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[This version of the document has been set up by Dr Robert N Moles]

RECEIVED 9 NOV 2004

Re: Dr. Manock: Ian Maddocks reflections

The complaint against Dr. Manock alleges:

1. that Dr. Manock’s forensic examination of the body of Ms. Anna Jane Cheney was incomplete and demonstrated incompetence sufficient to warrant a finding of unprofessional conduct.

2. that Dr. Manock’s interpretation of his findings, and the formulation of a theory of the manner of Ms. Cheney’ s death was fanciful, and took no account of other feasible hypotheses, and that this construct should also be regarded as constituting unprofessional conduct.

Regarding 1. The conduct and interpretation of the autopsy.

The written record of the autopsy, the record of available photographs of the body in the forensic laboratory, and the description of the routine of the examination as given by Dr. Manock established, in my view, that the conduct of the examination was not consistent with the standard expected from a Forensic Pathology service.

The brevity of the notes which have survived, the paucity and possible inadequacy of specimens taken for histological examination, the strange matter of whether colour photographs were taken or not, the poor quality of black and white photographs, the story of a whiteboard wiped clear of a record of organ weights all testify to work which was performed in a cursory, perhaps hurried, way.

Nevertheless, I have concluded that such evidence as has been presented from that examination indicates that Dr. Manock’s conclusion was correct, that death was due to drowning, and that though he has been criticized for stating that at no time did he consider alternative explanations for the death, no other cause than homicide has been advanced that satisfactorily accounts for the drowning.

As I understand it, the case was presented to Dr. Manock on a Sunday as one of three (four?) routine autopsies, and no suspicion of homicide was attached to the request to him to perform an autopsy. He was the individual who suggested that the manner of death was violent, as a result of finding bruises on the leg of the body consistent with a very firm grip prior to death. Other subsequent findings and circumstances quite outside the area of forensic pathology led to a charge being laid against Mr. Keogh.

Much has been made of the limited amount of evidence from photographs and histology regarding the marks found on the left leg. The evidence about photography was persuasive, suggesting that little significance can be placed on the marks shown in the photographs. However, the autopsy record demonstrates these bruises and some credibility must be attached, I believe, to Dr. Manock’s description of their appearance. He recognised bruises. Only one biopsy was taken from the lateral line of three (or four) ‘finger’ marks, and the one biopsy from the medial side contained no skin and showed no extravasation of blood consistent with a bruise. I conclude, however, that this specimen was deficient in its preparation, and absence of proof does not constitute proof of absence.

Concerning the finding of staining of the lining of the aorta but not of the pulmonary artery, the explanation given by Dr. Manock and Dr. James seemed plausible, but if it is not attested by experiment would have to be questioned. It was not the single or major finding in support of a diagnosis of drowning.

It seems very likely that Dr. Manock was not trained to a high standard in his time as a forensic pathologist prior to appointment in Adelaide, and had no formal qualification in his speciality. The Fellowship of the College of Pathology that he was subsequently awarded was conferred without any test or examination. He had been working in Adelaide at this demanding job for several decades prior to 1994, and does not appear to have up-skilled himself in any significant way or established and demanded standards for the service that could be seen as consistent with best practice developing over that period.

In the evidence from Dr. James and Dr. Thomas, plus discussion with other Board members knowledgeable about Adelaide pathology, I have concluded that the facilities available to Dr. Manock in 1994 were not satisfactory; that the staffing levels were such as to require of him and his colleagues a high pressure of work; that the culture of the service was not one in which the highest standards were consistently promoted; and that research and teaching were not seen by Dr. Manock to be part of his responsibility. I cannot determine whether the apparently unsatisfactory nature of the service was due mainly to poor funding, poor support and staffing levels, or can be laid firmly at Dr. Manock’s feet as an indication of his incompetence or failure in management and direction.

2. Regarding Dr. Manock’s suggestion concerning the manner of death

I felt the evidence concerning the bath, the depth of water, the position of the body being gripped, folded and forced so that the head was held under water was very confusing, mainly because of the lack of a comprehensive set of data such as bath dimensions, volumes and depth of water with and without an immersed body etc. There was no history available of the events leading up to the decision by Ms.Cheney to take a bath, no account of the removal of the body and its handling in the time immediately after death. Therefore I felt unable to judge whether Dr. Manock’s suggestion of the manner of death was fanciful or not, and conclude that this was a task for the court, and is not a matter in which the Board should be concerned.

With regard to the two photographs said to depict swelling, and used as a basis for the suggestion of anaphylaxis, I found the evidence for this quite unconvincing.

I concluded that it was appropriate for Dr. Manock to suggest a manner of death, but felt that scientific evidence concerning its validity was insufficient.

I believe that the Board should find that the procedure by which Dr. Manock conducted that autopsy was unsatisfactory according to the standards of 1994.

It certainly quite failed to fulfil the comprehensive and rigorous expectations of today.

However the Board heard no evidence that Dr. Manock’s findings were clearly incorrect or open to any convincing interpretation different from his own. We were concerned at the poor standards of practice revealed in the Forensic Pathology Laboratory in 1994, and must assign some (but not all) of the responsibility for this to Dr. Manock.

It would therefore be appropriate to reprimand Dr. Manock, and to require that he now agree not to undertake any role in forensic pathology other than as an assistant to a qualified pathologist, and under that pathologist’s supervision.

November 8.2004 Ian Maddocks

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