Key evidence to prosecute a Labrador father accused of causing a fatal head injury to his infant son was kept in a room with medical waste destined for the trash, and that's likely where it ended up, documents obtained by CBC News through access to information reveal.
Four-month-old Matthew Rich, from Sheshatshiu, was taken to hospital in Happy Valley-Goose Bay on Oct. 15, 2013, in serious condition, after suffering a head injury. He died later the same day.
Almost a month later, the RCMP laid a charge of second-degree murder against the baby's father, Thomas George Michel, 24.
But according to records obtained by CBC News, officials discovered in the summer of 2014 that the infant's brain and the dura — the membrane surrounding it — had gone missing at some point after the autopsy.
The revelation came after an RCMP officer requested the specimens for further testing by outside experts.
"Upon retrieval of the preserved specimens, it was noted that the brain had been misplaced," wrote chief medical examiner Simon Avis on Aug. 20, 2014.
"There is no documentation that the brain was discarded, however, it would appear to be a reasonable conclusion that the brain and dura were discarded contrary to the policies of Eastern Health and the Chief Medical Examiner's Office."
'Brain was discarded in error'
According to Avis's 2014 letter to the RCMP, the examination of Matthew Rich's brain could not be completed in the forensic pathology autopsy room due to occupational health and safety restrictions — it was instead done in the hospital's autopsy room, which had a fume hood.
A review found that Eastern Health had been using the hospital autopsy room to store "wet tissue from both autopsies and surgical specimens that are for disposal."
At the time, the anatomic pathology residency program was "receiving heavy criticism for the potentially toxic environment created by storage and dumping in the hospital autopsy room," Avis wrote.
In an attempt to rectify the issue, Avis wrote, "an attempt was made to correct the storage buildup and it is likely that the brain was discarded in error, mistaken for tissue for disposal."
Avis noted that this was against policy.
Last month, after the charge against the infant's father was dropped, a news release from Avis's office noted that it is policy for the examiner to keep "all relevant autopsy tissue for independent review."
Both Eastern Health and Avis's office said they would jointly review procedures. However, the status of that review, and when it began, is unclear.
In a statement to CBC News Wednesday, the health authority said a new secure storage space for forensic laboratory specimens for the Office of the Chief Medical Examiner is being constructed.
It is expected to be completed over the next several months.
No one was reprimanded from Eastern Health or the Office of the Chief Medical Examiner for the incident.
No case without it
More than a year after the mistake was discovered, Crown prosecutor Elaine Reid dropped a bombshell when she announced in court on Dec. 10, 2015, that the murder charge was being withdrawn. She said the victim's brain had gone missing and was presumably destroyed while in the possession of the Chief Medical Examiner's Office.
Michel, who had been free on bail, would not face prosecution.
Reid explained to CBC News Wednesday that the Crown was investigating other avenues to proceed with the case between the time she learned the evidence was missing and the day the charge was dropped.
But ultimately, Reid said, without the experts having access to the brain, there was not a reasonable likelihood of getting a conviction.