Cascading Faults

Responsible professionals, the leaders in their fields, those most highly trusted by the public, because they are led to believe they deserve to be trusted, shed blame as a duck does water. They exude a false humility when brought face-to-face with the undeniable fact that they have failed in their public duties. Humble in excusing themselves, in avowing regret, in pleading for understanding. Fingers of blame are pointed, but they are not really held to account for the damage they do.

And that's a curious thing. It shouldn't be that way. If a medical expert, like a pathologist, called in to examine evidence that would shed light on the cause of death of an infant, takes it upon himself to claim wrong-doing for no good reason other than his inclination to blame the parents, and in the process causes huge inconsolable grief, along with years of imprisonment, justice should have it that their freedom too, should be removed.

They should be held accountable for the intolerable damage they have done to society. An enquiry into the methodology and conclusions and attestations in a court of justice by former pathologist Dr. Charles Smith has released a studied opinion, a judgement on Dr. Smith and upon his superiors. They have all failed the most basic tests of professional integrity, decency, professional conduct, and human understanding and charity.

The practise operated by Dr. Smith in his forensic pathology laboratory was shoddy, amateurish, based on nothing but his own, unsuited instincts, and his allegiance to his supervisors at the Office of the Chief Coroner of Ontario. Justice Stephen Goudge's Inquiry Into Pediatric Forensic Pathology reached the conclusion of actual malpractise on the part of both Dr. Smith and Chief Coroner James Young, along with Deputy Chief Jim Cairns.

To this trio was entrusted the public interest in discovering the untimely causes of death of infants and children. Between them they had a vested interest in coming to conclusions that led invariably to charging that the unfortunate and grieving parents of deceased children were responsible for their deaths, despite evidence to the contrary. Evidence that they willingly construed to represent guilt, and no one, because of their presumed expertise, challenged them.

The result of which was that innocent parents and family members, in deep mourning for the loss of their beloved children, were charged with their deaths. And paid the penalties that society exacts for criminal injustice. Judge Goudge came to the conclusion that Dr. Smith's inaccurately damning conclusions were "fundamentally wrong". That he lacked forensic pathology knowledge, his autopsy practises were "sloppy" and "inconsistent".

Finally, he concluded that Dr. Smith's claim that his behaviour was unintended to cause harm; a byproduct of his incapacity. He very much regretted those unfortunate situations where his 'expert' testimony sent innocent people to jail, ruined family relations, harmed people who needed comfort, not accusations of murder. But, he said, it was not entirely his fault; he was placed in an unfortunate situation where it was demanded of him that he act as he did, without adequate training.

The simple fact was that the Office of the Chief Coroner of Ontario acted in this despicably unprofessional and harmful manner for decades. That when the alarm was raised on occasion by those who doubted the outcomes of certain trials, and who doubted the efficacy of Dr. Smith's expertise, he was shielded by his superiors so that the Office of the Chief Coroner of Ontario would not suffer public embarrassment.

There will never be any kind of compensation given to the wrongly accused and incarcerated that might atone for the wrongs done to them. But that Dr. Smith and his superiors might get off with not so much as a charge of deliberate mischief, in a court of law for grievous harm done through the deliberate mismanagement of a public office, would be despicable.

As they charged others with guilt in the commission of unspeakable crimes against children, they should now be charged with aggravated dereliction of duty, amounting to malicious malpractise.