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Digital Journal’s Autopsy of a Disgraced Pathologist Who Killed the Coroner’s Office

We put our trust in the legal system to convict criminals. But what happens when a pediatric pathologist abuses that trust and ruins people’s lives? An inside look at Dr. Charles Smith’s fall from grace and why an inquiry is only half a solution.

Digital Journal — In Ontario, Canada, a forensic pathologist was sending mothers and fathers to jail for supposedly killing kids. He studied skull X-rays and facial wounds, listened to testimony, and urged police to investigate cases he found suspicious. He also practised some unusual behaviour — in 1997, he took along his 11-year-old son to a graveyard to witness an exhumation of a dead baby boy.

Dr. Charles Smith is now enduring heavy criticism for failing to research cases thoroughly, and ultimately sending parents to jail without proper evidence to back up the decision. A review of 45 autopsies Smith oversaw revealed that he apparently erred in 20 of them. And today, a father who was convicted for killing his baby, partly based on expert evidence from this disgraced pathologist, was granted bail after spending nine years in prison.

As soon as it became known last month that Smith made mistakes in several autopsies, legal watchdogs demanded an immediate public inquiry. The Ontario government stalled one day before answering the call for an inquiry. Ontario Premier Dalton McGuinty said the province bears a “heavy responsibility” to conduct a detailed investigation.

Why did Ontario delay, even if it was for 24 hours? It’s as if the government was waiting to see if there would be an incensed reaction to Smith’s alleged incompetence. Exhibiting that hesitancy, though, rained down a storm of criticism on the political body responsible for balanced justice.


James Lockyer, a lawyer for the Association in Defence of the Wrongly Convicted, at his office in Toronto, ON. – Photo by Digital Journal

Take a look at the serious consequences behind the errors committed by Smith, an evangelical Christian now living in British Columbia. Among the 20 cases under scrutiny, 12 of them resulted in convictions. One Eastern Ontario woman, Sherry Sherrett, is trying to appeal her 1999 infanticide conviction, even though her window of time to do has long since closed.

Smith managed to slip under the radar because his peers may have been hesitant to question his work. “[Smith] managed to convince his colleagues that he was brilliant, and they became apprehensive about taking him on,” James Lockyer, a lawyer for the Association in Defence of the Wrongly Convicted, told the Globe & Mail.

The role of a forensic pathologist should not be taken lightly. Often called as an expert witness, the pathologist is an aid to Crown attorneys looking for the exact reason for a person’s death. There are very few experts of this nature, so their opinions matter immensely. That responsibility has given pathologists an almost God-like status which can sometimes boost egos.

“Pathologists tended to illuminate themselves, and the courtroom provided a platform,” said Dr. John Butt, a former medical examiner who reviewed Smith’s past cases.

Butt went on to attack certain practises that give pathologists unprecedented control. “What is a forensic pathologist doing reading a skull X-ray?” he said in a Globe article. “I know of a system — not Ontario — where it was a house rule that X-rays were read by radiologists. But when the money got a little tight, that went out the window. The defence ought to have been saying: ‘Wait a minute. What is your expertise in reading X-rays?’”

Criticism levelled at Smith will undoubtedly reach public ears during the inquiry, but is that enough? The Ontario government, and particularly the attorney general, should be held accountable for allowing Smith to hoodwink lawyers for so long. As the Law Times points out, the inquiry should look into whether there was any cover-up in the coroner’s office or the Crown’s office for fear of liability. As well, the process of hiring new employees at the coroner’s office should be thoroughly investigated, apart from the actual inquiry. A makeover is due.

Even before the hiring step, pathology education needs to be overhauled. As Butt suggests, Canada should adopt national standards for this medical stream, instead of the current inconsistent standards tabled by individual provinces. Butt also notes that Canada is only just catching up to the UK and the US when it comes to properly training pathologists.

What kind of impression does this give to grieving families? Or to young students in both the pathology and legal fields? In this case, one bad apple can spoil the whole bunch, but at the very least, this rotting fruit is exposing us to a flawed branch in the coroner’s office. It’s sad, yet also routine, that change only comes when a disaster hits home. Ontario residents might be feeling the pain, but the Smith controversy should impact anyone fascinated with what goes on behind the curtain of the justice system.

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There is no statutory immunity. There never was any immunity. Move on.