2020–2021 results

Register of Pathologists

Under the Coroners Act, the Chief Forensic Pathologist (CFP) maintains a Register of Pathologists who are qualified to provide medicolegal services under the act. Based on their qualifications and the recommendations of the credentialing subcommittee of the Forensic Pathology Advisory Committee (FPAC), registered pathologists will be assigned a categorical classification that corresponds to the medicolegal services they can provide, including:

• all medicolegal autopsies, including homicide and criminally suspicious cases (Category A)
• routine cases only (Category B)
• non-suspicious pediatric cases (Category C)

During the reporting period, 114 registered pathologists were active in Ontario, including 40 Category A pathologists permitted to conduct all types of autopsies. These 40 pathologists are recognized as having additional experience, training and/or certification in forensic pathology.

Pathologists are registered for a five-year term, after which their appointments are considered for renewal. The quality team assembles data for review by the credentialing subcommittee, including:

• case load, cumulative over five years and year-by-year
• turnaround time for autopsy reports
• peer review history
• complaints, incident reports and critical incidents and remediation by the CFP and by the CPSO, where applicable

Performance management of registered pathologists related to the quality of medicolegal autopsies is the responsibility of the CFP. When there is professional misconduct or incompetence, the CFP is legislatively obligated to report any registered pathologist to the CPSO. Similarly, the CPSO is obligated to inform the CFP of any issues with a registered pathologist.

The redesigned pathologist register process will be available in early 2022.

Chart 1: Register Composition by Pathologist Category, 2010-21

Chart 1 summary (Year: A/B/C):

• 2010-11: 24/142/5
• 2011-12 27/132/7
• 2012-13: 29/115/7
• 2013-14 31/99/7
• 2014-15: 31/97/7
• 2015-16: 34/66/6
• 2016-17: 39/65/7
• 2017-18: 40/66/7
• 2018-19: 41/70/9
• 2019-20: 40/73/8
• 2020-21: 40/68/6

The OFPS Register is available publicly at Ontario.ca.

Supervision and direction of pathologists

To promote consistent and high-quality practices across Ontario and support registered pathologists, the OFPS provides a practice manual and toolkit.

The practice manual includes the Code of Ethics, practice guidelines for medicolegal autopsies and explanations of the quality assurance program and Register. Together, these documents provide the professional and policy foundation for the OFPS.

The Code of Ethics was adapted from the Forensic Pathology Section of the Canadian Association of Pathologists.

Since a number of recommendations have come out of the Auditor General’s Report and other Inquiries, the practice manual is expected to be updated by mid-2022.

Pathology Information Management System

The OFPS uses the PIMS to collect information about autopsies performed across Ontario. All registered pathologists contribute information to the system through the Post Mortem Examination (PME) record. This record is completed and submitted electronically to the OFPS after each autopsy. The record is reviewed daily by the pathology administrators to ensure that autopsies are done according to guidelines. The collected information is also used to evaluate resources, as well as provide statistics about performance and quality.

Caseload statistics

Caseload statistics are derived from PME records submitted during the reporting period.

Each OFPS case begins with a coroner’s request for an autopsy through a warrant to a pathologist. All medicolegal autopsies, including homicide, criminally suspicious and paediatric cases, are performed in FPUs by appropriately qualified forensic pathologists. Routine cases are conducted at the FPUs and community hospitals. Some non-suspicious (medical type) paediatric cases are performed at paediatric sites. In 2020-21, approximately 88 per cent of all autopsies were performed in FPUs and paediatric sites, and 12 per cent in community hospitals.

Chart 2 shows the distribution of autopsies captured in the system performed by FPUs and community hospitals from 2020-21.

Chart 2: Distribution of Autopsies by FPUs and Community Hospitals, 2020-21

Chart 2 summary:

• PFPU: 5636 (59.13%)
• Community Hospitals: 1147 (12.03%)
• London FPU : 785 (8.24%)
• Ottawa FPU : 896 (9.40%)
• Sudbury FPU : 539 (5.66%)
• Kingston FPU : 381 (4.00%)
• Sault Area FPU : 147 (1.54%)

Chart 3 shows the annual distribution of autopsies captured in the system performed by FPUs and community hospitals. 

Chart 3: Distribution of Autopsies by Year, 2010-21

Chart 3 summary: (Year: Total/FPUs/Community Hospitals)

• 2010-11: 5360/3534/1826
• 2011-12: 5568/3937/1631
• 2012-13: 5963/4417/1546
• 2013-14: 5728/4529/1199
• 2014-15: 6105/4990/1115
• 2015-16: 6419/5312/1107
• 2016-17: 7279/6206/1073
• 2017-18: 7797/6556/1241
• 2018-19: 8588/7344/1244
• 2019-20: 8577/7389/1188
• 2020-21: 9727/8740/987

Paediatric autopsies (for children five years and under) are often complex, requiring additional ancillary testing and/or consultation with other medical specialists. All paediatric autopsies of a criminally suspicious nature are performed in FPUs.

In 2020-21, there were a total of 154 paediatric cases (routine and criminally suspicious) completed across the province (Chart 4).

Chart 4: Paediatric Cases Involving Children under 5 Years by Locations, 2020-21

Chart 4 summary:

• PFPU: 84
• Community Hospitals: 24
• London FPU: 22
• Ottawa FPU: 19
• Sudbury FPU: 4
• Sault Area FPU: 1

Chart 5 provides a breakdown of autopsies by case type for 2020-21. The category ‘sudden’ includes non-homicidal gunshot wounds, drug overdoses and other cases not specified in the captured categories.

Chart 5: Distribution of Autopsies by Case Type, 2020-21

Chart 5 summary:

• Sudden: 53.09%
• Hanging: 4.85%
• Collision: 3.75%
• Decomposed: 2.26%
• Homicide: 2.51%
• Water: 1.85%
• Fall: 1.13%
• External: 0.79%
• Other: 28.29%
• Suspicious: 0.78%
• Fire: 0.66%
• DND: 0.03%

In some cases, the decision is made to limit an autopsy to an external examination where sufficient information can be obtained from a limited examination. There were 1,266 such cases performed in PFPU in 2020-21.

Forensic pathologists at the PFPU rely on imaging technology (such as CT scans) to inform their decisions about targeted examinations. Targeted examinations limit the extent of dissection to areas of interest based on case and medical history. In 2020-21, 61.7 per cent of cases were targeted examinations (Chart 6).

Chart 6: Distribution of Autopsies by Autopsy Type in PFPU, 2020-21

Chart 6 summary:

• Targeted: 61%
• Full: 18%
• External: 21%

Quality management

The OFPS has a robust quality assurance program comprised of the following:

• the OFPS Register/pathologist credentialing
• practice guidelines, including standardized reporting templates and forms and standard operating procedures available in compliance management software
• consultation between pathologists in difficult or challenging cases
• collection of standardized case information through the PME record
• peer review of all autopsy reports on homicide, criminally suspicious, SIU^{footnote 1[1]} cases and complex paediatric cases (deaths under five years of age) before the report is distributed, including special peer review committees
  • Child Injury Interpretation Committee (CIIC) for paediatric deaths
  • Complex Case Expert Committee (CCEC) for complex cases
• quality reviews of reports related to routine autopsy cases
• peer review of courtroom testimony and/or transcript review
• detection and follow-up on significant quality issues and critical incidents
• reporting key performance indicators to clients and stakeholders

• tracking complaints to ensure timely resolution and corrective action
• continuing medical education in forensic pathology to:
  • maintain specialist competency as required by the Royal College of Physicians and Surgeons of Canada
  • continuing professional development

Peer review of autopsy reports for homicide, criminally suspicious, paediatric and SIU cases

There were 342 autopsy reports peer reviewed in 2019-20. On average, about 10 reviews were completed by each reviewing forensic pathologist per year. The average turnaround time for peer review was 7.1 days in 2019-20. The OPFS standard for peer review is ten working days.

Peer review of courtroom testimony by forensic pathologists

Forensic pathologists who testify are required to submit one transcript of courtroom testimony each year for review by another forensic pathologist. Courtroom testimony is assessed for:

• preparedness
• qualifications (such as the testifying pathologist has the appropriate level and sphere of expertise)
• presentation style (for example, responses to questions in chief and cross examination appropriate in tone, length and thoroughness)
• knowledge (for example, responses to questions are scientifically sound)
• interpretation/opinion/conclusions (for example, to ensure they are credible and objective with strengths, and limitations are fairly presented)
• general comments on the registered pathologist’s court testimony

Seventeen courtroom testimonies were reviewed in the reporting period.

Quality review of autopsy reports for routine cases

Autopsy reports for routine cases are reviewed for administrative and technical accuracy by FPU medical directors. Reports from community hospitals are reviewed by the CFP or designate.

The administrative review focuses on completeness and adherence to guidelines. All community hospital reports undergo administrative review and 10 percent of routine autopsy reports from FPUs undergo this type of review.

The technical review focuses on the content of the report to ensure that the approach, conclusions and opinions derived from the evidence are reasonable and appropriate.

A technical review is performed for all reports that fall into the following categories:

• cases with an undetermined/unascertained cause of death
• non-traumatic and non-toxicologic deaths of individuals younger than 40 years old
• reports from pathologists performing fewer than 20 medicolegal autopsies per year
• the Quality Assurance Unit receives a notification that the case should undergo the technical audit process

Key performance indicators

Key performance indicators for autopsy reports, such as submission compliance, completeness, consistency and turnaround time are collected through the administrative and technical reviews and reported.

Table 1 shows the indicator, target outcome and overall performance for FPU and community hospital pathologists from 2020-21.

Table 1: Key Performance Indicators for Autopsy Reports, 2020-21
(Note: Turnaround time may be influenced by case complexity and availability of ancillary testing.)

Pathologists in community hospitals are expected to follow the best practices set out in the practice manual.

Note: Community hospitals may use their own institution’s report templates if they include the required template fields.

Chart 7 illustrates consistency of the content and opinion of autopsy reports as assessed by the reviewing pathologist during the period, as shown by a technical review.

Chart 7: Consistency Measures as Shown by Technical Review, 2020-21

Chart 7 summary:

• Appropriate Ancillary Testing: FPUs 100.0%; Community Hospitals 100.0%
• COD Reasonable: FPUs 99.4%; Community Hospitals 96.9%
• Free of Language Errors: FPUs 99.4%; Community Hospitals 99.3%
• Independently Reviewable: FPUs 100.0%; Community Hospitals 100.0%
• Opinions are Reasonable: FPUs 99.4%; Community Hospitals 99.3%
• Satisfactory Descriptions: FPUs 100.0%; Community Hospitals 98.3%

Significant quality issues

Significant quality issues include substantial errors, omissions and other deficiencies.

A critical incident is a significant quality issue that contributes to a serious error in a death investigation. All critical incidents are analyzed to determine the root cause(s) and the corrective action that needs to be implemented to prevent future issues. There were no critical incidents for the reporting period.

If the reviewing forensic pathologist detects a significant quality issue during the technical review, feedback is provided to the case pathologist. For the given reporting period, there were no significant quality issues detected in routine case reports from FPUs or community hospitals.

When a significant quality issue is detected, the reviewing pathologist contacts the original pathologist directly to discuss and recommend changes to the report. Continued improvement of autopsy practice and report writing is supported with:

• continuing education events such as the Annual Education Course for Coroners and Pathologists, and special workshops on autopsy practice
• resources, such as the Practice Manual for Pathologists and Toolkit, including synoptic reports, annotated autopsy report templates and the CFP's guidance with case examples.

Turnaround time

Turnaround time is influenced by case complexity, return of ancillary test results, pathologist workload and staffing levels. The OFPS standard regarding turnaround time is:

• 90 per cent of autopsy reports are to be completed within 120 days of the day of the autopsy
• cases involving homicides, paediatric deaths, deaths in custody and those in which the coroner has requested that the report be prioritized (due to requests from family or other parties) are to be expedited as a matter of routine
• no more than 10 per cent of cases should be greater than six months old without a justifiable reason for delay (for example, awaiting results of ancillary testing)

Chart 8 depicts the turnaround time for community hospital pathologists and forensic pathologists in FPUs for the last 11 years. The longer turnaround time for forensic pathologists may be explained by the more complex nature of the autopsies performed.

Chart 8: Average Turnaround Time, 2010-21

Chart 8 summary:

Average turnaround time by location and years

• 2010-11: Community Hospitals 85; FPUs 165
• 2011-12: Community Hospitals 55; FPUs 91
• 2012-13: Community Hospitals 66; FPUs 121
• 2013-14: Community Hospitals 75; FPUs 121
• 2014-15: Community Hospitals 67; FPUs 99
• 2015-16: Community Hospitals 72; FPUs 101
• 2016-17: Community Hospitals 75; FPUs 115
• 2017-18: Community Hospitals 100; FPUs 112
• 2018-19: Community Hospitals 100; FPUs 117
• 2019-20: Community Hospitals 82; FPUs 107
• 2020-21: Community Hospitals 93; FPUs 101

Clinical forensic medicine

Currently, qualified expert opinions and testimony by forensic specialists are usually available only in cases of violent death. However, cases of serious assault with a surviving victim can often benefit from the review and interpretation of injuries by a forensic expert, and the expert’s opinion can be useful to the criminal justice system. Forensic pathologists consult by reviewing medical records and digital photographs.

Forensic anthropology

Forensic anthropologists are experts in the study of skeletal remains in the medicolegal context. They make an important contribution to death investigations where the remains are skeletonized, burned, decomposed, mutilated or otherwise unrecognizable. Forensic anthropologists act as part of the death investigation team. They are the experts at determining whether found bones are human or non-human by examining digital photographs or the remains themselves. They help to plan for multiple fatality events by providing advice and training to staff and to manage identification when such events occur. They are also the experts who determine whether found remains are of recent forensic interest or are archaeological or historical in nature. 

The OFPS has one full-time forensic anthropologist on staff along with several fee-for-service consultants. During the reporting period, there were 753 anthropology cases managed at PFPU.

The Identification Team works alongside the anthropologists to provide oversight and coordinating activities related to all unidentified cases at the PFPU. The Identification Team is comprised of the Forensic Human Remains Analyst and the Unidentified/Unclaimed Human Remains Coordinator. The Human Remains Analyst provides services for forensic anthropology examinations conducted at the PFPU in addition to scene examinations across Ontario, while facilitating scientific identification requests. The Unidentified-Unclaimed Human Remains Coordinator provides oversight and coordination of activities related to Ontario's unidentified and unclaimed human remains. The position holds a joint portfolio with the OCC to provide oversight and coordination of activities related to management of Ontario’s unclaimed bodies.

Other professional consultants

The OFPS relies on the expert contributions of other professionals, including cardiovascular pathologists, neuropathologists, forensic odontologists, radiologists and a forensic entomologist.

At the PFPU, there were 426 consultation cases completed during the reporting period. These included neuropathology, cardiac and dental consultations.

Histology

Histology is the preparation of microscope slides from tissues obtained at autopsy for examination by a pathologist. The number of slides prepared for each case varies depending on the type of case and the pathologist’s preference.

Histology services are provided by laboratories at community hospitals and FPUs located in hospitals. The PFPU employs three full-time Histotechnologists who processed about 4,100 tissue specimens each month in 2020-21.

Toxicology

Toxicological analysis of post-mortem samples is performed by scientists (toxicologists) at the CFS. In many cases, pathologists rely on the results and interpretive notes provided by toxicologists to arrive at an opinion about the cause of death.

During the reporting period, toxicological analysis was requested in 6,714 death investigations. The average time to issue a toxicology report by the CFS was 52.4 days. In cases where toxicology was required, 93.2 per cent of the autopsy reports were issued within 120 days of receiving the toxicology reports.

“Quick Tox” program

In March 2020, the CFS introduced a new type of toxicology testing available to pathologists called Quick Tox. Quick Tox provides fast analytical results for select non-criminal cases. The pilot period with the PFPU ran from March 4, 2020 to September 30, 2020. During the pilot, 330 cases were reported with an average turnaround time for toxicology results of 13 days and a range extending from six days to 21 days. Quick Tox testing became available provincewide on October 1, 2020. Over the first 12 months, CFS Toxicology reported 2,157 cases of Quick Tox with an average turnaround time of 15 days and a range extending from seven to 35 days. The program allows routine cases to be signed out by the Forensic Pathologists in an expedited fashion as they no longer need to wait the average 59 days for their report. 

Molecular autopsy/cardiovascular pathology

Many natural disease processes are now recognized to have a genetic underpinning. For a number of these conditions, characterization of the genetic mutations involved is becoming the standard of care in hospitals and is part of the movement towards targeted therapy and personalized medicine. The first significant manifestation of such a disease may be sudden and unexpected death, which may be first recognized and diagnosed following the autopsy. Identifying a genetic contribution to sudden death can have huge implications for the surviving family members, particularly for young people, as well as the health care system.  

A large proportion of cases where genetic disease may have contributed to death involve the heart and blood vessels. The OFPS provides high quality cardiovascular pathology services to investigate sudden cardiac and vascular deaths in Ontario and occasionally by request from across Canada. In cases that may have an underlying genetic predisposition, DNA banking and genetic testing will also be performed (the molecular autopsy). With the results of the autopsy and clinical investigation, DNA analysis can help define the underlying disease that caused death, facilitate screening in surviving family members and sometimes contribute prognostic information for affected relatives.

High-quality pathological diagnoses are essential. Through the OCC, we communicate with families to give them information about a potential genetic condition and their options for care in subspecialty hospital clinics. Next-of-kin clinics have also set up between the PFPU and the OCC to improve communication with family members. Families meet with coroners, forensic pathologists and the Family Liaison Coordinator at the FSCC in person, via video or through teleconferencing, to review the findings of a death investigation.

It is also increasingly accepted that unrecognized genetic disease may play a role in deaths following interactions with correctional officers or police, or in the course of a criminal act. In these circumstances, a molecular autopsy can help provide answers in these challenging death investigations and contribute to coroner’s inquests and the criminal justice system.

Child Injury Interpretation Committee

In 2017, the OFPS established a committee to provide enhanced peer review of certain paediatric deaths that may require a higher level of transparency and broader input due to the level of complexity or a criminal justice interest. Membership includes a Chair along with forensic pathologists from across Ontario, particularly those with special interest in paediatric deaths, and child abuse paediatricians along with neuropathologists, cardiovascular pathologists and forensic pathologists from other provinces, as necessary. The peer review takes place before the autopsy report is released to provide a broad spectrum of specialist opinions for each case to ensure the quality of these challenging death investigations.

During the reporting period, 16 cases were peer-reviewed by this committee.

Complex Case Expert Committee

The OFPS introduced a new quality assurance process, the Complex Case Expert Committee (CCEC). This standing committee of the Forensic Pathology Advisory Committee (FPAC) focuses on cases where there is a persistent difference of opinion during peer review and on cases that require a higher level of review due to significant public or criminal justice interest. The CCEC consists of a Chair, a Deputy Chief Forensic Pathologist, senior forensic pathologists and other experts, as necessary (i.e., neuropathologists, etc.). This new process replaces and/or expands the usual peer review for certain cases.

The first CCEC panel review was on March 1, 2021.

Forensic imaging

Forensic pathologists at the PFPU incorporate advanced post-mortem imaging (CT and MRI) findings into their case management decisions. Incorporating these non-invasive techniques into forensic pathology practice has resulted in increased numbers of external and targeted examinations.

Senior residents from the University of Toronto’s Diagnostic Radiology Residency Program spend one month at the PFPU where they are integrated into daily service work. As a rotation preparing them for practice, radiology residents learn about lethal injury and disease as well as changes in the body after death. They report post-mortem CT and MRI scans and are able to see pathologic lesions in the autopsy room in a way that is not possible in the clinical setting. 

Tissue recovery for donation

The OFPS and OCC are committed to facilitating and increasing the availability of tissue for transplantation through the Trillium Gift of Life Network (TGLN). The Provincial Forensic Pathology Unit houses a dedicated Tissue Recovery Suite that is used exclusively for obtaining donor tissues, including corneas, heart valves, skin and bones. After consent from the family, tissues are recovered by trained staff from TGLN as well as the OCC and OFPS.

TGLN performed 201 tissue recoveries using the PFPU Tissue Surgical Suite during the reporting period, including bones, skin and heart valves This accounts for 96 per cent of TGLN multi-tissue donor recoveries for the reporting period.

Continuing education events

Annual Education Course for Coroners and Pathologists

This two-and-a-half-day course is offered jointly by the OCC and the OFPS each autumn. This meeting qualifies as continuing education for the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada.

The 2020 course did not run due to the pandemic.

Department of Laboratory Medicine and Pathobiology, University of Toronto

The Department of Laboratory Medicine and Pathobiology (LMP) at the University of Toronto has a goal to advance teaching and research in forensic medicine. Many of the forensic pathologists working in the Ontario Forensic Pathology Service are faculty for the university’s continuing educational programs.

LMP hosts continuing education events that bring national and international experts to University of Toronto to discuss topics in forensics. The courses are attended by academics, those working in forensic disciplines, other medical and legal professionals, and law enforcement practitioners. Since the last annual report, no courses were offered.

Dr. Frederick Jaffe Memorial Lectureship

A special lecture series was created in memory of Dr. Frederick Jaffe, one of the first forensic pathologists in Canada. Dr. Jaffe authored a textbook, Guide to Pathological Evidence, which was used for many years by attorneys and judges. He was also the first director of a provincewide forensic medical service.

The lecture in October 2020 was given by Forensic Anthropologist and Member of the Argentine Forensic Anthropology Team (EAAF) as Identification Coordinator, Mercedes Salado Puerto, PhD., where she described the role of forensic science in large-scale investigations into missing persons. 

Training Canadian forensic pathologists

The PFPU, in partnership with the Forensic Pathology Residency Training Program at University of Toronto and with funding support from the Ministry of Health and Long-Term Care, has the first training program in Canada leading to certification in forensic pathology by the Royal College of Physicians and Surgeons of Canada (RCPSC). Since 2008, 21 pathologists have completed training, 18 of whom are now working within the Ontario Forensic Pathology Service. The PFPU has improved the RCPSC-accredited residency program and has implemented Competency by Design (CBD).

In 2020, two new residents began training in forensic pathology in the University of Toronto program:

Dr. Maliha Khara completed her Bachelors in Neuroscience and Psychology from the University of Toronto, her medical training at Medical University of Lublin, Poland, and her Anatomical Pathology residency at Queen's University, Kingston. Her research interest includes uncovering the molecular basis of neuropathology in Sudden and Unexpected death in Epilepsy (SUDEP) and hypoxic-ischemic injury in the central nervous system.

Dr. Daniel Smyk completed his undergraduate degree in human sciences followed by a Bachelor of Medicine and Surgery degree from King's College London. He completed a research fellowship at King's College London prior to returning to Canada and completed his residency in Anatomical Pathology at the University of Alberta in June 2020.

Clinical fellows in forensic medicine

The Provincial Forensic Pathology Unit and the University of Toronto are committed to developing global forensic medicine and have outreach activities and training collaborations with Jamaica, Iraq, Egypt, Afghanistan, Sri Lanka, Chile and Zambia. Since 2007, 15 international fellows have trained in forensic pathology at the PFPU. Since 2016, clinical fellows are eligible to write the Royal College of Physician and Surgeons of Canada examination in Forensic Pathology through the Subspecialty Examination Affiliate Program.

The PFPU did not host a clinical fellow in 2020.

In 2020, one research fellow from Japan trained at the PFPU:

Dr. Yosuke Usumoto received his Doctor of Medicine from the Kyushu University (Fukuoka, Japan) in 2005. After he undertook two years of advanced clinical training, he entered the Graduate School of Medical Sciences (PhD course, Department of Forensic Pathology and Sciences), Kyushu University and graduated in 2010. He is currently working as a Forensic Pathologist in Yokohama.

Some trainees benefit from the G. Raymond Chang Forensic Pathology Fellowship through the University of Toronto’s Department of Laboratory Medicine and Pathobiology. This is the first fund in the world that enables young physicians from the developing world to train and ultimately strengthen forensic capacity in their home countries. This fellowship provides financial support to trainees whose countries may not be able to fund a year of training in Canada, particularly those from the West Indies.

In keeping with the Chang Foundation’s philanthropic vision, the partnership was enhanced in 2017 through the addition of a Catalyst Fund to broaden the strategy to focus on critical infrastructure development in Jamaica, training of West Indian non-physician learners and extension to other global areas in need. 

The PFPU did not host a Chang Foundation fellow in 2020.

The Raymond Chang Foundation

The Raymond Chang Foundation is named after the late Toronto-based businessman and philanthropist who had a passion for adult education and was dedicated to improving opportunities where it was most needed. Born in Jamaica, Mr. Chang was a proud and active member of the Caribbean-Canadian community. He was appointed to the Order of Jamaica in 2011 and as an officer of the Order of Canada in 2014.

Raymond Chang understood the relevance of forensic pathology as a truth-seeking tool for justice. The fellowship is a legacy that lives on through ‎the dedication of his children, Andrew Chang and Brigette Chang-Addorisio. Their generosity and shared vision have ensured a sustainable fellowship training program at the University of Toronto.

Recruitment of forensic pathologists

The capacity of the OFPS has been enhanced through the recent addition of talented new recruits, including:

Dr. John Alex MacNeil MD MSc FRCPC completed a Master of Applied Science degree in Forensic Anthropology at Saint Mary’s University before receiving his Doctor of Medicine from Dalhousie University in 2014. He completed his residency in Anatomical Pathology at Dalhousie University and passed the RCPSC examination in Anatomical Pathology in 2019. In 2020, Dr. MacNeil successfully completed the RCPSC accredited Forensic Pathology training program administered through the Provincial Forensic Pathology Unit and the University of Toronto. He joined the PFPU in July 2020.

Dr. Linnea Duke MA MSc MD FRCPC (AP and FP) received a Master of Criminology and MSc in Statistics from Simon Fraser University before receiving her Doctor of Medicine at University of Calgary. She completed her residency in Anatomical Pathology at McGill University and passed the RCPSC examination in Anatomical Pathology in 2019. Dr. Duke successfully completed the RCPSC accredited Forensic Pathology training program administered through the Provincial Forensic Pathology Unit (PFPU) and the University of Toronto. She joined the Eastern Ontario Regional Forensic Pathology Unit in Ottawa in November 2020.

Forensic Pathology Units

Sault Ste. Marie Forensic Pathology Unit

The Sault Ste. Marie Forensic Pathology Unit is led by Medical Director, Dr. Michael D’Agostino. Approximately 147 autopsies were performed during the reporting period.

The unit hosts medical trainees, pathologist assistant students from Western University on elective rotation, and police and CFS staff.

The unit has offered stable regional forensic services and ensured continuity of service in the COVID‑19 pandemic with two pathologists, two pathologists’ assistants and administrative staff supporting the work.

Eastern Ontario Regional Forensic Pathology Unit (Ottawa)

When the Ontario Forensic Pathology Service was established in 2009 the Eastern Ontario Regional Forensic Pathology Unit (EORFPU) had two full-time forensic pathologists. It is now staffed by four full-time forensic pathologists: Dr. Kepron, the Medical Director, and Drs. Milroy, Parai and Walker. In addition, Dr. Leslie Hamilton works in the EORFPU as well as in paediatric and adult neuropathology as she is dual-qualified in both forensic pathology and neuropathology. Dr. Linnea Duke joined the group in November of 2020 with a combined practice of forensic pathology, cardiovascular pathology and genitourinary pathology. The forensic pathology workload has increased from under 600 cases annually to more than 890 medicolegal autopsies per year. As well as covering Eastern Ontario, the unit also provides medicolegal autopsy services for the eastern half of Nunavut.

In addition to providing a complete medicolegal and hospital autopsy service, all of the pathologists hold academic positions at the University of Ottawa and teach undergraduate medical students as well as residents within the anatomical pathology residency training program.

Teaching is also provided for the Canadian Police College, the Faculty of Law at the University of Ottawa, the Office of the Chief Coroner for Nunavut and the Office of the Chief Coroner for Ontario through the annual training course for new coroners and the annual education course for coroners and pathologists. Dr. Parai chairs the Canadian Association of Pathologists forensic pathology section and, along with Dr. Milroy, has organized the forensic pathology seminars at their annual meeting. Dr. Walker provides annual teaching at the University of the West Indies and has organized court room testimony training for professional and expert witnesses through the Belize National Forensic Science Service and the St. Lucia Forensic Science Services. He also organized and hosted a successful trilogy of conferences on the topic of Deaths in Custody that ran virtually between June and September 2020. All members of the unit have been active at the American Academy of Forensic Sciences and the National Association of Medical Examiners with Dr. Parai serving as the Program Chair for the 2021 annual scientific meeting of the American Academy of Forensic Sciences, Pathology/Biology section.

Drs. Parai, Milroy and Kepron serve on the forensic pathology specialty committee of the Royal College of Physicians of Canada with Dr. Parai serving as Chair and Dr. Kepron as Chair-Elect. Dr. Milroy serves as the past chair of the examination board in forensic pathology. Dr. Hamilton is an examiner with the neuropathology examination board. Under the auspices of the University of Ottawa Faculty of Medicine, the unit has applied to the Royal College for an accredited residency program in forensic pathology. The unit hopes to welcome the first candidate in July of 2022. Ottawa forensic pathologists also contribute to the administrative and quality assurance activities of the OFPS with Dr. Milroy serving as the Chair of the Credentialing Committee, Dr. Kepron serving as the Chair of the Child Injury Interpretation Committee and Dr. Walker serving as Co-Chair of the Equity, Diversity and Inclusion Committee.

Many members of the unit have been active in publishing academic papers in peer-reviewed journals and book chapters. Dr. Milroy is the Editor-in-Chief of the journal Academic Forensic Pathology while Dr. Walker sits on the editorial boards for Academic Forensic Pathology and the Caribbean Medical Journal.

Kingston Forensic Pathology Unit

The Kingston Forensic Pathology Unit is based at Kingston General Hospital in the Department of Pathology and Molecular Medicine and is affiliated with Queen's University. Dr. Tanguay is a forensic pathologist and has been the Medical Director since 2018. During this reporting period the unit performed approximately 394 medicolegal autopsies, 60 hospital consent autopsies and participated in the education of anatomical pathology residents and medical students. As of January 1, 2021, the Kingston Unit restructured the autopsy program to reduce the number of Category B pathologists from 19 down to seven, with the goal of having a more subspecialized team performing medicolegal autopsies. Dr. Tanguay is a member of the Royal College of Physicians and Surgeons of Canada Examiners Committee in Forensic Pathology.

London Forensic Pathology Unit

The London Regional Unit has met the challenge of operating during the pandemic.  In 2021, 805 medicolegal autopsies were performed continuing the steady increase of the last few years. The autopsy work has continued without major changes, performed by the same core team of dedicated professional staff of pathologists and pathologists’ assistants. Nevertheless, COVID‑19 is at least under consideration in nearly all cases, whether playing an active role in a death or indirectly having an influence through the detrimental social, health and economic consequences of the pandemic.

Northeastern Regional Forensic Pathology Unit (Sudbury)

The Northeastern Regional Forensic Pathology Unit (NERFPU) of Health Sciences North in Sudbury is affiliated with Laurentian University and the Northern Ontario School of Medicine (NOSM) and performs over 500 medicolegal autopsies each year for the Sudbury area, providing coverage for much of Northeastern Ontario, including the James Bay Coast and Manitoulin Island. The Medical Director of the unit is Dr. Kona Williams, who is also the Laboratory Medical Director for Health Sciences North. She has succeeded Dr. Martin Queen, a veteran forensic pathologist who has served the region for over 20 years.  Dr. Bojana Mitrovic has recently stepped in to help, performing a limited number of Category B cases.

In 2020, a full-time Forensic Pathologist Assistant, Evan Stewart, was hired. He has been instrumental in providing support to the unit and the pathologists.

In addition, the unit teaches NOSM medical students and Laurentian Forensic Science students; each student is required to observe an autopsy as part of their graduation/course requirements. Dr. Williams is also in the process of obtaining a Master’s Degree at NOSM, with a focus on post-mortem toxicology.

International assistance and capacity development

Ontario has a proud history of providing leadership and support to international Disaster Victim Identification missions. These humanitarian missions are assembled following natural or human-caused disasters where help is needed to identify victims. The Ontario Forensic Pathology Service has participated internationally with Interpol, the International Committee of the Red Cross (ICRC), the Federal Bureau of Investigation and other experts from the forensic community.

Some nations do not have a robust system of forensic medicine to support human rights and justice. Dr. Pollanen has worked to build forensic medicine capacity and support human rights investigations in regions such as the Middle East, South Asia, Africa and the Caribbean. Some of this work has involved United Nations agencies and the International Criminal Court, as well as the ICRC.

In 2020-21, the PFPU was not able to host domestic and international guests and observers due to the COVID‑19 global pandemic.

Professional activities and outreach

Registered pathologists and forensic consultants enrich the practice of forensic science and medicine by participating in provincial, national and international professional organizations, such as the Ontario Association of Pathologists, Canadian Association of Pathologists, National Association of Medical Examiners, Canadian Society of Forensic Sciences, American Academy of Forensic Sciences, the International Association of Forensic Science and other organizations.

The OFPS forensic pathologists participate in activities of the Royal College of Physicians and Surgeons of Canada that focus on the promotion and accreditation of forensic pathology and anatomical pathology in Canada.

OFPS pathologists lectured and delivered courses to audiences that included forensic pathologists and scientists, medical practitioners, the judiciary, lawyers, police, advocacy groups and others.

OFPS pathologists serve as members of editorial boards of international peer-reviewed forensic journals and act as reviewers for other specialist journals.

Scholarly activities

Teaching

Most forensic pathologists and forensic consultants hold academic appointments at their respective universities. They teach undergraduate and graduate forensic science students, medical students, pathologist assistant and physician assistant students, dentists, nurses, medical artists, law students, medical imaging residents, and pathology and forensic pathology residents. Forensic pathology units also host many medical students and pathology residents from Canadian universities and elsewhere.

The PFPU participates in the University of Toronto’s Department of Laboratory Medicine and Pathobiology’s digital library by providing digital histological images of forensic interest to help pathology residents learn. 

Forensic pathologists also act as visiting faculty to foreign universities.

The PFPU partners with the “LAWS” initiative of the Toronto District School Board, the University of Toronto Faculty of Law and Osgoode Hall Law School to offer an educational program for Grade 11 students to understand forensic pathology, its intersection with the law, and the different career options available in the field. Case-based sessions, for more than 100 students each, are offered at the Forensic Services and Coroner’s Complex. The students are exposed to a wide range of forensic specialties involved in a case. The program was not offered during the reporting period due to the pandemic.

Research

Forensic pathologists contribute to, and support research aimed at understanding causes of sudden death and improving public safety.

Academic Activity

Journal publications

Bellis M, Cunningham KS, Pickup MJ. Heart of glass: fatal hematemesis caused by bronchiole-cardiac fistula. Forensic Sci Med Pathol. 2020 Nov 27. doi: 10.1007/s12024-020-00320-6. Epub ahead of print.

Bodwal J, Herath J. Fatal bleeding from a laceration of superficial temporal artery: A rare case. J Forensic Leg Med. 2020 Oct;75:102054. doi: 10.1016/j.jflm.2020.102054. Epub 2020 Sep 8.

Bodwal J, Napoleone M, Herath J. Post-mortem CT with macroscopic and microscopic correlation in a case of sudden death due to systemic sarcoidosis. Forensic Sci Med Pathol. 2020 Sep;16(3):544-547. doi: 10.1007/s12024-020-00259-8. Epub 2020 May 31.

Cullip M, Tran VC, Ball CG. Tattoo visualization using cross-polarized lighting and infrared photography. Forensic Sci Med Pathol. 2021 Jan 6. doi: 10.1007/s12024-020-00347-9. Epub ahead of print.

Dilliott AA, Wang J, Brown E, Singh G, Shkrum MJ, Clin M, Rupar CA, Hegele RA, Siu VM. A novel homozygous variant in REN in a family presenting with classic features of disorders involving the renin-angiotensin pathway, without renal tubular dysgenesis. Am J Med Genet A. 2020 Oct;182(10):2284-2290. doi: 10.1002/ajmg.a.61780. Epub 2020 Aug 17. PMID: 33043632.

Fadel S, Walker AE. The Postmortem Interpretation of Cardiac Genetic Variants of Unknown Significance in Sudden Death in the Young: A Case Report and Review of the Literature. Acad Forensic Pathol 2020.

French K, Jacques R. Postmortem changes. PathologyOutlines.com website.  Accessed March 31st, 2021.

Gale NS, Kalloger SE, Cai E, Abozina A, Derakhshan F, Hickey T, Liu A, Ongaro D, Wolber R, Schaeffer DF. Immunohistochemistry Critical Assay Performance Controls (ICAPC) Reduce Interobserver Variability in the Interpretation of BRAFV600E Immunohistochemistry. Appl Immunohistochem Mol Morphol. 2020;28(6):422-427. doi:10.1097/PAI.0000000000000784

Gershon A, Little D, Ball CG, Williams AS. Fatal secondary aortoduodenal fistula diagnosed with postmortem computed tomography angiography. Forensic Sci Med Pathol. 2020 Sep;16(3):515-518. doi: 10.1007/s12024-020-00256-x. Epub 2020 May 11.

Gorski Z, Parai J, Milroy C.M.  Evaluating small vessel neutrophils as a marker for sepsis. Journal of Forensic Sciences 2021

Hadden WJ, Herritt B, Hoang R, Milroy C, Hooper J, and Wilkin G. "Fatal Cerebral Fat Embolism After Pelvic and Multiple Long Bone Fractures without Associated Lung Injury: A Case Report." JBJS Case Connector 2020;10: e20.

Herath JC, Herath SO. Is it time for targeted and minimally invasive post-mortem examination using total body computed tomography in a medicolegal autopsy? Forensic Sci Med Pathol. 2021 Mar;17(1):175-176. doi: 10.1007/s12024-020-00279-4. Epub 2020 Jul 10.

Hickey TBM, MacNeil JA, Hansmeyer C, Pickup MJ. Fatal methemoglobinemia: A case series highlighting a new trend in intentional sodium nitrite or sodium nitrate ingestion as a method of suicide. Forensic Sci Int. 2021;326:110907. doi:10.1016/j.forsciint.2021.110907

Hojilla C, Armstrong S, Pun C, Hickey TBM, Mete O, Han R, Hahn E, Shivji S, Done S, Lu FI.A Holistic Approach to Pathology Education During the Coronavirus Disease 2019 (COVID‑19) Pandemic. Arch Pathol Lab Med. 2021;145(8):923-924. doi:10.5858/arpa.2020-0668-LE

Klaric K-A, Milroy CM, Parai JL. Utility of postmortem vitreous biochemistry testing for distinguishing sudden from prolonged deaths and for diagnosing ketoacidosis. Journal of Forensic Sciences 2020;  65:1588-1593.

Mathews RZ, Gonsalves AT, Hickey TBM. Fire fatalities in long term oxygen therapy users due to smoking: A description and analysis of 11 deaths. Can J Resp Critical Care Sleep Med. 2020 Oct 6. doi: 10.1080/24745332.2020.1819174

Richards N, Herath J. Death Due to Obstruction of Airways by a Hyperplastic Polyp: An Unusual Complication of Treated Desmoid Fibromatosis. Academic Forensic Pathology. First Published November 25, 2020. https://doi-org.myaccess.library.utoronto.ca/10.1177/1925362120964084

von Both I, Pollanen MS. Fatal pneumococcal septicemia in a girl with visceral heterotaxy and polysplenia: a case report. Forensic Sci Med Pathol. 2020 Sep;16(3):519-522. doi: 10.1007/s12024-020-00252-1. Epub 2020 May 13.

Yorke JA, McNaughton-Filion L, Herath JC. Fatal Fluorosilicic Acid Exposure After a Motor Vehicle Crash: A Case Report. Am J Forensic Med Pathol. 2021 Mar 1;42(1):54-56. doi: 10.1097/PAF.0000000000000602.

Yung F, Herath J. An investigation of demographic and drug-use patterns in fentanyl and carfentanil deaths in Ontario. Forensic Sci Med Pathol. 2021 Mar;17(1):64-71. doi: 10.1007/s12024-020-00321-5. Epub 2020 Nov 16.

Chapters

Herath JC, Pollanen, MS. Autopsy of Asphyxiation, Suffocation and Neck Pressure Deaths. In: Asphyxiation, Suffocation, and Neck Pressure Deaths. CRC Press 2020.

Parai JL, Milroy CM. Hypothermia and Hyperthermia in the Geriatric Population. In: Geriatric Forensic Medicine and Pathology Editors R Byard, K Collins. Cambridge University Press 2020 

Presentations

Gorski Z, Parai JL, Milroy CM. Evaluating small vessel neutrophils as a marker for systemic infection. 73rd Annual Scientific meeting of the American Academy of Forensic Sciences; Virtual meeting, February 15-19, 2021

• For her work, Dr. Zuzanna Gorski won the Best Resident Paper award of the Pathology/Biology section at the American Academy of Forensic Sciences 73rd Annual Scientific Meeting. This is the second year in a row that a University of Ottawa resident has won this award.

Klaric KA, Parai JL, Kepron C, Walker AE, Milroy CM. Post-Mortem survey of hemoglobin A1c, non-alcoholic steatohepatitis and liver fibrosis within a general population. 110th Annual Meeting of the United States and Canadian Academy of Pathology (USCAP); Virtual meeting, March 13-18, 2021. Abstract accepted for presentation in the Stowell-Orbison Autopsy award poster session

Committees

Forensic Pathology Advisory Committee

The FPAC provides advice to the CFP regarding professional medicolegal autopsy practices. This committee includes the directors of the FPUs and the President (or delegate) of the Ontario Association of Pathologists.

During the reporting period, the committee convened twice to discuss policy issues, including body management, transfer payments and the OFPS response to a number of external reviews including the 2019 Provincial Auditor General’s report.

Two FPAC subcommittees were formed during the reporting period to address recommendations from the 2020 Workplan.