An inquiry into flaws in Ontario's system of investigating child deaths is expected to recommend major changes in how the provincial coroner's office operates while also possibly pointing the finger at key individuals.

Commissioner Stephen Goudge arrives for the first day of public hearings in an inquiry into the work of discredited pathologist Dr. Charles Smith, on Nov. 12, 2007. (Frank Gunn/ Canadian Press)

The public inquiry, headed by Ontario Court of Appeal Justice Stephen Goudge, was launched after it emerged that Charles Smith, formerly the province's chief pediatric pathologist, had made grievous errors in 20 child autopsies between 1991 and 2001. His mistakes led to wrongful criminal convictions and accusations against parents and caregivers who were accused of abusing or killing their children.

The inquiry, which is to deliver its final report Wednesday, is expected to offer a far-reaching analysis of how the province handles criminally suspicious child deaths and how the system broke down under Smith's leadership, several people familiar with the inquiry and the field of pathology said Tuesday.

"We are all interested to see what will come out and be his recommendations," said Chitra Rao, medical director of the regional forensic pathology unit at Hamilton General Hospital and an associate professor at McMaster University medical school.

"One problem throughout all of Ontario is that we are understaffed and overworked. What the inquiry may suggest is that there be a pay increase so that they may attract more young people."

Staff shortages have been blamed for a lack of oversight in pediatric forensic pathology, which uses lab tests and autopsies to try to unearth the facts surrounding suspicious child fatalities.

Accreditation lacking

Rao also anticipated the report would recommend that the province's chief forensic pathologist shoulder more responsibility for investigating cases of suspected foul play, with Ontario's coroners — doctors who examine the scene of a death, but have far less specialized training — carrying less of the burden.

"Everything shouldn't lie on the coroner's side," Rao said.

Dr. Charles Smith sits on the stand as he waits to deliver testimony at the Goudge inquiry in Toronto on Jan. 28, 2008. (Adrian Wyld/ Canadian Press)

The inquiry's report is also expected to touch on how forensic pathologists are recruited and accredited as well as other issues.

Until this year, there was no system in Canada to certify forensic pathologists. Doctors practising in the field, like Smith, generally did a four-year residency in general pathology, followed by a one-year fellowship, but did not need to pass licensing exams.

As of next year, all newly graduated forensic pathologists in Canada will have to have some form of certification, while senior practitioners will have to pass an as-yet-undetermined examination process, Rao said.

The inquiry is likely to find that the lack of proper accreditation meant that, in some cases, the doctors tasked with identifying a cause of death weren't fully trained in how to do so.

In his testimony at the inquiry, Smith admitted he had had very little experience in criminally suspicious cases and had never trained with a certified forensic pathologist. Nevertheless, he still managed to rise to the top of the profession in Ontario.

The report may also point the finger at individuals, with former Ontario chief coroner James Young a possible target for some of the criticism, a physician familiar with the coroner's work who asked not to be named said Tuesday. Under Young's leadership, there was precious little oversight of Smith's work.

Smith, who worked at Toronto's Hospital for Sick Children but functioned under the Chief Coroner's Office, said he felt his job was to help prosecutors nail child abusers and not to provide impartial scientific evidence on what caused a child's death.

"I honestly believed it was my role to support the Crown attorney," Smith testified at the inquiry.

Dubious conclusions

The Goudge inquiry was launched in April 2007 after a review by Ontario's chief coroner of 45 criminally suspicious children's deaths in which Smith had done, or consulted on, the autopsies.

The review found that in 20 instances between 1991 and 2001, Smith had made mistakes leading to dubious conclusions of criminal wrongdoing. Thirteen of those cases resulted in criminal convictions.

The revelation was all the more shocking because Smith was seen as "a world-renowned pathologist, who was considered to be at the top of his field," the Chief Coroner's Office said in submissions to the inquiry last year.

Smith has apologized repeatedly for his errors, telling the inquiry in January that "I have come to appreciate mistakes that I made, and I am sorry for them. … I do accept full responsibility for work."