None of his colleagues threw themselves into the challenging area of pediatric forensic pathology, untrained, quite the way Dr. Charles Smith did.
From 1981 to 2005, he was a pediatric pathologist at the world-renowned Hospital for Sick Children in Toronto, where staff pathologists conducted most of the region's pediatric forensic autopsies.
None of the hospital's pathologists had forensic training, and some felt unqualified for forensic work. Smith, because of his strong interest in autopsies, began performing more of them.
Smith began lecturing on pediatric forensic pathology in the mid-1980s, and by the 1990s, he regularly participated in educational courses for coroners.
In 1992, he was appointed director of the Ontario Pediatric Forensic Pathology Unit, Ontario's first regional forensic pathology service.
He worked at the best children's hospital in Canada. His experience seemed unequaled, and his manner brooked no denial. He was widely seen as the "go to" expert for the most difficult, criminally suspicious pediatric deaths.
Actually, Smith had no forensic pathology training and had only conducted 10 to 15 criminally suspicious cases when appointed. His reputation seems to have been based mostly on his effective speaking style.
Besides, he was the only pathologist willing to take on the role.
During the 1990s, as Smith's reputation grew, so did concerns about his competence. Warning signs were largely ignored, and Smith's work was defended by Ontario's chief coroner.
Fourteen years after the first questioned case, in 2005, a new chief coroner asked five highly respected forensic pathologists to review 45 criminally suspicious cases autopsied by Smith during the 1990s.
In 20 of the 45, they disagreed with Smith. In 12 of those 20, someone had been found guilty. This report was released in the spring of 2007.
Six days later, the province of Ontario established the Inquiry into Pediatric Forensic Pathology in Ontario, headed by the Honorable Stephen T. Goudge, who released his report in October. Most of what you are reading is taken directly from it. You can read the report by visiting www.goudgeinquiry.ca/.
Goudge noted that Smith did not view forensic pathology as a separate discipline that could inform his work.
Smith failed to understand that his role as an expert in the criminal justice system required independence and objectivity.
He presented his opinions in a dogmatic manner, sometimes failing to provide a balanced view of the evidence and to acknowledge the existence of controversy.
He sometimes misled the court by overstating his knowledge and testified on matters outside his expertise.
He actively misled those who might have engaged in meaningful oversight of his work.
During the inquiry, Smith described his forensic training and expertise as "woefully inadequate." He said he was unaware of what he did not know and how damaging that lack of knowledge was to the validity of his work.
He acknowledged his belief that his role was to act as an advocate and to "make a case look good."
He said he did not know he shouldn't speculate.
Speaking directly to a man convicted of murdering his niece, Smith struggled with emotion: "Sir, I don't expect that you would forgive me, but I do want to make it - I'm sorry. I do want to make it very clear to you that I am profoundly sorry for the role that I played in the ultimate decision that affected you. I am sorry."
Smith insisted his failings were never intentional. A skeptical Goudge wrote, "I simply cannot accept such a sweeping attempt to escape moral responsibility."
And Smith is not the only one.
Some people familiar with this report seem to think such a catastrophe could happen only in a foreign (therefore, inferior) country. Not so.
I trained in New York under one of the most highly regarded forensic pathologists in the country. He was conservative on most issues, but in later life he became an adamant opponent of the death penalty.
Often called upon to review the reports and opinions of other pathologists, he had seen innumerable bogus and ill-founded opinions and knew how dangerous such opinions were in court.
A person wrongly imprisoned can be exonerated and released, he told me, but the death penalty is irreversible.
Only half the population of the United States is served by medical examiner systems. The other half has coroners.
Some coroners, particularly in larger jurisdictions, are excellent administrators who hire or refer cases to qualified forensic pathologists and rely on their findings. But a great many - mostly in smaller, rural jurisdictions - have limited experience, little or no training and no access to competent forensic pathology. They likely are to see all pathologists and all autopsies as the same, and even if they know otherwise, no forensic pathologist is available to them.
As I wrote in a recent column, I trained as a general pathologist in such a system and was inspired, in part by the obvious lack of local expertise, to pursue a forensic pathology fellowship.
I recently reviewed a case in which the autopsy was done by a hospital pathologist like Smith. Investigators had uncovered a wealth of suspicious circumstantial information, but the autopsy examination and report were so inadequate, I could not determine cause of death or manner with any certainty. I told the referring coroner I didn't see how a successful prosecution would be possible.
I didn't directly say he had wasted county money on an incompetent examination, but he probably got that message.
Wouldn't money spent nationwide on inadequate autopsies done by pathologists with little or no forensic training be better spent making sure competent forensic pathologists are available to all jurisdictions?
Public, political and media outrage in Ontario is such that I am confident its system will be fixed. Smith's arrogance and utter disregard for the public interest and the failure of elected officials to recognize and address the problem at least accomplished that.
I wonder what it will take to fix our system.
Dr. Carol J. Huser, a forensic pathologist, has served as La Plata County coroner
since January 2003.