Beyond the Goudge inquiry: is the coroner part of "the Crown" for Stinchcombe disclosure obligations?

Author:Martin, Andrew Flavelle
Position:Justice Stephen Goudge - Canada


Pediatric forensic pathology evidence is a critical component of the investigation and prosecution of child and infant death. Several years ago, concerns arose over the work of Dr. Charles Smith, then a renowned expert in the field. The Office of the Chief Coroner for Ontario ("The Coroner") then commissioned an external review of his work on 45 cases. For each case where his findings or conclusions were disputed and the accused had not been acquitted, the defence counsel was given the corresponding reports. In response to the review, the Government of Ontario commissioned a public inquiry led by Justice Stephen Goudge. While the report by Commissioner Goudge strongly endorsed the performance of quality assurance, it did not specifically address whether such quality assurance must, or should, be disclosed to the defence. These events raised three critical questions for criminal cases involving pediatric forensic pathology: (1) Is there an obligation to perform quality assurance, such as external review? (2) Is there a corresponding obligation to disclose the results? (3) Does that obligation include all of the pathologist's work, or only his or her work in that case?

To suggest answers to these questions, this paper examines the jurisprudence governing the disclosure and production of evidence in criminal trials, relating this case law to the particular context of pediatric forensic pathology. While the Supreme Court of Canada's well-known holding in R. v. Stinchcombe clearly requires "the Crown" to disclose the records that it possesses in a criminal investigation to the defendant for the purpose of his or her trial, there is uncertainty in the literature and the Courts of Appeal over which government actors comprise "the Crown". Specifically, government actors other than the prosecuting Crown attorney's office and the investigating police force may be considered to be "third parties" to the investigation--in which case the acquisition of their records by the defence would be governed by the more restrictive standard established in R. v. O'Connor. This article uses the issue of quality assurance in pediatric forensic pathology to critically re-examine the meaning of "the Crown" for the purpose of disclosure.

First the author discusses the nature of pediatric forensic pathology and the Coroner's obligation to perform quality assurance. The author then outlines the disclosure regime of Stinchcombe and the production regime of O'Connor, and the differing obligations to create and preserve records under those two regimes. On this foundation, the author then provides an overview of the academic literature and case law that consider the question of which government actors comprise "the Crown", and establishes a purposive framework for the meaning of "the Crown". Next, this framework is applied to the Coroner's work in the area of pediatric forensic pathology in order to demonstrate that the more inclusive Stinchcombe standard should apply to the Coroner. Finally, the author discusses what this standard of disclosure would require in practical terms. He argues that historical quality assurance records--that is, records relating to the work of the investigating pediatric forensic pathologist on previous cases, not just the instant case--are disclosable according the standard established in Stinchcombe.


L'attention publique etait recemment fixee sur le cabinet de pathologie legale de pediatrie a cause d'une serie de condamnations inequitables du pathologiste Charles Smith, qui etait auparavant celebre. Le juge Stephen Goudge a dirige l'enquete criminelle contre le bureau du coroner de l'Ontario, et il a donne son appui a une politique des examens pour identifier les erreurs des pathologistes; cependant, il n'a pas dit si ces examens doivent, ou devraient, etre divulgue au defenseur dans un proces criminei. Ces evenements posaient trois questions importantes pour les dossiers criminels avec des problemes de pathologie legale de pediatrie, et avec le bureau du coroner de maniere generale: 1) Est-ce qu'il y a une obligation d'executer un examen d'assurance-qualite? 2) Est-ce qu'il y a une obligation correspondante de reveler les resultats d'un examen d'assurancequalite? 3) Est-ce que cette obligation inclue tous les travaux d'un pathologiste, ou seulement son travail dans ce dossier-la?

Afin de suggerer des reponses a ces questions, cette dissertation examine la jurisprudence qui gouverne la revelation et production de preuves dans un proces criminel. Le resultat bien connu de la Cour Supreme du Canada dans l'arret R. c. Stinchcombe dit qu'une revelation de tous les comptes rendus dans un proces criminel au defenseur par la couronne est necessaire, mais il reste incertain qui est la couronne dans le gouvernement. Particulierement, des representants du gouvernement qui ne sont pas l'accusateur-procureur et la police peuvent etre considere comme des "tierces" a l'investigation--donc, l'acquisition des comptes rendus par le defenseur pourrait etre gouverne par l'etendard plus restrictif etablit dans l' arret R. c. O'Connor. Cette dissertation utilise le sujet d" assurance-qualite de pathologie legale de pediatrie afin de reexaminer le sens de "la couronne" dans le contexte de revelation de preuve.

Premierement, l' auteur explore la nature de la pathologie legale de pediatrie et l'obligation du coroner de faire de l'assurance-qualite. Ensuite, l'auteur decrit le regime de revelation de Stinchcombe et le regime de production d'O'Connor, et les differentes obligations pour faire des comptes rendus sous ces regimes. L'auteur dorme une vue d'ensemble de la litterature academique et des dossiers qui considerent la question de quels representants du gouvernement sont "la couronne" et etablit une structure pour definir le sens de "la couronne. " Cette structure est utilisee pour examiner le travail du coroner dans le domaine de pathologie legale de pediatrie pour demontrer que le standard plus libre de Stinchcombe devrait s'appliquer au coroner. Finalement, l'auteur explore les repercussions pratiques de ce standard. Il argumente qu'on peut reveler des comptes rendus historiques d' assurance-qualite--ce qui veut dire des comptesrendus avec une connexion au travail du pathologiste sur ses autres dossiers, et non pas seulement le dossier en question--avec le standard de Stinchcombe.

I INTRODUCTION II PEDIATRIC FORENSIC PATHOLOGY AND THE PERFORMANCE OF QUALITY ASSURANCE The Nature and Status of Pediatric Forensic Pathology The Imperative to Perform Quality Assurance III THE APPLICABILITY OF STINCHCOMBE DISCLOSURE OBLIGATIONS TO THE CORONER The Basics of "First Party" Disclosure under Stinchcombe and "Third Party" Production under O'Connor The Implications of "First Party" Disclosure versus "Third Party" Production for Record Creation and Retention The Meaning of "The Crown" for Stinchcombe Disclosure: A Purposive Analysis The Disclosure Obligations of the Coroner II PEDIATRIC FORENSIC PATHOLOGY AND THE PERFORMANCE OF QUALITY ASSURANCE The Relevance of Quality Assurance The Privacy Implications of Quality Assurance V CONCLUSION I INTRODUCTION

Pediatric forensic pathology has been defined as "the study of diseases and injuries of children with subsequent medico-legal interpretation of findings for police and the courts". (1) It plays a critical role in the investigation and prosecution of child and infant death, especially in differentiating between natural and unnatural causes of death. In April 2007, the Office of the Chief Coroner for Ontario ("the Coroner") announced the results of an extensive review of the work of Dr. Charles Smith, then a renowned expert in pediatric forensic pathology. (2) In such reviews (which will generally be termed "quality assurance") another forensic pathologist examines the evidence from the autopsy and related tests to determine if they agree with the reported facts and the interpretations of those facts. (3) Of the 45 cases reviewed, Dr. Smith's observations or conclusions were disputed in 20 cases, of which 12 had resulted in convictions. (4) In response to the review, the government established a commission under the Public Inquiries Act, (5) led by Justice Stephen Goudge of the Ontario Court of Appeal, (6) with the mandate to "conduct a systemic review ... in order to make recommendations to restore and enhance public confidence in pediatric forensic pathology in Ontario and its future use in investigations and criminal proceedings". (7)

Following the review of Smith's work, the Coroner provided each of the defence and Crown counsel with the quality assurance reports associated with their cases. (8) The errors discovered under review and the Coroner's eventual disclosure underscores just how important it is that quality assurance reports be disclosed in advance of a trial. The Supreme Court of Canada has clearly expressed that "[t]he Crown has a public duty to avoid the wrongful conviction of accused individuals". (9) This duty suggests an obligation to evaluate the accuracy of pediatric forensic pathology evidence through a process of quality assurance. Such a legal obligation suggests three possible components. The first is the performance of quality assurance itself, and the documentation of the results. Next is the disclosure to the accused of such results from his or her individual case. The last possible component is the additional disclosure to the accused of 'historical' results--that is, those from all of the cases previously performed by the pathologist in question.

Not all of these component issues were addressed in the Goudge Report, as they were not central to its mandate, and none were evaluated in terms of legal obligation. The Report did emphasize that quality assurance--in particular, peer review--is essential in order to produce pediatric forensic pathology evidence that is worthy of public confidence. (10) Yet, while Commissioner Goudge...

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