Ontario’s chief coroner has launched a review into what investigators call “concealed homicides” — deaths going back decades that were initially written off as natural, accidental, suicidal or undetermined that were later revealed to be criminally suspicious.

The move to examine how homicides fly under the radar comes in the wake of a Star story that documented failures in the Harrison family death investigations. In that case, a mother, father and adult son died years apart in their Mississauga home, but authorities did not treat their cases as homicides until after the third death.

The Office of the Chief Coroner and the Ontario Forensic Pathology Service in March launched an internal review into the handling of the Harrison investigations, but are now expanding it to cover missed homicides stretching back to Tammy Homolka, whose 1990 death at the hands of notorious killers Paul Bernardo and Karla Homolka was initially classified as natural.

“We believe there’s greater strength in looking at this more broadly and really trying to ensure that we’re doing the best that we can from a learning point of view,” chief coroner Dr. Dirk Huyer said in an interview.

The review will also include some of the victims of serial killer Elizabeth Wettlaufer, who was sentenced to life in prison after pleading guilty last year to killing eight residents under her care in two nursing homes, and seriously harming six others. Those crimes came to light when she confessed. Her actions are the subject of a public inquiry in St. Thomas, Ont.

The purpose of the “concealed homicides” review is to compare cases where the system failed to detect homicides to see if “themes” surface in an effort to understand what happened and improve the work of coroners and forensic pathologists, Huyer said.

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It will not examine “active cases” like the death of Wayne Millard, 71, father of Dellen Millard, who is on trial for his murder. Wayne’s 2012 death in his Etobicoke home was ruled a suicide, but investigators reopened the case after his son was charged in two other killings. And it will not probe the December 2017 murders of billionaires Barry and Honey Sherman, a Toronto police investigation that has been criticized for its apparent early focus on a theory of murder-suicide, rather than double homicide.

Huyer did not yet know how many cases of undetected homicides there are, or how many will be part of the review, but “it’s a small number over many years.”

Huyer called the internal review a “first step” and said his organization will likely ask an independent party to review the findings. He said he expects the review will be shared with the family and made public.

Three members of the Harrison family died in their home on Pitch Pine Cres., one after the other, between 2009 and 2013: Bill, then Bridget, then Caleb. Relatives believe two deaths could have been prevented, had the first been properly investigated.

In January, Caleb’s ex-wife, Melissa Merritt, and her common-law spouse, Christopher Fattore, were convicted of first-degree murder in his 2013 death. Fattore was also found guilty of first-degree murder in Bridget’s 2010 death, and not guilty of second-degree murder in Bill’s 2009 death.

Their convictions followed a criminal trial in which prosecutors argued the Harrisons were murdered at key moments in a bitter custody battle over Merritt and Caleb’s two children — a motive the victims’ family had pointed to all along. Merritt and Fattore have both filed appeals.

“We appreciate that the coroner’s office is expanding its probe to a broader system review of what they call ‘concealed’ homicide cases,” Wanda Jamieson, a close family friend, said on behalf of the Harrison family. “We believe that we and other families who have had similar experiences need answers about how and why these homicides were missed.”

But the family remains concerned that the only probes into what went wrong are being led by the organizations whose work is under scrutiny.

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Peel police are conducting their own internal review, but have not said whether any of the findings will be shared with the extended Harrison family or made public, and they have not responded to the family’s request for an independent review. Chief Jennifer Evans has not personally spoken to the Harrison family — unlike her leadership counterparts at the coroner’s office and the forensic pathology service — and has refused all interview requests from the Star, with her spokesperson citing “the integrity of the process” and the criminal appeal as reasons.

The Harrison family is calling for a full independent inquiry — probing actions of Peel police, coroners and pathologists.

Bill Harrison’s 2009 death was initially deemed natural until his wife, Bridget Harrison, died in their home one year later under suspicious circumstances, and concerns were raised about inadequacies in his autopsy. Bridget’s 2010 autopsy suggested competing theories: strangulation and a fall down the stairs. Yet four months after her death, Peel police closed the case, saying there was “no evidence to suggest (she) was the victim of foul play or any other criminal act.” A coroner classified the deaths of husband and wife as “undetermined.”

Of the 16,000 deaths a year investigated by coroners in Ontario, on average, roughly 420 receive the “undetermined” label, according to figures from the coroner’s office.

An “undetermined” manner of death means the coroner, taking into consideration a pathologist’s autopsy findings and expert opinion on cause of death, could not conclude whether it was natural, an accident, a suicide or homicide.

Cases like the Harrisons, where the findings suggest homicide or an accident as competing manners of death, are very rare, Huyer said. Many “undetermineds” are drug overdoses where it’s unclear if it’s an accident or suicide. Others are the unexplained deaths of infants, which were in the past more often labelled sudden infant death syndrome — where, despite thorough examination at autopsy, a cause of death cannot be determined.

Families are often unhappy with the “undetermined” conclusion, Huyer said. “But for me, that is the truth. And if we don’t know, we don’t know, and we should say that we don’t know.”

The 2008 Goudge Inquiry, which probed mistakes made in pediatric forensic pathology cases handled by Dr. Charles Smith that led to miscarriages of justice, stressed that evidence at autopsy must be followed wherever it leads, “even if that is to an undetermined outcome.”

The Harrison family wonders if, in the aftermath of Goudge, some forensic pathologists are being too careful to avoid favouring one theory over another in cases where there are competing findings on the cause of death. And “in what ways is classifying a manner of death as ‘undetermined’ influencing police to stop working on an investigation?” Jamieson wondered.

Earlier this year, members of the extended Harrison family were troubled to see a case that appeared to resemble their personal tragedy playing out in the news again in the deaths of Barry and Honey Sherman, a case which echoed some of the concerns they had about the investigations into the deaths of Bill and Bridget.

The Shermans were found dead Dec. 15, hanging by belts from a railing beside the indoor pool in their North York mansion. In the immediate aftermath, a Toronto police officer said no suspects were being sought, and police sources told several news outlets that the investigation was focused on murder-suicide. Appalled and not willing to accept that theory, the family hired private police investigators and a forensic pathologist. Six weeks after the bodies were discovered, Toronto police announced they believed both Shermans were the victims of a targeted killing. No one has been charged.

“We care deeply about justice for our family and for all other families that have, or are suffering through similar experiences,” Jamieson said on behalf of the Harrisons. “The Sherman family was fortunate to have the financial resources to hire a parallel set of independent investigators to get answers. This should not be necessary in Ontario’s death investigation system. Everyone should have equal access to justice.”

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