The Inquiry into Pediatric Forensic Pathology in Ontario, commonly known as the Goudge Inquiry, was created to address serious concerns over the way criminally suspicious deaths involving children are handled by the Province of

Ontario Ontario is the southernmost Provinces and territories of Canada, province of Canada. Located in Central Canada, Ontario is the Population of Canada by province and territory, country's most populous province. As of the 2021 Canadian census, it ...

Canada Canada is a country in North America. Its Provinces and territories of Canada, ten provinces and three territories extend from the Atlantic Ocean to the Pacific Ocean and northward into the Arctic Ocean, making it the world's List of coun ...

. The inquiry was primarily the result of evidence that arose in regards to discredited pathologist Charles Smith.

Creation

By 2005, the existence of serious and disturbing errors in several

criminal investigations In ordinary language, a crime is an unlawful act punishable by a State (polity), state or other authority. The term ''crime'' does not, in modern criminal law, have any simple and universally accepted definition,Farmer, Lindsay: "Crime, definiti ...

into suspicious deaths involving children had been confirmed. While there appeared to be significant problems in the entire system, the majority of cases being re-investigated involved those for which Charles Smith, of the Hospital for Sick Children in

Toronto Toronto ( , locally pronounced or ) is the List of the largest municipalities in Canada by population, most populous city in Canada. It is the capital city of the Provinces and territories of Canada, Canadian province of Ontario. With a p ...

, had provided his expert opinion. In response to a shockingly large number of

wrongful convictions A miscarriage of justice occurs when an unfair outcome occurs in a criminal or civil proceeding, such as the conviction and punishment of a person for a crime they did not commit. Miscarriages are also known as wrongful convictions. Innocent p ...

(for

murder Murder is the unlawful killing of another human without justification (jurisprudence), justification or valid excuse (legal), excuse committed with the necessary Intention (criminal law), intention as defined by the law in a specific jurisd ...

sexual assault Sexual assault is an act of sexual abuse in which one intentionally Physical intimacy, sexually touches another person without that person's consent, or Coercion, coerces or physically forces a person to engage in a sexual act against their w ...

, and

infanticide Infanticide (or infant homicide) is the intentional killing of infants or offspring. Infanticide was a widespread practice throughout human history that was mainly used to dispose of unwanted children, its main purpose being the prevention of re ...

, to name but a few), the provincial government directed that an inquiry be held to determine the state of the

Forensic Pathology Forensic pathology is pathology that focuses on determining the cause of death by examining a corpse. A post mortem examination is performed by a medical examiner or forensic pathologist, usually during the investigation of criminal law cases ...

system in Ontario. The goal of this inquiry was to come up with suggestions to improve the system, which the province was capable of implementing, in order to ensure that these errors would not be repeated.

Inquiry and report

Ontario Court of Appeal judge Stephen Goudge was named as commissioner. He heard evidence from November 2007 through the early months of 2008. His report was released on October 1, 2008. Goudge found that Smith had "actively misled" superiors and made "false and misleading" statements in court. In his report, among the host of problems he addressed, he took issue with: * the qualifications of practitioners in the field of Pediatric Forensic Pathology – specifically the problems with a lack of a formal

certification Certification is part of testing, inspection and certification and the provision by an independent body of written assurance (a certificate) that the product, service or system in question meets specific requirements. It is the formal attestatio ...

program in Pediatric Forensic Pathology; * training of practitioners that failed to place a heavy emphasis on the

forensic Forensic science combines principles of law and science to investigate criminal activity. Through crime scene investigations and laboratory analysis, forensic scientists are able to link suspects to evidence. An example is determining the time and ...

aspects of pediatric forensic pathology; * a lack of knowledge of the legal system on the part of those conducting autopsies as part of criminal investigations and, as a result, a fundamental lack of appreciation of the proper role the Forensic Pathologist plays in the

criminal justice Criminal justice is the delivery of justice to those who have been accused of committing crimes. The criminal justice system is a series of government agencies and institutions. Goals include the rehabilitation of offenders, preventing other ...

system; and * an improper system of checks-and-balances leading to a total lack of oversight into the work of those who make the determinations that often lead to serious criminal convictions.

Aftermath

On October 23, 2008, the

Government of Ontario The Government of Ontario () is the body responsible for the administration of the Provinces and territories of Canada, Canadian province of Ontario. The term ''Government of Ontario'' refers specifically to the executive—political Minister ...

announced it would accept all legislative changes recommended in the report and introduced a bill in the

Legislative Assembly of Ontario The Legislative Assembly of Ontario (OLA; ) is the legislative chamber of the Canadian province of Ontario. Its elected members are known as Members of Provincial Parliament (MPPs). Bills passed by the Legislative Assembly are given royal as ...

to implement the changes. One change was the introduction of the Ontario Forensic Pathology Service, which serves as the head for all forensic pathology investigations in the province.

References

External links

Goudge Inquiry
Commissions and inquiries in Ontario 2008 in Canadian politics 2008 in Ontario

Creation

Inquiry and report

Aftermath

References

Further reading

External links