Wednesday 28 November 2001 - Legislative Council

[This version of the document has been edited by Dr Robert N Moles
Underlining where it occurs is for editorial emphasis]

ABC 4Corners and Dr Colin Manock

The Hon. T. Crothers:

Adjourned debate on motion of Hon. Nick Xenophon:

1. That this Council expresses its deep concern over the material presented and the allegations contained in the ABC's Four Corners report entitled `Expert Witness' broadcast on 22 October 2001, involving Dr Colin Manock, forensic pathologist, and the evidence he gave from 1968-1995 in numerous criminal law cases;

2. Further, this Council calls on the Attorney-General to request an inquiry by independent senior counsel or a retired Supreme Court judge to report whether there are matters of substance raised by the Four Corners report that warrant further formal investigation; and

3. That the Attorney-General subsequently report, in an appropriate manner, to this Council on the allegations made in the Four Corners report and their impact on the administration of justice in this state.

I rise to make my position clear to some of our more loquacious members in this chamber. I normally am not of that variety: I am normally short, sharp and shiny. However, this subject is very dear to my heart and I may well be on my pins for some three-quarters of an hour. I do not watch Four Corners all the time, but just as it happened on that night-

The Hon. L.H. Davis

Can you see around them?

The Hon. T. Crothers

I could. I just envisaged you in my mind and I could see everything. On that night-

The Hon. T.G. Roberts

On the slab.

The Hon. T. Crothers

Yes, exactly. Not moving. On that night I was watching Four Corners and, from what I saw with respect to what was made of the evidence by doctors, by other qualified medical specialists and witnesses, and by several detectives, certainly there seemed to be something quite rotten in the state of Denmark relative to the occupation of the office of forensic pathologist in the state of South Australia by the now retired Dr Manock.

From the outset in respect of this contribution I wish to mention the Keogh case. What the Attorney understands of that is that Dr Manock, the former State Forensic Pathologist, only gave evidence of what he saw and did not express any opinions. The government believes that Dr James gave the opinions. I am reliably informed that that is not true. In fact, the reverse is true, that is, that Dr James did not give any opinion and the state relied on Manock.

If this stands true, then the Attorney may wish, in the interests of justice, to reconsider the matter as it relates to the Keogh case. An experiment using the bath alleged to have been involved in the Keogh case indicated that in this case, in the opinion of the presenters, `Manock's theory is what it always has been: bullshit.'

I turn to other matters. Suffice for me to say that what concerns me as an ordinary citizen of this state (secondly) is that innocent people have been unjustly punished. But first, and even worse than the contents of the second, is that some of the real murderers could still be running free. I am led to believe that this view that I hold is held by a significant number of investigating police. 

Some of these cases went before the Coroner, Mr Wayne Chivell, a man known to me in another life and a man whose absolute integrity is beyond dispute. Let me now for the benefit of honourable members turn to three coronial cases heard by him, each of which came before him for examination and discussion. The three babies in question, ranging in age from three months to nine months, were, first, the infant Storm Deane, aged three months; secondly, the infant William Barnard, aged nine months; and, thirdly, the infant Joshua Nottle, aged nine months.

If I may, let me return to the coronial inquiry into the death of the infant Storm Deane. Little Storm Deane was found to have multiple rib fractures of varying ages and two skull fractures. Let us now pause to consider the diagnosis and the assertions of the then State Forensic Pathologist Dr Manock. Dr Manock's diagnosis of the infant's death was bronchopneumonia, and he also asserted that a histological examination confirmed bronchopneumonia.

Members interjecting

I am trying to get justice for infants, and all the Hon. Carolyn Pickles and the Hon. Mr Davis can do, in the light of these poor innocents' death, is to carry on across the parliament like two insane Charlies. I ask you to call them to order, sir: this is a very serious matter.

Dr Manock's diagnosis of the infant's death was bronchopneumonia. He also asserted that a histological examination confirmed bronchopneumonia. It was further opined that Dr Manock did not observe the skull fractures. He said the rib fractures could be caused by rough play such as throwing the child in the air and catching the child. Members should remember that this infant was only three months old, and Detective Fielder - the investigating officer - found that difficult to accept.

Further medical evidence was led by Dr Donald, the Director of Child Protection Services - he is not a forensic pathologist-and Dr Richard Burnell, consultant physician at the hospital and senior lecturer in paediatrics. Like Dr Donald before him, he is also not a forensic pathologist.

Thirdly, evidence was given by Dr Roger Byard, a consultant histopathologist at the hospital. He agreed with the evidence already led by Dr Donald and Dr Burnell. In fact, Dr Byard said that Dr Manock did not conduct an appropriate histological analysis: in other words, he lied. To complete this medical picture, honourable members must understand that, regarding Dr Donald's evidence, when that worthy individual asserted that infant Deane had been the subject of serious physical abuse on at least two different occasions before his death, the Coroner accepted his evidence.

I turn now to Dr Richard Burnell, who, honourable members will recall, was the consultant physician at the hospital and senior lecturer in paediatrics. He led that he agreed with his medical colleague, Dr Donald, about infant Deane's fractures. He further said that neither the clinical fracture nor the sole X-ray in the child's life were compatible with bronchopneumonia. In the light of this overwhelming evidence given by these three doctors, the Coroner ordered that Dr A.C. Thomas, senior specialist in tissue pathology, review the case. His findings were as true as they were deadly. He found:

Manock's work did not conform to basic forensic pathology procedure .

Further, Dr Lloyd Morris, Director of Radiology, agreed that the injuries were non-accidental and, in addition, both of these latter physicians disagreed with Manock's diagnosis of bronchopneumonia. As a result of this foregoing evidence given under oath in the court, the Coroner found the death was not caused by bronchopneumonia. This decision means that either Dr Manock was incompetent, at least, on this occasion.

In fact, I put it to honourable members that there are two points worth considering that arise from Manock's assertion that examination of tissues (that is, histological) under the microscope confirmed his diagnosis of bronchopneumonia. First, he did not examine the tissues under the microscope and, secondly, bronchopneumonia was not the cause of death. In fact, Dr Donald said with respect to Dr Manock:

“That's the kind of opinion I'd expect from a relatively untrained, inexperienced junior medical officer, not a person practising as a senior forensic pathologist. It just doesn't add up. It doesn't make any sense at all”.

In the light of all the medical opinions-that is, those of Dr Donald, Dr Burnell, Dr Byard and Dr Morris - and the opinion of Detective Fielding, of the South Australia Police, and another doctor whose name I do not have, and some commonsense (that is, throwing a two month old baby in the air for fun), I ask how is it possible, with even just a modicum of commonsense, for anyone to say that Dr Manock's mistakes are only related to some lack of skill in a particular specialist area against the weight of all the evidence laid against Dr Manock? My mind boggles at trying to embrace such a concept. The only apparent thing I can say is that this was all a big mistake by Dr Manock.

I turn now to the untimely death of a nine month old infant, William Barnard. When this child was medically examined, he was found to have, first, a fracture of two bones in the right forearm (two to four weeks old), which would have been very painful every time he was being dressed (the pain would have been reproduced because of the movement of the bone ends) and, secondly, an unusual pattern of bruises and scars.

Turning now to Dr Manock's diagnosis, which stated that the infant's death was related to bronchopneumonia with fractures of the right radius and ulnar (that is, the infant's forearm), Dr Manock asserted that histological examination confirmed a diagnosis of bronchopneumonia. The mother admitted a serious assault on her son, thereby breaking his arm, and he `whinged' when he was dressed. It appeared that Dr Manock failed to inquire about this and, again, the Coroner asked Dr Thomas to review the case. Dr Thomas found, and the Coroner agreed:

first, the diagnosis of bronchopneumonia was wrong;

secondly, Dr Manock did not follow basic forensic pathology procedures; and,

thirdly, Dr Manock did not conduct an appropriate histological examination.

Two points emerge from the Coroner's findings:

first, the Coroner found that Dr Manock's explanation for his failure to consult with the police investigators was spurious; and,

secondly, William Barnard, an infant aged nine months, suffered an agonising period of at least two weeks before his death. It is obvious that those responsible for this little child's death escaped justice due to basic elementary mistakes made by Dr Manock and, again, the point must be made that this piece of incompetence, coupled with his mistakes, have nothing whatsoever to do with lack of skill in a particular specialist area.

Turning now to the third infant, Joshua Nottle, aged nine months, he was found to have suffered the following:

first, multiple rib fractures of varying ages and,

secondly, bruising to the spine, back and head.

The diagnosis of Dr Manock was as follows:

Bronchopneumonia associated with multiple rib fractures.

His assertion was as follows:

The spinal injuries were associated with vigorous attempts to resuscitate and the rib fractures with throwing the child in the air and catching the child.

The investigating police officer, Detective Frick, was unhappy with Dr Manock's explanation. In fact, he complained to Dr Donald and Dr Byard. In addition to the foregoing, Dr Byard reviewed Manock's work. He found, and the Coroner agreed with him:

first, the diagnosis of bronchopneumonia was wrong;

secondly, Manock's explanation for the spinal injuries was not possible;

thirdly, Manock's explanation for the rib fractures was not possible; and,

fourthly, Manock had not carried out histological analysis, as he should have (and Dr Thomas agreed with Dr Byard and Dr Donald). The Coroner therefore found as follows:

1. Dr Manock's diagnosis of cause of death was wrong.

2. Dr Manock's investigations and his subsequent report provided innocent explanation for the most serious injuries found on Joshua's body, explanations which I am now satisfied were incorrect.

3. Dr Manock's explanations for failing to consult with police investigators were spurious.

When I look at the Coroner's findings, I have to believe that, at best, Dr Manock is incompetent or, at worst, he is an absolute liar.

I would like to make some generic points germane to this long and sad saga.

First, whoever killed Joshua Nottle escaped justice because of Manock's incompetence.

Secondly, Dr Manock was the senior forensic pathologist in this state. He claimed that he had the qualifications and the skills to carry out the autopsies on these babies. Since the Attorney-General and the Director of Public Prosecutions now say he did not have those special skills, how many other babies have been killed without the killers having been brought to justice?

Thirdly, since the mistakes and incompetencies are not just related to the investigation of infant deaths (ask the people who know, such as Detective Fielder, Detective Frick and Drs Donald, Burnell, Byard, Thomas and Morris ), how many other people have escaped justice? An example of this could be the Szach murder, the Gambardella bullet in the head case, and the Keogh case, more recently.

Fourthly, how many people are in prison because of Dr Manock's proven incompetence? This question, and this question alone, is sufficient reason why there must be an inquiry; and, equally, I imagine that the three infants are crying out for justice from their early graves because of the pain and suffering they endured in their short and very sad lives. I direct the following questions to the Attorney- General. Does the Attorney-General accept the following:

1. That throwing a two month old child in the air and catching the child in such a way to break the baby's ribs is just rough play, as Manock asserts?

2. That three incompetent diagnoses are acceptable from South Australia's foremost forensic pathologist?

3. That the Coroner's finding that Manock's explanation for his failure to cooperate with police investigations were spurious (that is, Manock lied) is a matter of the gravest concern?

4. That Dr Donald's assessment-that is, what you would expect of `an untrained inexperienced junior medical officer'-refutes the explanation that Manock's mistakes in infant cases are solely related to these cases?

Commencing my conclusion, I return to Mr Xenophon's proposition and, in particular, paragraph 2, which states:

Further, this Council calls on the Attorney-General to request an inquiry by independent senior counsel or a retired Supreme Court judge to report whether there are matters of substance raised by the Four Corners report that warrant further formal investigation.

Mr Xenophon's motion contains two other paragraphs, that is, paragraphs 1 and 3, which also assume importance when linked with paragraph 2. However, in my view, it is the legal application of paragraph 2 which, if carried by both houses, would enable justice to be done.

There are two further points that I wish to emphasise in support of the Xenophon proposition. First, innocent people may have served and, indeed, still may be serving long gaol sentences for crimes they did not commit.

Secondly, murderers may well still be free, thus enabling them to commit further crimes in addition to the crimes already committed. There is also the fact that the three infants, and perhaps other infants, are crying out for this House to give these innocents proper justice.

This Council is the only place capable of giving those instructions to its ministers. This can best be done in the first instance by carrying out the proposition standing in the name of the Hon. Nick Xenophon. Finally, this House is the last court of appeal on this matter. The Attorney, I am sure, well realises like the rest of us that a nation's laws work at their best and fairest when they are seen by the population at large to be applied with justice as their end view and without any fear or favour. I have much satisfaction in supporting the Xenophon proposition and I call on all other honourable members, in the interests of justice, to do the same.

The Hon. T.G. ROBERTS

I indicate my support for the intentions outlined in the motion moved by the Hon. Nick Xenophon. I will not go into detail on the cases mentioned in the Four Corners report because the information that was provided by the Four Corners reporter was very detailed and very graphic. The justice that the Hon. Mr Crothers spoke of can be sought by those people who may be concerned by some of the accusations made by the Four Corners report, who, through the current justice system, could seek an investigation that may bring about the justice that they require, given that those broad accusations have been made. The first paragraph of the motion reads:

That this Council expresses its deep concern over the material presented and allegations contained in the ABC's Four Corners report entitled `Expert Witness' broadcast on 22 October 2001 , involving Dr Colin Manock, forensic pathologist, and the evidence he gave from 1968 to 1995 in numerous criminal law cases.

If all the accusations made in that Four Corners report were true, the honourable member's concerns and the concerns raised by the report would be the concerns of every member in this House. Of the other two paragraphs in the motion, one calls on the Attorney-General to request an inquiry by independent senior counsel or a retired Supreme Court judge to report whether there are matters of substance raised by the Four Corners report that warrant further formal investigation. The third paragraph states:

That the Attorney-General subsequently report, in an appropriate manner to this Council, on the allegations made in the Four Corners report and their impact on the administration of justice in this state.

As to the opposition's position in relation to those two paragraphs, I will leave them open to allow the mover of the motion to discuss any further actions that may be supported by the shadow Attorney-General in another place. I do that not because the opposition wants to be awkward about the way in which we would like to pursue this case as set out in the motion but because we have some sympathy with the government's position that, if any or all of those accusations were found to have merit, the justice system that we have would be failing, particularly those infants and those who have possibly been wrongly charged.

If that were the position, a number of guilty people would have gone free in relation to some of those infants' deaths and, in relation to the accusations that some of the evidence in some of the murder cases was wrongly assessed by the accused forensic pathologist, Dr Colin Manock, some people would have been wrongly incarcerated. It appears to me that our justice system could not have failed in so many cases.

As I said, I have indicated that discussions will go on, so I will seek leave to conclude and have this motion adjourned while they continue. The opposition's position is that processes are in place to investigate the accusations contained in the report, and that relatives and interested parties can make an application for a further investigation through the Attorney-General's office.

In his contribution, the Attorney- General indicated that, if evidence was available to open up all or any of those cases, an avenue was open for individuals to seek justice if they thought that justice was not done. That is the opposition's position, and I seek leave to conclude.

Leave granted; debate adjourned.

Top of Page