R. c. Goulet, 2021 QCCQ 5233
[7] L’article 30 permet le dépôt en preuve, sous certaines conditions, de documents établis dans le cours normal des affaires. Il prévoit que :
30. (1) Les pièces commerciales peuvent être admises en preuve -Lorsqu’une preuve orale concernant une chose serait admissible dans une procédure judiciaire, une pièce établie dans le cours ordinaire des affaires et qui contient des renseignements sur cette chose est, en vertu du présent article, admissible en preuve dans la procédure judiciaire sur production de la pièce.
[8] La Juge Christine Auger dans DPCP. c. Saillen[1] énonçait à titre d’exemple plusieurs types de documents dont l’art. 30 avait permis la mise en preuve :
La jurisprudence en matière criminelle a qualifié certains documents comme « pièces établies dans le cours ordinaire des affaires », tels :
a) Document de la Régie de l’assurance automobile du Québec qui fait état de la révocation de permis de conduire (R. c. Charron, 1995 CanLII 5222 (QC CA) ;
b) Document produit par Service correctionnel Canada (R. c. Grégoire, 1998 CanLII 17679 (Man CA) ; R. c. Grégoire, 1998 CanLII 17679 (Man CA) ;
a) Registre (« crab book » - « fish book ») gardé par un employé (R. c. Wilcox, 2001 NSCA 45 ;
b) Photos de tatous de l’accusé prises dans le cours normal de son arrestation (R. c. Crate, 2012 ABCA 144 ;
c) Rapports d’alcootests passés à l’hôpital, R. c. Smith, 2011 ABCA 136 l;
d) Rapport d’inventaire dressé par des employés R. c. Penno, (1977) 1977 CanLII 1626 (BC CA), 35 C.C.C. (2d) 266 (BC CA);
e) Photos d’un véhicule prises par une compagnie d’assurance Laroche c. R., [2005] J.Q. no. 16315 (QC CS);
f) Fiche qui émane du Bureau fédéral d’enquête contenant des empreintes de l’accusé R. c. Grimba and Wilder, (1977) 1977 CanLII 1952 (ON SC), 38 C.C.C. (2d) 469 (Ont CtC).
[9] Dans R. v. Smith[2], la Cour d’appel de l’Alberta traitait de la portée de l’article 30 et particulièrement en ce qui concerne les dossiers médicaux. Dans ce cas, il s’agissait de déterminer si l’article 30 permettait la mise en preuve de résultats toxicologiques. La décision se basait en partie sur l’arrêt de la Cour suprême du Canada rendu dans Ares v. Venner[3]:
[15] In effect, s. 30 creates a statutory exception to the rule against the admission of hearsay evidence. This statutory exception is very similar to the common law business records exception. The fundamental principles and intent of both exceptions are the same.
[16] Hospital records have been found to bear this imprimatur of reliability and have previously been admitted into evidence under s. 30 of the CEA: see R. v. Malko (1994), 1994 CanLII 16741 (MB CA), 92 Man. R. (2d) 194 (C.A.); R. v. L.(C.) (1999), 1999 CanLII 1491 (ON CA), 138 C.C.C. (3d) 356, 124 O.A.C. 45 (Ont. C.A.). In Ares v. Venner, 1970 CanLII 5 (SCC), [1970] S.C.R. 608 , 14 D.L.R. (3d) 4 [cited to S.C.R.], the Supreme Court of Canada held that under the common law business records exception “[h]ospital records ... made contemporaneously by someone having a personal knowledge of the matters then being recorded and under a duty to make the entry or record, should be received in evidence as prima facie proof of the facts stated therein” (626).
[17] In R. v. Monkhouse (1987), 1987 ABCA 227 (CanLII), 83 A.R. 62 at para. 17, [1988] 1 W.W.R. 725, this Court cited with approval the following passage from Wigmore on Evidence, 3d ed., vol. 6, at section 1701 on the topic of hospital records:
There is a circumstantial guarantee of trustworthiness; for the records are made and relied upon in affairs of life and death. Moreover, amidst the day-to-day details of scores of hospital cases, the physicians and nurses can ordinarily recall from actual memory few or none of the specific data entered; they themselves rely upon the record of their own action; hence, to call them to the stand would ordinarily add little or nothing to the information furnished by the record alone. The occasional errors and omissions, occurring in the routine work of a large staff, are no more an obstacle to the general trustworthiness of such records than are the errors of witnesses on the stand. And the power of the court to summon for examination the members of the recording staff is a sufficient corrective, where it seems to be needed and a bona fide dispute exists.
This passage was also cited with approval by the Supreme Court of Canada in Ares at 617.
[18] Therefore, to suggest that records such as the toxicology report in question here - which are used to make life and death decisions in hospitals - must nonetheless be considered unreliable until proven reliable by other evidence at a trial, in other words essentially corroborated by that evidence, runs counter not only to the realities of modern medicine but also to the goal of s. 30 of the CEA.
[19] In this context, hospital records are not only reliable, given that the makers of the records depend on them on a day-to-day basis, but they are often necessary. The modern reality of large healthcare operations is that the volume of cases or transactions staff are involved in precludes the personal recollection of specific cases or data. In this sense, calling the record keeper or maker would add little evidentiary value to the business record. Moreover, the admission of documents made in the ordinary course of business has the added benefit of avoiding the “cost and inconvenience of calling the record keeper and the maker”: R. v. Martin (1997), 1997 CanLII 9717 (SK CA), 152 Sask R. 164 at para. 49, [1997] 6 W.W.R. 62 (C.A.).
(…)
[32] In conclusion, hospital records are capable of being admitted as evidence for the proof of their contents sufficient to meet the requirements of proof beyond a reasonable doubt under s. 30 of the CEA, without more, in the absence of other evidence sufficient to raise a doubt in the mind of the trier of fact. Here, the trial judge made an error of law in refusing to consider the toxicology report submitted into evidence under s. 30 of the CEA as evidence capable of proving its contents beyond a reasonable doubt.
[10] La Cour d’appel de l’Alberta concluait donc à l’admissibilité des dossiers médicaux, incluant les rapports toxicologiques qu’ils contenaient. Un raisonnement similaire était utilisé par la Cour d’appel du Québec dans R. c. Laflamme[4] qui concluait que : « le dossier médical formait un tout et qu’il était, en l’espèce, admissible en preuve conformément à l’article 30 de la Loi sur la preuve au Canada[5]. »
[11] La jurisprudence ne fait pas de distinction entre les simples observations factuelles et les diagnostics posés par les médecins, et considère le dossier médical comme étant admissible en preuve.
[12] Dans une décision récente, le juge Pierre Lortie, C.Q., applique les enseignements de la Cour suprême dans l’arrêt Ares et conclu que les rapports médicaux, dont ceux qui contiennent des évaluations psychosociales, font preuve de leur contenu[6].
[13] Finalement, tel que le souligne la juge S.L. Martin de la Cour du Banc de la Reine de l'Alberta, les principes de l’arrêt Ares ont une portée générale et peuvent donc s’appliquer aux dossiers tenus par un psychologue :
[43] Closer to home, the Alberta Court of Appeal has interpreted subsection 30(1) of the Canada Evidence Act to include hospital records in R v Smith, 2011 ABCA 136. In Smith, the accused had undergone blood-alcohol testing at a hospital. The Crown sought to tender those hospital records as evidence under subsection 30(1). The Court held at para 23 that subsection 30(1) applied to all business records, which “by definition, includes hospital records”. Moreover, the Court held at para 1 that “[u]nless the reliability of that evidence is successfully challenged through other evidence, as permitted under s. 30(6) or otherwise, the contents of the reports are thus proven, without the need to call viva voce evidence to establish their reliability”.
[44] The common law has long stated that declarations made in the course of duty are admissible for their truth where they are made (1) reasonably contemporaneously; (2) in the ordinary course of duty; (3) by persons having personal knowledge of the matters; (4) who are under a duty to the make the record or report; and (5) there is no motive to misrepresent the matters recorded. The leading case, Ares v Venner held at 626 that “[h]ospital records, including nurses’ notes, made contemporaneously by someone having personal knowledge of the matters then being recorded and under a duty to make the entry or record should be received in evidence as prima facie proof of the facts stated therein.” While the records in question in Ares were nurses’ notes, the case has general application and in Alma v Zachary, 2005 ABQB 468, the Court held the rule in Ares applied to records kept by a psychologist.
[45] The reasoning of the admissibility of hospital records was expanded upon by the Alberta Court of Appeal R v Monkhouse 1987 ABCA 227. The Court cited the following passage from Wigmore on Evidence, 3d ed., vol. 6, at section 1701 on the topic of hospital records, at para 17:
There is a circumstantial guarantee of trustworthiness; for the records are made and relied upon in affairs of life and death. Moreover, amidst the day-to-day details of scores of hospital cases, the physicians and nurses can ordinarily recall from actual memory few or none of the specific data entered; they themselves rely upon the record of their own action; hence, to call them to the stand would ordinarily add little or nothing to the information furnished by the record alone. The occasional errors and omissions, occurring in the routine work of a large staff, are no more an obstacle to the general trustworthiness of such records than are the errors of witnesses on the stand. And the power of the court to summon for examination the members of the recording staff is a sufficient corrective, where it seems to be needed and a bona fide dispute exists.
[46] Moreover, in Smith, supra, the Alberta Court of Appeal stated at para 18 that hospital records are used “to make life and death decisions” and to consider them unreliable until proven otherwise “runs counter not only to the realities of modern medicine but also to the goal of s. 30 of the CEA”.
[47] Dr. Tano, who is the section chief for outpatient mental health in the Calgary zone, provided evidence as to how the medical records containing nurse and physician notes are created at SAFPC. Dr. Tano testified that the procedure for assessment of a patient as discussed above is the normal procedure followed at SAFPC and that this procedure was followed with regard to Mr. Paxton. According to Dr. Trifiletti the nursing notes kept by SAFPC are a history of the patient, as well as a summary of the observations that the nursing staff are required to complete. The documents are used by the psychologist, social worker, pharmacy, and psychiatrists with a view toward contributing to an overall assessment of the clinical status of the patient. Dr. Trifiletti stated that keeping and using these documents is “pretty much standard procedure for all patients at SAFPC… [a]ll the charts have nursing notes, case conference summaries, physician notes and also some brief notes from other disciplines at the hospital”.
[48] I am satisfied that the records maintained by SAFPC are done in the “ordinary course of business”, as required by subsection 30(1) of the Canada Evidence Act. Similarly, these and other medical records, following the case law of Ares, Smith and Alma, are deemed to be reliable unless proven otherwise. As no evidence was led to question the reliability of the SAFPC records or other records, they are also admissible under the common law. In relying on the SAFPC and other notes, these three authors were relying upon admissible evidence and these Exhibits may now become evidence in the dangerous offender application.[7]
II. CONCLUSION
[14] La défense reconnaît son intention de mettre en preuve les diagnostics posés par le Dr Boily à des moments bien précis dans le cours normal de sa pratique, alors qu’il était habilité à le faire. Cette preuve se retrouve inscrite au dossier médical de la victime.
[15] La jurisprudence confirme que la mise en preuve des documents contenus au dossier médical est permise par l’article 30 comme un tout pour faire preuve de leur contenu[8].
[16] Il ne s’agit pas ici d’une preuve visant à interpréter la portée du diagnostic posé à ces dates ni à interpréter les rapports médicaux en fonction de la question en litige, mais plutôt de confirmer qu’à ces moments, le médecin a posé certains diagnostics. Toute interprétation de ces diagnostics, au-delà de ce qui est inscrit dans les dossiers médicaux, nécessiterait l’application de l’article 657.3 C.cr. Par contre, comme ce n’est pas le cas ni l’objectif recherché par la défense; la production des rapports est donc permise, d’autant que le témoin est présent et pourra être contre-interrogé sur le dossier médical. Ce qui inclut le contexte dans lequel les notes ont été prises, par exemple, le fait qu’il agissait à titre de médecin psychiatre qualifié et, les éléments qui l’ont mené à son diagnostic.
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