2022-2023 Results

Register of pathologists

Under the Coroners Act, the 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 paediatric cases (Category C)

During the reporting period, 85 registered pathologists were active in Ontario, including 43 Category A pathologists permitted to conduct all types of autopsies. These 43 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 and Continuing Professional Development Committee, 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

The CFP is responsible for the quality of medicolegal autopsies performed throughout the province. 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.

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 of pathologists. 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.

Pathology Information Management System (PIMS)

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 2022-23, approximately 89 per cent of all autopsies were performed in FPUs and paediatric sites and 11 per cent in community hospitals.

Chart 2 shows the distribution of autopsies captured in the system performed by FPUs and community hospitals from 2022-23.

Chart 2: Distribution of autopsies by FPUs and community hospitals, 2022-23

Summary:

• Provincial Forensic Pathology Unit - 6,314 (60.86 per cent)
• Local forensic pathology units:
  • Ottawa - 991 (9.55 per cent)
  • London  - 845 (8.15 per cent)
  • Sudbury - 485 (4.68 per cent)
  • Kingston - 438 (4.22 per cent)
  • Sault Ste. Marie area - 164 (1.58 per cent)
• Community hospitals - 1,137 (10.96 per cent)

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 2022-23, there were a total of 203 death under 5 cases (routine and criminally suspicious) completed across the province (Chart 4).

Chart 4: Paediatric cases involving children under five years by locations, 2022-23

Summary:

• Provincial Forensic Pathology Unit: 98
• Local forensic pathology units:
  • London: 35
  • Ottawa: 30
  • Sudbury: 8
  • Sault Ste. Marie area: 1
• Community hospitals: 31

Chart 5: Distribution of autopsies by case type, 2022-23

Summary:

• Routine: 8,464
• External: 1,433
• Homicide: 283
• Deaths under 5: 194

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 with no dissection. There were 1,444 such cases performed at the OFPS in 2022-23.

Forensic pathologists at the PFPU use imaging technology, such as CT scans, as a tool to inform their decisions about targeted examinations, where one or more body cavities are examined. In 2022-23, 39.2 per cent of cases were targeted examinations (Chart 6).

Chart 6: Distribution of autopsies by autopsy type in PFPU, 2022-23

Summary:

• Targeted: 39.2%
• Full: 42.4%
• External: 18.4%

The OFPS has seen an unprecedented increase in overall caseload by about 29.9% due to opioid-related deaths and suspected drug-related deaths.

Quality management

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

• the OFPS register and 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 cases and complex paediatric cases (deaths under five years) prior to report dissemination, 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 of key performance indicators to clients and stakeholders
• tracking of 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 (RCPSC)
  • continuing professional development

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

There were 383 autopsy reports peer reviewed in 2022-23. On average, about 10 reviews were completed by each reviewing forensic pathologist. The average turnaround time for peer review was seven days in 2022-23. The OFPS standard for peer review is 10 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 are appropriate in tone, length and thoroughness)
• knowledge (for example, responses to questions are scientifically sound)
• interpretation, opinion and conclusions (for example, these 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 on routine cases, such as non-criminally suspicious, are reviewed for administrative and technical accuracy by FPU medical directors and medical managers.

The administrative review focuses on completeness and adherence to guidelines. All community hospital reports undergo administrative review by the OFPS quality assurance unit and 10 per cent of routine autopsy reports from FPUs are reviewed by the medical director or medical manager.

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. In general, 10 per cent of routine reports are reviewed on this basis.

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

• cases with an undetermined or 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
• where the quality assurance unit is notified that the case should undergo a mandatory technical review

Key performance indicators (KPIs)

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

Pathologists are expected to follow the best practices set out in the practice manual. Pathologists are provided feedback from routine quality reviews with the goal of improving report quality.

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

Chart 7: Consistency measures as shown by technical review, 2022-23

Summary:

• Appropriate ancillary testing: FPUs 100.0%; community hospitals 99.2%
• COD reasonable: FPUs 100%; community hospitals 98.4%
• Free of language errors: FPUs 100%; community hospitals 100%
• Independently reviewable: FPUs 100%; community hospitals 100%
• Opinions are reasonable: FPUs 100%; community hospitals 99.2%
• Satisfactory descriptions: FPUs 100%; community hospitals 100%

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.

The purpose of quality assurance is to improve the quality of autopsies and reports. 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

Timeliness of autopsy reports is a KPI. 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, such as waiting for the results of ancillary testing

Chart 8: Average turnaround time by year, 2010-23

Summary: Chart 8 depicts the turnaround time for community hospital pathologists and forensic pathologists in FPUs for the last 13 years. The longer turnaround time for forensic pathologists may be explained by the more complex nature of the autopsies performed.

Clinical forensic medicine

At present, 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 and manage identification when they 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 826 anthropology cases managed at the 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 forensic human remains analysts and an unidentified-unclaimed human remains coordinator. The forensic human remains analyst provides services for forensic anthropology examinations conducted at the PFPU in addition to scene examinations across the province of 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.

During the fiscal year, there were 1,166 unidentified bodies managed by the PFPU. Of these, 1,156 were positively identified and the additional 10 continued to be managed to determine their identity.

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 459 consultation cases completed. 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 with 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 3,586 tissue specimens each month in 2022-23.

Toxicology

Toxicological analysis of postmortem samples is performed by scientists known as 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 7,619 death investigations. The average time to issue a toxicology report by the CFS was 58 days. (Statistics provided by the Centre of Forensic Sciences).

Molecular autopsy and 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 for living patients 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. Thus, particularly for young people, the identification of a genetic contribution to sudden death can have huge implications for the surviving family members 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 been 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 becoming increasingly accepted that unrecognized genetic disease may play a role in deaths following interactions with correctional officers or police, or during 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 (CIIC)

In 2017, the OFPS established the CIIC 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, 21 cases were peer reviewed by this committee.

Complex Case Expert Committee (CCEC)

The OFPS introduced the CCEC as a new quality assurance process. This standing committee of 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, such as neuropathologists. This new process replaces or expands the usual peer review for certain cases.

During the reporting period, 10 cases were peer reviewed by this committee.

Forensic imaging

Forensic pathologists at the PFPU incorporate findings from advanced postmortem imaging, such as CT and MRI scans into their case management decisions. Incorporation of these non-invasive techniques into forensic pathology practice has resulted in increased numbers of external and targeted examinations leading to efficiencies and benefits to families.

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 postmortem CT and MRI scans and can see pathologic lesions in the autopsy room in a way that is not possible in the clinical setting.

During the reporting period, there were 6,243 total scans completed at the PFPU.

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 PFPU houses a dedicated tissue recovery suite that is used exclusively for obtaining donor tissues, including corneas, heart valves, skin and bones. After consent by the family, tissues are recovered by trained staff from TGLN as well as the OCC and OFPS.

TGLN performed 97 tissue recoveries using the PFPU tissue surgical suite during the reporting period, including bones, skin and heart valves. This accounts for 76 per cent of TGLN’s 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.

In 2022, the course focused on “Bodies, Bugs and Ballistics”, where lectures on managing mass fatalities, postmortem changes, impacts of the COVID-19 pandemic and other viruses to public health, entomology and investigative impacts of ballistics and explosives were highlighted.

Department of Laboratory Medicine and Pathobiology (LMP), University of Toronto

The Department of LMP 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 the 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. Courses were offered virtually and covered various topics in pathology.

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 2022 was given by Dr. Tania Delabarde, the identification referent from the Forensic Anthropologist Institute of Legal Medicine, Paris, France, where she described forensic anthropology and its contribution in France.

Training forensic pathologists

Since 2007, Department of LMP has been a partner of PFPU of the OFPS to train the next generation of forensic pathologists for Canada and the world. The OFPS is committed to the virtuous cycle of service, research and teaching as the primary driver for advancing and sustaining the profession of forensic pathology. To this end, the University of Toronto and OFPS have become leaders in promotion and training of forensic pathology and forensic medicine practitioners in Canada and internationally to support public death investigations, as well as criminal justice and human rights. The forensic pathology residency training program is funded by the Ministry of Health and administered by LMP. It is the first training program in Canada leading to certification in forensic pathology by the RCPSC.

In February 2021, the RCPSC accredited a new forensic pathology residency training program at the University of Ottawa and the Eastern Ontario Forensic Pathology Unit. This augments the capacity of the only two active training programs in Canada, in Toronto and Alberta, and helps to ensure the sustainability of the profession in Ontario and Canada.

The PFPU training program has two branches administered by the University of Toronto:

1. Forensic pathology residents who are primarily graduates of Canadian anatomical pathology training programs
2. International clinical fellows with variable backgrounds in pathology and forensic medicine. The training takes place at the PFPU at the Forensic Services and Coroners Complex in Toronto. Both branches of the program are accredited by the RCPSC, and residents and fellows are eligible to sit the RCPSC sub-specialty examination in forensic pathology.

Training Canadian forensic pathologists

Since 2008, 25 pathologists have completed training, 22 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.

In 2022, two new residents began training in forensic pathology in the University of Toronto program and one from the University of Ottawa.

Clinical fellows in forensic medicine

The PFPU and the University of Toronto are committed to developing global forensic medicine and Dr. Pollanen has outreach activities and training collaborations with Jamaica, Peru, Iraq, Sri Lanka, Chile and Zambia. Since 2007, 20 international fellows have trained in forensic pathology at the PFPU. Since 2016, clinical fellows are eligible to write the RCPSC examination in forensic pathology through the subspecialty examination affiliate program.

In 2022, the PFPU hosted one research fellow.

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 strengthen forensic capacity in their own 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.

Building on the success of our Jamaican program, we have extended our outreach to other global areas of need, such as Africa, and have broadened our advocacy for critical infrastructure development.

One of our previous fellows facilitated the commencement of national legislation that would set the framework to develop forensic pathology in Zambia. He is also spearheading an initiative to establish a medicolegal training centre for sub-Saharan Africa. In partnership with the University of Zambia in the Zambia College of Medicine and Surgery, existing forensic facilities are being refurbished to host a new one-year forensic pathology fellowship for trained pathologists, as well as a new four-year specialty training program for medical officers. The goal is to train 20 forensic pathologists by 2032.

The PFPU hosted two Chang Foundation fellows in 2022.

Recruitment of forensic pathologists

The capacity of the OFPS was enhanced through the addition of three talented new recruits.

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 OFPS 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 with a focus on forensic pathology in conflict zones. The value of forensic science is that it can clarify the facts of what actually happened, as the forensic pathologist’s focus is on interpretation of injuries, how they may have occurred and determination of cause of death. During these international missions, interdisciplinary teams of anthropologists, archaeologists and odontologists, etc., work together to identify remains and assist with the humanitarian response.

Some nations do not have a robust system of forensic medicine to support human rights and justice. Ontario’s Chief Forensic Pathologist, Dr. Michael Pollanen, has worked to build forensic medicine capacity and support human rights investigations in geographic areas 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 2022-23, the PFPU hosted three domestic and international guests and observers from the University of Coimbra, University of the West Indies and Nigeria, Africa.

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 RCPSC 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 for the educational purposes of pathology residents.

Forensic pathologists also act as visiting faculty to foreign universities.

Committees

Forensic Pathology Advisory Committee

The Forensic Pathology Advisory Committee 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 three times and has begun to host open sessions with all pathologists across the province. Discussions about policy issues, including the framework for pathologist peer-mentoring, development of the provincial case management system, F-Path, response to recommendations and external operational review.