Report of the Paediatric Death Review Committee and Deaths Under Five Committee

Canadian CW report

Office of the Chief Coroner


Office of the Chief Coroner, Province of Ontario, 113 pages.


Information relevant to the mandate was collected, evaluated and collated over a number of months following announcement of the Inquiry. The electronic database comprised 135,000 pages of documents obtained from persons/parties thought to be in possession of relevant materials. 11 research papers were commissioned by the Inquiry to assist in fulfilling its mandate. Experts on forensic pathology and the legal system from Canada, Australia, the United Kingdom and the United States of America contributed.

47 witnesses testified before the Commissioner during 52 hearing days with live web cast available throughout. 13 parties were granted standing, i.e. these parties were entitled to participate in the proceeding by asking questions of witnesses and making submissions to the Commissioner. Following witness testimony, there were 18 roundtable meetings held over 11 days. The Commissioner attended each of these sessions which brought together people who were knowledgeable about the specific issues identified for discussion.

After the evidence was presented, written and oral submissionswere provided to Justice Goudge by the parties with standing.

Additional Information