Channel 7 Today Tonight (Adelaide)

Medical Board and Dr Manock 22 June 2005

This version of the transcript has been edited by Dr Robert N Moles

In order of appearance

Rosanna Mangiarelli, Presenter
Kevin Borick QC, Keogh’s lawyer
Dr Bob Moles, author and academic lawyer
Graham Archer, Producer and interviewer
Professor Ross Kalucy, Member of the Medical Board, Former President [File tape]

Program

Rosanna Mangiarelli

But first, the South Australian Medical Board's released its long-awaited report on the performance of the State's former Chief Forensic Pathologist, Dr Colin Manock, in the controversial Henry Keogh case. While Keogh's lawyers weren't surprised the Board dismissed their complaint, they say many of the issues they raised simply weren't addressed. The Board itself is under increasing pressure over its own failures to take appropriate action in a series of cases, the latest drawing severe criticism from the State Coroner. And, as Graham Archer reports, Keogh's lawyers say they will now appeal the matter in the Supreme Court.

Kevin Borick QC

The reasons for the decision are exactly what I expected. It was disappointing and perfunctory and they clearly haven't dealt with the issues.

Bob Moles

I was shocked by how superficial the judgment was and how, after all the effort they'd make us go to - to particularise the complaints - that they've utterly failed to deal with them.

Graham Archer

Yet again, the Medical Board has failed to find any sign of its own pulse.

Kevin Borick QC

Dr Manock is a pathologist, and a pathologist has to be a registered doctor. The Medical Board's responsibility is to ensure that registered medical doctors act in accordance with the highest standards of the profession, so their job was to make a judgment about whether Dr Manock had done that, particularly in relation to the Keogh case.

Graham Archer

Today, after much delay, the Board handed down its findings on the professional competence of Dr Colin Manock, the State's Senior Forensic Pathologist from 1968 to '95, based upon his work in the Henry Keogh case.

Bob Moles

They have the powers to report and investigate it, and they can investigate things and look at things and ask questions. They've never appointed an investigator. No investigation has been done by the Medical Board at all.

Graham Archer

Predictably enough, the doctor was given a clean bill of health. It was made easier for the Board that Dr Manock's work was limited to people already dead.

Bob Moles

One of the more famous pathologists in the country, the head of the Victorian Institute of Forensic Medicine, said that he couldn't think of another pathologist in the whole of Australia that would have conducted himself as Dr Manock did.

Graham Archer

As author and lawyer Bob Moles, and this program, have revealed, contrary to today's report there are scores of examples of Dr Manock's flawed forensics. Back in the 1980s, his finding in the Emily Perry case almost sent an innocent woman to jail for fifteen years, and the High Court was scathing.

Bob Moles

One of the judges in the High Court said that the forensic work that had been done in this case by Dr Manock represented an appalling departure from acceptable standards and, as I said before, that's no minor criticism.

Graham Archer

Was there any official follow-up to that criticism?

Bob Moles

No there wasn't.

Graham Archer

So in a sense, sitting in judgment of Dr Manock, the Board was also sitting in judgment of themselves?

Bob Moles

Absolutely, and we made that clear to them at the outset.

Graham Archer

Behind each bizarre finding is a human tragedy, the most poignant being the deaths of three babies in the early '90s. All suffered from severe injuries but, according to Dr Manock, all died from natural causes. A subsequent coronial investigation found his work to be incompetent and his errors scuttled any chance of criminal charges being laid. There's never been any official reaction to this scandal, but it provides a powerful clue to how unsatisfactory the Board's report today really is. Was the Medical Board prepared to hear evidence about those baby death cases?

Bob Moles

No it wasn't, and they said at the very outset that it would be quite inappropriate for Henry Keogh to raise what we would call “similar-fact” evidence - that is - evidence of previous shortcomings by Dr Manock in the baby deaths cases and in the many other cases that we've referred to.

Graham Archer

That's right. After refusing to hear evidence on the baby death blunders, they selectively quote from the case to support their own findings? Trouble is, they chose to quote Dr Godfrey Oettel whose opinion on the case was discarded by the Coroner.

Bob Moles

The Coroner said that in so far as it bore any resemblance to the evidence that he'd heard in those baby deaths, it was simply inapplicable - it was wrong.

Graham Archer

So effectively, the Medical Board have used a discredited report which supports incompetent work to justify their decision?

Bob Moles

Yes. The expert report that had been rejected by the Coroner, in a matter that we were not allowed to refer to, was brought in by the Board as the only way of justifying Dr Manock acting in accordance with proper standards.

Graham Archer

The Board also made the startling judgment that his standard of work should be measured by that of those working with him. Given there was only one other full-time pathologist, it's hardly representative of international standards.

Bob Moles

The Medical Board also said that there weren't any proper national or international standards at that time. They may have changed a little but, but we're not talking about the Dark Ages here.

Graham Archer

Their approach to the disputed thumb bruise claimed by Dr Manock to be proof of a hand grip and claimed by the DPP in the case as the one positive indication of murder is equally bizarre. If the bruise couldn't be seen using a microscope, as Dr Manock admitted (but told no-one) that didn't mean that it didn't exist.

Bob Moles

It simply doesn't make any sense at all. The procedure was that they'd taken, or said they'd taken, some tissue from what looked like a bruise and examined that under the microscope. It then didn't show any signs of bruising. In normal scientific circles you would say that that had falsified the hypothesis. In other words, the claim that there was a bruise has now been proved to be wrong. What Dr Manock said was that it simply failed to confirm the existence of a bruise, but nevertheless the bruise existed because he saw it, and because he could point to it on a rather grainy black and white photograph.

Graham Archer

One of the main criticisms of Dr Manock, levelled at him by interstate and international experts, was his failure to rule out other possible causes of death. Not a problem says the Medical Board.

Bob Moles

But they said that because Dr Manock had a practice that wasn't set out in textbooks, because it was supported by his peers - meaning by the other pathologist there - his subordinate - then that justified his methods.

Graham Archer

As we've shown, there are many, many fundamental problems with the Keogh prosecution, to the point of there being insufficient water in the bath to make the Dr Manock murder theory even physically possible, and Dr Manock admitted as much to the Board, a point they seem to have missed.

Bob Moles

We asked him, “did you check the level of water in the bath at the time?” and he said, “no I didn't”, and we said, “well, the bath was only one third full, and that can be established from the photographs”, and he said, “oh, well, if I'd known that I wouldn't have put forward the drowning scenario”.

Kevin Borick QC

There were over 40 Particulars of Complaint. Hardly any of them were dealt with in this report. They then said that they would consider Dr Manock's conduct in performing the autopsy, and they said they would consider Manock's conduct in giving evidence at the murder trial. The first they hardly mentioned, and the second they did not even mention at all.

Graham Archer

Henry Keogh's counsel, Kevin Borick QC, says the findings are totally deficient.

Kevin Borick QC

What really stood out in my mind was that they said that in 1994 there were no established standards for ‘best practice’ in forensic pathology in South Australia. But then said that Dr Manock complied with those non-existent standards.

Graham Archer

Of course, the Medical Board itself is under a darkening cloud for the way it's handled its own duties, leading a current parliamentary select committee to effectively threaten  members to be more up-front. While Medical Boards around the country have been put on notice by the catastrophic lapse in quality controls following the Dr Death case in Queensland, it appears the Board here have failed to get the message. But then it has a long history of denial.

Professor Ross Kalucy

[File tape] If the doctors messed up, we’d pick them up like that. [clicks fingers]

Graham Archer

Well, what about the case of Dr Stephen Rabone, for instance?

Professor Ross Kalucy

[File tape] I don't know about that.

Graham Archer

I think you would have.

Professor Ross Kalucy

[File tape] No, I don't know.

Graham Archer

You were the President of the Board when that case went through.

Former President, Ross Kalucy, seemed to have forgotten his supervisory role in the case of Dr Stephen Rabone, who is alleged to have infected over a dozen patients with Hepatitis C while injecting himself with their painkillers. Rabone was allowed to continue practising despite a chronic drug habit. He was reinstated by the Board, went to Barmera and started injecting himself with his patients' medicine. Now in that case, why would the Board allow someone like that to go into a hospital?

Professor Ross Kalucy

[File tape] You're not going to mention his name, are you?

Graham Archer

Well, it's in the courts, and has been ...  

Professor Ross Kalucy

[File tape] I won't take part in that discussion.

Graham Archer

And just a few weeks ago the Coroner blasted the Board for their inactivity over the Dr Stephen Mauro case (after the death of one of his patients) in evidence of his drug abuse.

[Speaking to Kalucy] Can I say it gets down to how ... the Board performs in individual cases?

Professor Ross Kalucy

[File tape] Stop there, or else I'll walk out. Okay?

Graham Archer

Well okay, let's change ...

Bob Moles

What happens sometimes is that these Boards and Committees and things, maybe they don't do their job properly, and there may be all sorts of reasons for that - but the public know the difference between right and wrong.

Graham Archer

The plan from the Keogh side is now to challenge the board's decision in the courts.

Kevin Borick QC

We have the right to go to the Supreme Court to seek judicial review, and there are a number of precedents for that, and that's what we will be doing.

Bob Moles

There's no prospect that this issue is going to go away. There's every prospect it will lead to a Royal Commission or to a major investigation to find out why it is that we seem unable to face the truth in relation to these prior acts of misconduct.

Rosanna Mangiarelli

Graham Archer reporting there.

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