Henry Keogh - Forensic Reports - notes on background documents

[This page has been prepared by Dr Robert N Moles]

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Correspondence and Pathology Investigations – Anna-Jane Cheney

21 March 1994 – Autopsy report on AC

Version 1 - with handwritten amendments

Version 2 - 29 April 1994 - prepared as "witness statement"

Post mortem no 14889 – Coroner’s No K888 – deceased booked in at 22.12 on 18 March 1994. Identified right lung 840 left lung 700 (60). Diagnosis drowning – re examined 21-22 and polylight photographs were taken. There are 2 copies of the body chart. There is also a fax cover to Paul Rofe DPP showing 4 pages were sent.

29 March 1994 Alcohol analysis

AC Dinan Forensic scientist – forensic science reference no 940710 - .08% alcohol.

18 May 1994 – Police Running Sheet regarding drug testing

Police officer Yelland contacted Dr Manock who is checking that full screening for poisons and drugs are made regarding the blood of Ms Cheney. Manock stated that chloroform will show up in blood. He is inquiring of the toxicologist with regard to the possible testing. He will advise of results.

23 June 1994 – Toxicology Report by Felgate

Sen Forensic Scientist. No common drugs were found in blood or liver. Chloroform was not detected in the blood.

25 June 1994 – Police officer Yelland follow up with Dr Manock

Test for chloroform on body negative. Toxicology results for other drugs also negative. Suggest file.

28 June 1994 - Dr Manock report after visit to scene

11 August 1994 – Dr Byron Collins to Michael David QC

Dr Manock is not entitled to state that the cause of death is drowning – other causes have to be excluded – the pathologist in this case has not fulfilled this basic requirement.
The general practitioner says there are no diseases – however, it is important to determine if there is any possibility of asthma, epilepsy or myocarditis; this requires microscopic examination of the heart muscle and I would need to review the heart slides.
The possible role of drug ingestion has not been properly ascertained. Negative results of EMIT analysis totally inadequate. In suspicious deaths, analysis of blood, bile, urine, liver, stomach and contents must be performed. The gratuitous comment by Dr Manock regarding blood alcohol is meaningless.
Bruising to the lower legs is a common occurrence of everyday living. The location is a little strange, as the most appropriate place for a grip would be the ankle, not the shin. There is also the possibility of post mortem bruising. I am at complete loss to explain why Dr Manock should reflect the scalp 2 days later. It should be done at the original examination to avoid the possibility of artifactual bruising. I have seen false bruises produced in this way. Dr Manock was not entitled to say that fresh bruises means “close to time of death”. This opinion is completely unsupportable. It is impossible to say whether head bruises would change the level of consciousness.
My strong advice is not to permit Dr Manock to embark on one of his well known flights of fancy in divining a time of death, using spurious and unreliable post mortem findings on a body.
I can find no lung weights in the autopsy report. Oedema can occur in heart failure. “Water squeezed from lungs” is descriptive but inaccurate.
One should look for diatoms in organs on the systemic side of the circulation such as in bone marrow or in the kidneys. I can definitely say that a search for these organisms in lung tissue is a complete waste of time.

23 August 1994 –Dr Byron Collins to Stephen Ey solicitor

The Gospel according to St Manock was most enlightening to hear, but would require a “true believer” to accept.

22 December 1994 –Dr Ross James Report on Anna Cheney

I have reviewed the post mortem report by Dr Manock. There were 10 histology slides, 3 bags of photos, 75 black and white, mostly extra copies. A toxicology report by Felgate. Fresh water drowning appears to be cause of death. It is unusual for a healthy adult to drown in a bath. Apparently there was no natural disease such as epilepsy or cardiovascular disease. BAC [blood alcohol content] 0.08% was insufficient to precipitate drowning. There were 7 bruises on the right shin, 3 bruises above the left ankle and 2 to the back of the head, 1 on top of the head and which appear to be recent. Colour photos may or may not have been helpful. The Polylight does not appear to have been helpful. Bruises to the head are not consistent with a simple fall. Bruises to the legs could be a grip with the possibility of assisted drowning. [There is no mention in this report of the bruise said to be the thumb mark]

6 February 1995 – Byron Collins report to Stephen Ey solicitor

Discussed with Michael David.
Scene visit – obvious ease whereby individual could slip on tiled floor – taps and water spout on side wall could cause bruise – anatomically impossible for right leg to strike ledge behind bath – bruises on shin could not be produced in this way or by striking side of bath. Gripping left leg as postulated by pathologist most unusual and not likely to be adopted for hurried drowning.
The no of slides in totally inadequate to investigate a suspicious death. Autopsy is incomplete because no histo by Manock of brain, therefore cannot exclude cerebral conditions such as encephalitis. Size of lung tissue grossly insufficient to assess features such as death by drowning. His claim about vomiting occurring after drowning cannot be substantiated on the basis of lung tissue which contained only 2 small bronchioles.
Bruises could have occurred in 24 hours before death to early postmortem period.
EMIT analysis insufficient to test for drugs in system. Quite possible to have ingested drug and for it to affect consciousness before it appears in the urine.
Statement by Manock re BAC 0.08% is meaningless and inaccurate. Could impair motor function and affect balance, especially with drugs or slippery floor.
Strongly disagree with Manock re trauma affecting consciousness would leave a bruise. Common sense dictates that this is not the case.
Interpretation of bruises on left leg being caused by application of fingers is misleading and unsound. Described as faint in autopsy report, but enhanced in photos.
No cause of bruise in occipital region can be proposed. Postmortem bruising can result from rough handling of body from scene to mortuary table.
Manock’s less than comprehensive autopsy means that natural causes have not been excluded as a reasonable explanation. Even if drowned insufficient evidence to say it was homicidal.

16 December 1996 – Professor Stephen Cordner to Sykes Bidstrup

This report makes extensive use of the Coroner’s comments from the Infant Deaths Report, including the following:
It is extraordinary that Dr Manock did not conduct further inquiries in order to either verify or exclude it ..
Dr Manock made no inquiries to ascertain what Storm Deane’s condition was on admission to hospital nor did he suggest that Detective Fidler should do so
Dr Manock explained that in his view a pathologist should be careful not to influence the investigation and suggest suspicion which is unwarranted.
I am quite unable to accept Dr Manock’s explanation ...
It is spurious [for Dr Manock] to suggest that ...
Dr Manock’s investigation provided innocent explanations for the most serious injuries ... which I am now satisfied were incorrect.
Dr Manock’s explanation that he was waiting further information was spurious.

27 May 1998 –Dr Hilton Kobus Forensic Science Centre Adelaide

We were instructed in this matter by the Coroner and the material prepared for trial was provided to the DPP. We would only release material on their instructions as they are the primary client. Would not make Murray Billet [the technician] available to discuss matters. No serum sample is available. Serum was not prepared at the post mortem. Toxicological analysis was performed on whole blood.

7 September 1998 – Dr Cordner’s notes on slides

1 – bruising no leucocytes 2 – ditto 3 – adipose tissue – minor haem no leuccos 4 – head bruising no leucos

Heart kidney NAD Lungs small amount foamy material some sectioned alveolar walls no pre-exist path exc occ macrophage – non specific findings Smear NAD

31 March 1999 – Dr Byron Collins to Paul Rofe DPP

I would like to have negatives of the photographs regarding the death of Anna Cheney.

13 April 1999 – Letter from Dr Kobus

We have no problem with Dr Thomas viewing pathology specimens re Cheney. Defence were given access to these at time of the trial. A second pathologist examined the specimens on behalf of the prosecution. Need formal process to access samples. Pathology work at FSC done under instruction from the State Coroner. Under his instruction we would be happy to accommodate Dr Thomas. Examination would need to be done at our laboratories.

15 April 1999 Paul Rofe DPP to Dr Byron Collins

Acknowledge letter of 31.3 re request for photo negatives. This is the 3rd such request in recent weeks. I cannot respond to piecemeal uncoordinated approaches such as these. The negatives you seek are not in my possession thus an approach to govt is required.

16 April 1999 Professor Cordner to Paul Rofe DPP

My recollection is that I never saw photos of body in situ at the scene, and no colour photos of that or of autopsy. If the photos exist, then I was at some disadvantage in not seeing them. Primary objective of autopsy is to enable another pathologist to make their own conclusions. Dr Manock’s report and black and white photos do not score highly in this regard. Would be helpful if all photos could be made available to me.

The conclusion that this woman drowned, is based partly on the fact that no natural disease process was found to account for faint or other condition. There are a number of conditions which can cause this to happen which are not observable at autopsy – epilepsy, diabetes mellitus, arrhythmias of the heart and asthma. I have been told records are available to detail her medical attendances. Given the importance of her medical background, I think any such records should be made available for scrutiny.

21 April 1999 From Paul Rofe DPP to Professor Cordner

I have received a number of requests similar to yours over recent months. I have no difficulty in cooperating with formal request to govt by way of petition or to reopen investigation, I cannot respond to sporadic individual requests for material that is no longer in my possession. Mr Keogh’s advisers should coordinate such an approach.

19 May 1999 Professor Corder to Wayne Chivell Coroner

I have provided advice to defence. To extent that the conviction was based on Dr Manock’s view that this was homicide by drowning, I have reservations. I seek permission to cut more sections from the histology blocks. Does any original tissue remain? In particular is there any formalin fixed skin, cardiac or pulmonary tissue available?

5 July 1999 – From Professor Cordner to David Eitzen Forensic Science Centre

2  copies – 1 with notes by Dr Thomas

Enclosed are unstained sections of 14859/94 Cheney. 2 sections of heart, 1 of kidney, 1 of lung. Skin sections labelled 1 – R leg,  2 – L leg (lateral),  3 L Leg (medial), 
4 – Head  Note that block 3 we re-embedded through 180 degrees for Byron Collins on 21.10.98 We do have some more formalin fixed tissue of all specimens except block 3 L leg medial.

27 August 1999 – Paul Rofe DPP to Frances Bedford MP

I have reviewed the Medicare claims history of Anna Cheney from 1989 to 1994. There is no relevant medical history to emerge from those records. I am happy for an independent medical expert to peruse these records at my office. The medical history of AC was a live issue at the trial. Dr Forbes gave evidence – copy attached. Dr Forbes had perused Anna Cheney’s health records and there is no notation of anything but minor consultations. I apologise if I have gone back on what was agreed at our meeting, but I am not prepared to have medical professionals questioned for no apparent reason.

With regard to the photos, apparently some negatives cannot be found, but there is no reason to think there is anything untoward about that fact.

7 October 1999 – Henry Keogh to Professor Roberts CEO IMVS

A leading histopathologist has recommended we obtain the expert opinion of David Gilles regarding Anna Cheney’s medical records to be made available by the DPP. Dr Gilles has consented to this request.

12 October 1999 Professor Roberts IMVS to Henry Keogh

I am advised that contrary to your statement in the letter of 7 October Dr Gilles has not consented to provide professional assistance.

19 November 1999 – Professor Cordner to Dr Tony Thomas

I enclose the slides – it is best for you to handle them as you have some specific ideas and techniques. After you have looked at them, perhaps you, me and Byron Collins can get together to discuss them.

10 January 2000 – Notes by Dr Thomas of meeting at Forensic Science Centre

6 pages of notes – note re medial left leg bruise says “no bruising” – notation re right leg – “most likely artifactual” – notation re left leg lateral – “most in keeping with artefact” – notation re bruising to head “again most likely artefactual in nature”.

17 January 2000 – Notes by Dr Thomas following visit to Forensic Science Centre

It seems to be that there is no bruising present within the sections of legs – where blood cells are present, they are more likely to be artefactual. In all cases there is no haemosiderin deposition ie no insoluble iron staining in the cells of the skin, which would happen with real bruising. In all cases there are no eosinophils – the white cells which are involved in healing. It takes time for this reaction to develop and their absence was made much of at trial.

At the time Dr Manock was there, Leeds University would not have been an accredited training university in forensic pathology.

21 January 2000 –Notes from Byron Collins (2copies) + cv

21 August 2000 – David Eitzen Forensic Science Centre to Professor Cordner

Blood liver and stomach contents were taken at pm 22 March 1994 (Tuesday) specimens were returned to the freezer 30 June 1994, retained for 12 months and then disposed of. Vaginal swab, washings and blood spot have been stored frozen.

Formalin fixed samples of lung kidney and heart have been retained. Residual formalin fixed skin samples have been retained for left leg lateral, right leg and head. There is no residual tissue for left leg medial. Stained H & E slides of above are stored in file along with 2 stained smears.

Parafin blocks from each of the above samples are available ie 2 x heart kidney lungs and 4 skins. No 3 block was re-embedded through 180% at request of Byron Collins. Material to be made available to you, but not to leave the building, so we could make extra sections for Dr Thomas, or to make wet tissue available so he can do his own sections.

4 April 2001 –Southpath to Flinders Medical Centre Histopathology

list of slides in possession of Dr Thomas as at 2 April 2001 – all labeled “14859”

1 – section of skin 2 – section of skin 3 – section of subcutaneous tissue – 4 – section of skin 5 – section of heart 6 – section of heart 7 – section of lung 8 – section of kidney 9 – histamine sections

Additional duplicate slides from FSC – all further wet tissue blocked and processed – no residual tissue now available.

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