Affidavit of Dr. Michael Pollanen, Dated July 6, 2018

In the matter of the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System, pursuant to the Order in Council 1549/2017 and the Public Inquiries Act, 2009 Affidavit of Dr. Michael S. Pollanen TABLE OF CONTENTS My Training and Experience 2 Pathologists and Forensic Pathologists 3 Training and Accreditation for Forensic Pathologists in Ontario 4 The History and Creation of the OFPS 6 The Register 9 The Present Structure of the OFPS 12 Performing a Medicolegal Post Mortem Examination 16 (a) Determining the Scope of the Post Mortem 18 (b) Complete vs. Limited Post Mortems 18 (c) Collection and Submission of Samples 20 (d) Histology and Additional Laboratory Testing 22 (e) Determining Cause of Death 23 (f) Preparation of the Report of Post Mortem Examination 27 Post Mortem Examinations in LTC Home Death Investigations 29 Insulin and Glucose 29 Challenges of Diagnosing Hypoglycemia Through Post Mortem Examination 30 Independent Review of the Death Investigation System 34 No OFPS Involvement Contemporaneous to the Offences 35 My Involvement in Retrospective Death Investigations 36 (a) Initial Involvement and Report 36 (b) Post Mortems and My Post Mortem Reports 39 (c) My Review of the Clinical Cases 41 OFPS Initiatives Since Discovery of the Offences 42 1 In the matter of the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System, pursuant to the Order in Council 1549/2017 and the Public Inquiries Act, 2009 Affidavit of Dr. Michael S. Pollanen I, Dr. Michael S. Pollanen, of the City of Toronto, in the Province of Ontario, SOLEMNLY AFFIRM AND SAY: 1. I am the Chief Forensic Pathologist for Ontario (the "CFP"). I affirm this Affidavit as part of my evidence for the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (the "Inquiry") on the work of the Ontario Forensic Pathology Service ("OFPS") and my involvement in the retrospective death investigations that arose after Elizabeth Wettlaufer confessed to the offences. Except where otherwise stated, I have knowledge of the information contained in this Affidavit. My Training and Experience 2. I obtained a PhD in pathology from the University of Toronto in 1995, and completed medical school at the University of Toronto in 1999. I completed a four year residency in anatomical pathology in 2003, in addition to obtaining postgraduate training in forensic pathology in 2002. I was named one of the Founders of the subspecialty of forensic pathology in Canada, as an honorary designation from the Royal College of Physicians and Surgeons of Canada. 3. I began working full-time as a forensic pathologist for the Provincial Forensic Pathology Unit in Toronto in 2003. 2 4. I became the CFP of the OFPS in 2006. This is a full-time, salaried position. I was also appointed as a Deputy Chief Coroner in 2015. I do not have a specific portfolio or oversight role in this position, as it reflects an attempt to further collaboration between OCC and OFPS. I continue to hold both these positions. 5. Presently, I am a full Professor and Vice Chair (Innovation) in the Department of Laboratory Medicine and Pathobiology at the University of Toronto. I am responsible for the growth and development of the academic program in forensic pathology at the University of Toronto. In 2008, I founded the University of Toronto forensic pathology residency, and was its first Program Director. I stepped down as Program Director in early 2018. In 2006, I founded the University of Toronto forensic pathology fellowship, and was its first Program Director. I continue in that role today. In 2009, I was the founding Director of the University of Toronto Centre for Forensic Science and Medicine. I continue in this role today as well. 6. A copy of my curriculum vitae (LTCI00071737) is attached as Exhibit A to this Affidavit. Pathologists and Forensic Pathologists 7. Pathology is the application of medical and scientific principles to understand the causes and mechanisms of disease. 8. Pathologists are specialized medical doctors who have undertaken postgraduate medical training in pathology. 9. Forensic pathologists have undertaken additional postgraduate training in forensic pathology, which is the application of medicine and science to legal issues, usually in the context of sudden death. More specifically, forensic pathologists are a specialized group of pathologists, who are trained to apply pathologic principles and methodologies to support the medicolegal and judicial 3 systems in determining cause and manner of death, to support the investigation of circumstances surrounding deaths, and to assist in the interpretation of post-mortem findings of medicolegal significance. 10. The role of the death investigation system under the Coroners Act generally is to conduct investigations in those circumstances where someone has died and there is a public interest in investigating that death. The majority of individuals die naturally of known diseases, such that there is no public interest to investigate their deaths further, and a family physician can sign their Medical Certificate of Death / Form 16. However, there are a smaller number of people in any society where the manner of death is not clear (e.g. where it is sudden and unexpected, related to violence, drugs, injury and/or crime). In those circumstances, a coroner and/or pathologist should investigate in the public interest. 11. Currently in Ontario, both pathologists and forensic pathologists perform forensic pathology services in the course of death investigations under the Coroners Act, as described in more detail below. Training and Accreditation for Forensic Pathologists in Ontario 12. Prior to 2009, there was not a formal accreditation of "forensic pathology" in Ontario. In practice, physicians with pathology training (and not necessarily subspecialty forensic pathology training) conducted post mortem examinations ("post mortems" or "autopsies") in death investigations pursuant to the Coroners Act. Under this system, the pathologists were paid per case completed (i.e. fee-for-service). 13. Forensic pathology is now, since 2009, a formal medical subspecialty of anatomical pathology and general pathology. Copies of the Standards ofAccreditation for Residency Programs 4 in Forensic Pathology (LTCI00071739), the Forensic Pathology Training and Experiences (LTCI00071740) and Forensic Pathology Competencies (LTCI00071741) documents established by the Royal College of Physicians and Surgeons of Canada (the "RCPSC") are attached as Exhibit B, C and D, respectively. 14. As outlined in the aforementioned documents, in order to obtain a RCPSC certification in forensic pathology, a physician must: (a) obtain a RCPSC certification in anatomical pathology or general pathology, which is obtained after completion of a five year residency program; (b) successfully complete the RCPSC examination in forensic pathology; and (c) successfully complete the forensic pathology portfolio, which is a log of case work and the main educational points of the cases. 15. Forensic pathologists are required to participate in professional development activities and continuing medical education in forensic pathology to maintain their specialist competence. The OFPS collaborates with the Office of the Chief Coroner (the "OCC") and the University of Toronto, Center for Forensic Science and Medicine, to provide educational activities in forensic pathology. 16. One example is the Annual Education Course for Coroners and Pathologists, which is a two- and-a-half day course offered jointly by the OCC and OFPS each autumn. This meets the continuing education for Maintenance of Certification program by the RCPSC. Other continuing education events for forensic pathologists are held throughout the year, including, by way of example, an Elder Abuse Conference that was held in February 2017. A copy of the agenda from the Elder Abuse Conference (LTCI00071744) is attached as Exhibit E. 5 The History and Creation of the OFPS 17. Ontario's death investigation system is a "coroner system". It differs from that in many jurisdictions in the United States and certain provinces in Canada including Alberta, Nova Scotia, Manitoba and Newfoundland, which have "medical examine' systems. 18. In a medical examiner system, forensic pathologists oversee death investigations and certify deaths, in addition to performing post mortems. In contrast, in Ontario, death investigations are run by coroners, who are responsible for certifying deaths, and who decide whether to involve forensic pathologists in the death investigation to perform a post mortem. 19. While Ontario remains a coroner system, in 2009, significant legislative and structural changes were implemented in respect of forensic pathology in Ontario, in large part as a result of the Inquiry into Pediatric Forensic Pathology in Ontario (the "Goudge Inquiry"). Amendments to the Coroners Act established the OFPS and the modern role of the CFP. 20. Prior to these changes, what was originally called the Forensic Pathology Branch (the "FPB") was part of the OCC. Historically, there was a CFP who was autonomous, but this role was also subsumed under the OCC in the mid-1990s. Prior to my appointment as the CFP in 2006, there were approximately 5 years where there was no individual acting as the CFP in Ontario. 21. A diagram of the pre-2009 structure of the OCC and its forensic pathology practice is excerpted below. 6 Before 2009 III Chief Coroner Deputy Deputy Forensic Chief

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