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A Kingston pathologist said he ignored a provincial directive to "think dirty" when conducting autopsies on children because doing so could have led him to conclude they'd died of abuse when they hadn't.
In 1995, former chief coroner Jim Young issued a new protocol for pathologists, coroners and chiefs of police to use in death investigations involving children. It stated:
"Unfortunately in this day and age CHILD ABUSE IS A REAL ISSUE and it is extremely important that all members of the investigative team 'THINK DIRTY.'
"They must actively investigate each case as potential child abuse and not come to a premature conclusion regarding the cause and manner of death until the complete investigation is finished and all members of the team are satisfied with the conclusion."
Public hearings began today at the inquiry, set up to examine the practice of pediatric forensic pathology in Ontario.
The inquiry will also cover the work of Dr. Charles Smith, who said in a statement read by his lawyer, Niels Ortved, that he was "truly sorry." Smith issued the apology to all those who may have been "affected by his errors."
The Ontario government promised to hold the inquiry last April after a review Smith's work found that he had made errors in 20 of 45 child autopsies dating back to 1991.
Criminal proceedings resulted in 13 of those cases.
Commission lawyer Linda Rothstein said the inquiry will try to take a comprehensive look at pediatric forensic pathology and at the specific cases that Smith was involved in.
During Mooers's trial, social workers testified they were too overworked to intervene properly before two-year-old died, even though they had fielded 15 calls from people concerned about the girl's well-being.