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Ontario Completes Review Of "Shaken Baby" Cases

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Ontario Completes Review Of "Shaken Baby" Cases

Ministry of the Attorney General

In December 2008, following the release of Justice Stephen Goudge's Report on The Inquiry into Pediatric Forensic Pathology in Ontario, the Attorney General initiated a medical/legal review of pediatric cases that resulted in criminal convictions based on evidence of abusive head trauma or "shaken baby syndrome."

In light of the significant evolution of pediatric forensic pathology relating to shaken baby syndrome and pediatric head injuries over the last 20 years, this review was undertaken to determine whether there are any concerns with convictions registered where these injuries played a significant role.

The "Shaken Baby" Death Review Committee consisted of:

  • The Honourable Justice Donald A. Ebbs of the Ontario Court of Justice and former Associate Chief Justice of Ontario
  • Dr. Michael Pollanen, Ontario's Chief Forensic Pathologist
  • Dr. Dirk Huyer, Regional Supervising Coroner
  • Marie Henein, Senior Defence Counsel
  • Mary Nethery, Senior Crown Attorney and Director of Justice Excellence.


The committee adopted a consensus-based approach and developed rigorous criteria to systematically review the medical and legal aspects of pediatric head injury cases that occurred between 1986 and 2006. During the Goudge Inquiry, reference was made to 142 potential pediatric death cases involving head injuries. Further review determined that, due to duplication in the files, there were actually 129 cases.

Based on an initial triage of all 129 cases, the committee established that 48 required a more in-depth analysis. Of those, 10 cases were ultimately referred to an international medical panel of world-renowned leaders in forensic pathology, neuropathology and pediatrics to provide their expertise and views.

The international medical panel consisted of:

  • Dr. Stephen Cordner, forensic pathologist from Australia
  • Dr. Kim Collins, forensic pathologist from the U.S.
  • Dr. Helen Whitwell, forensic pathologist/neuropathologist from England
  • Dr. Carole Jenny, professor of pediatrics and child maltreatment expert from the U.S.
  • Dr. Kent Hymel, child maltreatment expert from the U.S.


The vast majority of cases that resulted in conviction, and that received a more in-depth analysis by the committee, do not involve allegations of flawed pediatric forensic pathology or allegations of wrongdoing on the part of any individual.

The committee identified four cases that may give rise to concerns based on reports prepared by an international medical panel and the facts and circumstances reviewed by the committee in each of these cases. The committee did not make any decisions about anyone's guilt or innocence in the cases it examined.

This information has been provided to the Chief Prosecutor of Ontario, and forwarded to the Ministry's Crown Law Office - Criminal, to review and take appropriate action, including working with the defence counsel. 

Read the report about "Shaken Baby" cases in Ontario.

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