The right skills for a job few would want

The bodies arrive at the Royal Inland Hospital's morgue by 10 a.m. One of several body-transport companies typically delivers the child from whichever part of B.C. they're from.

Dr. Lisa Steele and an autopsy assistant get to work quickly.

The babies are first weighed and measured. Then, Steele takes full-body X-rays to look for fractures. She takes nasopharyngial swabs, inserting extra-thin swabs into the tiny nasal passages to collect samples from back of the throat, to test for infections.

When a baby dies unexpectedly anywhere in British Columbia, it is Dr. Steele's responsibility to find out why they died.

It's a grim job and one that few are trained for or would want to do. Steele has completed autopsies on close to 80 children – some only hours old – over the past two years. For hours on each case, she inspects and dissects the body, trying to make sense of what she finds. Occasionally, after an exceptionally tragic case, she cries. And as with other forensic pathologists across the country, she bears the scrutiny brought upon their field since pathologist Charles Smith was disgraced nearly a decade ago. You have to wonder: Why would anyone do this job?

For Steele, the answer lies in a printed e-mail she keeps in her desk drawer.

Impact of Goudge Inquiry

Pathologists are often considered doctors' doctors. They're the mystery-solving specialists whom physicians consult to provide diagnoses based on analyses of tissues, organs, blood and other samples. Some pathologists sub-specialize in forensic pathology, which involves determining causes of death based on the examination of corpses. And among them, an even smaller group has a special interest in the deaths of children.

The practice of pediatric forensic pathology in Canada came under the microscope a decade ago, surrounding the 2007-08 Goudge Inquiry in Ontario. The inquiry, led by commissioner Stephen Goudge, was sparked by concerns about wrongful criminal convictions for children's deaths, based on the flawed findings of Toronto pathologist Charles Smith. A coroner's review found Smith's reports and testimony problematic in 20 cases, of which 12 resulted in convictions.

The inquiry report, released in 2008, noted Smith, who was a pediatric pathologist at Toronto's Hospital for Sick Children, lacked training or certification in forensic pathology. In spite of this, he developed a reputation as an expert on suspicious pediatric deaths and conducted autopsies often in isolation without consulting his colleagues.

Among the many recommendations that came out of the inquiry were measures to help train and recruit forensic pathologists to address an "acute" shortage. It also recommended that once there was a sufficient number of trained experts, post-mortem examination in all criminally suspicious pediatric cases should be conducted by certified forensic pathologists with pediatric forensic experience.

The effects of the Goudge Inquiry rippled through other parts of the country, prompting greater oversight and accountability. Saskatchewan, for instance, adopted a policy requiring that in all cases of sudden, unexpected deaths of infants under the age of one, the autopsy is completed by a forensic pathologist. Previously, they could also be completed by general pathologists. In Alberta, all forensic examinations must be conducted by board-certified forensic pathologists. Since 2011, all completed case files have undergone peer review by another medical examiner at the province's Office of the Chief Medical Examiner to double-check the findings.

Still, few in Canada perform autopsies on infants. Ontario has 37 forensic pathologists who do the job. Quebec has four. In Saskatchewan, the vast majority of pediatric autopsies are completed by two forensic pathologists. In Alberta, they are done by seven. B.C.'s coroners service has forensic pathologists in Vancouver, New Westminster, Penticton and Vernon who also tackle suspicious infant death autopsies. But Steele is tasked with all of the non-suspicious cases – that is, all deaths of infants under the age of one and with no previous medical history – as well as some of the suspicious ones.

Steele has a distinct edge. Not only is she a general pathologist with forensic pathology training, she also has training in neuropathology, which involves identifying neurological diseases and abnormalities based on the examination of the brain and other nervous system tissue. Having both forensic pathology and neuropathology sub-specialties makes her exceptional. As does the fact that her neuropathology training included working with pediatric brains.

"That makes her uniquely qualified to do this work," B.C. chief coroner Lisa Lapointe says.

Finding answers

When a child's body arrives at her morgue, Dr. Steele methodically searches for clues. Tiny red dots, or petechial hemorrhages in the eyelids typically indicate asphyxiation; fingernails appear blue or dark purple when a co-sleeping adult has rolled onto an infant in bed; tears to the anus or hymen suggest sexual abuse. She takes samples of blood, organ tissues, cerebrospinal fluid and urine (although the latter is not always possible since babies don't hold their urine) to test for infections, genetic anomalies and toxicology.

She generally finishes the autopsy by midafternoon the same day, in time for a body-transport company to collect the body and be back on the road by 3 p.m. so that the child may be returned home that evening.

Steele tries to imagine the loss the parents feel. She knows they'll want answers.

"I think people tend to blame themselves when people die. And it's just not the case. So much is out of the control of people, of parents," Steele says.

The majority of the pediatric cases she's handled have involved death by natural causes. Infections are particularly common culprits.

Rarely, the cause of death remains undetermined, such as in the recent case of a three-month-old girl. There had been no suspicion of child abuse, Steele explains. Authorities were told the baby had been placed on a queen-sized bed at 6 a.m. after being fed and when she was checked on at 9 a.m., she was deceased.

When Steele examined the body, however, X-rays showed multiple rib fractures and fractures of the leg and arm. She also noticed small abrasions around the infant's nose and mouth. Steele could not tell from the marks around the baby's face whether she had been smothered, but neither could she rule out the possibility. And, while the fractures were a pattern of injury that suggested abuse, especially in a three-month-old yet unable to walk or crawl, Steele found all the fractures were healing. They were not new.

"All of that information, it's relevant, but the cause of death is undetermined because I don't know exactly what happened to her on the morning of her death," she says, noting this case will soon be heard in court.

The right skills

Steele didn't initially come to Kamloops with the intention of performing infant autopsies. An American who grew up in the small town of Richfield Springs, N.Y., she arrived in the arid interior city in 2012 to take a general pathologist job at the Royal Inland Hospital. Her multiple daily responsibilities range from running the hospital's blood bank to determining patients' cancer diagnoses.

In 2014, the B.C. Coroners Service asked Steele to take on cases of unexplained infant death as well. It had dropped the routine practice of retaining all infants' brains and fixing them (or firming them in a chemical solution), prompted by a request from the First Nations Health Authority to satisfy a cultural belief that the deceased must enter the spirit world intact. The coroners service needed someone who had the expertise and was comfortable examining babies' brains without fixing them first, Lapointe explains. Steele had the right skills.

Forensic pathology requires an excellent general background in all areas of medicine, says Dr. Toby Rose, deputy chief forensic pathologist at the Ontario Forensic Pathology Service in Toronto. But it also takes a certain character.

To be a forensic pathologist, Rose says, you need to enjoy problem-solving and working with your hands. You also have to have an ability to approach cases with an open mind and the communication skills to be able to explain complicated ideas and cases in a way that non-medical people, from families to police and lawyers, can understand.

While in training, Steele was inspired by Dr. Barbara Wolf, a forensic pathologist she met who had worked on aspects of the O.J. Simpson case. She watched Wolf testify in court and found her able to give very clear descriptions, while also knowing her limits on the stand. She didn't "jump into the realm of, you know, always/never," Steele says, noting that even though lawyers and police want to hear absolute answers about what always occurs or what never happens under certain circumstances, it's not so clear-cut in medicine.

When Steele finished medical school in Albany, N.Y., she did a year of internal medicine, but was frustrated by the lack of time she was able to spend with patients. She thought about going into obstetrics and gynecology. But she recalls that an obstetrician warned her, "When you're 50 years old, do you really want to be up all night delivering babies?"

When dealing with death, Steele has found she can work at her own pace. "It's kind of weird. Like, I can spend five hours on an autopsy, but somebody who's in infectious disease can't spend five hours with an incredibly complicated infectious patient," she says.

Personality for pathology

Steele, who is now in her 40s, doesn't have children of her own. She says it would be harder to perform infant autopsies if she did.

She has a surprisingly cheerful disposition. She calls strangers "my dear." Her humour is self-depreciating (the dread of buying "fatter fat clothes" prompted her to start an exercise program and lose 65 pounds, she quips). And she has many outlets: She's recently taken up paddleboarding, she plans to run a half-marathon and "Art is my relief," she says, noting her favourite Canadian artists are Walter Phillips and Emily Carr.

It also helps to have friends and colleagues who work on death investigations. Her friend and running partner Cory Robinson, who is a community coroner in Kamloops, says that in a male-dominated arena, Steele is her sounding board, confidante and ever-enthusiastic companion for hikes and movies.

Robinson suggests Steele is able to cope with the tragedies she encounters, in part, because she doesn't generally deal directly with the families of the deceased.

"She is a ray of sunshine in a really dark world," she says.

Steele's significant other, Iain Currie, a crown counsel in Kamloops whom she met during a murder case, says Steele was different from other pathologists he had encountered, who were often lone wolves – not very social.

"We spend a fair amount of time talking about our jobs," Currie says. "I think one of the things that attracts her to me, and for sure one of the things that attracts me to her is that we can talk about the dark aspects of both of our jobs without sort of pulling punches."

Currie believes when Steele is performing an autopsy, she doesn't spend a lot of time personalizing the child in front of her.

"She is an extremely sympathetic person and empathetic. And it's not that she turns it off in those circumstances, but I think she recognizes that there's no useful place for that sympathy at the time that you're trying to get to the bottom of how an infant died," Currie says.

Afterward, however, she sometimes expresses her horror and outrage. "She can swear like a sailor and she can, in private, make moral judgments about the people involved," Currie says.

Last summer, Steele received an e-mail from a coroner from the Northern Regional Coroners Office, which she printed to keep a copy in a desk drawer in her office. The e-mail was brief. Three sentences thanking her for the speed of her work on an autopsy of a young boy from Kitkatla on Dolphin Island, near the mouth of the Skeena River.

"Dr. Steele," the e-mail read. "The Kitkatla community and family rep, including father, were incredibly grateful for the timeline we met (four day burial protocol from time of death – child will be home early tomorrow morning). I explained all the people involved to make this happen and they specifically asked that I extend their thanks to you as the pathologist for making this a priority as quickly as you did (and they don't know the half of it in terms of your workload!!). they were also grateful he was returned whole as the community has known of incidents where organs were retained….So THANKS!"

"It made me cry," Steele says.

It's a reminder, she says, "Yes, this matters. Yes, this has intense value for somebody who I have never met."