Area coroners ordered unnecessary autopsies into natural deaths alleges a former director of the Hamilton Regional Forensic Pathology Unit.

Dr. Jane Turner makes these accusations in a compaint lodged against the province's top bosses for death investigations.

The Spectator has learned the unproven allegations being reviewed by the Death Investigation Oversight Council accuse Ontario's chief forensic pathologist Dr. Michael Pollanen and chief coroner Dr. Dirk Huyer of doing nothing to prevent the unnecessary autopsies which she says overloaded the already-busy unit.

The high caseload exceeding the capacity of the under-staffed unit was one of the reasons given for Pollanen and Huyer's controversial decision to end the service at Hamilton General Hospital and move the cases to Toronto by July, 2020.

"He had no interest in addressing the root cause which was that the coroners were ordering unnecessary autopsies," Turner told The Spectator. "My complaint to Pollanen about this fell on deaf ears."

Ontario coroners get paid $450 whether they do all the work themselves to investigate a natural death or order an autopsy, confirms Cheryl Mahyr, spokesperson for Pollanen, Huyer and Dr. Karen Schiff, regional supervising coroner for West region.

Turner describes the alleged unnecessary autopsies as "passing on the work to someone else" and getting paid the same money.

"With natural deaths, the coroner has the option of doing an investigation on their own, reviewing medical records and determining the cause of death based on their review or they can just shunt the case so that the forensic pathologist does the records review and the autopsy," said Turner. "Fill out a form that takes them five minutes ... and get an autopsy or go through 400 pages of medical records."

Autopsies for natural deaths at the Hamilton unit surged 60 per cent to 440 a year from 272 between April 1, 2015 and March 31, 2018, according to data provided by the Office of the Chief Coroner and the Ontario Forensic Pathology Service.

The only other manner of death to see that kind of jump was accidental which was expected because it's partly driven by the national opioid crisis which has hit Hamilton and Brant particularly hard.

"What is unexpected is the marked increase in natural death (autopsies)," said Turner. "Why isn't the chief coroner looking at this?"

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Pollanen, Huyer and Schiff declined to comment through Mahyr becasue of the ongoing DIOC review which is not a public process.

But Mahyr said in a statement, "The increase in the number of autopsies in natural deaths has occurred province-wide."

She provided guidelines used by coroners to determine when to order an autopsy but it's dated Feb. 9, 2011 which is well before the spike in Hamilton.

Autopsies for natural deaths appeared to decrease between April 1, 2017 and March 31, 2019 but it corresponds with a massive 122 per cent rise in undetermined deaths. The latter includes cases that haven't yet been finalized so the number of natural deaths could go up. It's also important to note not all autopsies into natural deaths are needless.

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"After a coroner's investigation, it may be determined that the death was natural but that investigation was necessary to confirm the classification," said Mahyr.

In Ontario, deaths that are reasonably forseeable don't require a coroner or a forensic pathologist. In fact, fewer than 20 per cent of deaths are investigated. The provincial dispatch office gets around 100,000 calls a year but coroners investigate only about 17,000 of them. Of those, an autopsy is required about 40 per cent of the time.

"Because coroners are knowledgeable and experienced with regard to natural diseases and injury patterns, they often don't require autopsies," said Mahyr.

The complaint alleges area coroners were ordering autopsies when they should have been able to determine the cause of death themselves.

"Some coroners do this and some don't," alleges Turner. "There are some very professional coroners and then there were those that weren't."

She said Hamilton's forensic pathologists often pushed back, questioning why their already-overburdened unit was required to investigate cases where they were just "confirming what is medically known." Turner said she also brought the issue to the attention of Pollanen.

"It got to the point where it was just too frustrating for me to argue," said Turner.

She resigned as director of the unit in March 2018 and returned to Missouri to do death investigations there.

Her complaint lodged in March, 2019, also alleges Pollanen improperly interfered in area death investigations and pressured forensic pathologists to change their findings. A similar second complaint was made in July by Hamilton pathologist Dr. Elena Bulakhtina.

Hamilton Regional Forensic Pathology Unit investigations by manner of death

Fiscal year Natural Accident Suicide Homocide Undetermined 2014/2015 282 237 224 16 52 2015/2016 272 302 243 31 43 2016/2017 333 365 221 22 50 2017/2018* 440 458 288 23 67 2018/2019* 389 494 266 24 149 Fiscal year is April 1 to March 31. *Undetermined includes cases that have not been finalized yet so numbers can change once manner of death is determined.

Source: Office of the Chief Coroner and the Ontario Forensic Pathology Service.