Ontario will move to amend the province's Coroner's Act this fall to implement recommendations made in a report that slams a "flawed" child forensic pathology system, government officials said Wednesday afternoon.

The government will also form an expert panel to work out compensation for people who became victims of the system and will undergo a review of about 220 medical cases where it was determined that babies had been shaken to death.

Attorney General Chris Bentley, Community Safety and Correctional Services Minister Rick Bartolucci and Ontario's Chief Coroner Dr. Andrew McCallum all apologized for the failures at a news conference as they formally responded to a scathing report on the state of Ontario's pathology system.

"We will work diligently with our partners in our review of recommendations and we'll work quickly in our response," Bartolucci said. "Public confidence in the system can only exist when the integrity of the system stands beyond reproach."

The 1,000-page report, released to the public Wednesday morning, was written by Justice Stephen Goudge after he presided over an inquiry into Dr. Charles Smith, the former chief pediatric forensic pathologist in Ontario.

At the height of his career, Smith was widely regarded as the leading child forensic pathologist in Canada but the inquiry found that a large number of his conclusions were mistaken and his assessments flawed. Smith was harshly criticized in the report.

"When the pathology is flawed or there is a failure of oversight to ensure its quality, the consequences are devastating," Goudge told a news conference as he released his report Wednesday afternoon.

"Sadly, in the years I examined, both occurred."

Report recommendations

Goudge's report was formally handed to the Ontario government on Tuesday. The report contains 169 recommendations meant to reform the system and ensure accountability and credibility into a coroner's conclusions.

Those recommendations include:

  • setting up a committee to oversee the chief coroner's office
  • ensuring pathologists take better care in how they form their opinions about wrongdoing
  • addressing staff shortages by increasing a pathologist's salary and setting up university programs to train them
  • conducting a review of more than 140 cases involving forensic pathology

Bentley said the province committed to reviewing a lot more "shaken-baby" cases than Goudge recommended because it is "the right thing to do."

"We are committed to doing everything we can to prevent terrible tragedies and injustices from happening," he said. "For those living in the shadow of doubt, we will remove as quickly and as expeditiously as we can to make sure the necessary reviews are undertaken.

"The right thing to do is to make sure that where the shadow of doubt exists, we shed light."

Britain reviewed a number "shaken-baby" cases after the conclusions were questioned by new medical findings. Bentley said Ontario would follow suit.

"To ensure that where the evolution of the science has rendered the conviction unsafe or questionable, it will be brought for further review so that every injustice is righted," he said.

Bentley also addressed the issue of compensation for affected families. He said he will work immediately on putting together an expert panel with a judge and two senior civil litigators -- one who works for a private firm and the other from within the ministry --  to develop an approach for victim compensation.

As a result of the report, the province also announced it would expand their  "child homicide team." The team of senior prosecutors, who have experience and expertise in dealing with murdered children, was formed after the inquiry into Smith's work.

"Our goal has always been to get it right," said Bentley.

Inquiry findings

The inquiry into Smith's work found proof that the coroner erred in his conclusions in 20 of 45 autopsies. His opinion in 13 of those cases led to criminal convictions.

Williams Mullins-Johnson is just one victim of the process. He spent 12 years in jail after Smith concluded his four-year-old niece was raped and murdered. Her death was later attributed to natural causes.

In another instance, Smith wrongfully concluded that a mother had killed her 11-month old son after he knocked his head on a table. The inquiry also heard that Smith said a mother was responsible for stabbing her seven-year-old daughter to death when in fact, the girl's injuries were the result of a dog mauling.

"He achieved the status of a leading expert in the field in large part because there was noone who had the training, experience and expertise to take him on," Goudge told reporters. "He worked all too much in isolation. The situation was prolonged because there was then, the way there is now, a severe shortage of forensic pathologists."

Smith has said that he blamed his lack of training and his ignorance about how the justice system worked for his mistakes.

"Dr. Smith was adamant that his failings were never intentional," Goudge said in the report. "I simply cannot accept such a sweeping attempt to escape moral responsibility."

The judge also found that Smith "admitted his own arrogance" and continuously offered misinformed opinions to people who relied on his judgement.

'Too little, too late'

Goudge concluded that Smith deliberately dodged attempts to call him to account for his assessments and "actively misled" the courts and his superiors, former chief coroner James Young and his deputy Jim Cairns.

The report is also quick to point out that Smith was a victim of a broad system that had inadequate oversight, putting the blame on Young who had the "ultimate responsibility."

Dr. Young continued to defend the indefensible in the name of saving the reputation of the (coroner's office)," Goudge writes.

"When he finally did act, it was to protect the reputation of the office and not out of concern that individuals and the public interest may already have been harmed."

He said any action after was "too little, too late."

During the inquiry, Smith, Young and Cairns all offered apologies for their errors.

The inquiry heard that the coroner's office -- headed at the time by Young and Cairns -- failed to act on repeated complaints about Smith and failed to monitor his work.

"None of (the complaints) stuck with me," Young told the inquiry. "I regret it deeply but I can't go back and change history."

Cairns apologized for defending Smith and testified that no one dared to question Smith's work because of his stellar reputation.

Smith was eventually relieved of his duties more than ten years after the coroner's office first received a complaint about him.

Peter Wardle, a lawyer representing five families, said the victims of erroneous child forensic pathology findings will be scrutinizing the report and keeping a close eye on what comes out of it.

"They're going to be very important to the death-investigation process in the province," he told CP on Tuesday.

"It's going to be critical that the government act on those recommendations."

With reports from CTV Toronto's Chris Eby and Paul Bliss and files from The Canadian Press