With his skeleton staff of pathologists leaving their jobs, Ontario's chief forensic pathologist prepared to give up in defeat and resign in 1999, the Goudge commission was told yesterday.

"I thought there was a crisis," David Chiasson testified. "I was feeling somewhat beleaguered and embattled trying to maintain our current model. We had been taking several steps forward for several years, but now we were going backwards."

Dr. Chiasson's account shed new light yesterday on a chaotic situation that prevailed in the Office of the Chief Coroner of Ontario at the time a series of autopsy mistakes by Charles Smith were beginning to come to light.

The inquiry has already heard evidence that officials either ignored warning signs or failed to take firm action to bring Dr. Smith into line. Dr. Chiasson's testimony yesterday outlined a motive for their inaction - the office's desperate need for Dr. Smith's services.
Mr. Justice Stephen Goudge is trying to get to the bottom of how Dr. Smith became the star pediatric pathologist in the coroner's office despite a record of errors that ultimately put at least 20 criminal cases in jeopardy.

A series of letters and e-mails filed as evidence yesterday by commission counsel Linda Rothstein provided an intimate glimpse of the pressures that had come to bear on the office.

Dr. Chiasson testified that his frustration was rarely far below the surface through the late 1990s, as he battled against chronic staff shortages and a pay scale so low it was virtually impossible for him to attract full-time replacements.

In a letter of resignation which he wrote - but didn't deliver - to chief coroner James Young on June 16, 1999, Dr. Chiasson said that three forensic pathologists had quit within a period of 10 months, leaving just himself and one other pathologist on staff.
Dr. Chiasson pointed out that one of the pathologists who had resigned accepted an offer from a B.C. hospital that raised his salary by 50 per cent.

His departing colleagues made it clear that they were tired of being little more than "autopsy technicians," Dr. Chiasson testified. He said that they wanted a more active role in death investigations - including determining the cause and manner of death.
"As troubling as the acute staff shortage is, I am even more concerned about the long-term future of this forensic pathology unit," Dr. Chiasson wrote in his letter to Dr. Young.

On June 1, 2001, he gave up for good. In a letter of resignation he delivered to Dr. Young, Dr. Chiasson said that his frustration had peaked after deputy chief coroner James Cairns prevented him from playing a central role during a strike of fee-for-service pathologists.

The inquiry has heard that the questions surrounding Dr. Smith's competence could hardly have come at a worse time. Although untrained as a pediatric forensic pathologist, Dr. Smith had developed the field as a personal specialty. The coroner's office had become highly dependent on him to carry a major share of autopsies.
Dr. Chiasson also testified that one of the most serious factors underlying the Smith affair was a lack of scrutiny of forensic pathologists who testified in criminal courtrooms. Dr. Smith's testimony often differed from what he had told prosecutors or police officers, he said, jeopardizing many prosecutions.

"I think it is at that level that a lot of the cases really erupted or came out," he said.