59

38 Ibid

39 Ibid @p 61

40 Inquiry into Pediatric Forensic Pathology in Ontario: Executive Summary, vol 1 (Toronto: Ministry of the Attorney General, 2008) at 6 [Goudge Report volume 1]

41 Ibid at 12-13

42 Jeffrey Manishen, “Wrongful Convictions and Pediatric Forensic Pathology” Ross & McBride LLP (3 October 2011)

43 Inquiry into Pediatric Forensic Pathology in Ontario: Systemic Review, vol 2 (Toronto: Ministry of the Attorney General, 2008) @p 22 [Goudge Report volume 2]

44 Ibid @p 27

45 Goudge Report volume 1, supra note 40 @p 14

46 Goudge Report volume 2, supra note 43 @p 11

47 Goudge Report volume 1, supra note 40 @p 16

48 Ibid @p 15

49 Ibid @p 7

50 R v Mullins-Johnson, 2007 ONCA 720 – At trial, Smith misidentified a natural post-mortem relaxation and expansion of the anus as signs of sexual injury and abuse. In 2007, a new team of forensic pathologists revealed that this change was a natural occurrence and William Mullins-Johnson’s conviction for the first degree murder of his niece, Valin, was subsequently overturned.       

51 R v Sherret-Robinson, 2009 ONCA 886  – At trial, Smith testified that the infant had died of asphyxiation, likely as a result of smothering or suffocation by a third party. In 2009, a new team of experts concluded that there were no signs of smothering or suffocation, and that the child likely died accidentally. Sherry Sherret-Robison’s conviction for  the first degree murder of her son was subsequently overturned.  

52 R v Marquardt, 2011 ONCA 281  – At trial, Smith testified that the infant had died of asphyxiation, likely as a result of smothering or suffocation by a third party. In 2011, a new team of experts concluded that there were no signs of smothering or suffocation and that the child may have died suddenly and naturally. Tammy Marquardt, the mother, was subsequently expected to undergo a new trial, but murder charges were dropped in 2011.

53 Goudge Report volume 1, supra note 40 @p 21-22

54 Ibid @p 11

55 Ibid @p 22 & 24

56 Ibid

57 Ibid @p 35

58 Ibid @p 11-12

59 Ibid @p 35

60 Ibid @p 43-44

61 Ibid @p 47-48

62 Office of the Chief Coroner, Publications and Reports- Death Investigations

63 Coroners Act, RSO 1990, c C.37 s 1 [Coroners Act]

64 Ibid @s 7(1)

65 Ibid @s 29(1)

66 Ibid @s 6

67 Ontario Forensic Pathology Service [OFPS]

68 Coroners Actsupra note 63 @s 7.1(1)

69 OFPS, supra note 67

70 Ibid

71 Coroners Act, supra note 63 @s 8.1(1)

72 OFPS, supra note 67

73 “Subspecialty Training Requirements in Forensic Pathology” (1 July 2012) Royal College of Physicians and Surgeons of Canada.

74 Ibid