Letter from Elsewhere

Wellington Street, Ottawa

Thirteen years ago I did my last post-mortem examination in England and started a new phase of my career in sleepy Ottawa, the capital of Canada – at least, “sleepy” is how many people think of the city. As a forensic pathologist based in Sheffield I had mostly conducted examinations on people who’d died in suspicious circumstances and then been called to present the evidence in criminal trials. It may seem a strange speciality for a doctor, since I never see live patients or give medical treatment to individuals, but in our own way we treat society and assist public health. My UK career included travelling to trials and conferences around the UK and Ireland, flying around the globe to give evidence in court, examining victims of the Srebrenica massacre, and lecturing in such places as Hong Kong, New Zealand and Australia.

I didn’t go to Canada until 2006, when I travelled there for a public inquiry, but it proved a decisive visit. I met my wife (another forensic pathologist) and ended up being interviewed for my current job in Ottawa, a city I’d never set foot in before. Before we married, she persuaded me that Ottawa was preferable over Toronto, a bigger city that holds itself out as the centre of the universe (at least in Canada), but which she said visitors find boring (ironic, as that’s what the uninitiated feel about Ottawa). Toronto did have a crack cocaine-smoking mayor, though. Plus an NHL hockey team that hasn’t won the Stanley cup for over 50 years, a running gag in Canada.

During my job interview in Ottawa, one of the panel said: “Well, there’s not much murder in Ottawa, are you sure you want to move here?”, reflecting a general misconception that forensic pathologists only do autopsies on murdered people. “Pathology” means “the study of disease” and pathologists work on laboratory investigations such as cancer diagnoses, using biopsies and blood tests. (The
organisation I now work for conducts over twelve million tests a year in its laboratories.) When a forensic pathologist works on an autopsy, to find the cause of death, few are criminally suspicious, though when they are you want trained people to do those examinations.

The public inquiry for which I originally travelled to Canada was called because the person conducting the examinations, on children who had died in suspicious circumstances, wasn’t trained and had drawn the wrong conclusions. Innocent people were imprisoned for long periods as a result. Conversely, I have also been involved in cases where a guilty party went free because evidence had been missed. In one case, the defendant went on to kill again when he should have been in prison for a previous murder. Trained forensic pathologists are very aware of the potential damage when we get it wrong. Society justly demands we get it right.

Being Canadian, court proceedings are polite, but you get blunt personal writeups in the press. I’ve been described as “bulky with blue eyes and a thick British accent” and “preposterously well educated”. I once received an email saying I was an “unscrupulous Phatologist”, which I guess tallies with bulk

In England, the focus of my work was on criminally suspicious cases, whereas in Ontario we perform all the autopsies required by the Coroner system. Broadly there are four categories of sudden death: homicides, suicides, accidents and natural diseases. Heart disease predominates in the latter category, but there are plenty of other causes. For example, we know there are genetic diseases that cause sudden death and now through post-mortem genetic testing we can try to raise awareness and prevent future premature deaths among relatives of the victim.

Accidental deaths include what you’d expect: road crashes, lake drownings and similar misadventures. It also includes recreational drug use, which has plagued North America in recent years. During the Covid-19 pandemic Ontario saw a 40% increase in opioid-related deaths in 2020, mostly due to the use of fentanyl. This is a real public health crisis. Covid-19 has represented a major challenge to autopsy services as well as health care systems, across the world.

Canada has a much lower rate of homicides than the USA, which saw a 33 per cent increase in 2020. It also has a lower rate of firearms violence. But we have to deal with our fair share of suicides, which are always tragic. Suicide represents a sad end point of mental illness, often involving factors like addiction and loneliness. Documentation of cases is important and can refute accusations of foul play as well as providing relatives with closure.

Homicides are when forensic pathologists interact with the public and the media most, as we present our evidence in court. Courts in Canada feel very familiar to someone brought up with English Crown Courts. There’s a judge and twelve jurors, though one variant is that trial can be by judge alone, which can even happen in murder trials, with agreement. “Ah, English murder trials, that’s where you have those crazy guys in wigs,” a Dutch colleague once said to me. Well, not in Canada. Here, the judge and lawyers do wear the same gowns, but not the headgear.

In Ontario, at least, you also sit rather than stand to give your evidence. This took a little getting used to, as it’s easier to relax and slump when not standing up. But being Canadian, proceedings are very polite. You just have to get used to typically blunt personal write-ups in the press. I’ve been described as “bulky with blue eyes and a thick British accent” and on another occasion as “preposterously well educated”. I once received an email (about an international case) saying I was an “unscrupulous Phatologist”, which I guess tallies with bulky.

When you work in Canada you quickly realise how vast it is, and different cultures are. Three groups are classified by law as indigenous – First Nations, Inuit and Métis. I was very ignorant of their history and customs when I first arrived, but I learned fast, since Indigenous issues are common in our work. The recent, much-reported finding of unmarked graves at Residential schools – institutions where children were forcibly removed from their parents and culture to be educated by European settlers – was typical of a case where I needed to be up to speed on cultural sensitivities. The identification skills of my colleagues can only be called upon if the communities consent.

For me, one of the privileges of being a forensic pathologist in Ottawa has been to travel to the self-governing territory of Nunavut and visit the Inuit communities there, as we provide the forensic pathology service for Eastern Nunavut. This responsibility does present issues as the top end of Baffin Island takes at least a day to get to if going to court, but it is always an illuminating experience. Speaking to my translator in a hotel after one court case in the North she recalled how she was sent away from home to a residential school and educated in English rather than her native language of Inuktitut. Nowadays, people in Nunavut can be educated locally in their own language and she pointed out that the younger generation aren’t as fluent in English as she is, since they’re no longer forced to assimilate, as in the past.

Maintaining indigenous culture remains very important, she told me. In court, it was fascinating hearing her translate my testimony into Inuktitut, where not a single word was remotely familiar. The trial was otherwise the same as any in Canada: in this case with judge, jury and robed lawyers, but held in the local community, with local people deciding the case.

How do forensic pathologists cope with seeing so much death and destruction? The answer is, surprisingly well. In Ottawa we still go out to dinner after work and discover new foods and wines (and no, they don’t all involve a new use for maple syrup). One senior colleague said going home to a warm bed was the best part of the job. Others, when asked, will describe their best case. But many will feel as I do that the best part of the job is always the next case.

You just don’t know what it will be or what you will find. Since I started in medicine, we’ve had to tackle AIDS, West Nile fever, “mad cow disease” in humans (variant CJD) and various types of drug use. Covid-19 has presented forensic pathologists with a new evolving disease to get to grips with, and our understanding of each disease has been helped by the autopsy process. Who knows what my colleagues and I will have to investigate next?

Meantime, being a forensic pathologist in Canada has certainly opened up new vistas. My wife and I continue to teach and do academic work and I’ve enjoyed discovering Ottawa’s vibrant culture. I’ve learnt to talk about hockey, not ice hockey, and I’ve developed a taste for butter chicken poutine. My Canadian children can already skate, though my wife won’t let me have a go as she thinks I’ll fall and get a head injury. I fear she’s probably right.

As in England, there are four clear-cut seasons, though winter in Canada is seriously cold, and brings a different pathology to our workload. We see hypothermia, but not as much as you might think – Canadians know there’s no such thing as bad weather, just bad clothing. The more common problem is people trying to walk across frozen rivers and lakes when it’s too early to ice-fish or attempting cross-country skiing across them. In fact, we regularly see unnecessary risk-taking. I have yet to do an autopsy on someone killed by a polar bear or a moose, apparently the most dangerous animal in Canada. But it could be one of the mysteries waiting to be unravelled in my next case.

Dr Christopher Milroy works at Eastern Ontario Regional Forensic Pathology Unit and is a Full Professor at the University of Ottawa