Inquiry to shine light on coroner's findings

Wrongful convictions, ruined lives and families torn apart were the result of the questionable findings of a doctor who worked for the Office of the Chief Coroner for Ontario
Dr. Charles Smith was a pediatric forensic pathologist. That means that when a child died in suspicious or mysterious circumstances, it was his job to try and determine what had caused the death. His findings were given great weight by police in deciding whether or not to lay charges, and his evidence was taken very seriously in court, resulting in the conviction of family members of the deceased children on many occasions over the past couple of decades.
But in a number of cases, he was wrong. One of the most notorious was that of Williams Mullins-Johnson, an Aboriginal man who languished in jail for 12 years while protesting his innocence in the 1993 death of his niece. Mullins-Johnson, 22 at the time, lived with his brother and sister-in-law in their Sault Ste. Marie home. He had babysat their three children the night before Valin, 4, was found dead in her bed on the morning of June 28.
Smith determined from marks on the child's body that she had been raped and strangled several hours earlier. No forensic evidence linked Mullins-Johnson to the crime, but he was charged and convicted of first-degree murder and sentenced to life in prison. His case was taken up in 2003 by the Association in Defence of the Wrongly Convicted. A review by international experts found that the laceration that prompted Smith to conclude there had been a sexual assault had in fact occurred after death, when her body was prepared for the autopsy.
Normal post-mortem changes to the body caused the marks that Smith had attributed to strangulation and sexual assault. Although the cause of death could not be pinpointed, sudden natural death during sleep could not be excluded..
It took two years for these conclusions to be reached-in part because Smith had lost key evidence that was finally found in his office. During that time, colleagues and superiors closed ranks to protect him, and Jim Young, the chief coroner of the time, closed his ears to a rising tide of protest regarding Smith's shoddy work-from sources as disparate as Mullins-Johnson's lawyer, writing as a concerned private citizen, to an Ontario judge, to a Peterborough MP, to the Fifth Estate and Maclean's magazine.
After the evidence was re-evaluated, Mullins-Johnson was released on bail in September 2005, and in April 2007, the Ontario government supported his request for a review of his conviction by the federal justice minister. Finally, in October, he was acquitted by the Ontario Court of Appeal-with an apology.
"It is regrettable that as a result of flawed evidence, you were wrongly convicted and you spent a long period in custody," Justice Dennis O'Connor told him. The Ontario government also apologized.
Mullins-Johnson was not alone. Louise Reynolds of Kingston spent almost two years behind bars after Smith concluded that her 7-year-old daughter Sharon had been stabbed to death. Charges were withdrawn after other pathologists determined her daughter was killed by a dog. And Lianne Thibeault of Sudbury was investigated for manslaughter after her son died in 1995 after apparently hitting his head on a table. Smith concluded the boy suffered a deliberate blunt-force injury. No charges were laid because prosecutors decided there was not enough evidence, but Thibeault had to fight off intervention by child welfare authorities when she gave birth to another child. Her parents spent their life-savings to prove her innocence and assure her unrestricted access to her daughter.
Now, Judge Stephen Gouge is heading a provincial inquiry into 18 cases in which Smith made questionable findings-including the deaths of Valin, Sharon and Nicholas. Transcripts of proceedings are available at www.goudgeinquiry.ca. The site also features a live Web cast. Smith is expected to take the stand for a week, starting Jan. 28.
A coalition of two Aboriginal groups have standing at the inquiry-Aboriginal Legal Services of Toronto (ALST), which represents the interests of a growing urban Aboriginal community, and the Nishnawbe Aski Nation (NAN),which represents 45,000 people in 49 communities across an area that covers two-thirds of Ontario. They'll be focusing on the lack of coroners' services to remote communities in northern Ontario, said NAN Deputy Grand Chief Alvin Fiddler. It's hard enough getting a doctor to see to live people, let alone a coroner to see to the dead, Fiddler explained. "It was very important for the commissioner to see that first-hand."
At the invitation of the ALST-NAN coalition, Goudge visited Mishkeegogamang and Muskrat Dam First Nations in October, before the Nov. 11 start of public hearings, and met with families who have lost children."Just to hear that people didn't know who a coroner was, that the chief and council had never met a coroner," that made an impression on the commissioner, said ALST executive director Kim Murray.
Although Goudge's mandate is to look at child death investigations, the coalition's interest is more than pediatric, Murray said. "We're not getting any service for adults, we're not getting any service for children."
The coalition will be pushing for changes to legislation to allow a lay person to act as a coroner as is the practice in several other provinces and territories. The current situation in Ontario is that only a medical doctor can be a coroner, although the coroner can delegate investigative duties to a police officer.
That's a problem, Murray said, because in communities that are policed by the Ontario Provincial Police, there's a lack of trust so the findings will be questioned; and in communities policed by the Nishnawbe-Aski Police Service, it's a question of adding a further layer of responsibility to a severely under-funded force.
Just getting an inquest is an uphill battle, Fiddler said. "The only inquests that I'm aware of in recent years are those cases where it's mandatory for an inquest to happen." Those cases would include deaths in custody.
"The system needs to change-it shouldn't matter where the death occurs. It's up to the government and the system to ensure that there's adequate resources."