Friday, February 10, 2017

September 2014 was a difficult time in the office of Alberta’s chief medical examiner. Dr. Anny Sauvageau, then in charge, was engaged in a full-scale battle with the Conservative government of the day, alleging political interference by politicians and bureaucrats in the administration of her office. On September 18, CBC Edmonton broke a story that Sauvageau had written to then-justice minister Jonathan Denis with her complaints. -------On the same day, Sept. 18, 2014, a four-year-old First Nations girl named Serenity was rushed by air ambulance to the Stollery Children’s Hospital, suffering from starvation, hypothermia and a catastrophic brain injury. Her emaciated 18-pound body was covered in bruises, old and new, including bruises to her pubic, genital and anal area.------------------Alberta’s new chief medical examiner says a long delay in completing an autopsy report after the death of a four-year-old in government care isn’t a sign of systemic problems in her office. Dr. Elizabeth Brooks-Lim said Serenity’s case, which led to a ministerial panel and calls for the human services minister to resign, was tragic and said she’s been following it since 2014, when the girl died. Brooks-Lim was previously the acting interim chief medical examiner and has worked in the office since 2011. The delay in completing the autopsy report was caused by the complexity of the case and the fact that outside experts had to be consulted, she said. A small percentage of cases require these outside experts, such as brain specialists or forensic anthropologists who specialize in bone remains. “The Serenity case was very specific. It was a complex case file. Our staff worked diligently on that case file,” Brooks-Lim said.-------------



#justiceforserenity--Two years is just way too long for an autopsy report. I don't care what the excuses are the GOA needs to do better. Without sufficient staff and with  political interference it is no wonder that Dr. Anny Sauvageau was in a toxic work place. I feel sorry for her. It's clear the new chief medical examiner is on board to keep up the #GOASPIN but we will know the truth by the performance of the office under her command.
It's time for a change at the medical examiner's office and the GOA should do the right thing by Dr. Anny Sauvageau.


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http://edmontonjournal.com/news/local-news/serenity-case-delay-isnt-sign-of-systemic-problems-says-new-chief-medical-examiner

Serenity case delay isn't sign of systemic problems, says new chief medical examiner

Published on: December 26, 2016 | Last Updated: January 12, 2017 4:44 PM MST
Alberta's new chief medical examiner, Dr. Elizabeth Brooks-Lim, in the toxicology lab at the Medical Examiner's Office on Monday, Dec. 19, 2016.
Alberta's new chief medical examiner, Dr. Elizabeth Brooks-Lim, in the toxicology lab at the Medical Examiner's Office on Monday, Dec. 19, 2016. DAVID BLOOM / POSTMEDIA
Alberta’s new chief medical examiner says a long delay in completing an autopsy report after the death of a four-year-old in government care isn’t a sign of systemic problems in her office.
Dr. Elizabeth Brooks-Lim said Serenity’s case, which led to a ministerial panel and calls for the human services minister to resign, was tragic and said she’s been following it since 2014, when the girl died. Brooks-Lim was previously the acting interim chief medical examiner and has worked in the office since 2011.
The delay in completing the autopsy report was caused by the complexity of the case and the fact that outside experts had to be consulted, she said.
A small percentage of cases require these outside experts, such as brain specialists or forensic anthropologists who specialize in bone remains.
“The Serenity case was very specific. It was a complex case file. Our staff worked diligently on that case file,” Brooks-Lim said.
Emaciated and suffering from hypothermia, the four-year-old indigenous girl died in September 2014 after being airlifted to the Stollery Children’s Hospital with a catastrophic brain injury.
Her 18-pound body was covered in bruises, including bruises to her genital and anal areas. Serenity and her siblings had been living in kinship care with private guardians. No charges have been laid in relation to her death.
The case raised questions about turmoil in the medical examiner’s office after Postmedia revealed the report took two years to complete.
Brooks-Lim said her focus was on the work, not media reports of turmoil, but admitted that delays for routine case files have been increasing. She said the problem was mostly due to the province’s increasing population and the fact that the medical examiner’s office has been short-staffed.
“With our routine reporting, there is a backlog and there is a delay. It’s because we have a very, very high case load,” she said.
In 2014, one per cent of the office’s cases took longer than nine months. In 2015, that number rose to 1.75 per cent.
The office usually employs eight medical examiners, but has been making do with seven and Brooks-Lim said the medical examiners simply can’t find the time to write their reports. After working in the lab all morning, there’s often not enough time for paperwork and her staff will sometimes work evenings and weekends, for no overtime, just to get their reports finished.
“That’s how dedicated the staff are here. One of the main reasons I’m here is because our staff is outstanding and they’re trying their best with limited resources,” she said.
Brooks-Lim said she hasn’t requested a budget increase or more staff, but “just like every other branch and department in government, we would always welcome more resources.”
Adding to the workload was a Supreme Court ruling in July that set caps of 18 months for criminal cases before the provincial courts and 30 months for superior courts. Cases can be stayed if the cap is exceeded. Brooks-Lim said her office is aware of the decision and prioritizes cases that may go to trial.
It’s a fine balance, though. While a quick report can bring some measure of closure for families and keep the courts running smoothly, Brooks-Lim said she doesn’t want her staff rushing their reports.
Brooks-Lim also said she has reached out to Del Graff, the province’s child and youth advocate, to open up the lines of communication. Postmedia reported that Graff’s office was never forwarded Serenity’s autopsy report and couldn’t even get a response from the medical examiner’s office when it requested information.
Now that she’s permanently in the job, Brooks-Lim hopes to have regular communication with Graff and his office, but she stressed that there will be limits.
“On certain occasions, we don’t release reports to interested parties because there’s still an ongoing police investigation,” she said. “It’s not that we’re not wishing to release the report publicly … it’s because we’re ensuring the integrity of a police investigation.”
sxthomson@postmedia.com
With all due respect to the new chief medical examiner there appears to be a hole in the spin. I don’t believe that it is proper for an autopsy report to take two years. This is just plain ridiculous.
Also I do believe that there are systemic problems in the office that she has been in charge of that are now in the courts. The last chief medical examiner is hopefully going to tell us about the problems that the new medical examiner is fervently indicating to the public are not present.
It is always useful to have other points of view.  Dr. Anny Sauvageau indicates political interference and with all the poor incidents of the PCs in the past such as the Tapcal Trust Fund that seems to me at least provide an unfair advantage to the PCs-I am inclined to believe Dr. Sauvageau in her allegations.


The short staffing of the office is also problematic. Court cases depend on timely delivery of information to the system and it seems -just based on the Serenity case that there are unacceptable delays in the production of autopsy results for no reason I can determine.


It seems rather odd also that if the medical examiner’s office had determined the cause of death quite early on --why then did the report itself take so long to generate? Surely there should be a correlation from knowing the cause of death to generating a report on the known cause of death? Why the years of delay? This delay is not explained by the need for getting outside consultants.   
Alberta Justice says the medical examiner determined Serenity’s cause of death “within a few days of the death.”
It is also curious that Alberta Justice can’t find any other cases that required two years for an autopsy report. This appears to be the only report. This sort of prolonged report generation is interesting to me because it suggests that the delay is due to political reasons.


Alberta Justice was unable to tell me this week whether any autopsy in its history, apart from Serenity’s, has ever taken two years to complete.


*****
In any case the delay shows a GOA that has not provided good turnaround on the Serenity case. We have excuses but these aren’t really acceptable. There needs to be good performance and we also need to have the work done to ensure that we don’t have politics resulting in long delays in justice work.




Paula Simons: Chaos, short-staffing in medical examiner's office put justice at risk

Published on: November 24, 2016 | Last Updated: January 12, 2017 4:59 PM MST
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September 2014 was a difficult time in the office of Alberta’s chief medical examiner.
Dr. Anny Sauvageau, then in charge, was engaged in a full-scale battle with the Conservative government of the day, alleging political interference by politicians and bureaucrats in the administration of her office.
On September 18, CBC Edmonton broke a story that Sauvageau had written to then-justice minister Jonathan Denis with her complaints.
That same day, the former chief medical examiner, Dr. Graeme Dowling, who was still working in the office, went public himself, giving an interview to the Edmonton Journal, refuting Sauvageau’s allegations.
Since Anny Sauvageau's departure, the office of Alberta's chief medical examiner has had a revolving door. Did short-staffing and personnel chaos contribute to the delays in completing Serenity's autopsy?
Since Anny Sauvageau’s departure, the office of Alberta’s chief medical examiner has had a revolving door. Did short-staffing and personnel chaos contribute to the delays in completing Serenity’s autopsy? SHAUGHN BUTTS /EDMONTON JOURNAL
One can only imagine how toxic the atmosphere in the medical examiner’s office might have been.
On the same day, Sept. 18, 2014, a four-year-old First Nations girl named Serenity was rushed by air ambulance to the Stollery Children’s Hospital, suffering from starvation, hypothermia and a catastrophic brain injury. Her emaciated 18-pound body was covered in bruises, old and new, including bruises to her pubic, genital and anal area.
She died nine days later, after doctors removed her from life support. Serenity and her siblings had been living in kinship care with private guardians. No charges have ever been laid in relation to her death.
Serenity’s battered body went to the Office of the Chief Medical Examiner for an autopsy.
Alberta Justice says the medical examiner determined Serenity’s cause of death “within a few days of the death.”
But Dan Laville, who speaks for the department, says it took until Sept. 9, 2016 — almost exactly two years later — for the Office of the Chief Medical Examiner to complete its autopsy report into her death. Serenity’s cause of death has never been made public. Even Alberta’s Child and Youth Advocate, Del Graff, was denied the information which his office had been requesting for more than a year. In September of this year, just before his report went to print, Graff’s office was told the autopsy still wasn’t finished.
Despite protestations from Premier Rachel Notley this week that Graff couldn’t be told the cause of death without putting the police investigation at risk, and despite Notley telling the house Wednesday that the medical examiner provided interim reports to Graf, Tim Chander, who speaks for the Office of the Child and Youth Advocate, says they were told no such thing, and received no response from the medical examiner to their repeated requests for information on Serenity’s autopsy.
“We were told the report wasn’t complete. We knew there was a police investigation,” says Chander. “We were not told that we couldn’t have the report because it might prejudice a police investigation.”
So what on earth explains the extraordinary two-year delay?
“Cases, even high priority cases such as this one, can take a long time to complete for a number of reasons, including complexity of a case, competing high-priority cases and external delays beyond the control” of the chief medical examiner, says Laville,
“Due to the complex nature of cases like this one, additional time was needed to consult with external experts, such as neuropathology, who balance OCME cases with their other work.”
Let’s translate.
OCME stands for Office of the Chief Medical Examiner. That’s easy enough.
But those phrases “competing high-priority cases” and “balance cases with their other work” should set alarm bells ringing. Decoded, they suggest staff in the medical examiner’s office and outside consultants were all handling heavy workloads.
And Serenity’s case isn’t the only one that should have us asking tough questions.
Last last month, the Crown charged Lauren Lafleche, 29, with second-degree murder and assault with a weapon in the death of her daughter, Shalaina Arcand. She was five when she died in Edmonton after suffering head trauma. Shalaina had been in foster care before she was returned to her mother’s care. Her autopsy wasn’t turned over to the Edmonton Police Service until 11 months after Shalaina’s death. Her mother was arrested the next month.
An image of Shalaina Arcand, from her funeral home obituary. She was five when she died in October 2015 from head trauma. It took 11 months for the medical examiner to complete her autopsy. Her mother was charged with second-degree murder a month after the medical examiner's report was sent to police.
An image of Shalaina Arcand, from her funeral home obituary. She was five when she died in October 2015 from head trauma. It took 11 months for the medical examiner to complete her autopsy. SUPPLIED
Let’s recognize the medical examiner’s office has been under incredible stress for much of the last two years.
In November, 2014, the province announced it would not renew Sauvageau’s contract. She, in turn, sued for $5 million.
Since then, the chief medical examiner’s office has had a revolving door. First Dr. Graeme Dowling filled it as interim chief medical examiner. Then the province hired an American, Dr. Jeffrey Gofton, to fill the role. He quit after less than 18 months in the post, although he remained on payroll until the end of last month. Since July, the role has been filled by Dr. Elizabeth Brooks-Lim, who carries the absurd title “interim acting chief medical examiner.”
That’s left the office short one medical examiner for a large part of the past two years.
Each year, the Office of the Chief Medical Examiner investigates about 20,000 deaths and performs about 4,000 post-mortems.
In 2014, 589 of those cases, or about 15 per cent, took more than six months to process, and of those, 47 cases, or about one per cent, took more than nine months to complete.
In 2015, by contrast, 979 cases, or almost 25 per cent, took more than six months to conclude, and of those, 70, or 1.75 per cent, took more than nine months.
Alberta Justice was unable to tell me this week whether any autopsy in its history, apart from Serenity’s, has ever taken two years to complete. They could tell me the office currently has 770 open files and that the competition to hire a new chief medical examiner has just closed.
I think we should be rightly concerned that long delays might have put investigations and prosecutions in the cases of both Serenity and Shalaina in peril. And who knows how many other investigations have also been delayed or prejudiced? The work of Alberta’s medical examiners is vital for so many reasons. It would be tragic if personnel issues, office politics and under-staffing put our administration of justice at risk.     
psimons@postmedia.com
www.facebook.com/PaulaSimons

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