Ontario Responds To The Goudge Report

    McGuinty Government Commits To A Stronger, More Accountable Coroners

    TORONTO, Oct. 1 /CNW/ -


    Ontario proposes to overhaul its forensic pathology system through the
introduction of new legislation, and to pursue measures to redress past
injustices, in response to the Honourable Justice Stephen Goudge's Inquiry
into Pediatric Forensic Pathology in Ontario.
    Justice Goudge released his report and recommendations earlier today. The
McGuinty government called the inquiry in April 2007 - six days after the
chief coroner announced the results of a review into the work of pediatric
pathologist Dr. Charles Smith.
    The proposed legislation will, if passed, establish a framework to
strengthen the death investigation system, provide for greater oversight and
accountability and improve coroner and pathology services in Ontario. Guided
by Justice Goudge's recommendations, the legislation will build on the
progress Ontario has made in the past five years to improve the province's
coroners system.

    In addition, the Ministry of the Attorney General will:
    -   Work with justice partners to expedite cases where an injustice is
    -   Develop a compensation framework for those who suffered injustice.
    -   Establish a medical/legal review of convictions involving "shaken
        baby" deaths.


    "Justice Goudge has provided a roadmap for change to build a stronger,
more accountable coroners system. We intend to move quickly and aggressively
in responding to the report and to build on the work we've already done to
prevent this from happening again," said Community Safety and Correctional
Services Minister Rick Bartolucci

    "Justice Goudge's recommendations will strengthen the justice system's
response to child death cases," said Attorney General Chris Bentley
(http://www.attorneygeneral.jus.gov.on.ca/english/about/ag/agbio.asp). "We
will build on the changes in approach already in place for child homicide
cases. We will also initiate a review of past shaken baby death cases to
determine whether the evolution in scientific opinions affects the validity of
the conviction."

    "Over the past few years we've made great strides to strengthen Ontario's
death investigation system. Commissioner Goudge's recommendations will help us
navigate the way forward," said Ontario's Chief Coroner Dr. Andrew McCallum


    -   Since 2002, pediatric autopsies in Ontario are conducted in one of
        four centres (London, Ottawa, Hamilton and Toronto) to ensure they
        are carried out where pathology and pediatric expertise are greatest.

    -   Since 2006, coroners, pathologists, police and other members of the
        death investigation team now follow a new and more stringent protocol
        when investigating the death of any child under age five.

    -   Since 2004, all forensic autopsies on criminally suspicious cases,
        homicides and cases going to inquest undergo a peer review process to
        ensure the quality of the autopsy and the resulting conclusions.


    Learn more about Ontario's coroners

    Read Justice Goudge's report and recommendations


                                                      Disponible en français




    The Office of the Chief Coroner for Ontario performs high quality death
investigations and inquests to ensure that no death will be overlooked,
concealed or ignored. The findings are used to generate recommendations to
help improve public safety and prevent deaths in similar circumstances.
    Ontario's coroners are physicians trained to investigate sudden and
unexpected deaths, as well as deaths in circumstances requiring further
examination. The purpose of these investigations is to answer five questions:

    -   Who died?
    -   How did they die?
    -   When did they die?
    -   Where did they die?
    -   By what means did they die?

    Coroners also determine whether a death warrants an inquest - a public
hearing during which evidence is presented to a jury of members of the
community in which a person died. The jury must answer the five questions and
may also make recommendations to avoid deaths in similar circumstances.
Approximately 75 inquests are held each year.
    Each year in Ontario, there are approximately 80,000 deaths. The
province's coroners investigate 20,000 deaths per year, 250 of which involve
pediatric deaths (under the age of five).
    Ontario has more than 300 coroners. Of these, 65 are also qualified to
conduct inquests.


    Pathologists are physicians trained in the examination of body tissues
and the impact of disease on tissues and organs. Forensic pathologists have
additional training in matters likely to be presented to the courts. Pediatric
forensic pathology is a particular sub-specialty of pathology focusing on
complex cases involving the death of young children.
    Pathologists conduct autopsies when warranted by a coroner, who decides
what is required under the Coroners Act. Autopsies are usually conducted when
a death may have resulted from an accident, foul play or criminally suspicious
circumstances. Each year, coroners warrant more than 7,000 autopsies conducted
by pathologists. Of these, between 200 and 250 involve criminally suspicious
deaths or homicides.
    Ontario's chief forensic pathologist reports to the chief coroner and is
responsible for establishing guidelines for the conduct of forensic pathology
in the province.


    The Office of the Chief Coroner for Ontario has made many operational and
management improvements to strengthen the death investigation system and
ensure quality.

    New Standards

    -   Protocol for investigating pediatric deaths
        The Office of the Chief Coroner has implemented a protocol for
        coroners, pathologists, police and other members of the death
        investigation team to follow when examining pediatric deaths under
        two years of age. Since 2006, all deaths of children under the age of
        five years are now subjected to this standardized investigation.

    -   Standardized peer review process
        Since 2004, all forensic autopsies on criminally suspicious cases,
        homicides and cases going to inquest undergo a peer review process.
        This process helps to ensure that all key examinations are performed,
        and that the facts and conclusions emerging from the exams are
        logical and clearly supported by materials available for any
        independent review.

    -   Autopsy and death investigation guidelines
        Under the direction of the chief forensic pathologist, new guidelines
        have been prepared for autopsies on all criminally suspicious and
        homicide cases. The guidelines include instructions and information
        specific to pediatric autopsies. These guidelines also focus on the
        important observations to make at death scenes, what should be
        included in reports and how information should be presented, as well
        as the essential communication expected among pathologists and other
        members of the death investigation team.

    -   Early case conferences
        Since 2002, members of a death investigation team hold early case
        conferences following all homicides or criminally suspicious cases
        where there are outstanding issues or significant unanswered
        questions. The conferences include a senior coroner, the pathologist
        who conducted the examination, scientists from the Centre of Forensic
        Sciences, police and any other appropriate experts. The conference
        ensures that members of the investigative team know the findings of
        an autopsy and provides them an opportunity to identify any
        outstanding examinations necessary before a pathologist can reach

    Ensuring Expertise

    -   Expert pediatric autopsies
        Since 2002, pediatric autopsies are conducted in four centres
        (London, Ottawa, Hamilton and Toronto). This ensures that the complex
        autopsies are conducted at centres where resources and pathology and
        pediatric expertise are greatest.

    -   Professional training for pathologists
        A special new course emphasizing the importance of fair and balanced
        testimony has been developed for pathologists who provide expert
        testimony in court.

    Quality Assurance

    -   Coroner's reviews
        The Chief Coroner's Review Process allows the chief coroner to
        appoint a panel to review the work of a coroner should serious
        concerns be raised about that work.

        As well, child deaths are the exclusive focus of two new expert
        committees in the chief coroner's office. They are the Deaths Under
        Five Committee, which reviews the deaths of all children under five
        and the Pediatric Death Review Committee, which reviews complex cases
        where children of any age have died.

    -   Management and operational review
        In the fall of 2007, the Office of the Chief Coroner engaged an
        external consulting firm to review its quality assurance processes
        and practices in the areas of strategic planning, human resources,
        leadership and support and internal communication. The review was
        submitted to the Goudge Inquiry, and the chief coroner's office is in
        the process of acting on its recommendations.

    Resources and Infrastructure

    -   Increased funding
        The government has nearly doubled annual funding to the Office of the
        Chief Coroner from approximately $20 million in 2003-04 to more than
        $36 million in 2008-09. The additional funds have been used to
        improve remuneration for investigating coroners and pathologists, as
        well as to meet other increases in the operational costs of the chief
        coroner's office.

    -   A new Forensic Services Complex
        The ministry is in the planning stages of a new Forensic Services
        Complex that could put the Office of the Chief Coroner and the Centre
        of Forensic Sciences on one site. The proposed complex would provide
        the space and advanced technology to support a growing population and
        keep pace with the demands of the justice sector.

    -   Central dispatch for coroners
        A three-month pilot program to evaluate the effectiveness of a
        central dispatch system will begin in Halton Region this fall. This
        initiative addresses the need for proper communication among regional
        supervising coroners and investigating coroners so that regional
        offices are aware of all active cases within their jurisdiction.


    As well as the improvements made by the chief coroner's office, the
Ministry of the Attorney General has also implemented a number of initiatives
to improve the way it handles child homicide cases, including:
    -   Appointing a nine-person Child Homicide Resource Team to provide
        advice to Crowns at all stages of a child homicide prosecution.
    -   Developing a database to better track child homicide cases and the
        pathologists involved in those cases.
    -   Enhancing Crown training and education on pediatric forensic
        pathology issues and assessing expert evidence.

    The Ministry of the Attorney General has retained the Honourable Patrick
LeSage, former chief justice of the Superior Court of Justice, to advise the
Criminal Convictions Review Committee.
    Mr. LeSage and the committee provide advice to Crowns on trends emerging
from child homicide cases and other cases.


    Learn more about the Office of the Chief Coroner of Ontario


                                                      Disponible en français

For further information:

For further information: Laura Blondeau, Ministry of Community Safety
and Correctional Services, Minister's Office, (416) 325-4973; Stuart
McGetrick, Ministry of Community Safety and Correctional Services,
Communications Branch, (416) 325-9686; Sheamus Murphy, Ministry of Attorney
General, Minister's Office, (416) 326-1785; Brendan Crawley, Ministry of
Attorney General, Communications Branch, (416) 326-2210

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Ontario Ministry of Community Safety and Correctional Services

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Ontario Ministry of The Attorney General

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