[1] By 2005, the existence of serious and disturbing errors in several criminal investigations 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 Smith, of the Hospital for Sick Children in Toronto, had provided his expert opinion.
In response to a shockingly large number of wrongful convictions (for murder, sexual assault, and infanticide, to name but a few), the provincial government directed that an inquiry be held to determine the state of the Forensic Pathology 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.
Goudge found that Smith had "actively misled" superiors and made "false and misleading" statements in court.