Their baby died. But their nightmare was only beginning. How a flawed child death investigation system tore a grieving family apart

Part one in a two-part investigation. Read Part 2: What happened to baby Alexander? Police found no criminality but the coroner still ruled it a homicide

Under the harsh lights of a Hamilton, Ont., emergency room, Brooke and Ryan sat together on a gurney, cradling their lifeless infant. They couldn't make sense of the sudden death of their seven-week-old, brown-eyed boy.

Doctors had been closely monitoring Alexander and his twin brother, who were born prematurely, throughout their short lives.

Alexander had always been the bigger, stronger one. After 11 days in the neonatal intensive care unit, he was discharged first. He was eating well and gaining weight. Brooke's family doctor, who saw the twins for weekly checkups, hadn't flagged any concerns.

On that December evening in 2017, Ryan made a panicked 9-1-1 call. He was home alone with the kids, giving Alexander a bottle, when the baby's warm, wriggling body suddenly went limp.

Alexander was wearing his Santa onesie. The day before, the family posed for Christmas photos.

A few hours after that call, Alexander laid still, wrapped in a white and blue hospital blanket. On the other side of the curtain, Brooke and Ryan could hear the medical staff tending to other patients. There was nothing more they could do for Alexander.

Brooke sobbed as she held the baby. Ryan felt he might pass out. The parents made a promise to their son. All we kept saying to him," Brooke recalls, is that we're sorry, and we're going to find out what happened."

The system that was supposed to find such answers did not do so.

Instead, it became mired in infighting while the grieving parents were shut out of a process that was supposed to include them.

The medical experts within that system clashed about the cause of fractures identified in both twins. They complained about each other's conduct. The dispute ended up in court, where it is still playing out four years later.

Brooke and Ryan had no idea that any of this was happening. Two weeks after their baby died, they sat helplessly in a boardroom in another Hamilton hospital, while Children's Aid workers took his surviving twin and his one-year-old sister. The parents didn't have a chance to say goodbye to their children before they were placed in separate foster homes. They felt they were being punished like criminals.

In Ontario, families in desperate situations such as this are supposed to be informed about their child's death investigation. Brooke and Ryan were kept in the dark.

No one told them the forensic pathologist who performed the autopsy, Dr. Jane Turner, believed Alexander's fractures were likely caused by a bone disease, and that this could also explain the fractures found in his twin brother. The investigating coroner and a bone pathologist agreed. The police had not seen evidence of abuse.

They didn't know that a Hamilton pediatrician advising Children's Aid believed it was abuse and intervened, or that this opinion had prompted Ontario's top pathologist, Dr. Michael Pollanen, to become involved, and change the course of the investigation.

To Staff-Sgt. Dave Oleniuk, a veteran detective who probed the case from the beginning and found no criminality, it seemed that among some experts, there was just some determination to find abuse." Turner, the forensic pathologist, was disturbed, too. She believed these experts hijacked the investigation into Alexander's death, that they had tunnel vision. She alleges as part of an ongoing court case that Pollanen withheld autopsy findings while he and the other experts refused to believe the baby could have died from natural causes.

Christmas passed, and then the twins' first birthday. Brooke and Ryan were still fighting to get their kids back.

By the end, Ontario's chief coroner would quietly change the final determination in this case, to the shock of police and some medical experts involved.

This story is found in thousands of pages of court documents, including sealed medical records, police reports and emails between the death investigators, made public last month after a challenge by the Toronto Star and the Hamilton Spectator. (The family's names have been changed to protect their identities as required under the law governing child protection cases.)

Pollanen and Ontario's chief coroner, Dr. Dirk Huyer, declined to be interviewed for this story. Their spokesperson, Stephanie Rea, said she could not comment on the case, but that death investigations are conducted in a thorough, detailed and transparent manner."

Internally, Pollanen has characterized Turner's allegations as unfair" and contrary" to the evidence. He said he has dedicated his career to preventing miscarriages of justice and that he has been publicly humiliated" by Turner's personal attacks."

The court records show the investigation into Alexander's death was complex. After the baby died, the discovery of multiple fractures on both twins - without a conclusive medical explanation - presented a challenge for police, as well as Children's Aid, which was responsible for keeping Alexander's siblings safe.

It is a challenge that Ontario's death investigation system should have been poised to tackle. Nearly 15 years ago, Pollanen played a key role in a $10-million public inquiry into the scandal involving disgraced pathologist Charles Smith. Smith's flawed autopsy analyses tainted more than a dozen criminal cases and led to parents wrongfully convicted of killing their children. In some of those cases, the surviving siblings were apprehended. Their parents never got them back.

Justice Stephen Goudge, who led the inquiry, wrote in his 2008 report that to fully restore confidence in pediatric forensic pathology, we need to look at how it can better serve child protection proceedings and the needs of the families affected by suspicious pediatric deaths." Goudge called for continuous information-sharing between medical experts, police, child protection agencies and families. It is vital that the family of the deceased child be kept informed as much as possible."

That did not happen in this case.

Brooke and Ryan walked through the doors of the downtown Hamilton police station on King William St., to answer questions. They did so voluntarily, without consulting a lawyer. They felt they had nothing to hide.

Ryan remembers chatting casually with some of the officers who were milling about, trying to distract himself from the grief creeping in.

The parents were interviewed separately. Brooke bristled at some of the questions they asked her about whether Ryan had substance abuse issues or a bad temper. She had known him since high school and didn't believe he was capable of hurting their baby.

When Brooke and Ryan got together in 2012, he was a devoted dad to a three-year-old boy. Their first-born, Nicole, quickly became daddy's girl." Brooke and Ryan found out they were expecting twins. They were stunned, and worried about having enough money and space. Ryan worked as a cabinetmaker and they lived in a one-bedroom apartment.

Ryan came with her to all her prenatal appointments. They were together at Brooke's 36-week checkup when the doctor became concerned that the twins had stopped growing. She decided to induce her that day. Their parents helped out with Nicole so Ryan and Brooke could be with the babies while they were in the neonatal intensive care unit.

Once Alexander and his twin brother Holden came home, the parents tackled the chaos together - a constant cycle of feeding, changing, cleaning, putting babies to sleep. A family of six.

Det. Oleniuk inspected the family's one-bedroom apartment.

Nothing from the scene was suspicious and the house was fairly well-kept with obvious signs of children living in and being cared for in the apartment," the police report states.

Another homicide detective wrote that both parents were devastated and emotionally distraught" - reactions that were expected and appeared genuine."

Oleniuk later told the Star, There were no real alarm bells with the scene or the family, or anything."

The investigating coroner, Dr. Richard Porter, also toured the second-floor unit. He noticed the handles of the pots on the stove were turned in. This told him the parents were thinking of the kids' safety. Porter noted in his preliminary coroner's report that this was seemingly a quite appropriate home for children."

In the emergency room, he started his examination of Alexander's body and saw no trauma other (than) from resuscitation attempts," his report states. The baby had a bit of a cold right before he died, Porter noted, but he had been seen routinely by doctors since birth and was otherwise healthy.

In a death investigation, the coroner is like a contractor, managing the overall project and subcontracting out various specialty tasks before making a determination of how someone died.

As the forensic pathologist assigned to the case, Turner's role was more discrete. She narrowly focused on the medical evidence from the body, to try to answer the cause of Alexander's death.

Turner found abnormalities that can indicate abuse, including bleeding in the retina and around the surface of the brain, and abnormal bone changes and damage. But the baby had no bruises or other external evidence of injury.

Turner reported what she'd found to the police, and told them these preliminary observations were not typical and her investigation was continuing. Then there was another red flag: the radiologist who reviewed the x-rays confirmed the presence of multiple, healing fractures.

Turner ordered more tests and collected samples of the bone lesions. Though she couldn't rule out abuse, the basic facts of the case didn't fit. There were no signs of acute trauma. These were old fractures with some unusual characteristics. Alexander had been in hospital for the first 11 days of his 55-day life and had been examined weekly by his family doctor. Could there have been abuse" significant enough to cause healing fractures, without any signs of injury at these weekly visits?

She soon began to suspect it could be a metabolic bone disease, like rickets, that makes bones weak and brittle, and can be common in premature babies. Her investigation carried on.

Ten days after Alexander's death, while Turner probed, Porter told Children's Aid about the fractures - information he told the Star he was mandated to pass along.

Det. Ross Johnson, who was investigating the case with Oleniuk, urged Children's Aid to be patient," and wait for Turner's opinion.

(We) don't have enough information at this point to warrant apprehension of any children from that household because we don't have all the answers," he wrote in his police report of the advice he gave the agency.

A spokesperson for the Hamilton Children's Aid Society, Tracy MacIsaac, said the agency can't comment on individual cases but that, speaking generally, when a child has died, the agency must evaluate the safety and well-being of any other children who may live in the home."

The day after Porter's call, Brooke and Ryan brought their kids to McMaster Children's Hospital to be assessed for signs of abuse. Children's Aid set up the appointment with Dr. Burke Baird, who is the head of the hospital's child maltreatment division and routinely provides evidence in child abuse cases.

In an unrelated child protection case in Brantford earlier this year, a judge refused to qualify him as an expert witness in the field of child maltreatment. The judge questioned the reliability of child maltreatment" theory, and was critical of Baird's reliance on second-hand information.

Before Alexander's family even set foot inside the hospital, Turner alleges, sensitive information from her ongoing investigation into the boy's death had trickled out to Baird. Baird was not Alexander's treating physician and was not involved in the death investigation, but inserted himself, Turner alleges in court records. She claims he somehow became aware of the fractures and of the radiologist's opinion that they were due to traumatic injury. Turner alleges Baird had back-channel discussions" with the regional supervising coroner, Dr. Karen Schiff, and the radiologist, Dr. Nina Stein, before she even had the chance to inform the coroner's office of the radiology findings herself. (Schiff, Stein and Baird all declined to comment for this story.)

At that point, Brooke and Ryan knew only that they were under investigation for abuse in Alexander's death. The handwritten notes from hospital staff indicate that Children's Aid was investigating the injuries" found in Alexander and instructed: DO NOT disclose this information."

There were no concerns of abuse raised regarding Nicole or Ryan's older son.

But Holden's x-rays showed multiple, healing fractures, just like his twin brother. Baird kept him through the weekend for more testing. Children's Aid told the parents they weren't allowed to be alone with their children, so the grandparents took shifts at the hospital. Brooke says they felt as though they had already been branded abusers by the doctors and nurses, who treated us like crap." They felt they were discriminated against because they were low-income and lived in a rough part of town. Ryan had taken a parenting course after a previous interaction with Children's Aid. His eldest son bit him and he bit him back to show how it hurt. It was a minor incident and the case was closed, according to court records.

Two weeks after Alexander died, they were told to leave Holden with a hospital worker and ushered into a boardroom. Security guards waited in the hall outside. Baird was waiting to present his findings, alongside Children's Aid.

Right when we walked in, (Brooke) looked at me, and said, They're taking my kids,'" Ryan said.

Baird claimed Holden had more than two dozen fractures. The parents don't remember any mention of the possibility of metabolic bone disease or pending tests. He said he had seen bruises on Holden, which his parents denied. The only remaining logical explanation for all of his injuries," as Baird would later conclude in his report on the assessment, is that he was subjected to at least one, and possibly multiple episodes of significant inflicted trauma."

Brooke was hot with rage. She couldn't sit still.

That same day, Turner reached out to Schiff in the coroner's office. Turner said she had been advised of Holden's fractures, and that those findings supported the opinion she was developing. She suggested testing both twins.

Holden's hospital discharge states: Work-up for metabolic bone disease pending."

After Alexander's death, Children's Aid had signed off on the children staying with both Brooke's and Ryan's parents. (Ryan's older son moved in full-time with the boy's mom.) Now they were told that the kids would have to go to foster homes. The grandparents had become suspects, too.

Brooke's mom, Nancy, who was in the meeting, was inconsolable. I said, How dare you do that,'" she recalls. We need to have this child because we just lost his brother.'"

Alexander's older sister, Nicole, was with her grandfather. Before the meeting at the hospital, he noticed police and Children's Aid parked outside his house. He fired a string of expletives at the officer and the Children's Aid worker, as she pried the little girl from his body.

Next in the series: As the investigation into baby Alexander's death continues and the fight among experts escalates, the parents get an urgent call. Then a decision made by a senior official stuns the detective on the case.

With files from Joanna Frketich, Hamilton Spectator

Rachel Mendleson is a Toronto-based investigative reporter for the Star. Follow her on Twitter: @rachelmendleson