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

Charlotte Durden

Peter McDonald

Sent: Thursday, 10 March 2005 9:01 PM

To: Charlotte Durden; Kalucy, Ross; Mark Coleman; Ian Maddocks

Cc: Bradley Williams

Subject: RE: Keough v Manock - advice from Richard Evans

Dear Richard et al.

I have been thinking about the Manoch case and I am glad that things are progressing. My ruminations have been circulated (attached again).

The most recent Borick papers have not added anything of substance to my conclusions. I suggest that Ian Maddocks comments are exactly on the mark and I fully endorse them

Overall, my conclusions as a pathologist are that the conduct of the autopsy under consideration did not conform with contemporary standards as specified in text books for the conduct of autopsies (Mark Coleman to provide specific references). The extent to which this lack of conformity with standards for general autopsy is relevant to a “forensic” autopsy, and the specific role of Manoch in the conduct of his professional responsibilities as a “specialist” in forensic pathology should take account of the following:

1. The overall conduct of forensic pathology is a responsibility of the Forensic Sciences centre (?correct name) which includes an autopsy component alongside the more laboratory based elements that have been the subject of review and compliance with national standards. The professional medical component of autopsy performance and analysis has not been the subject of quality review compliance which has been set in place for chemistry, molecular biology (DNA testing) and toxicology etc. QA systems have not been put in place for autopsy and medical (forensic pathologist) performance generally in Australia that mimic the standards that have been applied in UK, Canada and USA.

2. As far as I can ascertain, there are no agreed national standards for the conduct of forensic autopsies: such standards are under consideration by the college of pathologists (RCPA). The notion that forensic autopsies should be less rigorous than routine autopsies is unacceptable to me. Routine matters such as the documentation of weights of organs removed should be a routine practice for forensic autopsies. The role and standards of forensic pathology continues to be under review by the RACP which is the accrediting body for pathologists. I am attaching docs in this regard — a review by RCPA about forensic pathology and documents from Victoria about documentation, standards for forensic autopsies and an example of performance review.

3. It is apparent that the SA Forensic Sciences Centre has not established or maintained quality control systems for autopsy performance; however they have achieved a high standard of practice and QA for other aspects of their activity in toxicology and the like. There are no national standards for forensic autopsy performance that are akin to the standards that have been established for chemistry, toxicology and other laboratory aspects of forensic pathology for which the centre has achieved accreditation. This comment is explicated in the attached discussion paper — review of forensic pathology.

4. Manoch was appointed as director/head of forensic pathology (?) by the IMVS which (at the time) which had responsibility for the forensic autopsy service (I think). Prior to this the forensic autopsy service was conducted by Barb Dwyer who was the city of Adelaide Medical Officer of Health (or similar title) and had no training or competency in forensic pathology. In the late 1960’s there was some tension about control of Forensic sciences and in the end a separate entity was formed which is the current SA Forensic Sciences Centre.

5. The role and function of the Forensic Sciences Centre seems to be the responsibility of the Coroner (needs to be confirmed). The extent to which the coroner or the office has exercised their apparent responsibility for quality of Forensic Pathology is not apparent but it would seem that they should be ensuring at least adequate quality of service provision.

6. At the time of his appointment as head/director of forensic pathology by the IMVS, Manoch did not have specialist qualifications in forensic pathology but he did have some early training in the area.

7. Throughout his career, Manoch seems to have been an assiduous and diligent pathologist who at all times has acted in good faith and honestly.

8. During the period of Manochs ‘service’ in forensic sciences the standards and practice of Forensic Pathology evolved. By 1990’s in Australia and internationally there was the development of a clear standard of Forensic science and autopsy — perhaps best illustrated by the UK reports.

9. The resource and personnel requirements provided by the responsible authorities (SA Government through coroners office) to follow the 1990’s proclaimed international standards of forensic pathology were clearly not consistent with those determinations at the time of the Keogh case. The performance of 4 autopsies on a Sunday morning with no back-up exemplifies this situation. A culture of cutting corners and “making do” with available resources seems to have developed in a climate when professional standards and expectations had been internationally if not nationally established.

10. The extent to which Manoch should be held responsible for ensuring that the overall operation of Forensic Sciences in SA and the autopsy services in particular complies with standards is not clear. I believe that there is a general “Administrative” or government responsibility matter that the Board should bring to the attention of the Minister and/or responsible authorities in terms of.

11. There was a clear problem of forensic pathology in SA at the time of consideration of his appointment. The background circumstances include the Salisbury royal commission, the role of various agencies (Coroner’s office, IMVS, Barb Dwyer/Central Board of Health, newly developing pathology departments at Flinders University (and other matters of detail that I can provide).

12. And certainly not the type of O & M issue that the Medical Board should get into — notwithstanding that I feel we should expect that responsible authorities like government hospitals and state agencies should comply with “community standards”

13. The SA Public Sector Management Act may be relevant to this issue insofar as SA Forensic Sciences is bound by the same issues as commercial entities in terms of quality, accountability, etc

14.

----Original Message-----

From: Charlotte Durden [mailto: cdurden@medicalboardsa.asn.au]

Sent: Thursday, 24 February 2005 1:14 PM

To: Kalucy, Ross; Mark Coleman; Peter McDonald; Ian Maddocks

Cc: Bradley Williams

Subject: FW: Keough v Manock - advice from Richard Evans

Dear Panel Members

Please see Richard’s request in msg below. Any notes can be sent direct to Richard at [address deleted] NSW or if sent to me, I will send them on to him.

Charlotte Durden

Comp!aints Co-Ordinator Medical Board of SA

----Original Message-----

From:

Sent: Thursday, 24 February 2005 11:50 AM

To: Charlotte Durden

Subject: Re: Keough v Manock

Charlotte,

I am about to embark on writing the background and legal framework for the decision. Would you please inform the other panel members and invite them to forward notes, or telephone. I hope to circulate a draft by mid March.

Regards,

Richard

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