AUTOPSY NEEDED IN OFFICE OF CHIEF MEDICAL EXAMINER

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 Sept. 18, CBC Edmonton broke a story that Sauvageau had written to thenjustice 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.

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.

And despite protestations this week from the government that Graff couldn’t be told the cause of death without putting the police investigation at risk, Tim Chander, who speaks for the Office of the Child and Youth Advocate, says they were told no such thing.

“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.

She was five when she died in October 2015. It took 11 months for the medical examiner to complete her autopsy. Her mother was later charged with seconddegree murder.

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 BrooksLim, 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 postmortems.

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 understaffing put our administration of justice at risk.