Ontario Newsroom

Ministry of the Attorney General - Order in Council

Archived News Release

Ministry of the Attorney General - Order in Council

On the recommendation of the undersigned, the Lieutenant Governor, by and with the advice and concurrence of the Executive Council, orders that:

Ministry of the Attorney General

WHEREAS on April 19, 2007, the Chief Coroner for Ontario announced the results of a review of certain cases of suspicious child deaths where Dr. Charles Smith performed the autopsy or was consulted ("the Chief Coroner's Review") and found that some of the factual conclusions were not reasonably supported by the materials available;

AND WHEREAS the Ministry of the Attorney General and the Office of the Chief Coroner for Ontario are working together to identify, and the Minister of Community Safety and Correctional Services has requested that the Office of the Chief Coroner review homicide and criminally suspicious cases in which Dr. Smith performed an autopsy or provided an opinion prior to 1991;

AND WHEREAS the Chief Coroner for Ontario has announced that he has made the College of Physicians and Surgeons aware of the concerns identified in the Chief Coroner's Review;

AND WHEREAS the cases that have raised issues with determinations of fact and opinion that were submitted as evidence in criminal proceedings are currently being dealt with through the disclosure of the findings of the Chief Coroner's Review to defendants in related criminal proceedings;

AND WHEREAS there are processes in the Criminal Code of Canada for addressing individual cases of potential wrongful conviction;

AND WHEREAS there are civil and criminal proceedings that have arisen as a result of Dr. Smith's work that are the appropriate forum for the adjudication of those matters;

AND WHEREAS the Lieutenant Governor in Council considers it advisable to appoint a person to identify and make recommendations to address systemic failings that may have occurred in connection with the oversight of pediatric forensic pathology in Ontario;

AND WHEREAS the inquiry is not regulated by any special law;

THEREFORE, pursuant to the Public Inquiries Act:

Establishment of the Commission

  1. A Commission shall be issued effective April 25, 2007, appointing Honourable Stephen Goudge as a Commissioner.
  2. The Commission shall conduct the inquiry to ensure the expeditious delivery of its report and shall deliver its final report and recommendations to the Attorney General no later than April 25, 2008.
  3. Senator Larry Campbell shall chair an expert medical and scientific panel, which shall report to the Commissioner, to provide such information and advice as directed by the Commissioner.


  1. The Commission shall conduct a systemic review and assessment and report on:
    1. the policies, procedures, practices, accountability and oversight mechanisms, quality control measures and institutional arrangements of pediatric forensic pathology in Ontario from 1981 to 2001 as they relate to its practice and use in investigations and criminal proceedings;
    2. the legislative and regulatory provisions in existence that related to, or had implications for, the practice of pediatric forensic pathology in Ontario between 1981 to 2001; and
    3. any changes to the items referenced in the above two paragraphs, subsequent to 2001
    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.
  2. In fulfilling its mandate, the Commission shall not report on any individual cases that are, have been, or may be subject to a criminal investigation or proceeding.
  3. The Commission shall perform its duties without expressing any conclusion or recommendation regarding professional discipline matters involving any person or the civil or criminal liability of any person or organization.
  4. The Commission shall review and consider any existing records or reports relevant to its mandate, including the results of the Chief Coroner's Review announced on April 19, 2007, and other medical, professional, and social science reports and records. Further, the Commission shall rely wherever possible on overview reports submitted to the inquiry. The Commission may consider such reports and records in lieu of calling witnesses.
  5. The Commission shall rely wherever possible on representative witnesses on behalf of institutions.
  6. In delivering its report to the Attorney General, the Commission shall ensure that the report is in a form appropriate, pursuant to the Freedom of Information and Protection of Privacy Act and other applicable legislation, and in sufficient quantity, for public release and be responsible for translation and printing, and shall ensure that it is available in both English and French at the same time, in electronic and printed versions. The Attorney General shall make the report available to the public.
  7. Part III of the Public Inquiries Act applies to the inquiry and the Commissioner may have recourse to the powers contained in Part III as necessary to achieve the mandate of the inquiry


  1. Within an approved budget, the Commission may retain such counsel, staff, or expertise it considers necessary in the performance of its duties at reasonable remuneration approved by the Ministry of the Attorney General. They shall be reimbursed for reasonable expenses incurred in connection with their duties in accordance with Management Board of Cabinet Directives and Guidelines.
  2. The Commission shall establish and maintain a website and use other technologies to promote accessibility and transparency to the public.
  3. The Commission shall follow Management Board of Cabinet Directives and Guidelines and other applicable government policies in obtaining other services and goods it considers necessary in the performance of its duties unless, in its view, it is not possible to follow them.
  4. The Commission may make recommendations to the Attorney General regarding funding for proceedings before the Commission for parties who have been granted standing because they have information relevant to the systemic issues that would otherwise be unavailable and where in the Commission's view the party would not otherwise be able to participate in the inquiry without such funding. Any such funding recommendations shall be in accordance with Management Board of Cabinet Directives and Guidelines.
  5. All ministries and all agencies, boards and commissions of the Government of Ontario shall, subject to any privilege or other legal restrictions, assist the Commission to the fullest extent so that the Commission may carry out its duties and will respect the independence of the review.
  6. If during the course of the inquiry the Commission receives information, including in writing, from victims or families, the Commission may authorize the provision of counselling assistance. 

Additional Resources

Media Contacts



Law and Safety