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Ontario Responds To The Goudge Report

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Ontario Responds To The Goudge Report

McGuinty Government Commits To A Stronger, More Accountable Coroners System

Ontario proposes to overhaul its forensic pathology system through the introduction of new legislation, and to pursue measures to redress past injustices, in response to the Honourable Justice Stephen Goudge's Inquiry into Pediatric Forensic Pathology in Ontario.

Justice Goudge released his report and recommendations earlier today. The McGuinty government called the inquiry in April 2007 - six days after the chief coroner announced the results of a review into the work of pediatric pathologist Dr. Charles Smith.

The proposed legislation will, if passed, establish a framework to strengthen the death investigation system, provide for greater oversight and accountability and improve coroner and pathology services in Ontario. Guided by Justice Goudge's recommendations, the legislation will build on the progress Ontario has made in the past five years to improve the province's coroners system.

In addition, the Ministry of the Attorney General will:

  • Work with justice partners to expedite cases where an injustice is claimed.
  • Develop a compensation framework for those who suffered injustice.
  • Establish a medical/legal review of convictions involving "shaken baby" deaths.

Quick Facts

  • Since 2002, pediatric autopsies in Ontario are conducted in one of four centres (London, Ottawa, Hamilton and Toronto) to ensure they are carried out where pathology and pediatric expertise are greatest.
  • Since 2006, coroners, pathologists, police and other members of the death investigation team now follow a new and more stringent protocol when investigating the death of any child under age five.
  • Since 2004, all forensic autopsies on criminally suspicious cases, homicides and cases going to inquest undergo a peer review process to ensure the quality of the autopsy and the resulting conclusions.

Background Information

Additional Resources


“Justice Goudge has provided a roadmap for change to build a stronger, more accountable coroners system. We intend to move quickly and aggressively in responding to the report and to build on the work we've already done to prevent this from happening again.”

Rick Bartolucci

Minister of Community Safety and Correctional Services

“Justice Goudge's recommendations will strengthen the justice system's response to child death cases. We will build on the changes in approach already in place for child homicide cases. We will also initiate a review of past shaken baby death cases to determine whether the evolution in scientific opinions affects the validity of the conviction.”

Chris Bentley

Attorney General

“Over the past few years we've made great strides to strengthen Ontario's death investigation system. Commissioner Goudge's recommendations will help us navigate the way forward.”

Dr. Andrew McCallum

Chief Coroner of Ontario



Law and Safety