A top Ottawa forensic pathologist - Brian Johnston - was allowed to run the coroner's Eastern Ontario autopsy unit for 13 years after a disturbing record of autopsy mistakes first emerged, the Goudge commission heard yesterday.
In a scenario echoing the Charles Smith affair, the inquiry heard that Dr. Johnston's conclusions in criminal cases came into serious question within the coroner's establishment - yet he was not removed until early this year.
"I had significant concerns about the work coming out of the unit - specifically Dr. Johnston's work," testified David Chiasson, who became chief forensic pathologist in the chief coroner's office in 1994.
Dr. Chiasson said that he challenged Dr. Johnston about his competence and asked him to take remedial training in 1998. Dr. Johnston refused.
In a Feb. 3, 1998, memo to chief coroner James Young tabled at the inquiry, Dr. Chiasson stressed that internal concerns about Dr. Johnston's competency dated back to 1994. Dr. Chiasson recommended that Dr. Johnston be removed as director of the Eastern Ontario forensic unit.
"I never did get a formal reply to my memo," Dr. Chiasson told commission counsel Linda Rothstein yesterday.
He said that he eventually had informal discussions with Dr. Young about recruiting a new director for the unit, but nothing happened.
The inquiry was created to get to the bottom of how Dr. Smith maintained his position in spite of a record of botched autopsies. It is also looking at problems in the entire Ontario coroners' system.
Documents filed with the commission yesterday added several dramatic layers. A 2006 review of 11 autopsies in criminally suspicious cases at the Eastern Ontario unit featured nine in which Dr. Johnston had conducted the autopsy.
Reviewers found that in three, Dr. Johnston had misdiagnosed injuries; in another, his courtroom testimony was called misleading, and in still another, a toxicology examination that should have been conducted was not.
"These deficiencies have occurred on a historical background of errors, some resulting in the detention of accused persons," chief forensic pathologist Michael Pollanen wrote in a covering letter to chief coroner Barry McLellan.
Shortly afterward, Dr. McLellan ordered that all autopsies in criminal deaths in the Eastern Ontario region be conducted in Kingston or Toronto.
Ms. Rothstein told the commissioner, Mr. Justice Stephen Goudge, yesterday that Dr. Johnson is "about to retire" from the unit."
Dr. Chiasson testified that one of the cases he became aware of in 1998, in which Dr. Johnston concluded that a man died of manual strangulation, caused him "extreme concern." Dr. Chiasson said a proper interpretation would have pointed toward methadone in the dead man's blood and a history of heart disease as the likely cause of death.
"An individual had been arrested and was in custody" in connection with the alleged homicide, Dr. Chiasson testified. "The accused was released from custody, and charges were dropped."
Dr. Chiasson said that in the case of a man found with gunshot wounds that could have been suicide or homicide, Dr. Johnston's autopsy report was marred by poor terminology and unwarranted conclusions.
In a memo filed yesterday by Ms. Rothstein, Dr. Chiasson noted that Dr. Johnston was known for "an isolationist attitude" and refusal to ask for assistance.
His reports are "confusing, poorly organized, repetitious, and make unwarranted conclusions," Dr. Chiasson's memo said.
Dr. Chiasson also shed new light on why no one seemed willing or able to blow the whistle on Dr. Smith until it was too late.
He testified that Dr. Smith had carved out a specialty where few others had expertise - pediatric pathology - and the fact that he was senior to Dr. Chiasson made him uncomfortable about reviewing his work.