The Inquiry into Pediatric Forensic Pathology in Ontario, commonly known as the Goudge Inquiry, was created to address serious concerns over the way criminally suspicious deaths involving children are handled by the Province of Ontario

Ontario

Ontario is a province of Canada, located in east-central Canada. It is Canada's most populous province and second largest in total area. It is home to the nation's most populous city, Toronto, and the nation's capital, Ottawa....

 in Canada

Canada

Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

.

By 2005, the existence of serious and disturbing errors in several criminal investigations

Criminal procedure

Criminal procedure refers to the legal process for adjudicating claims that someone has violated criminal law.-Basic rights:Currently, in many countries with a democratic system and the rule of law, criminal procedure puts the burden of proof on the prosecution – that is, it is up to the...

 into suspicious deaths involving children had been confirmed. While there appeared to be significant problems in the entire system, the majority of cases being re-investigated involved those for which Charles Randal Smith

Charles Randal Smith

Charles Randal Smith was a Canadian pathologist who was the head pediatric forensic pathologist at the Hospital for Sick Children in Toronto, Ontario, from 1982 to 2003. The quality of his autopsies, and the resulting criminal charges and convictions of several people, have been called into...

, of the Hospital for Sick Children

Hospital for Sick Children

The Hospital for Sick Children – is a major paediatric centre for the Greater Toronto Area, serving patients up to age 18. Located on University Avenue in Downtown Toronto, SickKids is part of the city’s Discovery District, a critical mass of scientists and entrepreneurs who are focused on...

 in Toronto

Toronto

Toronto is the provincial capital of Ontario and the largest city in Canada. It is located in Southern Ontario on the northwestern shore of Lake Ontario. A relatively modern city, Toronto's history dates back to the late-18th century, when its land was first purchased by the British monarchy from...

, had provided his expert opinion.

In response to a shockingly large number of wrongful convictions

Miscarriage of justice

A miscarriage of justice primarily is the conviction and punishment of a person for a crime they did not commit. The term can also apply to errors in the other direction—"errors of impunity", and to civil cases. Most criminal justice systems have some means to overturn, or "quash", a wrongful...

 (for murder

Murder

Murder is the unlawful killing, with malice aforethought, of another human being, and generally this state of mind distinguishes murder from other forms of unlawful homicide...

, sexual assault

Sexual assault

Sexual assault is an assault of a sexual nature on another person, or any sexual act committed without consent. Although sexual assaults most frequently are by a man on a woman, it may involve any combination of two or more men, women and children....

, and infanticide

Infanticide

Infanticide or infant homicide is the killing of a human infant. Neonaticide, a killing within 24 hours of a baby's birth, is most commonly done by the mother.In many past societies, certain forms of infanticide were considered permissible...

, to name but a few), the provincial government directed that an inquiry be held to determine the state of the Forensic Pathology

Forensic pathology

Forensic pathology is a branch of pathology concerned with determining the cause of death by examination of a corpse. The autopsy is performed by the pathologist at the request of a coroner or medical examiner usually during the investigation of criminal law cases and civil law cases in some...

 system in Ontario. The goal of this inquiry was to come up with suggestions to improve the system, which the province was capable of implementing, in order to ensure that these errors would not be repeated.

Justice Stephen T. Goudge was named as commissioner. He heard evidence from November of 2007 through the early months of 2008. His report was released on October 1, 2008.

In his report, among the host of problems he addressed, he took issue with:

• the qualifications of practitioners in the field of Pediatric Forensic Pathology - specifically the problems with a lack of a formal certification
  Certification
  Certification refers to the confirmation of certain characteristics of an object, person, or organization. This confirmation is often, but not always, provided by some form of external review, education, assessment, or audit...
  
   program in Pediatric Forensic Pathology;

• training of practitioners that failed to place a heavy emphasis on the forensic aspects of pediatric forensic pathology;

• a lack of knowledge of the legal system on the part of those conducting autopsies as part of criminal investigations and, as a result, a fundamental lack of appreciation of the proper role the Forensic Pathologist plays in the criminal justice
  Criminal justice
  Criminal Justice is the system of practices and institutions of governments directed at upholding social control, deterring and mitigating crime, or sanctioning those who violate laws with criminal penalties and rehabilitation efforts...
  
   system; and

• an improper system of checks-and-balances leading to a total lack of oversight into the work of those who make the determinations that often lead to serious criminal convictions
  Conviction
  In law, a conviction is the verdict that results when a court of law finds a defendant guilty of a crime.The opposite of a conviction is an acquittal . In Scotland and in the Netherlands, there can also be a verdict of "not proven", which counts as an acquittal...
  
  .